slide1
Download
Skip this Video
Download Presentation
Airway management in the prehospital setting

Loading in 2 Seconds...

play fullscreen
1 / 29

Airway management in the prehospital setting - PowerPoint PPT Presentation


  • 183 Views
  • Uploaded on

Airway management in the prehospital setting. Dr X.Combes, SAMU du Val de Marne, Créteil, France. Airway management in the prehospital setting. Dr X.Combes, SAMU du Val de Marne, Créteil, France. Why airway control is mandatory out of hospital?. Airway protection Coma Sedation

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Airway management in the prehospital setting' - kaleb


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

Airway management in the prehospital setting

Dr X.Combes, SAMU du Val de Marne, Créteil, France

airway management in the prehospital setting

Airway management in the prehospital setting

Dr X.Combes, SAMU du Val de Marne, Créteil, France

why airway control is mandatory out of hospital
Why airway control is mandatory out of hospital?
  • Airway protection
      • Coma
      • Sedation
  • Respiratory assistance with positive pressure ventilation
      • Respiratory distress
      • Cardiopulmonary rescucitation
  • Limitation or prevention of evolutive injury :
      • severe head traumatism

Winchell Rj et col; Arch Surg 1997

Gentleman D et col; Lancet 1990

indications for prehospital tracheal intubation
Indications for prehospital tracheal intubation

Jabre P, SFAR 2003

Adnet F,Ann Emerg 1998

Ricard-Hibon A, Eur J Anaesthesiology 2002

characteristics of extrahospital airway management
Characteristics of extrahospital airway management
  • Emergency context
    • Hostile environnment
    • Non cooperative patients
    • Poor knowledge of medical patients history
    • Not much time to upper airway evaluation
    • Risk of pulmonary aspiration
    • Interaction between patient and operator body position
medical conditions and anatomical abnormalities may induce difficult laryngeal visualization
Medical conditions and anatomical abnormalities may induce difficult laryngeal visualization.....
incidence of failed prehospital intubation

100

80

60

failure

40

success

20

0

Incidence of failed prehospital intubation

100

80

60

Intubations (%)

40

20

0

a

b

c

d

e

f

g

h

i

j

k

l

a : Stewart 1994 (n = 779)

b :Pointer 1988 (n = 383)

c : Krisanda 1992 (n = 278)

d : Sayre 1998 (n = 103)

e : Hedges 1988 (n = 310)

f : Thompson 1994 (n = 862)

g : Cantineau 1997 (224)

h : Adnet 1998 (n = 691)

i : Orliaguet 1997 (n = 157)

j : Adnet 1997 (n = 394)

k : Ricard-Hibon 1997 (n = 147)

l : Adnet 1997 (n = 311)

influence of the sedation technique on intubation difficulties
Influence of the sedation technique on intubation difficulties

Adnet F; Eur J Emerg Med 1998

effect of a rsi protocol introduction in a medical prehospital unit
Effect of a RSI protocol introduction in a medical prehospital unit

Ricard-Hibon A et col; Eur J Anaesthesiol. 2002

rsi helps paramedics too

100

*

Without RSI

80

(n=100)

60

Successful intubations

40

With RSI

20

(n=100)

0

RSI helps Paramedics too…
  • Extrahospital paramedic heliported unit
  • Introduction of a RSI protocol in daily practice
  • Assessment of successful tracheal intubation

Rose WD; Air Med J. 1994

orotracheal or nasotracheal intubation
Orotracheal or Nasotracheal intubation?

Dronen SC et col;Ann. Emerg Med 1987 

slide14

BURP backward, upward, rightward laryngeal pressure

60% Cormack III => II

BURP > BACK

Knill R; Can J Anaesth 1993

bougie and stylet
Bougie and stylet
  • First use in 1943 by Macintosh
  • Successful blind tracheal intubation confirmed by tactile sensation
  • Helpful for patient with cervical immobilisation
  • Standard of practice in US emergency dpt
  • Rigid with little flexibility
  • Potentially traumatic for larynx and trachea
success rates of geb and stylet assisted intubation in cormack grade 3 patients
Success rates of GEB and Stylet assisted intubation in Cormack grade 3 patients

*

*

Gataure PS; Anaesthesia 1996

use of gum elastic bougie for prehospital difficult intubation
Use of Gum Elastic Bougie for Prehospital Difficult Intubation
  • Observationnal study during 30 months
  • 1442 intubations
  • 42 uses of GEB
  • Success rate : 80%
  • 60% of patients had associated factors for DI
      • ENT neoplasy
      • Morbid obesity
      • Cervical reduced mobility
      • Facial trauma

Jabre et al; submitted

pharyngeal artificial airways in extrahospital setting
Pharyngeal artificial airways in extrahospital setting
  • Pharyngeal / oesopharyngeal
  • Single / double cuff
  • Single/double lumen
  • Allowing or not blind intubation
combitube
Combitube
  • Often used as first airway device during CPR in paramedic system
  • Several extrahospital cases of difficult airway in trauma patients resolved with Combitube
  • Successful insertion by paramedics in 95% of patients with extrahospital difficult airway

Davis DP and al; Ann Emerg Med. 2003

Blostein PA and al; J Trauma. 1998

slide20
LMA
  • Proposed as initial method of airway control during CPR
  • Particulary interesting in the difficult intubation and difficult ventilation scenario
  • Several case reports of prehospital difficult airway resolved with LMA have been reported

Greene MK and col, Anaesthesia 1992

Martin SE and al;The journal of trauma: 1999

slide21
ILMA
  • ILMA, first described in 1997 has become a cornerstone of the in operating room difficut airway
  • Some case reports in prehospital settings have been reported
  • Its use with high success rate needs probably a minimal initial training

Gibbs M and al; Acad Emerg Med 2003

Combes and al; Ann Emerg Med 2004

new airway devices
New airway devices
  • CobraPLA™

(PerilaryngealAirway)

  • PAxpress™
  • Laryngeal tube™
cricothyroidotomy
Cricothyroidotomy
  • Ultimate Airway management strategy
  • Frequently used in North American prehospital paramedical system
  • Success rate : 80-100%
  • Major complications : 10%
what is the minimum training required for successful cricothyroidotomy a study in mannequins
What Is the Minimum Training Required for Successful Cricothyroidotomy?: A Study in Mannequins
  • 102 anesthesiologists
  • Vidéo démonstration
  • Performance of 10 cricothyroidotomies in manikins

Wong D et col; Anesthesiology 2003

slide26

Failure of intubation after 2 attempts under direct laryngoscopy

Success

New direct laryngoscopy with BURP

Success

Use of GEB ( 2 attempts)

Use of the ILMA and call for help

Success

Intubation through the ILMA

Ventilation through the ILMA

Success

Failure

Transfer to the Hospital with ventilation through the ILMA

Cricothyroidotomy

non invasive positive pressure ventilation
Non invasive positive pressure ventilation
  • CPAP or BiPAP
  • Validated for COPD decompensation and severe « cardiogenic pulmonary oedema »
  • Majority of the studies are inhospital
  • Potential large indications exist in the prehospital setting
conclusion
Conclusion
  • In the prehospital setting the gold standard of invasive airway management remains tracheal intubation under direct laryngoscopy
  • Rapid sequence induction should be performed for all patients with spontaneous cardiac activity in absence of contraindications
  • Predefined strategy including simple and effective devices is the best mean to solve difficult airway management situations
  • Non invasive airway control with face mask is feasible in prehospital setting. Further large studies are needed to precise the best indications of prehospital NPPV
ad