DIFFICULT
AIRWAY
Review
Kenneth W. Stuebing
Program Manager
A-EMCA, Critical Care Flight Paramedic
Objectives

During this presentation we will discuss:
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A systematic approach to airway assessment
Common terminology (talk the same language)
Pediatric airway concerns
Difficult airway assessment
Introduce facilitated intubation
Introduce Rapid Sequence Induction CONCEPTS
Introduce alternate airway adjuncts
Introduce an AIRWAY algorithm
Practice airway procedures
Kenneth W. Stuebing EMCA, CCP(F)
STRESSED ?

Let me paint the picture for you!
– WHEN: 16:00 hrs. on Friday
– WHERE: MAIN & JAMES
– WHAT: 8 year old female patient who was hit by a speeding car
(approximately 90 kph)
– She is unconscious, responds with groans to pain, does not open
eyes and withdraws from pain. She has a pulse of 50 and is
breathing but you notice her skin is pale and lips are blue. She is
bradycardic, hypotensive and tachypnic. You note multiple
fractures and copious amounts of blood loss with paradoxical
(seesaw) breathing. Her air entry is markedly diminished on the
left side and crackles on the right (aspiration?). She has a blown
left pupil and lateralizing signs.
Kenneth W. Stuebing EMCA, CCP(F)
First Things First

Indications for intubation
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 LOC
Obtain / Maintain / Protect Airway
Oxygenation
Positive Pressure Ventilation or control ventilation
Drugs (NAVEL)
 Fatigue
Access Tracheal Toilet (suction)
Kenneth W. Stuebing EMCA, CCP(F)
Why PAINFUL STIMULUS?
MEDICAL
TRAUMA
PROTECT C-SPINE
Kenneth W. Stuebing EMCA, CCP(F)
RESPIRATORY PROCESS
 ALVEOLAR PRESSURE
< ATMOSPHERIC
MECHANICAL:  ATMOSPHERIC PRESSURE
> ALVEOLAR PRESSURE
NATURAL:
Kenneth W. Stuebing EMCA, CCP(F)
SELLICK MANEUVER
or
CRICOID PRESSURE

FINGER PRESSURE ON
CRICOID CARTILAGE
WHICH AIDS IN
INTUBATION AND
PREVENTS GASTIC
DISTENTION & ASPIRATION
Kenneth W. Stuebing EMCA, CCP(F)
Airway Assessment
Once the decision to intubate has been made a deliberate
assessment process needs to be started.
 Is it a CRASH intubation?
– Death or near death (like “NIKE” “just do it”)
– Suction, stylette, lubed ETT, stethoscope, laryngoscope

Is it a DIFFICULT intubation?
– LEMON
(DO YOU NEED TO LOAD YOUR PATIENT ?)

Rapid Sequence Induction / Intubation (RSI) future?
– Sedation, analgesia, neuromuscular blocking agent
Kenneth W. Stuebing EMCA, CCP(F)
CRASH AIRWAY

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VSA
Pending VSA
Respiratory Arrest
GCS < 5
Airway compromise (blood / vomit unable to clear)
Note: positioning is the number 1 airway procedure to
prevent aspiration.
Kenneth W. Stuebing EMCA, CCP(F)
DIFFICULT AIRWAY

LEMON assessment scale.
– Prior to taking TOTAL control of airway
– May choose to facilitate intubation (versed)
– May need to LOAD patient
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Lidocaine
Opiate
Atropine
Depolarizing neuromuscular blocking agent (defasiculating)
Kenneth W. Stuebing EMCA, CCP(F)
LEMON
L - Look
1 point
 E - Evaluate
2 points
 M - Mallampati (1 - 4)
2 points
 O - Obstruction
2 points
 N - Neck
1 point
2 or more equals difficult

Kenneth W. Stuebing EMCA, CCP(F)
LEMON

L - Look (visual assessment) 1 point (each)
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Under / over bite
Big teeth
Facial hair
No neck
Barrel chest

Gut feeling tough tube!!!
Kenneth W. Stuebing EMCA, CCP(F)
LEMON

E - Evaluate
2 points
– Ability to open mouth 3 fingers
– Anterior Larynx 3 fingers
– Superior Larynx 2 fingers

Children and Asians have anterior and superior larynx.
Kenneth W. Stuebing EMCA, CCP(F)
LEMON

M - Mallampati
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(1 - 4)
= 0 or 2 points
1 = can see all of uvula
2 = can see most of uvula
3 = can see a part of uvula
4 = can see none of uvula - all hard palate

Paramedics should lean to a 1 or 4 interpretation.
Kenneth W. Stuebing EMCA, CCP(F)
LEMON

O - Obstruction
2 points
– Tumors
– Hematoma
– Swelling
Kenneth W. Stuebing EMCA, CCP(F)
LEMON

N - Neck
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1 point
Immobility, unable for flex or extend neck
C -spine precautions
Kyphosis
Osteoporosis
Severe Rheumatoid Arthritis

2 or more equals difficult airway is expected
Kenneth W. Stuebing EMCA, CCP(F)
What if it is difficult?
Concern for paralytics and heavy use of
analgesics and sedatives. If patient quits
breathing and you are unable to ventilate - you
have broken fundamental premise of medicine
“CAUSE NO HARM”.
 Before taking TOTAL control of a patient’s
airway an accurate / defendable assessment for
due diligence AND a back up must be available.
 Blind nasal intubation with slight sedation may
be beneficial.

