{"id":5289,"date":"2011-09-06T15:55:32","date_gmt":"2011-09-06T15:55:32","guid":{"rendered":"http:\/\/crashtext.org\/misc\/airway.htm\/"},"modified":"2015-08-27T11:23:10","modified_gmt":"2015-08-27T15:23:10","slug":"airway","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/resuscitation\/airway\/airway.htm\/","title":{"rendered":"Airway"},"content":{"rendered":"
(Our Notes from the National Emergency Airway Course http:\/\/www.theairwaysite.com<\/a>, Emergency Airway Management 4th ed, and The Airway Cam Guide to Intubation) RSI evidence review (Can J Anesth 2007;54(9):748) AirwayCam Videos<\/a> Levitan Pocket Guide<\/a> http:\/\/vam.anest.ufl.edu\/airwaydevice\/videolibrary\/index.html#airtraq<\/a> http:\/\/groups.msn.com\/DrMAGBOULAIRWAYPAGE\/homepage.msnw<\/a> www.airway911.com<\/a> Airway Academy<\/a><\/p>\n (Gag reflex is absent in up to 37% of population, so a poor predictor of airway protection (J Accid Emerg Med 16(6):444, 1999) Lancet. 1995 Feb 25;345(8948):487-8,Clin Otolaryngol. 1993 Aug;18(4):303-7)<\/p>\n Other Reasons include:<\/strong><\/p>\n Study that drunks and tox folks can stay non-intubated even with low GCS. Only 73 pts. (J Emerg Med 2009 Nov;37(4):451-5.)<\/p>\n The difficult airway is something you can predict, the failed airway is something that happens to you. Perform the difficult airway assessment on any patient who has any chance of needing intubation during their stay in the ED. \u00a0 <\/a><\/a><\/a><\/a><\/a><\/p>\n Beard Obesity No Teeth Elderly (>55) Snores Results: During a 24-month period, 22,660 attempts at MV were recorded. 313 cases (1.4%) of grade 3 MV, 37 cases (0.16%) of grade 4 MV, and 84 cases (0.37%) of grade 3 or 4 MV and difficult intubation were observed. Body mass index of 30 kg\/m2 or greater, a beard, Mallampati classification III or IV, age of 57 yr or older, severely limited jaw protrusion, and snoring were identified as independent predictors for grade 3 MV. Snoring and thyromental distance of less than 6 cm were independent predictors for grade 4 MV. Limited or severely limited mandibular protrusion, abnormal neck anatomy, sleep apnea, snoring, and body mass index of 30 kg\/m2 or greater were independent predictors of grade 3 or 4 MV and difficult intubation. Conclusions: The authors observed the incidence of grade 3 MV to be 1.4%, similar to studies with the same definition of difficult MV. Presence of a beard is the only easily modifiable independent risk factor for difficult MV. The mandibular protrusion test may be an essential element of the airway examination. (Anesthesiology 105(5), November 2006, pp 885-891)<\/p>\n Look at head and neck Evaluate 3-3-2 Mallampati (Using Samsoon and Young mod, which added class IV, 1987) Obstruction=hot potato voice, can’t handle secretions, and Stridor (if audible=90% obstruction) Neck Mobility S for saturation reserve (Ann Emerg Med June 2006)<\/p>\n <\/p>\n MA of difficult airway prediction (Anesthesiology 2005; 103:429\u009637) best values from combo of mallampati and thyromental distance, but still crappy. \u00a0 Surveys indicate 10-25% of patients with trisomy 21 have AAI. Two thirds of these cases are due to laxity of transverse ligament, whereas one third are due to abnormal odontoid development. Although this association has been depicted on radiographs, the clinical incidence of serious cervical spine injury is not increased in this population compared with other populations. About 25% of patients with rheumatoid arthritis have atlantoaxial instability, which is thought to be due to chronic inflammation. Congenital skeletal dysplasias may cause resultant odontoid hypoplasia. Marfan syndrome may involve to ligamentous laxity, and acute inflammatory processes can affect the retropharyngeal, neck or pharyngeal spaces. Rheumatoid Arthritis destroys ligaments causing increased movement of dens in spinal canal \u00a0 A physical examination may reveal the characteristic stigmata of OSAS including a short thick neck, nasal obstruction, tonsillar hypertrophy, narrow oropharynx, retrognathia, and obesity. Although these clinical features are typical, they are not reliable predictors of the presence of severity of the disease.49 Physical examination and laboratory studies may also reveal the presence of unexplained right heart dysfunction or erythrocythemia, suggesting the severity of OSAS. (Laryngoscope 1989) \u00a0 Obstructive Sleep Apnea Syndrome and Postoperative Complications<\/a>. Clinical Use of the STOP-BANG Questionnaire. Arch Otolaryngol Head Neck Surg. 2010;136(10):1020-1024.<\/p>\n <\/p>\n The incidence of failed airways is 10x greater in term pregnant women, they should always be considered a difficult airway. Intubation must displace the tongue somewhere, that somewhere is the submandibular space, if that space is occupied by infection\/tumor or entirely absent=difficult airway \u00a0 Failed Laryngoscopy (with 3 attempts) : 1 in 200-300 intubations Can’t intubate\/can’t ventilate (CICV): 1 in 10,000-20,000 intubations PGY 1 or 2: 65% successful on 1st attempt of laryngoscopy PGY 3\/4\/Attending 85% successful on 1st attempt of laryngoscopy \u00a0 We performed as well as anesthesiologists in trauma intubations (Academic Emergency Medicine Volume 11, Number 1 66-70)(Ann Emerg Med. 2004;43:48-53)<\/p>\n <\/a>J Trauma 2009;66(1):32)<\/p>\n Preparation of equipment All equipment at the bedside, including backup devices (should be present at every intubation) Have RSI and post-intubation meds already drawn up. An amp of phenylephrine is also a nice thing to have at the bedside in case the intubating agents cause vasodilatory hypotension. \u00a0 Mnemonic for Equipment during routine intubation (Weingart)<\/p>\n Lubricating the ET tube cuff may lower rates of aspiration (anesthesiology 2001;95:377) \u00a0 \u00a0 Straight to cuff with 35 degree bend probably is best (ACADEMIC EMERGENCY MEDICINE2006;13:1255\u00961258)<\/p>\n Eliminate all the N2 in the