Airway
Oropharyngeal airway aka Guedel
Nasopharyngeal airway
Rapid sequence induction (Anaesthesia)
Orotracheal intubation
Risks
Surgical airway
Risks of cricothyroidotomy
Tracheostomy
Next: see ventilation
- for unconscious (causes laryngospasm and gag/vomiting)
- Size
- Chin lift by second person
- Laryngoscope/tongue depressor
- Remove accessible foreign body
- insert right way up
- > Breathing
Nasopharyngeal airway
- Assess for base of skull abort if present
- size
- lubricate
- insert at 90 with slight rotation until flange at nare (will feel give as passes into nasopharynx)
- if difficulty try other nostril, then 1 size down
- > Breathing
Rapid sequence induction (Anaesthesia)
Orotracheal intubation
- Equipment (Tilting bed (shoulder roll if baby), Suction, O2, airway, breathing, RSI, CVS)
- Pre-oxygenate 100% for 3 mins (if effective spon/NIV in progress)
- Manual immobilisation if required
- RSI (if not apnoeic)
- BURP (release if vomits)
- Laryngoscope in left hand > to right mouth > sweep tongue left
- Baby > Insert straight blade to proximal oesophagus > slowly withdraw until cord pop into view
- Child > Insert curved blade into vallecula (pouch in front of epiglottis)
- Lift to far ceiling (don't lever)
- Intubation, re-oxygenate if unsuccessful at 30s (holding your breath not good for clarity)
- Check check bilateral, chest movement, ausc, fog, CO2 detector/monitor
- Inflate cuff
- Tape
- CXR
Risks
- oesophageal intubation (severe hypoxia, perforation)
- Endobronchial intubation (Left collapse, right pneumothorax)
- Subglottic oedema/stenosis
- Infection
- Exacerbation of existing spinal injury
- Gag/vomit, laryngospasm
- Pre-oxygenate 100% for 3 mins (if effective spon/NIV in progress)
- Deflate and Lubricate
- Extend neck and chin lift (if no c-spine injury)
- Finger behind superior cuff, follow curve of hard then soft palate avoiding tongue contact if possible, check line inline with nasal septum (i.e. no rotation)
- Inflate (rises slightly with inflation)
- Check check bilateral, chest movement, ausc, fog, CO2 detector/monitor
- Tape
Surgical airway
- needle cricothyroidotomy
- preferred <12yo
- in small baby or if FB is below cricoid can directly puncture trachea instead
- attach cricothyroidotomy cannula/IVC via y connector (syringe cannula open/thumb closed) to 5ml syringe
- Extend neck, sandbags under shoulders (if no c-spine injury)
- alcohol swab
- Left hand stabilises cricoid and protects vessels
- 45deg angle, aspirate as advancing, advance cannula once air drawn back
- Open y connector to all ports
- Set O2 flow L at pt age in years
- Use thumb to ventilate 1s on 4s off
- Chest rise/ausc?
- If nil increase L/min by 1L each breath until effective
- if complete upper airway obstruction i.e. no passive expiration reduced to 1-2L/min
- Check neck for emphysema
- Tape
- Tracheostomy if surg available, ET if Anaesth/ICU/NETS arrive
- surgical cricothyroidotomy
- preferred >12yo
- Prep
- Local anaesthetic if conscious
- Left hand stabilises cricoid and protects vessels
- Small vertical skin incision then lateral pressure to open/minimise bleeding
- Small horizontal membrane incision
- Insert scalpel handle and turn 90deg in space to open
- Insert smaller ET/trache
- Attach BMV and check ventilation
- Tape
Risks of cricothyroidotomy
- Bleeding
- Aspiration
- False passage and surgical emphasema (sub cut/mediastinal)
- Pulmonary barotrauma/pneumothorax
- Subglottic oedema/stenosis
- Oesophageal perf
- Infection
Tracheostomy
- Insertion
- Done by surgeon
- Blockage
- Stimulate
- Assess breathing
- Call
- Head tilt, Chin lift and Suction (go to Replace if can't pass suction)
- Assess breathing (Look listen feel over stoma)
- If >1w since insertion = Replace (use 1 smaller if can't pass, use suction tube as guidewire if that fails, Mouth/stoma or mask/mouth if that fails)
- If <1w since insertion = remove and occlusive dressing > 2 mouth breaths and normal ABCDEFG... Call ENT
- Assess breathing
- 2 breaths and continue normal ABCDEFG...
Next: see ventilation