Module 4 (Difficult Airway)
Cricothyrotomy (Seldinger Technique): - Step 7: Secure the airway catheter to the neck with the "__________" provided in the kit or other means.
"trach tape" 35
What are the 4 indications for a cricothyrotomy?
1) Failed airway 2) Immediate relief of upper airway obstruction 3) Traumatic injuries that make intubation impossible/difficult. 4) Need for a definitive airway for neck or facial surgery. 21
What 2 questions should you ask yourself when preparing for a cricothyrotomy?
1) Will a cricothyrotomy effectively bypass the airway obstruction? 2) Which cricothyrotomy technique will be used? 25
Cricothyrotomy (Seldinger Technique): - Step 4: Make a _____-_____ cm incision in skin at the entrance point of the __________. - The __________ must also be incised at this point.
1-2 cm, guidewire CTM 33
ASA Difficult Airway Algorithm When a patient is a difficult airway, what should the provider always evaluate for?
Always evaluate for emergency invasive airway 7
ASA Difficult Airway Algorithm After the intubation attempt after induction of general anesthesia failed, mask ventilation is not adequate, supraglottic airway is not adequate (cannot intubate, cannot ventilate), and the emergency pathway is activated, how should the provider proceed?
Attempt alternative intubation approaches as you prepare for emergency invasive airway 7
What are the 5 risk factors of difficult mask ventilation?
BONES B- Beard O- Obese N- No teeth E- Elderly S- Sleep Apnea (snoring) 8
Cricothyrotomy Complications: - __________ - __________ of cartilage - __________ of the posterior trachea - Unintentional __________ - Passage of the tube into a false tract - __________ - __________ and voice changes (chronic)
Bleeding Laceration of cartilage Perforation of the posterior trachea Unintentional tracheostomy Infection Subletting stenosis and voice changes (chronic) 36
Transtracheal (Translaryngeal) Block - Palpate the __________. - Attach a 22-24 gauge needle or angiocath to a syringe containing _____-_____ mL of _____% Lidocaine. - Place the needle __________ and advance it __________ through the _________ while __________.
CTM 3-5 mL, 2% Lidocaine midline, caudad, CTM, aspirating 15
ASA Difficult Airway Algorithm After the intubation attempt after induction of general anesthesia failed, and mask ventilation is adequate as confirmed by CO2, and the non-emergency pathway is followed (ventilation is adequate/intubation unsuccessful). The provider will limit attempts and consider awakening the patient. What else should the provider consider at this point?
Consider alternative intubation approaches, invasive access, or the feasibility of other options. 7
ASA Difficult Airway Algorithm If the intubation attempt with patient awake failed, how should the provider proceed?
Consider other options 7
ASA Difficult Airway Algorithm After the intubation attempt after induction of general anesthesia failed, and mask ventilation is not adequate, what should the provider consider/attempt?
Consider/attempt supraglottic airway 7
Is a cuffed or uncuffed tube better for high pressure?
Cuffed 27
Difficult __________: A situation where someone who knows what they are doing has difficult with facemark ventilation, laryngoscopy, intubation, or a combination of any of the 3.
Difficult Airway 5
Difficult __________: When an experienced person is unable to maintain a Sat >92% using 100% oxygen.
Difficult Facemask Ventilation 5
Difficult __________: Insertion of the tube with standard laryngoscope requires more than 3 attempts, multiple providers, or more than 10 mins.
Difficult Intubation 6
Difficult __________: Inability to visualize any portion of the vocal cords (Cormack and Lehane grade 3 & 4)
Difficult Laryngoscopy 6
ASA Difficult Airway Algorithm After the intubation attempt after induction of general anesthesia failed, mask ventilation is not adequate, supraglottic airway is not adequate (cannot intubate, cannot ventilate), the emergency pathway is activated and the alternative attempts of intubation failed, how should the provider proceed?
Emergency invasive airway 7
ASA Difficult Airway Algorithm After the intubation attempt after induction of general anesthesia failed, mask ventilation is not adequate, and supraglottic airway is not adequate (cannot intubate, cannot ventilate), the emergency/non-emergency pathway is activated and the provider should __________ attempts and be aware of what?