FRC Some BVMs allow active breathing by the patient of 100% O2 while others will give only ~30%. Need duckbill one way valve and an exhalation port. Do not let the patient take a single room air breath from the beginning of this phase. Kids desaturate much more quickly than adults. So they are not just little adults, they are little, fat adults 8 vital capacity breaths while wearing a non-rebreather mask is also an alternative. These masks can be augmented to provide near 100% FiO2 by placing a valve over both vents, providing flow at 15 lpm, and tightly fitting the mask to the face (Resuscitation, April 2003, 57:1, 69 – 72) When a patient is at <90% saturation, be scared, as this level is right at the nose dive point of the oxygen desaturation curve <\/a><\/a> \u00a0 Benumof’s seminal study on time to desaturation (pdf<\/a>) and where he actually go the calculations (Br J Anaesth 1996;76:284) Abandon the “hold your breath while intubating” method, it just leads to added stress and underestimates the amount of time you have to intubate Maximum oxygen in lungs is 87% as 6.5% taken up by CO2 and 6.5% by water vapor. While the fast track (8 vital capacity breaths) method will cause this 87% concentration, it will not fill the tissue and venous compartments. Therefore the traditional method will in various studies allow up to 3 minutes of extra time (Benumoff Lecture) \u00a0 The fast track method \u00a0 NRB only provides 70-80% fiO2 at best \u00a0 Much longer time to desat in the obese if you preoxygenate in sitting position (British Journal of Anaesthesia 2005 95(5):706-709) better laryngeal exposure as well (Lee BJ, Kang JM, Kim DO (2007) Laryngeal exposure during laryngoscopyis better in the 25 degrees back-up position than in the supine position. Br J Anaesth 99:581\u0096586) \u00a0 Patients who can not preoxygenate well with mask should be placed on NIV (Am J Respir Crit Care Med 2006;174:171) \u00a0 Can then use Vent to continue oxygenation until ready to intubate (JEM 2006;30(1):63) Place on AC: IFR-30 LPM, FiO2-100%, RR-15, Vt-500 cc, PEEP-based on situation<\/strong> attach a ETCO2 line to set-up<\/strong> \u00a0 Two rcts showed better preox when it is preceded with maximal exhalation(Anesth Analg 2003;97:1533) and (Can J Anesth 2000;47:1144) functional recovery time of 8.5 min after 1 mg\/kg of Sux (Anesthesiology 1997;87:979) \u00a0 Airway press <15 cm H20 rarely causes insufflation >25 will often cause it (Br J Anaesth 1987;59:315 and Acta Anaesthesiol Scand 1961;5:107) Can J Anaesth. 2007 Jun;54(6):448-52. Click here to read Links Efficacy of preoxygenation using tidal volume and deep breathing techniques with and without prior maximal exhalation. Nimmagadda U, Salem MR, Joseph NJ , Miko I. Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 W. Wellington Avenue, Chicago, IL 60657, USA. PURPOSE: We evaluated the influence of prior maximal exhalation on preoxygenation in 15 adult volunteers using tidal volume breathing (TVB) for five minutes and deep breathing (DB) for two minutes with and without prior maximal exhalation. METHODS: Inspired and end-tidal oxygen, nitrogen and carbon dioxide were monitored continuously and recorded during room air breathing and at 30-sec intervals during 100% oxygen TVB or DB (rate of 8 breaths.min(-1)). RESULTS: Tidal volume breathing with prior maximal exhalation resulted in an end-tidal oxygen concentration (ETO(2)) slightly higher (P = 0.028) at 0.5 and 1.0 min as compared with TVB without prior maximal exhalation at the same time periods. Regardless of whether TVB was preceded by maximal exhalation or not, 2.5 min was required to reach a mean ETO(2) value of 90% or higher. With DB, there were no differences in ETO(2) values at any time period and 1.5 min was required to reach an ETO(2) of 90% or greater, with or without prior maximal exhalation. CONCLUSIONS: Maximal exhalation prior to TVB slightly steepens the initial rise in ETO(2) during the first minute, but confers no real benefit if maximal preoxygenation is the goal. Maximal exhalation prior to DB has no added value in enhancing preoxygenation. \u00a0 \u00a0 Study of 3 minutes vs 4 deep breaths vs 8 deep breaths (Anesth 2003;99:841) \u00a0 comparison of Self-inflating manual resuscitators (SIMRs, i.e. bvms) for preox If there is not a one-way exhalation valve, useless for preox(Anesthesiology 2000;93:693) \u00a0 <\/a>Preox for claustrophobic Pt (Anesthesiology 104(2)) \u00a0 Nasal Cannula (Fio2 increases 4% per lpm from 24-44%) Benumof’s Airway Management Mask with reservoir bag (10 lpm = > 80 %) Benumof’s \u00a0 Finger pulse oximeter lags in poor perfusion states (Can J Anesth 2004;51(5):432) \u00a0 Can also use a SGA for preox and then take it out to intubate a la Darren Braude<\/p>\n a new article on the morbidly obese shows extension of time to desat if left on nasal cannula (J Clin Anesth 2010;22:164<\/a>)<\/p>\n Who needs pretreatment? \u00b7 Tight Brain (Elevated ICP\/Head Injury\/CVA) \u00b7 Tight Vessels (Aortic Dissection\/AAA) \u00b7 Tight Heart (ACS) \u00b7 Tight Lungs (Asthma) In TBI severity of brain injruy doesn’t predict the lack of need for pharmacologic blunting of increase in MAP or ICP (Journal of Trauma and Acute Care Surgery Issue: Volume 74(4), April 2013, p 1074\u20131080)<\/p>\n The larynx one of the most richly innervated areas in the body, this is a primitive airway protection scheme. \u00b7 Bronchospasm can result from laryngoscopy and from intubation. Stimulation of the carina also causes Bronchospasm. \u00b7 Laryngoscopy and intubation also cause increased ICP, both directly and by the catecholamine surge. Succinylcholine increases<\/p>\n ICP by causing more afferent traffic to brain, increasing metabolic activity. \u00b7 Catecholamine surge from adrenal cortex during laryngoscopy and intubation. Hypercapnia and hypoxia are causes of huge catecholamine surge.