EMERGENCY AIRWAY MANAGEMENT

"Tudo vale a pena se a alma não é pequena, quem quer passar além do Bojador tem de passar além da Dor"

in Fernando Pessoa

INTRODUÇÃO

No âmbito de uma equipa de exelência aqui fica:

Segurança e monitorização da via aérea em pacientes emergentes é a chave para Qualidade de vida no ege da nossa actuação - A PESSOA HUMANA. A protecção cerebral órgão que comanda o organismo é fulcral, mas este precisa de oxigénio, glicose, e irrigação sanguínea para SOBREVIVER, quanto maior for o tempo de exposição a factores agressivos e stressants para o organismo, maior será o grau de incapacidade para a PESSOA, o que limitará o seu quotidiano e em casos extremos a vai levar a uma nova aprendizagem de adaptação ao seu micro e macrossitema que é único e diferente para cada um de nós.

Estes quadros baseiam-se no livro de Andreas Thierbach and Tim Piepho, que são do corpo de profissionais do do Johannes Gutenberg University, Hospital Mainz, Germany: University Professor Christian Werner, MD., este livro pode pedir-se por mail para: Endopress@t-online.de , Thierbach@uni-mainz.de , Piepho@anaesthesie.klinik.uni-mainz.de , Phone: 0049 61 31/71_ Phone 0049 74 61/1 45 90

PROCEDURE FOR EVALUATING THE AIRWAYS WITH REGARD TO POTENCIAL DIFFICULTIES 

a) Brief, specific history (e.g., known intubation problems, surgery of the face, mouth, or neck, tumors of the upper respiratory tract)

b) Evaluation of physiognomy

c) Testing of maximum active mouth opening

d) Inspection of the neck, testing of cervical spine mobility (be careful in patients with suspected cervical spine trauma)

e) Basic dental status

f) Inspection on the oral cavity and mesopharynx

g) Clinical screening tests (e.g. the Mallampati test, Patil test)

DEFENITE SIGNS OF POTENCIAL INTUBATION PROBLEMS:

a) Decreased mobility of the cervical spine

b) Micriogenia

c) Mouth opening less than 2cm

d) Ankylosis of the TMJ

e) Extreme macroglossia

f) Severe rheumatoid spondylitis

g) Malformation syndromes (e.g., Down syndrome)

e) Scrarring (especially after tumor surgery, burns, and irradiation)

f) Advanced stage of rheumatoid arthritis

g) Epiglottitis

h) Tumors obstructing the airway

SUGGESTIVE SIGNS OF POTENCIAL INTUBATION PROBLEMS

Alpha) Prior history of difficult intubation

Beta) Progenia

Gamma) Retrogenia

Delta) Limited mouth opening

Épsilon) Protruding upper incisors

Digama) Loose incisors

Zeta) Missing teeth

Etá) High, narrow palate

Tehta) Moderate macroglossia or restrict mobility of the tongue

Iota)High position of the larynx

Kappa) Limited movement of the cervical spine or TMJ

Lambda) Bull neck and nuchal masses

Miu) Facial and neck injuries (e.g., midfacial fractures)

Nu) Obesity or a short, thick neck

Hetá) Foreign bodies in the upper respiratory tract

Sampi)Trapped or buried patients

PATIENT - AND ENVIRONMENT - RELATED FACTORS IN SLECTING A PROCEDURE FOR SECURING THE ARWAY

PATIENT - RELATED FACTORS

- Urgency of the situation

- Age and height

- General condition of the patient

- Special anatomical and pathophysiologic

ENVIRONMENT - RELATED FACTORS

- Availability of personnel

- Level of training and individual experiense of personnel

- Availability of necessary equipment

- Light, temperature and weather conditions

THECNIQUES FOR REDUCING GASTRIC INSUFLATION DURING MASK VENTILATION

Apply cricoid pressure by the Sellick maneuver

Reduce inspiratory flow by prolonging the ventilation stroke to 1.0-1.5 seconds

Avoid CPAP and PEEP

Limit the tidial volume during oxygen delivery to barely visible chest excursions

Immediately correct any airway obstruction

DISADVANTAGES OF MASK VENTILATION DURING CARDIOPULMONARY RESUSCITATION

Chest compressions are less efficient, since they must be synchronized with the bag-and-mask ventilation

Bronchial toilet and endobronchial medications cannot be applied

Decreased pulmonary compliance during chest compressions leads to a rise in airway pressure and further increases the risk in airway pressure and further increases the risk of gastric insufflation.

ADVANTAGES OF ENDOTRACHEAL INTUBATION OVER MASK VENTILATION

Secure ventilation with airway pressures adjusted to the patient

Optimum  protection against aspiration

Option of endobronchial application of medications (e.g. epinephrine, lidocaine, atropine, naloxone)

Allows for bronchial toilet

GENERAL INDICATIONS FOR THE INTUBATION OF EMERGENCY PATIENTS

-          Resuscitation

-          Severe dyspnea or respiratory depression

-          Multiply injured patient

-          Head-injured  patient

-          Patients with a high risk of aspiration

MEASURES TO FACILITATE INTUBATION IN DIFFICULT SITUATIONS

-          Place the head in the modified Jackson Position (“sniffing position”)

-          Have an assistant apply pressure to the cricoid

-          Perform the BURP (backward upward rightward pressure) maneuver to move the larynx closer to the visual axis of the intubator

-          Select a tube with a 0.5 to 1.0 mm smaller inside diameter

-          Bend the tube into a “hockey stick” shape with a stylus

-          Advance the stylus until projects 1-2 cm past the tip of the tube

-          Use a laryngoscope blade with a different shape or size

UNRELIABLE TESTS AND INDICATORS FOR CHECKING ENDOTRACHEAL TUBE PLACEMENT

-          Bilateral auscultation of the chest (first apical, then basal)

-          Auscultation of the epigastrium

-          Observation of equal chest excursions on both sides

-          Condensation of expiratory air during initial expiration in the endotracheal tube

FAIRLY RELIABLE METHODES OF VERIFYING ENDOTRACHEAL TUBE POSITION

-          Capnography or capnometry

-          Esophageal detector device (EDD)

RELIABLE PROCEDURES FOR CHECKING ENDOTRACHEAL TUBE PLACEMENT

-          Direct laryngoscopy (tube is visible between the vocal cords)

-          Flexible intubation fiberscope and BONFILS  intubation fiberscope (to detect tracheal cartilage rings and demonstrate the tracheal bifurcation)