Kenneth W. Stuebing EMCA, CCP(F)
Facilitated Intubation

Sedation (decrease LOC)
– Versed (January 2002 with patch)
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concerns for hypotensive patients
helps blunt sympathetic response
amnesia
Analgesia (stop pain)
– Morphine
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concerns for hypotensive patients
helps blunt sympathetic response
– Fentanyl (synthetic opiate 100 x stronger than morphine)
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concerns for hypotensive patients
helps blunt sympathetic response
Kenneth W. Stuebing EMCA, CCP(F)
Versed
Madazolam HCL

Classification: Sedative (anxiolytic and hypnotic)
– CNS depressant (benzodiazepines, barbiturates, etc)
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Mode of Action:
– Inhibitory action of the GABA receptors (ý~aminobutyric acid):
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When GABA binds to CNS receptors it increases the chloride that enters
the cell. This causes a SMALL hyperpolarization and moves the
postsynaptic receptor away from its action potential. (resting potential
more negative)
Benzodiazepines bind to specific, high affinity sites on CNS cell
membranes beside GABA receptors, resulting in more frequent opening of
the chloride channels. This hyperpolarizes the postsynaptic receptor even
MORE then GABA alone and further inhibits neuronal firing.
Benzodiazepines also interfere with the release of calcium from the
sacroplasmic reticulum in the CNS inhibiting these cells further.
Kenneth W. Stuebing EMCA, CCP(F)
Benzodiazepines

BENZODIAZEPINES:
– GABA receptors are
only found in the CNS
– have no analgesic or anti
psychotic effects
– do not affect the
autonomic nervous
system (still BP caution)
– all have exhibit varied
level of these actions:
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Anxiolytic
Muscle relaxant
Sedative / hypnotic
Anticonvulsant
Kenneth W. Stuebing EMCA, CCP(F)
Benzodiazepines

BENZODIAZEPINES:
– Anxiolytic

at low doses they are
anxiolytics, thought to
selectively inhibit
neuronal circuits in the
brain’s limbic system.
– Muscle Relaxant

relax spasticity of
skeletal muscle, by
increasing presynaptic
inhibition of the spinal
cord.
Kenneth W. Stuebing EMCA, CCP(F)
Benzodiazepines
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BENZODIAZEPINES:
– Sedative / hypnotic
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All Benzos have these
properties at high doses
can cause hypnosis and
respiratory depression
and hypotension.
– Anticonvulsant

Several types are used
to treat epilepsy
however some don’t
have a long enough
half life to be useful.
Kenneth W. Stuebing EMCA, CCP(F)
Benzodiazepines

Pharmacology:
– Absorption and distribution:

Lipophilic benzodiazepines are rapidly & completely absorbed after PO,
IV & SQ administration & distributed evenly throughout the body.
– Duration of actions:

Half lives of this classification of drug are VERY important for their
clinical use. They are divided into 3 categories:
Long acting: (Valium / Diazepam)
Intermediate acting: (Lorazepam)
Short acting: (Triazolam, Versed)
– Metabolism & Excretion:
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most are metabolised in the liver and therefore caution should be used
when administering to people with hepatic dysfunction
eliminated in the urine.
Kenneth W. Stuebing EMCA, CCP(F)
Versed
Madazolam HCL
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Adverse affects:
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Drowsiness and confusion
Hypoventilation
Tackycardia / bradycardia
Hypotension
Caution:
– It will potentiate effects of alcohol and other CNS depressants
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Versed in use by January - February 2002

Dose: > or = 40 kg
0.05mg/kg (0.1 mg/kg)
Kenneth W. Stuebing EMCA, CCP(F)
RSI

Induction / Sedation
– Versed & Morphine (?)