<\/p>\n \u00b7 Limit time of laryngoscopy \u00b7 Atraumatic laryngoscopy<\/p>\n Optimally, give premedications 3-5 minutes before RSI<\/p>\n o Use in tight brain to attenuate reflex increase in ICP from laryngoscopy\/intubation o Use in tight lungs to blunt bronchospastic response o 1.5 mg\/kg Rapid IVP While there is evidence that it blunts ICP rise and cough response, there is no good evidence that this has clinical results (Robinson N. Emerg Med Journal 2001; 18(6):453- 7.) Literature is pretty good on endotracheal suctioning. Not hemodynamically active in this study (Am J Emerg Med. 2012 May 23.Lin CC)<\/p>\n o Use in tight brain\/tight vessels\/tight heart to blunt catecholamine surge o Fentanyl 3 ug\/kg slow IVP \u00a0 \u00a0 \u00a0 At this stage, Emergency Airway Course only recommends Lidocaine and Fentanyl: LOAD is dead \u00a0 \u00a0 Intralingual succinylcholine injection provides a rapid onset of muscle relaxation in an emergency.Anaesthesia. 2001 Dec;56(12):1213.<\/p>\n in GI bleeds\/full stomachs<\/p>\n 1-2 mg\/kg ~ 3min beforehand<\/p>\n 3 mcg\/kg of remifentanyl can also be used \u00a0 ABC for asthma, brain, CV asthma gets lido, brain gets both, CV gets fentanyl<\/p>\n Paralysis after Induction \u00b7 \u00a0 \u00a0 RSI Review (Can J Anesth 2007;54(9):748) \u00a0 Brutane (forcing non-paralyzed musculature) is the worst choice of medications<\/p>\n \u00b7 Etomidate or Versed .3 mg\/kg \u00b7 Ketamine or Propofol 1.5 mg\/kg \u00b7 Pentothal 3 mg\/kg \u00a0 Etomidate mycoclonus can be attenuated c small dose benzo \u00a0 Use \u00bd dose of induction agents if vital signs are unstable or the patient is elderly. Consider using a dose of zero if the sympatholysis may result in decreased BP In a analysis of NEAR data, thiopental, methohexital, and propofol appeared to facilitate RSI over etomidate and versed. The postulated reason for this is that these agents allow a deeper plane of sedation making up for inadequate waiting time for paralysis. (Acad EM 10:6, 2003) \u00a0 Dose based on ideal body weight; estimate by Broca index: (height in cm-100 for men, -105 for women) \u00a0 ketamine for head injury review (emerg med australia 2006;18(1):37-44) (also see sedative<\/a> section) best evidence from EMJ<\/a> editorial on the use of ketamine in intubation ( Chest. 2007 Dec;132(6):2054) \u00a0 Ketamine may be the best choice for hemodynamically unstable<\/a> \u00a0 Ketamine is safe and may be the preferred sepsis agent (Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial Lancet 2009) \u00a0 Pharmacodynamics and kinetics of propofol in the shocked patient. Short message–give less, even if you resuscitate them, give less (Anesthes 2004;101:647) and (Anesth Analg 2006;103:1339-1340)<\/p>\n Complications of emergency intubation with and without paralysis. (Am J Emerg Med. 1999 Mar;17(2):141-3) Do not give sedatives without paralytics, as there is a good 6 minutes of IPIST (Interval of Progressively Increasing Sphincter Tone) between administration and full sedation Can get MR free good intubating conditions with propofol 2.5 mg\/kg, opioids, and 4% lidocaine spray of larynx (Acta Anaes Scand 1996;40(6):752) Most recent article; give propofol 2 mg\/kg and remifentanil 2.4 mcg\/kg (Journal of Clinical Anesthesia Volume 24, Issue 5, August 2012, Pages 392\u2013397) Administered with propofol 2 mg\/kg, the remifentanil dose necessary to produce acceptable intubating conditions was 2 mcg\/kg (Anesth Analg 2012;114:980\u20136)<\/p>\n Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care 18. (6): 417-423.2002; Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 46. (4): 328-336.2005; Full TextA comparison of rapid sequence intubation and etomidate only intubation in the prehospital air medical setting. Prehosp Emerg Care 4. (1): 14-18.2000; Abstract The utilization of midazolam as a pharmacologic adjunct to endotracheal intubation by paramedics. Prehosp Emerg Care 4. 14-18.2000; Abstract even more stuff on this<\/a> In the ICU, NMBs increased success and decreased hypoxemia (Crit Care Med. 2012 Jun;40(6):1808-1813)<\/p>\n Paralytics spare pupils (Shah. Emergency Neurology, p.5) and article<\/a> in neuro lit<\/p>\n Succinylcholine<\/strong> is the only one used in the US. Sux dosing 1.5-2 mg\/kg, always better to give more than less. Action in 45 seconds, clinical duration 6-8 minutes Typically causes a rise of 0.5 mEq\/L of potassium Dose based on actual not ideal body weight, gives better conditions in the fattys (Anesth Analg 2006;102(2):438) \u00a0 When not to use Succinylcholine: \u00b7 Any strokes with hemiparesis from 3 days to 6 months \u00b7 Burns\/trauma >24 hours old \u00b7 NMJ Disease \u00b7 Myopathies\/Muscular Dystrophies Theoretical Concerns \u00b7 Intraocular pressure: commonly used by anesthesiologists in this situation. (Anesth Clin North Am 1996 14:125-150 and Anesthesiology 1985; 62: 637-640) \u00b7 Preexisting Hyperkalemia (Renal failure is not a contraindication): In a retrospective study of all patients with hyperkalemia (38 of 40,000) receiving sux, there were not adverse events (Anesth Analg 2002 Jul;95(1)) \u00b7 Known plasma cholinesterase deficiency: (only risk is prolonged duration of action) Burns: no real risk as long as less than 7 days from the burn or several months after (after healing, return of normal appetite, and return to normal weight) Direct Muscle Damage: no risk until 4-5 days after insult Guillain-Barre: do not use during and for months afterward ICU: If chronic muscle atrophy, may be better not to use for up to a year afterwards Myopathies: Contraindicated forever if inherited (From correspondence from G. Gronert, MD) Multiple Sclerosis: Review of Sux & neuromuscular disorders (Anesth 1984;61:173) Not a great idea in patients with MS induced paresis (Curr Opin Anaes 2002;15:365) Case Series of Numerous MS Patients who received Sux (Ann Chir Gynaecol. 