lunes, 29 de enero de 2018

Bolsa de Reanimacion Manual AMBU, GUIA DE

OXIGENOTERAPIA Y NEBULIZACIONES by Dr.
Ramon REYES, MD "El Panchito"

Bolsa de Reanimacion Manual AMBU, GUIA DE OXIGENOTERAPIA Y NEBULIZACIONES

Esta y otras informaciones en;
Sociedad IberoAmericana de EMERGENCIAS en TELEGRAM
https://t.me/joinchat/FpTSAEHYjNLkNbq9204IzA

Ventilación Bolsa Válvula Mascarilla.

Un dispositivo de bolsa válvula mascarilla es un resucitador manual que se usa para provee una
presión positiva ventilatoria. La bolsa válvula mascarilla consiste de una bolsa autoinflable, una
válvula unidireccional, una mascarilla facial, un puerto de entrada de oxígeno, y un reservorio de
oxígeno.

Muchas de las bolsas válvulas mascarillas para adultos tienen un volumen aproximado de 1,600
mililitros. Cuando se usa sin oxígeno, el dispositivo solo va a entregar 21% de oxígeno, o sea la
cantidad de aire que se encuentra en el medio ambiente. Agregando oxígeno y un reservorio, vas a
proporcionar casi un 100% de oxígeno al paciente, una de las ventajas mayores de este
dispositivo.

Las ventajas principales de usar la bolsa válvula mascarilla sobre la ventilación boca a mascarilla
son la conveniencia para el Paramédico y la habilidad de entregar una mezcla de oxígeno más
enriquecido. Sin embargo, la bolsa válvula mascarilla muy pocas veces nos proporcionan
volúmenes tidales que son posibles utilizando la ventilación boca a mascarilla.

El dispositivo bolsa válvula mascarilla es más difícil de usar de lo que parece y es más cansado
para el operador. El Paramédico tiene que provenir simultáneamente un buen sellado de la
mascarilla, manteniendo abierta la vía aérea colocando la cabeza del paciente hacia atrás y
levantando la mandíbula, oprimiendo la bolsa para entregar la ventilación. Toma mucha practica
mantener los conocimientos necesarios para realizar una ventilación adecuada con este
dispositivo. A causa de la dificultad para trabajar con la bolsa válvula mascarilla, es muy
recomendable utilizar este dispositivo con dos personas, aunque no siempre es posible. Una
mascarilla para un solo operador, como la mascarilla de bolsillo, tiene muy poco de estas
desventajas, toma menos práctica y conocimiento, y es más fácil usarse para cualquier socorrista
con o sin experiencia.

Una bolsa válvula mascarilla debe de tener estas características:

Una bolsa auto inflable que es fácil de limpiar y esterilizarse.

Un sistema de válvula que no se atore, y que permita la entrada de un flujo de 15 lpm.
Tiene o no tiene una válvula de escape (pop off) que puede ser inhabilitado manualmente. Una
válvula de escape (pop off) que no puede ser inhabilitada puede provocar una ventilación
inadecuada en algunos pacientes.
Conexiones estándar de 15/22 mm que permite el uso con una variedad de mascarillas de
ventilación y otros accesorios.
Una entrada de oxígeno y un reservorio que puede conectarse con una fuente de oxígeno para dar
mayor concentración durante la ventilación. Un reservorio de oxígeno debe ser usado cuando se
ventila a cualquier paciente.
Una verdadera mascarilla no recirculante que permite la salida de la exhalación del paciente pero
no permite la respiración de esos gases nuevamente.
Adaptabilidad a toda condición ambiental y a temperaturas extremas.
Una variedad de tamaños de mascarillas en infantes, niños y adultos. Una mascarilla
correctamente colocada debe de permanecer fija sobre el puente de la nariz y debajo del mentón.
Mascarillas transparentes para permitir la detección de vomito, sangre o secreciones durante la
ventilación. Nota que las cánulas naso y orofaringeas permiten mantener abierta la vía aérea y
deben considerarse en cualquier momento que se use la bolsa válvula mascarilla.

Técnica Bolsa Válvula Mascarilla.

Un dispositivo de bolsa válvula mascarilla puede ser usado por uno o dos Paramédicos. Por
razones mencionadas arriba, el uso de este dispositivo con dos Paramédicos es preferible. Un
Paramédico sujeta la mascarilla asegurando un buen sello con las dos manos, mientras el otro
Paramédico utiliza las dos manos para oprimir la bolsa para entregar un volumen pleno de aire
oxigenado.

