GSACEP core man LECTURE series:
Lauren Oliveira, DO
LT, MC, USN
Updated: 01MAR2013

Disclaimer
Views and opinions expressed do not necessarily reflect those of GS-ACEP,
The Department of Defense, the U.S.
Government, the North American
Continent, the Western Hemisphere, or
Mother Earth.

Objectives
Anatomy/Physiology
Airway Assessment
Airway Management
Equipment and Medications
Skills Practice

Anatomy
Upper Airway

Anatomy
Lower Airway

Anatomy

Anatomy

physiology

Inhaling and exhaling
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Adding oxygen to the body system

physiology
Oxygen in
Hemoglobin on the RBCs carry O2 to the tissues
Carbon dioxide out

Airway assessment
Look, listen, feel (noisy is bad)

Rate/Quality
 Breathing fast?
 Working hard?
 Shallow breaths?
 Chest rising?

Airway assessment: Monitor
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Pulse oximetry
 The “oxygenation” vital sign
 >94%
Capnography (End Tidal CO2)
 The “ventilation” vital sign
 35-45mmHg

Airway assessment
Predicting a difficult Bag Valve Mask (BVM)
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Old
No teeth
Beard

Airway assessment
Predicting a difficult intubation
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Limited neck mobility
Large tongue
Facial trauma
Malampati score

Airway management
One person in charge

Assess, intervene, monitor

Airway management
Position
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Ear-to-sternal notch
 Universal ventilation and intubation position
 Independent of age and size

Airway management
Position
Head Tilt/Chin Lift
Jaw Thrust
(Maintains C-spine precautions)

Airway management
Unconscious/no gag reflex  intubate
Confused/combative patients are hypoxic until proven otherwise

Airway management
Cricoid pressure (Sellick maneuver) no longer recommended
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Aspiration still can occur
Makes it difficult to ventilate…complete AW occlusion in 11%
Detrimental effects on view and blocks tube passage
MRI studies show esophageal occlusion not reliable

Airway management
However, external manipulation of the thyroid cartilage by the person intubating is helpful to improve view

Equipment and medications
SOAP ‘EM
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S uction
O xygen (BVM ready and pre-oxygenate)
A irway adjuncts (OPA, NPA)
P osition
E nd Tidal CO2 (Capnography or colormetric device)
M eds & Monitors

Equipment
Suction
Oxygen Delivery

Nasal cannula, simple mask, non-rebreather
5-12L/min
Must be at least 10L/min

Equipment
Bag Valve Mask (BVM)


Connect to oxygen
Squeeze against hand to verify positive pressure

Equipment
Airway Adjuncts

Nasopharyngeal airway
 Okay in an awake patient
 Measure nose to ear lobe

Equipment
Airway Adjuncts

Oropharyngeal airway
 Only in a comatose patient (will gag)
 Measure corner of mouth to ear lobe

Equipment: Advanced airway
Endotracheal tube (ETT) and laryngoscope
Laryngoscope Blade
(here is a Miller)
Laryngoscope
Handle
Tape to secure tube
Syringe to inflate the cuff
ETT and Stylet

Equipment: advanced airway
LMA (Laryngeal Mask Airway)

Equipment: advanced airway
King LT

Equipment: advanced airway
Bougie

Equipment: advanced airway
Direct vs Video laryngoscopy

Equipment: advanced airway
Direct laryngoscopy

Equipment: advanced airway
Direct vs Video laryngoscopy

Equipment: advanced airway
Cricothyroidotomy
1. Vertical incision through skin w/ scalpel

Equipment: advanced airway
Cricothyroidotomy
2. Horizontal incision through cricothyroid membrane

Equipment: advanced airway
Cricothyroidotomy
4. Slide 6-0 ETT over bougie, remove bougie and secure tube
3. Bougie into opening

Equipment: advanced airway
Cricothyroidotomy
5. Confirm placement
Gold= Golden
Breath sounds

Equipment: medications
1 st = Sedate
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Etomidate
Ketamine
Midazolam (or other benzodiazepine)
2 nd = Paralyze
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Succinylcholine
Rocuronium
Vecuronium

SkillS practice…Go!
Intubation set up
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O2, BVM, suction, pulse ox, laryngoscope, tube(s), stylet, syringe, CO2
Medications
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Paralytics
Sedatives
Rescue devices
Cricothyroidotomy

Skills practice