1984;73(5):299-303) 1 case report in the literature of hyperkalemia in MS (JAMA 1970;213:1867) After about 2 weeks in critical care, pts are at risk from sux (Anesthesia & Analgesia 115(4), October 2012, p 873\u2013879) \u00a0 Sux remains 90% effective at room temperature for 3 months, longer if not exposed to light (Rosen\u0092s 2001) Lasts for months at room temp (Emergency Medicine Journal 2007;24:168-169) Sux can be injected intralingually if unable to obtain IV access (Intralingual\/Intraoral in Adult Anaesthesia 56:12, 1213 Dec 2001) \u00a0 Submental\/Intralingual use of Nalaxone–23-gauge, 1.5-inch needle attached to a 3-mL syringe was inserted in the midline, midway between the mandible and the thyroid cartilage. It was directed 1 inch superior, and 2 mL of naloxone solution was injected. The SM area was then massaged for 30 seconds Intralingual naloxone injection for narcotic-induced respiratory depression. Ann Emerg Med 1987;16:572-573. Mercurio JP: Emergency submental injection. JADA 1967;74:717-719. Redden RJ, Miller M, Campbell RL: Submental administration of succinylcholine in children. Anesth Prog 1984;12:1087-1091.<\/p>\n <\/p>\n If you wait 60 seconds, then induction agent is irrelevant (British Journal of Anaesthesia 2005 95(5):710-714)<\/p>\n A second doseof suxamethonium in the presence of masseter spasm. This shouldnot have occurred for two reasons:<\/p>\n IM Sux-need 4mg\/kg to get 2-3 minute induction time (Anaesthesia 2007;62:757)<\/p>\n Sux and Hyperkalemia<\/strong> Anesthesiology 2006; 104:158\u009669 (massive review down to receptor level) Ped Emerg Care 2000;16(6):441–can not blunt hyperkalemia with non-depols Chest 1992;102(4):1259–can not blunt hyperkalemia with non-depols Seminars in Anesthesiology 1985;4:65–same Anesth 1975;43:89–article references by Anesth 2006 JAMA 1969;210:490 Anesthesiology. 1973 Jul;39(1):13-22.–The response of denervated skeletal muscle to succinylcholine, using canine muscles both normal and denervated 25. R.E. Tobey, P.M. Jacobsen, C.T. Kahle, R.J. Clubb and M.A. Dean, The serum potassium response to muscle relaxants in neural injury. Anesthesiology 37 (1972), pp. 332\u0096337. View Record in Scopus | Cited By in Scopus (8) 26. A.A. Birch, G.D. Mitchell, G.A. Playford and C.A. Lang, Changes in serum potassium response to succinylcholine following trauma. JAMA 210 (1969), pp. 490\u0096493. View Record in Scopus | Cited By in Scopus (10) \u00a0 27. G.A. Gronert, Potassium response to succinylcholine. JAMA 211 (1970), p. 300. \u00a0 Anaesth Intensive Care. 1990 Feb;18(1):92-101.Links Suxamethonium and hyperkalaemia. review including 0.7-1.2 rise in renal pts<\/p>\n d<\/li>\n is being tested; it binds to roc and completely reverses its effects Phase II Study: Anesthesiology 2007;106:935-43 \u00a0 \u00a0 Ephedrine 70 ug\/kg Placebo Esmolol 0.5 mg\/kg CO 9.1 8 5.5 Onset of Roc 0.6 mg\/kg in sec 52 87 114 (Acta Anaesthesiol Scand. 2003 Oct;47(9):1067-72.) \u00a0 Aspiration is less likely with NMBA 1 mg\/kg of Sux will give excellent intubating conditions 63-80% of time Time until diaphragmatic movement were the same between 1 mg\/kg and 0.5 mg\/kg dose (Donati, Fran\u00e7ois – Muscule Relaxation for Rapid Sequence Induction IARS 2006 Review Course Lectures) \u00a0 Prefasic dose of Rocuronium is 0.03 mg\/kg 3-5 min before intubation You must increase dose of sux to 2mg\/kg if prefasic dose of non-depol is given \u00a0 Corrugator Supercillii, which moves the eyebrow in response to facial nerve stim has response to NMBAs similar to vocal cords and diaphragm. \u00a0 \u00a0 Article on intubating without paralysis (Br J Anaesth 2005;94(2):150) lidocaine sprayed on cords remifentanyl 2 mcg\/kg \u00a0 ROCURONIUM VERSUS SUCCINYLCHOLINE FOR RAPID SEQUENCE INDUCTION INTUBATION Background Rapid sequence induction (RSI) of anaesthesia is a method of quickly producing optimal conditions for intubation in the emergency situation. Classically, succinylcholine (also known as suxamethonium) is the muscle relaxant used because of its rapid onset and brief duration. Contraindications for its use include severe burns, major crush injuries, neurological disease involving acute wasting of major muscle and family history of malignant hyperthermia. Rocuronium is another rapid onset muscle relaxant with fewer contraindications than succinylcholine but its duration is significantly longer. The aim of this meta-analysis was to assess whether rocuronium is as effective as succinylcholine at producing ideal intubating conditions during RSI. Results Twenty six studies were identified that met the inclusion criteria. Succinylcholine produced a small but statistically significant increase in the number of excellent versus non-excellent intubation conditions (relative risk (RR) 0.87; 95% CI 0.81 to 0.94). There was no significant difference between the two agents when comparing excellent or good intubating conditions with poor conditions or failure to intubate. When propofol was used in place of thiopental, there was no difference in the numbers of excellent conditions produced by either rocuronium or succinlycholine. SOCRATES says Succinylcholine produces excellent intubation conditions more consistently than rocuronium and remains the first choice muscle relaxant for RSI. In cases where it is contraindicated, rocuronium is a valid alternative, especially if combined with propofol. Perry J, Lee J, Wells G. Rocuronium versus succinylcholine for rapid sequence induction intubation. In: The Cochrane Database of Systematic Reviews. 