Esta técnica es la más efectiva que con la operación por una persona y se utiliza siempre, a menos
que la disponibilidad de personal y las circunstancias no lo permitan (ej. cuando no hay
suficiente espacio para maniobrar con dos Paramédicos). Los procedimientos para el uso de la
bolsa
válvula mascarilla son:
Si es posible, colócate sobre la cabeza del paciente. Si no hay sospecha de lesiones espinales,
abra la vía aérea usando la inclinación de la frente hacia atrás y elevación del mentón. Levanta un
poco la cabeza del paciente con una toalla o almohada para llegar a una mejor posición de olfateo.
Selecciona la mascarilla correcta y el dispositivo de la bolsa válvula. Si el paciente no responde,
inserta una cánula oro o nasofaringea para mantener la vía aérea permeable.
Coloca la parte más angosta de la mascarilla sobre el puente de la nariz y la parte más anchasobre
la boca y el surco del mentón. Si la mascarilla tiene un mango redondo alrededor del puerto de
ventilación, céntralo sobre la boca.
Coloca tus dedos pulgares sobre la mitad superior de la mascarilla y el índice y el resto de los
dedos se colocan en la mitad inferior de la mascarilla. Usa el dedo anular y meñique para levantar
la mandíbula del paciente hacia la mascarilla. Los dedos medios, dependiendo del tamaño de las
manos del Paramédico, puede ser colocados bajo la mandíbula o encima de la mascarilla. Los
bordes de las palmas (del lado de los pulgares) se colocan sobre las orillas de la mascarilla para
mantenerla en su lugar y lograr un buen sellado.
Otro Paramédico debe conectar la bolsa válvula a la mascarilla si no ha sido ya conectada.
Comience la ventilación lo más pronto que sea posible. El otro Paramédico, o otra persona
capacitada, debe de oprimir la bolsa con las dos manos mientras observa la subida y bajada del
pecho. La ventilación debe de ser entregado en un periodo de 1.5 a 2 segundos en un adulto, y 1 a
1.5 segundos para infantes y niños.
La ventilación debe de ser dada como mínimo cada 5 segundos en un adulto y 1 vez cada
3segundos en infantes y niños. Debes monitorear constantemente la subida y bajada del pecho
para ver si es adecuada.
Si la bolsa válvula mascarilla no ha sido conectado al oxígeno suplementario, el paciente debe
recibir ventilaciones de presión positiva por un minuto. En este punto, el otro Paramédico debe de
conectar la mascarilla, ajustar el flujo a 15 litros por minuto, conectar el reservorio si no ha sido
conectado y resumir ventilación.

En aquellas situaciones cuando estas utilizando la bolsa válvula mascarilla solo, coloque la
mascarilla a la boca del paciente con una mano. Debe colocar su dedo pulgar sobre la parte de la
mascarilla que cubre el puente de la nariz, y su dedo índice sobre la parte que cubre el mentón.
Asegura un buen sello en la cara empujando hacia abajo con los dedos pulgar e índice, mientras
levantas el mentón con lo demás de los dedos para efectuar la inclinación de la cabeza y elevación
del mentón.

Oprime la bolsa con la otra mano mientras observas la subida y bajada del pecho para asegurar
que ambos pulmones están ventilados efectivamente. Se puede oprimir la bolsa alternativamente
contra su cuerpo, antebrazo o el muslo para entregar un volumen tidal mejor al paciente.
Problemas de la Bolsa Válvula Mascarilla Si el pecho del paciente no sube y baja, hay que re
evaluar el dispositivo de Bolsa Válvula Mascarilla y la vía aérea del paciente, considerando estos
problemas posibles y sus remedios:
Verifica la posición de la cabeza y mentón. Reposiciona la vía aérea y trata de ventilar otra vez.
Verifica el sello de la mascarilla para asegurar que no hay una cantidad excesiva de aire
escapando alrededor de la mascarilla. Reposiciona los dedos y la mascarilla para obtener un sello
más adecuado.
Evaluar por una obstrucción. Si hasreposicionado la vía aérea y el sello es el adecuado, debes
considerar una obstrucción de la vía aérea. Inspecciona la boca en busca de una obstrucción. Si
encuentras una obstrucción, retírala mediante un barrido digital. Si no encuentras nada, hay que
comenzar la maniobra de Heimlich hasta que pueda ventilar efectivamente otra vez.
Verifica el sistema de la bolsa válvula mascarilla para asegurar que todas las partes están
conectadas correctamente y están funcionando como debe ser. Algunos sistemas con una bolsa
reservorio se van a llenar muy despacio si hay un flujo de oxígeno inadecuado. Este causa una
reducción en el volumen tidal entregado al paciente y subsecuentemente produce una mínima
elevación y descenso del pecho.
Si el pecho no sube y baja, hay que utilizar un método alternativo para ventilar con presión positiva,
por ejemplo una mascarilla de bolsillo, o un dispositivo ventilatorio impulsado por oxígeno y con
flujo restringido.
Si tienes problemas manteniendo una vía aérea permeable, inserta una cánula orofaringea o
nasofaringea. Cualquier de los dos va a prevenir que la lengua caiga hacia atrás semi-bloqueando
la vía aérea.
Si notas que el abdomen del paciente sube con cada ventilación o está distendido, hay dos causas
posibles.

