11

Module B: Hour Module B: Hour 22

Intubation Intubation DifficultiesDifficulties

22

Think ahead !!!!Think ahead !!!!

If you suspect a difficult airway: call If you suspect a difficult airway: call for help earlyfor help early

What increases What increases

the risk of a the risk of a

difficult airway ?difficult airway ?

33

MallampatiMallampati

Is Mallampati a Is Mallampati a famous curry dish famous curry dish from the south of from the south of India ?India ?

44

55

The 6 “P’s” of RSIThe 6 “P’s” of RSI

Preparation (5 min)Preparation (5 min)

Pre-oxygenation (2 min)Pre-oxygenation (2 min)

Paralysis / inductionParalysis / induction

Protection and positioning (30 Protection and positioning (30 seconds)seconds)

Placement (45 seconds)Placement (45 seconds)

Post-intubation carePost-intubation care

66

P1 = Preparation P1 = Preparation

What preparations do What preparations do you make before you make before intubating ?intubating ?

What is “Soap Me” ?What is “Soap Me” ?

77

P2 = PreoxygenateP2 = Preoxygenate

What are the What are the physiological aims of physiological aims of pre-oxygenation ?pre-oxygenation ?

How are these achieved ?How are these achieved ?

88

P3 = P3 = Paralysis/InductionParalysis/Induction

What problems arise with What problems arise with the common induction the common induction agents ?agents ?

Compare the use of these: Compare the use of these:

Suxamethonium vs RocuroniumSuxamethonium vs Rocuronium

99

P4 = P4 = Protection/Positioning Protection/Positioning

How do you achieve in-How do you achieve in-line stabilisation if line stabilisation if necessary ?necessary ?

1010

1111

P5 = Placement P5 = Placement

How do you confirm How do you confirm your tube placement ?your tube placement ?

1212

P6 = Post-intubation P6 = Post-intubation carecare

SedationSedation

ParalysisParalysis

MonitoringMonitoring

HumidificationHumidification

NG tube and IDCNG tube and IDC

1313

Mrs AO, 72 years old Mrs AO, 72 years old

BIBA from GP’s waiting roomBIBA from GP’s waiting room

Sudden stridor: given adrenaline/ventolin/Sudden stridor: given adrenaline/ventolin/

phenergan/lasix at GPs for ? anaphylaxis ? phenergan/lasix at GPs for ? anaphylaxis ? APOAPO

Sats 95% on R/A on arrival, fairly comfortable.Sats 95% on R/A on arrival, fairly comfortable.

Intermittently complains of SOB, audible soft Intermittently complains of SOB, audible soft stridor, two word sentences. Epigastric pain.stridor, two word sentences. Epigastric pain.

What is your management ?What is your management ?

1414

Describe the X-rayDescribe the X-ray

1515

The patient needs a CT The patient needs a CT chest.chest.

How would you How would you proceed ?proceed ?

1616

1717

Mr DI, 73 years oldMr DI, 73 years old

GCS 7, found on floor by wife (E1 V1 M5)GCS 7, found on floor by wife (E1 V1 M5)

Increased tone /reflexes on right Increased tone /reflexes on right

PEARL, but small PEARL, but small

PMHx IHD , A/F on warfarinPMHx IHD , A/F on warfarin

Gurgling respirations Gurgling respirations

Sats 89% on R/A, RR 16/min Sats 89% on R/A, RR 16/min

What is your What is your management ?management ?

1818

You are unable to You are unable to intubate – this is your intubate – this is your

view.view.

What grade of What grade of laryngoscopy is this ?laryngoscopy is this ?

1919

LaryngoscopyLaryngoscopy

What would you do next ?What would you do next ?

2020

Second lookSecond look

STOP, re-oxygenate, rethinkSTOP, re-oxygenate, rethink

BURPBURP

IntroducerIntroducer

BOUGIE (if you can see the BOUGIE (if you can see the epiglottis)epiglottis)

Different bladeDifferent blade

2121

You remain unable to You remain unable to intubate.intubate.

What would you do What would you do next ?next ?

2222

End of the lineEnd of the line

What do you do if you What do you do if you can’t intubate and you can’t intubate and you can’t ventilate a can’t ventilate a patient ?patient ?

2323

Reminder:Reminder:

Nobody ever died from Nobody ever died from a failure to intubate. a failure to intubate.

They died from a They died from a failure to ventilate.failure to ventilate.

2424

DiscussionDiscussion