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| ==LEMON Mnemonic== | | ==Background== |
| *An airway assessment score based on criteria of the LEMON method is able to successfully stratify the risk of intubation difficulty in the emergency department.<ref>Reed, M. et al. Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J. 2005 Feb; 22(2): 99–102. doi: 10.1136/emj.2003.008771</ref> | | *ASA Difficult Airway Algorithm does not necessary apply to the ED since the patient can always be awakened and case cancelled |
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| ===LOOK=== | | ==Pre-Intubation== |
| *Look at the patient externally for characteristics that are known to cause difficult laryngoscopy, intubation or ventilation<ref> Rennie LM, Dunn MJG, et al. Is the ‘LEMON’ method an easily applied emergency airway assessment tool? European Journal of Emergency Medicine 2004;11:154–7</ref> | | See: |
| | *[[Predicting the difficult airway]] |
| | *[[Apneic oxygenation]] |
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| *Trauma
| | ==Difficult Intubation== |
| *Short neck
| | {{Advanced Airway Adjuncts Chart}} |
| *Micrognathia
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| *Prior surgery
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| *May also be difficult to bag
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| **Body mass index
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| **Advanced age
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| **Beard
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| **No teeth
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| **Snoring
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| **Dentures
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| ===Evaluate 3-3-2-1=== | | ===Intubation Options=== |
| *3 - Ideally the distance between the patient's incisor teeth should be at least 3 finger breadths
| | {| {{table}} |
| *3 - Distance between the hyoid bone and the chin should be at least 3 finger breadths
| | | align="center" style="background:#f0f0f0;"|'''Intubation Type''' |
| *2 - Distance between the thyroid notch and the floor of the mouth should be at least 2 finger breadths
| | | align="center" style="background:#f0f0f0;"|'''Pros''' |
| *1 - Lower jaw should not sublux more than 1cm
| | | align="center" style="background:#f0f0f0;"|'''Cons''' |
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| ===Mallampati=== | | | Traditional|||| |
| *The patient sits upright, opens mouth and protrudes tongue
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| *Grades are based on visibility of the uvula, posterior pharynx, hard, and soft palate
| | | [[Awake intubation]]|||| |
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| ===Obstruction===
| | | [[Nasal intubation]]|||| |
| *Assess for conditions leading to airway obstruction such as [[Peritonsillar Abscess (PTA)]], trauma, or [[Epiglottitis]].
| | *Lower success rate |
| | | *Higher complication rate (e.g. bleeding, emesis, and airway trauma) |
| ===Neck Mobility===
| | *'''Do not attempt in patients with posterior pharyngeal swelling such as in [[angioedema]]''' |
| *Patient places chin down onto their chest and extend their neck.
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| *Remove the hard collar and provide manual stabilization in trauma patients.
| | | Retrograde intubation|||| |
| *Poor neck mobility impacts ability to have airway access alignment.