Neuromuscular blocking agent
– Succinylcholine (depolarizing or fasiculating)
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Acetylcholine Agonist: causes systemic release of ALL
acetylcholine from motor nerve endings which bind to nicotinic
receptors on the neuromuscular endplates of all skeletal muscle.
This causes a fasiculation (seizure) while all muscles contract or
depolarize at once.
Since ALL acetylcholine is released it is impossible for muscle
contraction to occur until stores have been replenished.
– Note: skilled practitioners can usually intubate ~ 80 - 90% of
the population without too much trouble. The remaining 10
- 20 % falls under the difficult to very difficult category.
Kenneth W. Stuebing EMCA, CCP(F)
LOAD

Lidocaine
– to blunt ICP for patient with:



CVA
Head Injuries
Opiate - Analgesia
– Fentanyl



concerns for hypotensive patients
will also blunt ICP and reduce sympathetic response
Atropine (have ready)
– to stop vagal response - particularly pediatrics

Defasiculating neuromuscular blocking agent - ART
– used to stop fasiculation caused by Succinycholine
Kenneth W. Stuebing EMCA, CCP(F)
Emergency Cricothyrotomy Protocol
If a patient cannot be ventilated due to life-threatening
suspected upper airway obstruction, the Advanced Care
Paramedic may attempt a cricothyrotomy according to the
following protocol after receiving orders from the BHP.
Indications:
A patient that requires intubation and
Unable to intubate and
Unable to adequately ventilate
Conditions:
Patient  40 kg and  12 years old
Contraindications:
Suspected fractured larynx
Inability to localizeKenneth
the W.
cricothyroid
membrane
Stuebing EMCA, CCP(F)
Emergency Cricothyrotomy Protocol
Procedure:
1. Administer 100% O2.
2. Contact the BHP for on-line medical direction to proceed with this protocol.
3. If every attempt to contact a BHP has failed, the AC Paramedic may
continue with this protocol in a life-threatening situation if all other
indications and conditions are met. The AC Paramedic should contact the
BHP (and the Base Hospital) as soon as possible after the procedure and
document the patch failure and decision to proceed.
4. Place patient on his or her back, and then extend the head and neck
(provided there are no c-spine injuries).
5. Grasp the larynx with your thumb and middle finger. Locate the cricoid
cartilage and the cricothyroid membrane with the index finger. Prep the
area quickly.
Follow the appropriate procedures following for the specific equipment used.
The seldinger cricothyrotomy should be the primary method used but if the
equipment is not available, the needle cricothyrotomy procedures should be
followed.
Kenneth W. Stuebing EMCA, CCP(F)
Emergency Cricothyrotomy Protocol
Seldinger (Melker) Cricothyrotomy Kit:
1. While stabilizing the thyroid cartilage make a vertical incision in the midline
of the cricothyroid membrane with a scalpel.
2. Use the supplied 18g TFE catheter with the 6cc syringe attached. Insert the
catheter into the airway at a 45º caudal angle looking for free air in the syringe.
3. Remove the syringe and needle leaving the catheter in place. Always
maintain contact with the guidewire, never let go!
4. Advance the soft flexible end of the wire guide through the catheter and
into the airway several centimeters caudally.
5. Remove the catheter leaving the wire guide in place. (STEP # 1)
6. Feed the dilator (with airway catheter in place) over the wire. Ensure that
the stiff end of the wire protrudes out of the back of the dilator.
7. Advance the dilator into the airway until the flange of the 15mm airway
adapter is resting against the patient's neck.
8. Remove the dilator and wire guide. Use caution to ensure that the wire
guide is not lost into the trachea.
9. Secure the flange of the airway adapter to the patient.
10.Attach a BVM and attempt to ventilate the patient. Genesis or other ventilators
must not be used.
11.Initiate rapid transport to the closest appropriate hospital.
12.Patch to the Base Hospital if complications arise or further orders
Kenneth W. Stuebing EMCA, CCP(F)
are required.
Emergency Cricothyrotomy Protocol
Needle Cricothyrotomy:
7. Attach a 14 gauge over-the-needle catheter to a 10 cc syringe filled with
saline. Carefully insert the needle through the skin and cricothyroid
membrane into the trachea while aspirating for free air. Direct the needle
at a 45 degree angle caudally.
8. Aspirate with the syringe. If air is returned easily by way of seeing
