Upper airway obstruction (core) | Many potential causes of emergent airway obstruction: trauma, anaphylaxis, tumor, foreign body, vocal cord paralysis, retropharyngeal abscess, angioedema, etc Hoarseness or stridor? Short neck? Prior neck surgery? C-spine precautions? Limited mobility? Palpate thyroid cartilage, cricoid cartilage, tracheal rings, and sternal notch | Mallampati classification | Definitive airway = cuffed tube below the vocal cords Oral tracheal intubation can be attempted initially Several attempts at intubation are typically reasonable, but if unsuccessful, surgical airway should be placed in a timely manner to avoid sustained hypoxia Procedure of choice for emergent surgical airway is cricothyroidotomy | Intubation: - Make sure necessary supplies are readily available (ie, suction, lighting, bag mask, meds, ET tube, laryngoscopes, video laryngoscopy, bougies, and airway cart) - Preoxygenate patient, if able—can use chin tilt, oral airway, and 2-hand mask seal to help with bag masking - Administer medications—sedation and paralytic as appropriate, should be RSI - Place patient in sniffing position (if no C-spine precautions) - Place laryngoscope, visualize cords, insert ET tube - Confirm appropriate tracheal position (end tidal CO2, misting in tube, b/l breath sounds) - Inflate balloon, connect to ventilator, secure tube in place - CXR to confirm position Cricothyroidotomy: - Proceed with cricothyroidotomy in airway emergencies when unable to intubate from above - Palpate the cricothyroid membrane and other landmarks - Make vertical skin incision and dissect down to cricothyroid membrane - Incise cricothyroid membrane horizontally and dilate, can use back bend of scalpel - Insert tracheostomy tube or ETT - Confirm appropriate tracheal position (end tidal CO2), misting on tube, b/l breath sounds) - Inflate balloon, connect to ventilator, secure tube in place - CXR to confirm position | Typically convert cricothyroidotomy to formal tracheostomy when stabilized | Anaphylaxis (core): - May present with flushing, pruritis, laryngeal edema, wheezing, hypotension - Common causes of peri-op anaphylaxis: antibiotics, blood products, neuromuscular-blocking agents, latex - Treatment: remove trigger, immediately, give 0.3-0.5 mg of epinephrine (1:1000) IM, repeat q5 min as needed up to 3 times, fluids and pressors as needed for hypotension, can give albuterol, antihistamines, H2 blockers, and steroids as adjuncts - Intubate immediately if there is evidence of impending ... |