La inclinación de la cabeza con elevación del mentón no está bien hecha permitiendo una cantidad
excesiva de aire entrar el esófago y al estómago. Reposicionar la cabeza y cuello, y tratar de
ventilar otra vez.
Se está ventilando al paciente demasiado rápido o con demasiado volumen tidal. Estas
ventilaciones excesivas aumentan la presión en el esófago y permite la entrada de aire al
estómago. Oprime la bolsa lentamente para entregar el volumen sobre un periodo de 2 segundos y
dejar suficiente tiempo para la exhalación después de cada ventilación.
Fuente

Hojas Técnicas
Descarga: Ambu® Mark III Militar(223,27 Kb.)
Información Adicional
Descarga: ES detergentes compatibles resucitadores_web1.pdf(458,44 Kb.)

Relacionado

Ambu® Mark IV Adulto y Baby

GUIA DE OXIGENOTERAPIA Y NEBULIZACIONES

Dr. Ramon Reyes, MD

Enlace para bajar PDF Gratis

Medicamentos para el Manejo de la Via Aerea PDF

Consecuencias del uso en exceso del O2 Oxigeno en

Neonatos

Displasia Broncopulmonar y Fibroplasia Retrolental

Cómo puede ser tóxico el oxígeno en el período

neonatal

EMS España / Emergency Medical Services en España

Emergency Airway Controversies

There are so many emergency airway controversies in emergency medicine! Dr. Jonathan Sherbino, Dr.
Andrew Healy and Dr. Mark Mensour debate dozens of these controversies surrounding emergency
airway management. A case of a patient presenting with decreased level of awareness provides the basis
for a review of the importance, indications for, and best technique of bag-valve-mask (BVM) ventilation,
as well as a discussion of how best to oxygenate patients. This is followed by a discussion of what
factors to consider in deciding when to intubate and some of the myths of when to intubate. The next
case, of a patient with severe head injury who presents with a seizure, is the fodder for a detailed
discussion of Rapid Sequence Intubation (RSI). Tips on preparation, pre-oxygenation and positioning
are discussed, and some great debates over pre-treatment medications, induction agents and paralytic
agents ensues. The new concept of Delayed Sequence Intubation is explained and critiqued. They review
how to identify a difficult airway, how best to confirm tube placement and how to avoid post-intubation
hypotension. In the last case of a morbidly obese asthmatic they debate the merits of awake intubation vs
RSI vs sedation alone in a difficult airway situation and explain the best strategies of ventilation to avoid
the dreaded bradysystlolic arrest in the pre-code asthmatic. Finally, some key strategies to help manage
the morbidly obese patient’s airway effectively are reviewed.There are so many emergency airway
controversies in emergency medicine! Dr. Jonathan Sherbino, Dr. Andrew Healy and Dr. Mark Mensour
debate dozens of these controversies surrounding emergency airway management. A case of a patient
presenting with decreased level of awareness provides the basis for a review of the importance,
indications for, and best technique of bag-valve-mask (BVM) ventilation, as well as a discussion of how
best to oxygenate patients. This is followed by a discussion of what factors to consider in deciding when
to intubate and some of the myths of when to intubate. The next case, of a patient with severe head
injury who presents with a seizure, is the fodder for a detailed discussion of Rapid Sequence Intubation
(RSI). Tips on preparation, pre-oxygenation and positioning are discussed, and some great debates over
pre-treatment medications, induction agents and paralytic agents ensues. The new concept of Delayed
Sequence Intubation is explained and critiqued. They review how to identify a difficult airway, how best
to confirm tube placement and how to avoid post-intubation hypotension. In the last case of a morbidly
obese asthmatic they debate the merits of awake intubation vs RSI vs sedation alone in a difficult airway
situation and explain the best strategies of ventilation to avoid the dreaded bradysystlolic arrest in the
pre-code asthmatic. Finally, some key strategies to help manage the morbidly obese patient’s airway
effectively are reviewed.

