Airway management is one of the first priorities in the emergency care. Failure to manage the airway in a given time approximately 6 minutes can lead to hypoxic brain injury or even death. First step for airway management differs in terms of trauma emergency or medical emergency. Medical emergency method of establishing a patent airway is head tilt chin lift maneuver in an unresponsive patient.
For trauma emergencies, patient are highly suspected of cervical spine injuries therefore the method used to establish a patent airway is jaw thrust maneuver while providing in line cervical spine immobilization. Airway management includes assessment, establishment and protection of the airway in combination with effective oxygenation and ventilation.
Assessment of airway patency focuses on determining whether the airway is open (meaning that there are no obstructions or secretions in the mouth) and the airway is protected.
Observing the level of consciousness of the patient is also important during airway management, to assess the level of consciousness Glasgow coma scale is used. Airway management also focuses on determining whether breathing is present, spontaneous and adequate. If spontaneous breathing is noted the IPAP method is used for assessment. Inspection for bilateral chest rise and fall, inspect the color of the mouth or lips, percussion for normal resonance or dullness or hyper/hypo- resonance, palpate the chest for deformities and auscultate for equal air entry and breath sounds.
V, Garmel Gus M, page 23, 2012)
“Good alignment of the airway that comes out of optimal positioning of the head and neck is essential for an adequate laryngeal view during direct laryngoscopy. The combination of flexion at the atlanto-axial joint and extension at the atlanto-occipital joint is also known as the sniffing position. Sniffing position is known to providing better laryngeal view. It is the accepted maneuver for aligning the three axis (oral, laryngeal and pharyngeal). It also helps to maintain airway patency, facilitating good bag mask ventilation”.
Sniffing position is considered as it helps extend the head and flex the neck for aligning so as to be able to see the axis from the oropharynx to the glottis. This is important to use in obese patient and apneic patient who have narrow pharyngeal airways.
Is a tool used and designed to monitor management of difficult airway. The vortex is simple which is designed to be used by paramedics in real time during airway emergencies. It is used to recognize failing’s airway crisis during management. The vortex model is used to guide the airway practitioner through the non-surgical airway techniques i.e. face mask, LMA,SGA and endotracheal intubation.
Use of strategies like manipulation e.g. jaw thrust, sniffing position, use of adjuncts e.g. NPA,OPA, changing the size and type of device and suctioning of the airway to remove blood, secretions or foreign materials can be used before attempting the use of face mask, intubation and supraglottic devices.
“If one of the airway techniques result in confirmation of oxygen delivery, one moves out of the vortex into the green zone. The green zone is conceptualized as an airway “time out” during which alternative options can be explored including waking the patient or establishing a definitive airway via noninvasive or surgical means. If practitioner is unable to establish adequate oxygenation and ventilation by facemask, SGA or ETT within three attempts at any technique, the practitioner proceeds down the vortex”. (Page 16, 2015, Berkow and Sakles)
The green zone is when the patient is able to protect his or her airways or the airway is patent. The patient is no longer at a risk of oxygen desaturation. There is adequate alveolar oxygen deliver therefor the clinician is advised to maintain the airway in the green zone and to replace oxygen levels in the alveoli.
The funnel symbolizes that the patient is not able to protect their airway meaning the airway is not patent either there are obstructions or secretions in the mouth.it also means that the patient is not safe and has limited time if the problem is not fixed immediately which can lead to hypoxia. As the funnel narrows it shows that the patient status is compromised and there is desaturation which will lead to use of surgical means in order to maintain the airway.
SIMPLE FACE MASK
A basic disposable mask which delivers oxygen at a rate of 6-10 liters per minute.
Has two prongs projecting from a hollow face piece and delivers oxygen at a lower rate compared to simple face mask.
This are mask that delivers oxygen at a rate of 10-15 liters per minute and have an elongated reservoir bag.
INDICATIONS OF FACE MASK
Is a consideration in every airway management as it provides positive pressure ventilation. BVM can be used for resuscitation of patients with respiratory distress or difficult airway following the vortex approach.
CONTRAINDICATIONS OF BMV
ADVANTAGES OF BMV
DISADVANTAGES OF BMV
COMPLICATIONS OF BMV
According to my understanding I strongly believe that BVM is the quickest in performing ventilations and also believe that it provides positive pressure ventilation. If ventilations are exceeded it can cause accumulation of air in the stomach.
“Is a curved plastic device that is inserted over the tongue into the posterior pharynx. OPA is used when unconscious patient is at risk of developing airway obstruction or is used to prevent the tongue or the epiglottis from falling back against the posterior pharynx and occluding the airway in an unconscious patient or heavily sedated patient”. (Page 79, 2013, Hammond and Zimmermann)
INDICATIONS OF OPA
Patient at risk of airway obstruction because their upper airway muscles have relaxed or the airway is blocked by the tongue
CONTRAINDICATIONS OF OPA
ADVANTAGES OF OPA
DISADVANTAGES OF OPA
According to me, I think OPA helps in maintaining a patent airway as it avoids the tongue from falling back and help deliver oxygen when used with BVM.
“Are made of soft semi rigid rubber and are inserted through a non-obstructed nostril to provide air passage between the nose and nasopharynx” (page 79, 2013, Hammond and Zimmermann)
INDICATIONS OF NPA
CONTRAINDICATONS OF NPA
ADVANTAGES OF NPA
DISADVANTAGES OF NPA
COMPLICATIONS OF NPA
“According to K Roberts, H Whalley and A Bleetman the NPA is a simple equipment that is easily used as it does not require much knowledge and it is cheap”.
“Is used when patients are unable to control or mobilize their secretions such as blood or saliva, vomitus and also to remove foreign objects. To maintain a patient airway suctioning of the nasopharynx and trachea is required.”
INDICATIONS OF SUCTIONING
CONTRAINDICATIONS OF SUCTIONING
Severe bleeding disorder, unexplained hemoptysis
Severe bronchospasm or laryngeal spasm
ADVANTAGES OF SUCTIONING
DISADAVANTAGES OF SUCIONING
COMPLICATIONTS OF SUCTIONING
Damage to the mucosa, leading to risk of bleeding
I think suctioning is the best when it comes to aspirating secretions from the mouth or blood but can cause complications when ones suction the mouth for more than 10 seconds.
ADVANTAGES OF LMA
DISADVANTAGES OF LMA
INDICATIONS OF LMA
CONTRAINDICATIONS OF LMA
Airway management is considered the first priority in the pre hospital care of critically ill and injured patients because failure to obtain patent airway or protect patient’s airway can lead to many complications and eventually death. A patent airway can be established either by head tilt chin maneuver (medical patients) and jaw thrust (trauma patients). The three axis alignment (oral ,laryngeal and pharyngeal axis) which is also known as the sniffing position is used to provide a patent airway and it also gives a better view in the larynx, it is best at maintaining good bag mask ventilations. Providing patent airway and protecting it can be managed using the vortex approach which is used to choose which airway adjuncts will best protect and maintain a patent airway and if the chosen adjuncts fails to do so which other option can be used. OPA (oropharyngeal airway), NPA (nasopharyngeal airway), BMV (bag mask ventilation) and suctioning are known as the basic airway adjuncts used in airway management. The advanced airway adjuncts includes the LMA (laryngeal mask airway) and needle cricothyrotomy.
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