Emergency pathway Limit attempts Be aware of the passage of time, and call for help for invasive access 7
Internal/External laryngeal nerve branch innervates the cricothyroid muscle.
External 3
True or False You can RSI a difficult airway.
False; you do NOT want to RSI a difficult airway. 5
Internal/External laryngeal nerve pierces the thyrohyoid membrane and provides sensory input to the hypopharynx above the vocal folds (cords).
Internal 3
ASA Difficult Airway Algorithm If you do NOT suspect that the patient is a difficult laryngoscopy, difficult ventilation with face mask/supraglottic airway, signifiant risk of aspiration, increased risk of rapid desaturation, and difficult emergency invasive airway, what should the provider do?
Intubation attempt after induction of general anesthesia 7
ASA Difficult Airway Algorithm If you suspect that the patient is a difficult laryngoscopy, difficult ventilation with face mask/supraglottic airway, signifiant risk of aspiration, increased risk of rapid desaturation, and difficult emergency invasive airway, what should the provider do?
Intubation attempt with patient awake - Optimize oxygenation throughout 7
What are the 5 distinguishing characteristics of difficult laryngoscopy and intubation?
LEMON L- Look externally (shape of face, morbid obesity, pathology of the head and neck) E- Evaluate the 3-3-2 rule M- Mallampati score O- Obstruction (indications for upper and lower airway obstruction) N- Neck mobility 8
ASA Difficult Airway Algorithm After the intubation attempt after induction of general anesthesia failed, and mask ventilation is adequate as confirmed by CO2, and the non-emergency pathway is followed (ventilation is adequate/intubation unsuccessful). What should the provider limit and consider?
Limit attempts and consider awakening the patient 7
ASA Difficult Airway Algorithm If the intubation attempt after induction of general anesthesia failed, what is the rule of thumb before proceeding?
Limit attempts and consider calling for help 7
ASA Difficult Airway Algorithm After the intubation attempt after induction of general anesthesia failed, and mask ventilation is adequate as confirmed by CO2, the emergency/non-emergency pathway is followed.
Non-emergency 7
Difficult Airway: Awake Intubation - __________ the (nasal), oral, pharyngeal, laryngeal, and tracheal mucosa - __________ anesthetization and infiltration __________ - Nerve Blocks: - ___________ nerve block - __________ block
Numbing Topical anesthetization and infiltration nerve blocks Superior laryngeal nerve block Transtracheal block 9
ASA Difficult Airway Algorithm After the intubation attempt with the patient awake failed and the provider's options that were considered failed, how should one proceed?
Postpone the case 7
What are the 4 relative contraindications for cricothyrotomy?
Preexisting laryngeal/tracheal disease Distortion of neck anatomy Coagulopathy Pediatrics 22
What are the 4 distinguishing characteristics of difficult supraglotic airway placement?
RODS R- Restricted mouth opening O- Obstruction D- Distorted airway S- Stiff lungs or C-spine 8
What nerve is being blocked by a Transtracheal block?
Recurrent laryngeal nerve 14
What are the 5 risk factors for difficult surgical airways placement?
SHORT S- Surgery (neck surgery or previous scar) H- Hematoma O- Obesity R- Radiation (or other deformities) T- Tumor 8
Size _____ cuffed/uncuffed is the best size for adults for a cricothyrotomy.
Size 4 cuffed 28
__________ nerve divides into the internal and external branches.
Superior laryngeal nerve 3
Superior Laryngeal Nerve Block True or False - The block is then repeated on the other side.