2005 Issue 4 CD 002788<\/p>\n Number of Twitches After Stimulation<\/strong> Amplitude<\/strong> Corresponding Level of Neuromuscular Blockade<\/strong> 4-all 4 equal-0% (no blockade) 4-declining-< 75% 3-declining-75-85% 2-declining-85-90% 1-single weak-91-99% 0-none-100% 4:1 50% same 70% occupied 2-3 twitches same 75-85% occupied 1 twitch weak >90% Post tetanic twitching >5 occurs just beofre rgaining 1 twitch of TOF \u00a0 To Reverse, Need 1 twitch Neostigmine 0.07 mg\/kg, mix in same syringe with equal volume of glycopyrolate A better chart from anaestricks: <\/a> \u00a0 Lifting arm and flushing with 20 ml of saline made onset of vec sig. quicker ( Issue Anaesthesia Anaesthesia Volume 68, Issue 9, pages 904\u2013907, September 2013) \u00a0 Paralytics actually increase LES tone (Br J Anaesth 1984;56:37)<\/a> \u00a0 Sux without pretreatment causes quicker desatuaration than rocuronium or sux with pretreatment (Anaesthesia 2010;65:358) and here again in obese patients (Acta Anaesthesiologica Scandinavica Volume 55, Issue 2, pages 203\u0096208, February 2011)<\/p>\n First article from Bronx VA The experience of paralysis when awake is not so bad, but hypercarbia seems to suck (J Clin Anesth. 1993 Sep-Oct;5(5):369-74.<\/a>) 2nd article<\/a> used anesthesiologists as patients \u00a0 Med Dosing in the Obese Patient <\/a> Protection and Positioning<\/p>\n from 20-30 seconds after drugs until tube confirmation. Have assistant apply with third finger and thumb. Place their index finger on the thyroid cartilage, this will allow you to move it during laryngoscopy to retain BURP pressure. The proper amount of cricoid pressure can be learned by pushing on the bridge of your nose with middle finger and thumb until it hurts. \u00a0 But perhaps, the proper amount is no amount at all. All studies are inconclusive. (Canad J Anesthesia 1997;44:414 in JB) and it often screws up tube placement (Airway\u00b7Cam Book) and fiberoptic intubation (Acta Anaesthesiologica Scandinavica Volume 57, Issue 3, pages 358\u2013363, March 2013) and fiberoptic laryngoscopy (Videographic Analysis of Glottic View With Increasing Cricoid Pressure Force Ann Emerg Med. 2013 Apr;61(4):407-13)<\/p>\n \u00b7 Leave patient sitting until last moment in CHF\/Reactive Airway Disease \u00b7 Do not bag unless sat starts to fall below 90. If you bag with paralysis and properly performed cricoid pressure, 1-2 cc of air is insufflated per tidal volume ventilation. \u00b7 Also consider bagging patients with increased ICP. \u00b7 Never bag without an oral airway, just as you would not perform a rectal exam without a glove \u00a0 <\/a> \u00a0 Placement and Confirmation Wait till defasiculations cease if using Succinylcholine; flick the mandible to see if pt sufficiently blocked and<\/p>\n ETCO2 Detector-yellow is mellow. If tan, give 6 breaths. If still tan probably in trachea, but consider direct laryngoscopy to confirm. Purple with a Pulse, Pull the tube. If purple without a pulse, confirm with direct laryngoscopy. If using wave-form CO2, then tracheal intubation should produce waveform. Vinegar in an animal model turned permanently turned indicator yellow (Journal of Emergency Medicine Volume 28, Issue 1 , January 2005, Pages 5-11) \u00a0 The colour ranges for the Portex\u00ae device (Smiths Medical ASD, Keene, NH) are blue, green, green-yellow, and yellow, which correspond to levels of 0\u00961, 1\u00962, 2\u00965, and >5% CO2, respectively. Normally, end-tidal CO2 is > 4%.1<\/a>,2<\/a> \u00a0 Primary assessment (Lung sounds) more for tube depth than confirming tracheal placement. \u00a0 Self-Inflating Bulb-reliable even with uncuffed tubes (Acad Emerg Med April 2003, 10:4) \u00a0 Can confirm depth by ballotment. Location of the Endotracheal Tube by Pilot Balloon-CuffCounter-Ballottement (Anesth Analg. 1995 Jul;81(1):135-8) \u00a0 If confirming in a coded patient, first attempt to verify with DL-Displace tube posteriorly to be able to see it going through the cords (Benumoff 2nd ed) \u00a0 Also can place a boughie down tube, if you hit a stop point, it is in the bronchi and tube is between the cords. But you need to know what you are doing to get to 100% (American Journal of Emergency Medicine (2005)23:754\u0096758<\/p>\n We probably inflate too much (Academic Emergency Medicine Volume 11, Number 5 490-491) Emergency Physicians Cannot Inflate or Estimate Endotracheal Tube Cuff Pressure Using Standard Techniques (Annals EM 44:4 Oct 2004) and (AJEM 2006;24:139) \u00a0 15-25 mmHg is optimal <\/strong> \u00a0 Cuff Pressure Journal Club<\/a> \u00a0 1. Knowlson GTG, Bassett HFM. The pressure exerted on the trachea by endotrachealinflatable cuffs. Br J Anaesth 1970;42:834e7.2. Seegobin R, van Hasselt GL. Endotracheal cuff pressure and tracheal mucosal bloodflow: endoscopic study of effects of four large volume cuffs. BMJ 1984;288:965e8. 3. Susuki N, Kooguchi K, Mizobe T, et al. Postoperative hoarseness and sore throatafter tracheal intubation (effect of low intracuff pressure of endotracheal tube andusefulness of cuff pressure indicator). Masui 1999;48:1091e5.4. Pelc P, Prigogine T, Bisschop P, et al. Tracheo-oesophageal fistula: A case report andreview of literature. Acta Otorhinolaryngol Belg 2001;55:273e8.5. Spittle N, McCluskey A. Tracheal stenosis after intubation. BMJ 2000;321:1000e2.6. Friis J, Turner A, Da Fonseca J. Overinflated tracheal tube cuff. Emerg Med J2009;26:182 \u00a0 (From Cliff on resus.me) A study from China tested the hypothesis that an appropriate tracheal tube cuff (ETTc) pressure even in short procedures would reduce endotracheal intubation\u0096related morbidity. They compared bronchoscopic appearance of tracheal mucosa, and patient symptoms of tracheal injury, in two groups of elective surgical patients anaesthetised and intubated between 120 and 180 minutes: a control group without measuring ETTc pressure, and a study group with ETTc pressure measured and adjusted to a range 15-25 mmHg. The endoscopist was blinded to the study group allocation. The mean ETTc pressure measured after estimation by palpation of the pilot balloon of the study group was 43 +\/- 23.3 mm Hg before adjustment (the highest was 210 mm Hg<\/strong>), and 20+\/- 3.1 mm Hg after adjustment (p< 0.001). The incidence of postprocedural sore throat, hoarseness, and blood-streaked expectoration in the control group was significantly higher than in the study group. As the duration of endotracheal intubation increased, the incidence of sore throat and blood-streaked expectoration in the control group increased. The incidence of sore throat in the study group also increased with increasing duration of endotracheal intubation. Fiberoptic bronchoscopy showed that the tracheal mucosa was injured in varying degrees in both groups, but the injury was more severe in the control group than in the study group. So..time to get a cuff manometer for your ED or helicopter? Perhaps you already have one. What do you think? Correlations Between Controlled Endotracheal Tube Cuff Pressure and Postprocedural Complications: A Multicenter Study<\/strong>Anesth Analg. 