| | *Need time to set up |
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| [[File:Mallampati Score.png|thumb|Mallampati Score]]
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| [[File:LEMON Score.png|thumb|3-3-2 ruleDistance between patient's incisor teeth of 3 finger breadths and distance between the thyroid notch and the floor of the mouth should be at least 2 finger widths]]
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| ==ASA Difficult Airway Algorithm==
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| *Does not necessary apply to the ED since the patient can always be awakened and case cancelled
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| **[[Cricothyrotomy]] should always be the last step in patients with failure to oxygen and ventilate with BVM and inability to intubate
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| **Straight blade- Miller- may offer better manipulation of a large epiglottis in children or for micrognathia or "buck teeth" | |
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| ==Airway Adjuncts==
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| ===Gum Bougie===
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| *Blind orotracheal intubation
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| ===Blind Naso Trach Intubation===
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| *Not as successful but still an option
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| *Higher complication rate - bleeding, emesis, and airway trauma | |
| **'''Do not attempt in patients with posterior pharyngeal swelling such as in [[Angioedema (Upper Airway)]]'''
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| ===Lighted Optical Stylets===
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| *High success rate - esp good for trauma, c-spine precautions
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| *Use for both reg and nasotrach
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| *Lower complication rate
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| *Limited by fogging, secretion, recognition of anatomy, cost, and rare provider experience
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| ===[[LMA]]===
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| *Can use without muscle relaxants
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| *Better than face mask
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| *Can be used as bridge to fiberoptic intubation
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| *Limited by unreliable seal at peak insp pressure
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| *Aspiration risk
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| *Mucosal trauma
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| *LMA better than endotracheal for paramedics, especially in pediatric patients<ref>Zhu X-Y, Lin B-C, Zhang Q-S, Ye H-M, Yu R-J. A prospective evaluation of the efficacy of the laryngeal mask airway during neonatal resuscitation. Resuscitation. 2011;82(11):1405–1409. doi:10.1016/j.resuscitation.2011.06.010</ref><ref>Calkins MD, Robinson TD. Combat trauma airway management: endotracheal intubation versus laryngeal mask airway versus combitube use by Navy SEAL and Reconnaissance combat corpsmen. J Trauma. 1999;46(5):927–932</ref>
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| *Intubating LMA (LMA-Fastrach) provides the opportunity to convert to a definitive airway after rescue with the supraglottic device
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| ===Combitube- esoph obturator===
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| *Good for nurses and paramedics with limited intubation skill
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| *Indicated if difficult airway predicted: can't see glottis with laryngoscope
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| *Reduced risk for aspiration compared to face mask or LMA
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| *Can maintain spinal immobilization
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| *Large size predisposes to esophogeal dilatation and laceration as a complication
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| ===Trans Tracheal Jet Vent===
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| *TTJV
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| *Needle through cricoid membrane, connected to 50 psi 02- can ventilate and oxygenate ok
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| *Need adequate oxygen pressure
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| *1 sec insp and 2- 3 sec exp to avoid breath stacking
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| *May cause pneumothorax or barotrauma
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| *Contraindications
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| **Distorted anatomy
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| **Bleeding diathesis
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| **Complete airway obstruction
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| ===Retrograde Intubation===
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| *Percutaneous guide wire through cricoid and retrograde intubation over wire
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| *Use guide catheter over wire and then ett
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| *Need time to set up | |
| *Risk hematoma, pneumothorax | | *Risk hematoma, pneumothorax |
| *Contraindicated
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| **Bleeding
| | | Fiberoptic bronchoscopic intubation|||| |
| **Distorted anatomy
| | *Takes time to set up |
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| ===Fiberoptic Bronchoscopic Intubation===
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| *Takes time to set up | |
| *Good for c-spine injury or awake patient with diff airway
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| *Go through nose
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| *Use for all ages, can give 02 during procedure thru fiberscope, immediate confirmation of position
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| *Limited by secretions, bleeding, poor suction, | | *Limited by secretions, bleeding, poor suction, |
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| | | [[Blind digital intubation|Digital intubation]]|||| |
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| ===Rigid Fiberoptic Laryngoscopes=== | | ==Surgical Airways== |
| *Use for diff airway or spinal immobolization
| | ''A surgical airway should always be the last step in patients with failure to oxygen and ventilate with BVM and inability to intubate'' |
| *Not as good and longer time to intubate than flex scope
| | *[[Surgical cricothyrotomy]] |
| | | *[[Needle cricothyrotomy]] |
| ==Improving Passive Oxygenation==
| | *[[Pediatric jet ventilation]] |
| *Use in overweight, poor O2 reserve, hypoxia at baseline, concerns for rapid progression to hypoxia once apnea
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| *Pre-oxygenate while sitting upright, only lay back once RSI drugs pushed.
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| *30 degrees reverse trendelenburg position for intubation
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| *Nasal O2 while pre oxygenating and DURING intubation (after induction increase to 15L) | |
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| ==Surgical Airway==
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| *Can get subglottic stenosis | |
| *Rapid 4 step procedure faster but higher complication rate - cric cart fx | |
| *Can also do wire guided
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| *Long term morbid, mortality similar to tracheostomy
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| ==See Also== | | ==See Also== |