Written Summary and blog post by Lucas Chartier, edited by Anton Helman October 2010

In this episode on Emergency Airway Controversies, Dr. Sherbino, Dr. Healy and Dr. Mensour answer
questions like: Does Delayed Sequence Intubation have a role in airway management? Which is the best
induction agent for patients with head injury? Asthma? What are the pros and cons of Roccuronium vs
Succinylcholine? What is the evidence for pre-treatment using lidocaine and fentanyl and head injured
patients? Is the new drug Suggamadex useful? Should we be using Video Laryngoscopy (eg:
Glidescope) as the primary tool for endotracheal intubation? What is the newest evidence for what
constitutes a difficult airway? What are the best methods for confirming Endotracheal Tube placement?
How can we best prevent and treat post-intubation hypotension? What is the best positioning for obese
patients for intubation? What are the best ventilator settings for patients in status asthmaticus? and many
more…..

General approach to patient with respiratory depression

Transport patient to resuscitation area, notify the whole team (RNs, RTs, etc), and have all the
equipment ready (IVs, advanced airways, cardiorespiratory monitors)
Consider 500cc to 1L bolus IV of NS; consider 4‐point restraints before giving the naloxone to protect
the patient and medical staff, as well as one attempt at bag‐valve‐mask ventilation (BVM) to rule out
laryngospasm, which could cause negative pressure pulmonary edema if the patient inspires against a
closed glottis once the naloxone is given

Oxygen delivery
Nasal prongs deliver only slightly more than the 21% of O2 containted in air because of the entrainment
effect it creates, and “100% non‐rebreather mask” only delivers 65‐70% O2 at best To get better
oxygenation, a better seal is needed, whether through BVM, non‐invasive positive pressure ventilation
(NIPPV), or endotracheal intubation

Tips for good BVM technique

A health care provider (experienced with BVM) delegated exclusively to this task in order to perform it
adequately (RR = 8‐12/min, not more!) with the right sized equipment, and consider using an
oropharyngeal airway and/or 2 nasopharyngeal airways (trumpets)
2‐handed, 2‐person technique (2 hands on the mask, and a second person squeezing the bag) is much
more effective at opening up the airway by moving the mandible forward into the mask, i.e. jaw thrust,
instead of driving the mask down on the face, which makes the soft tissue obstruct the airway
two_person_bvm_1

Two methods for 2‐handed technique: (a) mirror image of what is usually done for onehanded technique
(image 1), which allows 3 fingers per hand to lift the mandible;and (b) thenar eminences holding the
mask with the thumbs in the direction of the patient’s feet, with 4 fingers per hand to lift the mandible
(image 2)
For bearded patients, consider putting a tegaderm patch on the beard (with a hole for ventilation!), or
lubricant jelly in order to improve the seal; for edentulous patients, keep the dentures in for BVM (and
remove for intubation), or put gauzes inside the cheeks
Mnemonic for difficult BVM: BOOTS – Bearded, Obese, Old, Trauma (eg, obstruction), Stiffness (eg,
OSA, COPD); also consider the effects of radiation therapy, which increases stiffness and decreases
mouth opening

Indications for intubation

General indications: obtain and maintain an airway in the setting of obstruction; correct deficient gas
exchange (hypoxia or hypercarbia); prevent aspiration of blood, saliva, or other secretions; and predicted
clinical deterioration
Additional pearls
Dogmatic approach like “GCS less than 8 means intubate” is inappropriate because it neglects the
expected clinical course of the patient, and also because the GCS scores have only been validated in the
setting of trauma (although GCS can still be used as a universal language to communicate with other
team members)
Patient not protecting his/her own airway is assessed by pooling of secretions in the oropharynx or
absence of cough reflex; the presence or absence of gag reflex is not reliable (many elderly patients
don’t have it at baseline, and shown to have no correlation with passive aspiration in patients undergoing
swallowing studies)
Other reasons to intubate: completely unresponsive patient with no expected early improvement; airway
protection needed to decontaminate a patient with overdose; and severe sepsis and refractory shock,
where the mechanical ventilation is meant to decrease the energy used by the patient for breathing,
energy which can then be diverted towards other productive uses by the patient’s body

Sellick’s maneuver
Cricoid pressure (different than BURP – see below) to prevent passive aspiration by occluding the
esophagus against the vertebral bodies
The evidence supporting it is poor: it does not decrease passive aspiration, it does not improve intubation
success rates, it increases air trapping, it distorts of laryngopharyngeal landmarks, and it decreases
venous return from the heart by occluding jugular veins
In order to decrease the likelihood of aspiration, Sellick’s maneuver may be used but should be
abandoned quickly if it impairs intubation attempts, and better techniques to avoid aspiration include
keeping a low positive pressure during ventilation in order to decrease gastric insufflation