2010 Nov;111(5):1133-7<\/a><\/p>\n Distally placed pulse ox has a 60-90 second lag from true saturation<\/p>\n <\/a><\/p>\n (Anaesthesia 2013;Volume 68, Issue 11, pages 1204\u20131205) \u00a0 November 2013 Additional Information(Show All) How to CiteAuthor InformationPublication History No external funding and no competing interests declared. SEARCH Search Abstract Article References Cited By Get PDF (100K) https:\/\/eresources.library.mssm.edu:2117\/getit.gif When securing a tracheal tube or laryngeal mask airway with cotton ties, the knots used should: (i) grasp the stem of the device securely to prevent it slipping out of position (both inwards or outwards), even when wet; (ii) be easy and quick to tie, with minimal chance of tying incorrectly; and (iii) allow quick removal of the device in case of malposition or if the patient begins to gag or cough. The clove hitch has been advocated to grip the stem of the airway device [1], but can slip or spill unless secured with additional half-hitches around the standing part, and does not grip as securely as the constrictor knot, which is the best knot for this purpose [2]. This application has been suggested previously [3, 4], but the method of tying is unclear. Therefore, I here illustrate two methods in detail in the hope that this will encourage more widespread adoption of this excellent solution. Following insertion of the airway device, the constrictor knot may be made \u2018in the bight\u2019, where the tie is twisted in the horizontal plane to form two loops, which are crossed to form a figure of eight, the loops being then folded backwards and dropped over the stem (Fig. 1a). The airway device is connected to the breathing system and the knot tightened once the correct position has been confirmed. image Figure 1. Method of securing airway device with a cotton tie. Alternatively, the constrictor knot may be tied around the stem of the airway device without disconnecting the patient from the breathing system, using the \u2018end\u2019 method (Fig. 1b). The end of the tie is passed around the stem, under the standing end, and around the stem in the same direction a second time. It is then tucked under itself, and then under the first turn to complete the knot. The tie may then be secured around the patient’s head using a slipped reef knot [5] over the patient’s mandible (Fig. 2). The first half-knot allows the loose ends of the tie to be joined under gentle tension without the knot slipping. The second half-knot incorporates a single bight (loop or \u2018bow\u2019). Pulling on the free end (arrowed) instantly releases the knot to allow removal of the airway device with attached tie. The above methods are effective, easily learned, and can be performed rapidly after minimal practice. <\/a><\/p>\n Ativan 4-6 mg Versed 0.1 mg\/kg bolus, then 0.1 mg\/kg\/hr 2-5 mg\/hr (Drip 50 mg in 250 cc NS, Start at 10-25 cc\/hr) Propofol .5-1 mg\/kg then 25-100 mcg\/kg\/min, start at 10 cc (100 mg)\/hr which correlates with 1 mg\/kg\/hour<\/p>\n HOB 30\u00b0 Big Tubes Secure \u0091em NGT HME ABG Inline Suction ETCO2 BVM c peep valve Cuff Pressure You must have your 4th and 5th digit on the blade to properly intubate (Anaesth Intensive Care 2009; 37: 791-801) Avoid post-intubation paralytics<\/strong> Vecuronium .1 mg\/kg then .03 mg\/kg q25-45 min or 1-2 mcg\/kg\/min use 2 electrodes over the ulna nerve, give train of four. shoot for 2 twitches while holding the thumb in abduction Acute quadriparetic myopathy syndrome (AQMS) can result in longstanding paresis if NMBAs are given in doses which are too high.<\/p>\n Assume hypoxia and therefore tube displacement until proven otherwise<\/p>\n D<\/strong>isplaced tube O<\/strong>bstruction-pass suction catheter through tube P<\/strong>neumothorax E<\/strong>quipment failure-take off vent and bag patient \u00a0 if all of the above have been evaluated, consider shunt physiology<\/p>\n <\/a><\/p>\n Always use an oral airway \u00b7 Take mask off of bag \u00b7 Lay over nose and let fall on the face \u00b7 Place thumb and first finger on mask with port against thumb web \u00b7 Attach the bag \u00b7 Use the other fingers to grasp along mandible, pulling face into mask 2 hand method: place both thumbs on mask, facing the patient\u0092s feet. Index fingers on mentum of chin. Other fingers performing jaw thrust. \u00a0 Use 2 nasal and oral airway if difficult to ventilate. \u0095 comparison of 4 standard bags with high-flow oxygen \u0095 Duck-bill mask with one-way valve gives FiO2 >0.9, other bags ~0.3 \u0095 Laerdal Silicone Resuscitator\u00ae, Mallinckrodt Capno-Flo\u00ae > 0.9 \u0095 Sims-Intertech 1st Response\u00ae, Vital Signs Code Blue\u00ae < 0.4 \u0095 Know your bag well: they\u0092re differentNimmagadda U et al. Efficacy of preoxygenation with tidal volume breathing: Comparison of breathing systems. Anesthesiology<\/em> 2000 Sep 93 693 -698 (Ron Wall’s Lecture) \u00a0 Esophageal sphincter is 20-25 cm H2O in normal healthy, less in sick or dead \u00a0 Pressures < 16.5 cm H20 are unlikely to cause gastric insufflation (Br J Anaes 1987;59:315) Once the LES is opened, much lower pressures will cause continued insufflation (Arch Dis Child 1983;58:373) \u00a0 \u00a0 Better technique may be to use mask and ventilator (Journal of Emergency Medicine 2006;30(1):63) \u00a0 Airway