The difficult airway: Difference between revisions

Revision as of 14:03, 2 February 2019

Does not necessary apply to the ED since the patient can always be awakened and case cancelled
- Cricothyrotomy should always be the last step in patients with failure to oxygen and ventilate with BVM and inability to intubate
- Straight blade- Miller- may offer better manipulation of a large epiglottis in children or for micrognathia or "buck teeth"

Intubation Type	Pros	Cons
Traditional
Awake intubation
Nasal intubation		Lower success rate Higher complication rate (e.g. bleeding, emesis, and airway trauma) Do not attempt in patients with posterior pharyngeal swelling such as in angioedema
Retrograde intubation		Need time to set up Risk hematoma, pneumothorax
Fiberoptic bronchoscopic intubation		Takes time to set up Limited by secretions, bleeding, poor suction,

Authors:

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 *[[Needle cricothyrotomy]]
 *[[Pediatric jet ventilation]]
-==Special Situations==
-===Severe [[Metabolic Acidosis]]===
-''Further drop in pH during intubation can be catastrophic''
-*NIV (SIMV Vt 550, FiO2 100%, Flow Rate 30 LPM, PSV 5-10, PEEP 5, RR 0)
-**SIMV on ventilator, not NIV machine
-**"Pseudo-SIMV" mode
-*Attach end-tidal CO2 and observe value
-*Push [[Rapid Sequence Intubation (RSI)|RSI]] medications
-*Turn the respiratory rate to 12
-*Perform jaw thrust
-*Wait 45sec
-*[[Intubate]]
-*Re-attach the ventilator
-*Immediately increase rate to 30
-*Change Vt to 8cc/kg
-*Change flow rate to 60 LPM (normal setting)
-*Make sure end-tidal CO2 is at least as low as before
-===Active [[GI Bleed]]===
-#Empty the stomach
-#*Place an NG and suction out blood
-#**Varices are not a contraindication
-#*Metoclopramide 10mg IV
-#**Increases LES tone
-#Intubate with HOB at 45°
-#Preoxygenate!
-#*Want to avoid bagging if possible
-#Intubation meds
-#*Use sedative that is BP stable (etomidate, ketamine)
-#*Use paralytics (actually increases LES tone)
-#If need to bag:
-#*Bag gently and slowly (10BPM)
-#*Consider placing LMA
-#If patient vomits
-#*Place in Trendelenberg
-#*Place LMA
-#*Use meconium aspirator
-#If patient aspirates anticipate a sepsis-like syndrome
-#*May need [[pressors]], additional fluid (not antibiotic!)
 ==See Also==