True 11
Transtracheal (Translaryngeal) Block - When __________ are aspirated, the tip of the needle is in the __________ lumen. - Advance the ___________ into the tracheal lumen and withdraw the __________, leaving just the angiocath in place and reattach the ___________. - The patient is then instructed to ___________. - On inspiration, _____-_____ of _____% Lidocaine is injected into the tracheal lumen, causing the patient to __________; therefore, spreading the local onto the __________.
air bubbles, tracheal lumen catheter, needle, syringe take a deep breath 4-5 mL of 4% Lidocaine, cough, vocal cords 15
Superior Laryngeal Nerve Block - Aspiration should confirm there is no __________ or __________ and _____ mL of LA (_____% Lidocaine) is deposited above the thyrohyoid membrane. - If the membrane is pierced, deposit another _____ mL upon withdrawal.
air or blood, 2 mL, 2% Lidocaine 2 mL 11
ASA Difficult Airway Algorithm Pre-Inubation: Before attempting intubation, choose between either an _________ or __________ airway strategy. Choice of strategy and technique should me made by the __________.
awake or post-induction clinician managing the airway 7
Cricothyrotomy (Seldinger Technique): - Step 3: When __________ appear, remove syringe, then remove the needle, leaving the catheter in place, with its distal tip in the __________. - Thread the __________ through the catheter into the trachea. - Remove the ___________, sliding it over the guidewire.
bubbles, trachea guidewire catheter 32
Cricothyrotomy (Seldinger Technique): - Step 5: Thread the __________ over the guidewire and advance it into the skin incision. - Following the __________ of the dilator, advance the dilator-catheter unit through the __________, __________, and into the __________ until the __________ of the catheter is flush against the skin of the neck.
combined tissue dilator-airway catheter - curve, SQ, soft tissue, trachea, cuff 34
The external laryngeal nerve branch innervates the __________ muscle.
cricothyroid 3
Cricothyrotomy Review - Establishment of an airway by surgically incising through the __________ and placing a tracheostomy tube or an ETT.
cricothyroid membrane (CTM) 19
Cricothyrotomy (Seldinger Technique): - Step 1: Insert ___________ into the airway catheter - Palpate the __________ with the __________ finger of dominant/non-dominant hand while immobilizing the __________ with the __________ and __________ finger.
dilator - CTM, index finger non-dominant, larynx, thumb and middle finger 30
ASA Difficult Airway Algorithm After the intubation attempt after induction of general anesthesia failed, and mask ventilation is adequate as confirmed by CO2, and the non-emergency pathway is followed (ventilation is adequate/intubation unsuccessful). The provider will limit attempts, consider awakening the patient, and consider alternative intubation approaches, invasive access, or the feasibility of other options. If that fails or there is deteriorating ventilation, then the emergency/non-emergency pathway is followed.
emergency pathway 7
Superior Laryngeal Nerve Block - Locate the __________ of the ___________ - Displace it toward/away from the side that is being injected to help stabilize the bone, identify structures, and inject the LA - The needle is inserted __________ to the skin to make contact with the __________ border of the __________ - The needle "walked off" the __________ edge of the hyoid bone where it meets the __________ membrane. -* This is where the __________ nerve pierces the __________ membrane.
greater Cornu of the hyoid bone toward perpendicular, inferior border of the greater cornu caudal, thyrohyoid membrane - SLN, thyrohyoid membrane 10 and 11
Cricothyrotomy (Seldinger Technique): - Step 2: Attach __________ needle to syringe filled with a small amount of __________ - Apply a small amount of positive/negative pressure on the syringe and insert the needle carefully into the __________ at a _____ degree angle with the needle oriented __________.
introducer, saline/water - negative pressure, cricothyroid membrane, 45 degree, caudad caudad- down towards lungs 31
ASA Difficult Airway Algorithm Any one factor alone (assessed difficulty with __________, __________, or __________ or __________ risk) may be clinically important enough to warrant an __________ intubation.
intubation, ventilation, or aspiration or desaturation risk awake intubation 7
ASA Difficult Airway Algorithm After the intubation attempt after induction of general anesthesia failed, mask ventilation is not adequate, and supraglottic airway is adequate, then the emergency/non-emergency pathway is followed.
non-emergency pathway 7
Several cricothyrotomy kits are available: - The tracheostomy tube is placed _________ using these kits by either an open incision with trocar or by a Seldinger method.
percutaneously 27
Cricothyrotomy (Seldinger Technique): - Step 6: Remove the __________ and __________ as a unit, leaving the airway catheter in the trachea.
tissue dilator and guidewire 35