pressure < 15 cmH20 rarely causes insufflation, but > 25 often will (Br J Anaesth 1987;59:315 and Acta Anaes Scand 1961;5:107)<\/p>\n Short Female Size 6 (pin 1cm from flange)<\/p>\n Average Female\/Short Male Size 6<\/p>\n Tall Female\/Average Male Size 7<\/p>\n Tall Male Size 8<\/p>\n Width does not matter, only length so that it is above cricoid but below tongue<\/p>\n (Emerg Med J 2005;22:394-396)<\/p>\n <\/p>\n NRB = ~65-80% \u00d8 BVM = > 90% \u0095 New Hi-Ox\u00ae Mask >80% @ 8L\/min \u00a0 New smart bag limits IFR (Intensive Care Medicine Volume 34, Number 2 \/ February, 2008) \u00a0 <\/a><\/a><\/a> \u00a0 Article on proper way to open the jaw and hold the mask<\/a> \u00a0 Facemask position ofr edentulous patients (see image above) Anesthesiology May 2010 – Volume 112 – Issue 5 – pp 1190-1193 \u00a0 Two hand mask grip is better than one hand<\/strong> (Anesthesiology 2010; 113:873\u00969) \u00a0 Paralysis augments the ability to mak ventilate (Anaesthesia 2011;66:163) and further validation in a huge study of a difficult airway algorithm (ANESTHESIOLOGY. 2011;114:25\u201333)<\/p>\n The tongue is your enemy, the epiglottis is your friend.<\/p>\n for direct laryngoscopy and tracheal intubation (Anaesthesia 2008;63:156) \u00a0 \u00a0 When passing the tube, first touch the hard palette with the tube\u0092s bevel lying horizontally. Guide the tube to the soft palette. Approach the cords from the right so as not to obscure your view. At the last second, rotate the tube counterclockwise 90\u00b0 to allow narrowest area to go through the cords. \u00a0 Macintosh must indirectly lift the epiglottis by use of the hyoepiglottic ligament. If the macintosh blade is too short for the patient, you may be able to reach the valeculla, but have inadequate traction to lift the epiglottis. \u00a0 Teach residents by telling them to life the head off of the bed with the blade rather than tilting the head back with the blade Visual acuity improves as the laryngoscope illuminance increases up to 700 lux. No statistically significant improvement was measured by increasing the illuminance up to 2000 lux. Subjectively, anesthesiologists favor illuminance of 2000 lux for direct laryngoscopy. It is a near-sighted activity (Anesth Analg 2013;116:343\u201350)<\/p>\n Task<\/strong> Task Completion<\/strong><\/p>\n Increased head elevation\/neck flexion results in much better view (Annals EM 2003;41(3):322) Mike Murphy agrees with editorial in same issue (Ann Emerg Med 2003;41(3):338) <\/a> <\/a> <\/a> <\/a> Ideal positioning causes the external auditory meatus to be on the same horizontal line as the sternal notch. If this is accomplished using the ramp method in this photo, obesity will not cause difficulty (Obesity Surgery 2004;14:1171) \u00a0 Another review article showing same in pregnant, obese woman (Can J Anaesth 1989;36(6):668) \u00a0 RCT with crossover of extension vs. 7cm head elevation, trend towards better with ramp, sig. better in obese or poor head extenders (Anesth 2001;95:836) Validation of the ears to sternal notch in anesthesia patients (Journal of Clinical Anesthesia (2012) 24, 104\u2013108) Laryngeal exposure was superior at 25\u00b0 than supine (Br J Anaesth 2007;99:581) \u00a0 Laryngoscopy with straight blade allowed better view, but intubating conditions were better with the curved blade. (Can J Anesth 2003, 50:5 p. 501-506) \u00a0 For difficult laryngoscopy, can try the left-molar approach. It may offer an improved laryngeal view. It can also be used to augment fiberoptic intubation attempts. (Anes 92:1, Jan 2000) and (Anaes 2002 57:1028-1044) <\/a> Consider having assistant grab the tongue with a 4×4 before the insertion of the blade. \u00a0 BURP and mandibular advancement gave the best visualized view. Either one alone helped over none in inexperienced laryngoscopists (Anesthesiology 2004; 100:598\u0096601) \u00a0 Comparision of cricoid\/burp\/bimanual laryng. (Ann EMerg Med 2006;47(6):548): on cadaver models, only bimanual consistently improved view \u00a0 \u00a0 \u00a0 Cormack-Lehane is scale for view of cords <\/a><\/a> \u00a0 Plastic Blades result in lower number of successful intubations (Anesthesiology 2006;104(1):60)<\/p>\n Nearly Dead, Newly Dead \u00a0 Still may consider using Sux if any muscle tone at all<\/p>\n If BVM and intubation are predicted to be successful, do double set-up RSI with failed airway equipment already set up and cric set open \u00a0 Sigma configuration for tube (Anesthesiology 2007;106(5):1069)<\/p>\n Give intubating dose of propofol, perform laryngoscopy, give paralytics if a good view is obtained<\/p>\n <\/p>\n <\/a> (Anesthesiology 2006;104(1):48)<\/p>\n <\/p>\n <\/a><\/p>\n Best Attempt Definition:<\/p>\n <\/p>\n <\/p>\n Pass till 20 cm at the teeth, you will feel it sliding over tracheal rings. Railroad the tube over the Eschmann while the laryngoscope is still in the mouth. \u00a0 The laryngoscopist obtains the optimal laryngeal view. The bougie is then passed below the epiglottis and through the vocal cords. This should elicit a clicking feel at the distal end of the GEB due to the “hockey stick” angled distal end [5]. If clicking is not felt distinctly, the GEB is advanced further until it “holds up” at the carina or when it comes in contact with a peripheral airway of a smaller diameter [5]. Advancement always must be gentle. The laryngoscope blade is left in place as the ETT is inserted over the GEB and into the trachea. It is important to rotate the ETT 90 degrees counterclockwise before the tip of the ETT passes through the vocal cords. This maneuver prevents the beveled tip of the ETT from catching on the right arytenoid process, aryepiglottic fold, right vocal cord, or epiglottis. Clicking and holding up are cardinal signs of tracheal insertion by the GEB, both of which were noted during the insertion of the GEB in our patient with the open zone II neck injury. Possible complications from a bougie insertion