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EXTREME Airways Crisis Performance..Rethinking our Approaches
finding landmarks
hypoxia
cric
Richard Levitan @airwaycam [email protected]
Stress & Fear
fluids
Call for help!
Call for help!
ENGINE FAILURE DURING FLIGHT1.FAILED ENGINE CONDITION LEVER - FEATHER & FUEL SHUT-OFF.2.Operative engine power lever - ADVANCE, as required.3.Gear - UP.4.Flaps - UP.5.Maintain minimum single-englne speed or above.6.Stores - JETTISON, as required.7.Attempt air starts.8.Failed engine power lever - FLIGHT IDLE.9.Failed engine FUEL EMERG SHUT OFF - SHUT OFF.
FAILURE OF BOTH ENGINES IN FLIGHT1.Maintain 130 KIAS.2.Fuel quantity - CHECK.3.Attempt air starts.
ELECTRICAL FIRE1. Generators - OFF.2. BATTERY - OFF.3. RAM AIR knob - PULL FULL OUT.4. All electrical equipment - OFF.5. BATTERY - ON.6. Generators - RESET separately.7. Voltammeter - CHECK during generator
reset.8. Defective equipment - ISOLATE.
incremental steps… 1st steps very important
To do two things at once is to do neither. —Publilius Syrus
one step at a time…
overcoming extremes
WHEN THERE IS A PERCEIVED IMBALANCE BETWEEN THE DEMANDS OF THE EMERGENCY AND YOUR PERCEPTION OF YOUR ABILITY TO MEET THOSE DEMANDS.
STRESS: Increased heart rate > compromises fine motor skills > affects breathing, vision, and fatigue
STRESS: impedes judgement, impairs focus, goofy loop—stuck on stupid.
PERFORMANCE STRESS
PERCEPTION
PERCEPTION
PERCEPTION
PERCEPTION
Intubation: Do you see the cords?
Hypoxia: Can you bag the patient?
Cric: Can you feel the CTM?
WRONG QUESTIONS! we’re rushing….slow is smooth, smooth is fast
Intubation: Do you see the cords?
Accept reality and responsibilityControl your thoughts: Self-talkControl physical response to stress: Breathing and muscle relaxation techniques, stabilization of hands, biomechanics.
Process insight: One step at a time
Procedural insights:Pre-oxygenation & apneic
oxygenationPositioning to optimize oxygenationPositioning to reduce regurgitationEar-to-sternal notch positioningMechanics of the upper airwayEpiglottoscopy Progressive landmark exposureBimanual laryngoscopyOpto-mechanics of tube delivery
Oxygenation is PRIORITY—not plastic
Vomit—active/passive—is THE enemyof direct/video laryngoscopy, mask,LMA/King, passive oxygenation &fiberoptics—every part of the process
- 2 finger grip at base of handle- Scissor opening mouth- Roll blade down tongue- Visualize uvula- Yankauer suction hypopharnyx- Lift tongue and jaw- Visualize epiglottis- Check tongue position- Blade right, tongue left
- Full grip on handle, thumb up- Blade aligned with forearm- Advance tip into vallecula- Bimanual laryngoscopy- Move larynx side to side- Move larynx posteriorly- Repeat suctioning as needed- Use assistant’s hand as needed- Head elevation as needed
- Bougie or straight-to-cuff stylet- Insert into right corner of mouth- Place behind maxilla, move to larynx- Pivot tube or bougie corner mouth- Advance tip over notch- Tracheal ring impaction > Rt turn- 21-23cm at teeth male/female- Inflate cuff, end-tidal CO2, pulse ox
Epiglottoscopy LaryngoscopyTube delivery
Introduction & Epiglottoscopy and Controlling Tongue
First Stage: 2 Fingers
Keys to Epiglottoscopy
★ – Proceed slowly, methodically midline down tongue ★ – Distract tongue and jaw forward, and lift epiglottis edge off the posterior
pharynx ★ – A light grip allows fine adjustment and fine tongue control
Beware of epiglottis camouflage !
fluids, blood, saliva pool in hypopharynx –
use suction tip if needed to clear hypopharynx and see
epiglottis edge
epiglottis: - reliable anterior landmark - able to be lifted out of fluids - top of laryngeal inlet
Epiglottoscopy
Epiglottoscopy: The Secret to the Airway Any Device—One Approach…find the epiglottis on insertion
Storz DCI Video Laryngoscope
Compartmentalize and then flatten the slope: Reduce each section of the procedure to its basic components
Individual steps are small, reliable, achievable, & reproducible.
Lighten the load (Mindset): Keep the wheelbarrow light and balanced
Engineering Procedural Teaching & Training for Crisis Performance
Tube delivery
Laryngoscopy
Epiglottoscopy2 finger grip roll midline down tongue
dab uvula, palatal arch, epiglottis
tongue controlbimanual
head lift
shape, bevel, rings
ear - sternal notch face plane parallel to ceiling
Hypoxia: Can you bag the patient?
36% of unconscious, non-paralyzed patients have complete UAO and 54% had partial UAO when the head was in the neutral position (Safar)
Lesson from Bromiley case: Failure to cut or…
wrong approach to oxygenation?
The NOSE is BETTER !
• No cheek flap • No pressure on unstable
joint (jaw) • Nasal has better
ventilation volumes vs oral/nask mask
• Soft palate functions as emergency exit door
Anesthesiology, V 108, No 6, Jun 2008 Liang et. al
NASAL MASK
ORAL- NASAL MASK
Can 15 lpm unobstruct airway?
Soft palate
Epiglottis
Tongue
Base
upright–good for alveoli, diaphragm, fluids passive patent airway is via the nose
pull mandible to unobstruct base of tongue, epiglottis
O’s Up the Nose Pull mandible forward
Sit patient up Oxygen On Pull mandible Sit patient up
OOPS
Cords
If you must ventilate… 1) Upright 2) Continuous flow O2 NC 3) PEEP valve
Maximizes FiO2 and alveolar-capillary absorption
Cric: Can you feel the CTM?
Mental Armor Will I cause
harm?
Do I have the skill set?
Am I sure where to cut?
Is it really needed?
The Surgically Inevitable Airway The Cartilaginous Cage
The Laryngeal Handshake Sternal Stabilization
Save a Life… Cut the neck.
back wall of the cricoid
cartilage
a firm stop... so don’t be
fearful !
Cricoid ring front: 2.5-5.0 mm Back wall:
16 - 29 mm
a firm stop... so don’t be
fearful !
Cricoid ring front:
2.5-5.0 mm
Cricoid back wall:
16 - 29 mm
2.5-5.0 mm
16-29 mm
“The Laryngeal Handshake” …rock the rhomboid
5 fingers >>>> not 1 finger Find midline >>>> not the CTM >>> vertical cut, then verify location CTM
Epiglottis = the center of the world in the internal airway Thyroid = center of the world for external laryngeal landmarks
Save a life & cut the neck! Rock the Rhomboid! Rock the Rhomboid!
Save a life & cut the neck! Rock the Rhomboid!
1. Laryngeal handshake 2) Non-dominant stabilizes larynx
3) vertical incision 4) verify CTM with finger 4) Sternal stabilization
Incrementalize Your Procedures
Performance Stress Beauty / Death Ratio
Celebrate the Victories
Richard Levitan @airwaycam [email protected]