bubbles in the saline filled syringe, you are in the trachea. If it is difficult to
aspirate with the syringe, or if you obtain blood, re-evaluate needle
placement.
9. Withdraw the stylette, while gently advancing the catheter downward into
position.
10.Attach an adapter to the hub of the catheter and begin ventilating with
100% O2 with a BVM. Genesis or other ventilators must not be used.
11.Secure the catheter and continue ventilation, allowing time for passive
expiration
12. Initiate rapid transport to the closest appropriate hospital.
13. Patch to the Base Hospital if complications arise or further orders are
required.
Kenneth W. Stuebing EMCA, CCP(F)
Needle Cricothyroidotomy
SECOND LINE PROCEDURE that should be used if Seldinger
technique is not possible. (BHP may give orders from 8 - 12 year old patient)
Provides temporary oxygenation but no ventilation
Note:
Exhalation may be difficult through such a small diameter catheter and the
paramedic should lengthen the time between breaths to allow for exhalation.
The BHP may consider giving orders for a second catheter horizontally next to the
first to allow for better exhalation and this should be discussed during the patch.
Kenneth W. Stuebing EMCA, CCP(F)
Cricothyroidotomy
(Melker)
Kenneth W. Stuebing EMCA, CCP(F)
Cricothyroidotomy
(Melker)
2
Landmark cricothyroid
membrane between the
thyroid and cricoid
cartilages and prep area.
Maintain landmark with one hand & insert
the 6cc syringe with 18 guage TFE catheter
and introducer needle. Advance needle on
a 45° angle to the frontal plane in the
midline in a caudad direction. While
inserting needle draw back on syringe to
verify when trachea has been found.
Kenneth W. Stuebing EMCA, CCP(F)
Cricothyroidotomy
3
Remove the syringe and needle
leaving the catheter in place.
Advance the soft, flexible end
of the guidewire through the
TFE catheter and into the
airway several centimeters.
4
While holding on to the
guidewire ensuring not to let it
move carefully remove the
TFE.
Kenneth W. Stuebing EMCA, CCP(F)
Cricothyroidotomy
6
5
While holding the guidewire
make a vertical incision with the
# 15 short handle scapel blade to
allow dilator to be inserted.
While holding on to the guidewire
advance the preassembled
dilator and airway catheter with the
tapered end first over the guidewire.
Kenneth W. Stuebing EMCA, CCP(F)
Cricothyroidotomy
Kenneth W. Stuebing EMCA, CCP(F)
Cricothyroidotomy
Kenneth W. Stuebing EMCA, CCP(F)
PLAY EMERGENCY AIRWAY
VIDEO!
Airway Assessment Algorithm
CRASH INTUABTION
DEATH OR NEAR DEATH
INTUBATE:
Lubricated Tube
Stylette
Suction
Stethescope
Syringe
YES
NO
SUCCESSFUL?
NO
YES: Confirm
(see Note 1)
DIFFICULT AIRWAY
LEMON
No
CONSIDER
PATCH FOR
FACILITATED
INTUBATION:
Versed/Morphine
Consider
Lidocaine
Yes
SUCCESSFUL?
NO
Rapid Sequence
Induction / Intubation
(future consideration)
REASSESS (see Note 2)
No
YES
Versed
Fentanyl
Succinylcholine
SUCCESSFUL?
YES: Confirm
(see Note 1)
Consider Adjunct Devices
 Lighted Stylette
 LMA
Can you ventilate the patient?
NO
YES
Perform Cricothyrotomy
Note 1:
Note 2:
Continue to ventilate
with adjunct or BVM
Confirmation includes 3 methods with 1 being end tidal CO2 confirmation
Reassess continually
to determineEMCA,
whether theCCP(F)
patient’s condition reverts to
Kenneth
W. Stuebing
“Crash Intubation” or “Facilitated” criteria.
NO
Airway Assessment Algorithm
CRASH INTUABTION
DEATH OR NEAR DEATH
INTUBATE:
Lubricated Tube
Stylette
Suction
Stethescope
Syringe
YES
NO
SUCCESSFUL?
NO
YES: Confirm
(see Note 1)
DIFFICULT AIRWAY
LEMON
No
CONSIDER
PATCH FOR
FACILITATED
INTUBATION:
Versed/Morphine
Consider
Lidocaine
Yes
SUCCESSFUL?
REASSESS (see Note 2)
Consider Adjunct Devices
 Lighted Stylette
 LMA
Can you ventilate the patient?
NO
Perform Cricothyrotomy
Note 1:
Note 2:
YES
Continue to ventilate
with adjunct or BVM
Confirmation by 3 methods; one must be end-tidal CO2 (when available).
Reassess continually
determine
whether the
patient’s CCP(F)
condition reverts to
Kennethto W.
Stuebing
EMCA,
“Crash Intubation” or “Facilitated” criteria.
NO
Questions
Kenneth W. Stuebing EMCA, CCP(F)
Reference Material
Website @ www.springnet.com/criticalcare
 PALS / NALS
 The ICU Book by Paul L. Marino
 Hemodynamic Monitoring by Darovic
 Lippicotts Pharmacology
 Merck Manual
 Hemodynamic Monitoring by Dana Oakes
 Handouts
- Compiled Information (Sunnybrook)

Kenneth W. Stuebing EMCA, CCP(F)
Thank you
Kenneth W. Stuebing
Clinical Co-ordinator H.B.H.
CCP(F), AEMCA
Kenneth W. Stuebing EMCA, CCP(F)