are pharyngeal perforation, mediastinal emphysema, and pneumothorax. (JEM April 2003) \u00a0 The obstruction is caused by impingement of the tube on the right vocal cord complex and arytenoids [2<\/a>]. Cossham [3<\/a>] described a pre-emptive 90\u00b0 anti-clockwise rotation of the tube (90CCWR), the Cossham twist<\/strong> \u00a0 Am J Emerg Med. 2004 Oct;22(6):479-82. Links Use of the endotracheal bougie introducer for difficult intubations. A difficult to intubate patient occurs infrequently in the emergency department. The endotracheal tube introducer or gum elastic bougie is a device used by British anesthesiologists in difficult airways. The device is inexpensive, has few complications and is easy to use. Similar to the Seldinger technique for gaining access to a large central vein, the endotracheal tube introducer is used to assist in cannulating the trachea and acts like the wire in central vein access. PMID: 15520943 [PubMed – indexed for MEDLINE] \u00a0 Anaesthesia. 1988 Jun;43(6):437-8.Links Successful difficult intubation. Use of the gum elastic bougie. Kidd JF, Dyson A, Latto IP. Department of Anaesthesia, University Hospital of Wales, Heath Park, Cardiff. The reliability of two signs of tracheal placement of a gum elastic bougie was studied. These signs were clicks (produced as the tip of the bougie runs over the tracheal cartilages) and hold up of the bougie as it is advanced (when the tip reaches the small bronchi). Ninety-eight simulated and two genuine Grade 3 difficult intubations were attempted with the aid of a gum elastic bougie. Seventy-eight tracheal and 22 oesophageal placements of the bougie resulted. No clicks or hold up occurred with the bougie in the oesophagus. Clicks were recorded in 89.7% of tracheal placements of the bougie. Hold up at between 24-40 cm occurred in all tracheal placements. We conclude that these signs are reliable and that they should be taught as part of any difficult intubation drill in which the gum elastic bougie is used. From Seth Manoach “<\/strong> From an abstract Julio and colleaugues wrote and sent me a few years ago I learned the tricks of using the larygoscope to lift the epiglottis enough during ETT placement so the lip of the epiglottis does not catch the ETT as it is railroaded over the bougie. With this the more often described corkscrewing of the ETT during introduction to sneak the beveled edge of the tube under the epiglottis. Both of course are ways to contend with the main bougie problem, circumferential bougie:tube size mismatch. These tricks changed my relationship to the device and are to me like the up and down and chandy maneuvers with the fastrach\/ilma — shouldn’t really talk about success rates without them.”<\/p>\n<\/span>Three Emergent Indications for Intubation<\/span><\/h2>\n
Can’t Protect Airway<\/h4>\n
\n
Can’t Maintain Ventilation\/Oxygenation<\/h4>\n
\n
Expected decline in Clinical Status<\/h4>\n
\n
\n
<\/span>Assess for Potential Difficult Airway<\/span><\/h2>\n
<\/span>Difficult to Bag<\/span><\/h3>\n
<\/span>Difficult to Intubate (validated Emerg Med J<\/em> 2005; 22<\/em>:99-102)<\/span><\/h3>\n
<\/span>Difficult Extraglottic Device<\/span><\/h3>\n
\n
\n
\n
<\/span>Difficult Cricothyrotomy<\/span><\/h3>\n
\n
<\/span>Additional info on prediction of difficult airway<\/a><\/span><\/h3>\n
<\/span>Miscellaneous Statistics<\/span><\/h2>\n
<\/span>Complications in 1000 trauma intubations for absolute and relative indications<\/span><\/h3>\n
<\/span>The Seven Ps of Rapid Sequence Intubation<\/span><\/h2>\n
Bag<\/h4>\n
Airway (oral airway)<\/h4>\n
Suction (preferably two)<\/h4>\n
Intubating equipment (tube, blades, etc.)<\/h4>\n
Capnometer<\/h4>\n
<\/span>Preoxygenation<\/span><\/h2>\n
Keep them in semi-fowlers<\/h4>\n
\n
<\/span>Apneic Oxygenation<\/span><\/h2>\n
<\/span>Pretreatment<\/span><\/h3>\n
<\/span>Reflex responses to intubation<\/span><\/h3>\n
<\/span>Non-Pharmacologic Methods to Blunt Reflex Response<\/span><\/h3>\n
<\/span>Pretreatment Meds (LOAD)<\/span><\/h3>\n
\u00b7 Lidocaine<\/h4>\n
\u00b7 Opiates<\/h4>\n
Reglan<\/h4>\n
Esmolol<\/h4>\n
\n
<\/span>Old pretreatment regimens (atropine, defasiculating paralytics)<\/a><\/span><\/h3>\n
<\/span>Induction\/Sedative Agents<\/span><\/h3>\n
<\/span>Sedation without Paralysis<\/span><\/h3>\n
Not as successful<\/h4>\n
<\/span>Paralytics<\/span><\/h3>\n
Depolarizing<\/h4>\n
<\/h4>\n
<\/h4>\n
<\/h4>\n
\n
<\/h4>\n
Nondepolarizing<\/h4>\n
\n
\n
Sugammadex<\/h4>\n
<\/span>Train of Four<\/span><\/h3>\n
<\/span>Perceptions of Paralysis<\/span><\/h3>\n
<\/h4>\n
Cricoid Pressure (Sellick’s) NOT RECOMMENDED<\/h4>\n
Position the patient<\/h4>\n
<\/h4>\n
Intubate<\/h4>\n
\n
Confirm Placement<\/h4>\n
Tube Cuff Pressure<\/h4>\n
Pulse Ox<\/h4>\n
<\/span>Postintubation Management<\/span><\/h3>\n
\n
Secure Tube<\/h4>\n<\/li>\n<\/ul>\n
<\/span>Knots to secure airway devices<\/span><\/h3>\n
\n
Post Intubation Medications<\/h4>\n<\/li>\n<\/ul>\n
\n
<\/span>Abnormal Vital Signs Postintubation<\/span><\/h3>\n
Bradycardia<\/h4>\n
Desaturation<\/h4>\n
Hypotension<\/h4>\n
\n
<\/span>Skills of Airway Management<\/span><\/h2>\n
<\/span>Using a BVM<\/span><\/h3>\n
<\/span>Nasopharyngeal Airways<\/span><\/h2>\n
<\/span>Laryngoscopy and Intubation<\/span><\/h3>\n
A proposed model<\/h4>\n
Cognitive Tasks of Intubation<\/h4>\n
\n
How to actually placed the tube<\/h4>\n
<\/a><\/h4>\n
<\/span>Crash Airway<\/span><\/h2>\n
<\/span>The Predicted Difficult Airway<\/span><\/h2>\n
<\/span>Quick Look<\/span><\/h3>\n
<\/span>Blind Nasotracheal Intubation<\/span><\/h2>\n
<\/span>Retrograde Intubation<\/span><\/h2>\n
<\/span>Awake Intubation and Fiberoptic Intubation<\/a><\/span><\/h2>\n
<\/span>Failed Airway<\/span><\/h2>\n
Can’t Intubate\/Can’t Ventilate or three failed attempts<\/h4>\n
\n
<\/span>Devices and Techniques for the Failed\/Difficult Airway<\/span><\/h2>\n
<\/span>Eschmann\/Gum Rubber Bougie\/Gum Elastic Bougie<\/span><\/h3>\n
<\/span>Combitube