BURP maneuver
Backwards, Upwards, Rightward Pressure used by intubator or assistant to improve laryngoscopic view
by pushing the larynx towards the patient’s right while the laryngoscope pushes the tongue towards the
patient’s left

Difficult airway
Predictors of difficult laryngoscopy: LEMON
Look externally for gestalt assessment of difficulty (not sensitive but quite specific) such as small
mandible, large teeth, large tongue and short neck
Evaluate 3‐3‐2, with 3 of patient’s own fingers between the teeth during mouth opening, 3 fingers of
mandibular length between the chin and the hyoid bone, i.e. the base of the tongue, and 2 fingers
between the hyoid bone and the thyroid cartilage
Mallampati: Class I when all buccal structures visible with mouth opening and tongue out; Class II when
tonsillar pillars not visible; Class III when minimal pharyngeal wall visible; Class IV when only palate
visible
Obstruction or Obesity
Neck mobility: C‐spine collar or rheumatoid arthritis preventing C‐spine movement

Predictors of successful intubation

Experienced intubator, patient’s lack of muscle tone, optimal positionining of intubator and patient (see
below), optimal blade length and type, adequate laryngeal manipulation (eg, BURP)

7 Ps of Rapid Sequence Intubation (RSI)

Preparation, Pre‐oxygenation, Pretreatment, Paralysis and induction, Position, Placement with proof,
Postintubation management
Preparation

SOAP ME: Suction, Oxygen, Airways (BVM, blades, with plan B and C – eg, Glidescope, Trach light,
intubating LMA), Pharmacology, Monitors, Escape plan (anticipate 2‐3 steps down a worst‐case
scenario for each individual patient)
Preoxygenation

Non‐rebreather mask or BVM in order to replace the patient’s FRC (functional residual capacity) from
nitrogen to oxygen, which will allow for more time before arterial desaturation
Delayed Sequence Intubation (DSI):
DSI is a form of procedural sedation for means of pre‐oxygenation with positive pressure ventilation
when traditional pre‐oxygenation is unsuccessful (due to alveolar shunting seen in primary pulmonary or
septic conditions)
Method: insertion of behavioural control of the patient (i.e. calm him/her) before paralysis with ketamine
sedation while still maintaining spontaneous respirations in order to tolerate oxygenation with PEEP (eg,
CPAP), which will ultimately result in better pre‐oxygenation and better intubation conditions
for more on Delayed Sequence Intubation go to EMCrit website
Pretreatment (3min before induction)

Lidocaine 1.5mg/kg IV used in reactive airway diseases and elevated intracranial pressure (ICP), but
theevidence is poor
Fentanyl 3μg/kg IV used in elevated ICP and patients with cardiovascular disease to prevent the reflex
sympathetic response to laryngoscopy, which raises both heart rate and blood pressure
Volume rehydration with 12cc/kg of crystalloid to correct the patient’s relative dehydration
Avoiding hypotension, hypoxia and hypercarbia is even more important than the above methods, and
therefore an individualized approach to each patient should be done (eg, if patient is hemodynamically
unstable and propofol is the only available induction agent, then foregoing fentanyl would be reasonable
as it will create even more hypotension)
Non‐defasciculating dose of non‐depolarizing neuromuscular blocking agent (when succinylcholine will
be used as the paralytic agent) should not be used as pretreatment
Induction agent choices

Etomidate (might lower seizure threshold), Ketamine (can be used in head‐injured patients as the
concerns about raised ICP are unfounded), Propofol (probably best in the setting of seizures given
antiepileptic properties, although it might cause hypotension), Ketofol (not recommended by EMC
experts as an induction agent)
Paralytic agent choices

Neurologic assessment needs to be performed before paralysis in order to assess serial changes,
including GCS score (including best motor response), pupillary size and reaction, and reflexes
The 3 EMC experts use rocuronium (1mg/kg) because of the lack of contraindications attached to
succinylcholine (SCh), and they feel that the longer time to action (60sec compared to the 45sec of SCh)
is not clinically significant; moreover, they feel that the longer time of action (40‐60min compared to
7min) is irrelevant because the patient will need paralysis to go to the CT scan, and the neurological
status of the patient cannot have changed so dramatically that another neurological assessment is
necessary within minutes of intubation
Suggamadex is a new medication that completely reverses the effects of rocuronium in 1‐2min at a dose
of 4mg/kg; in most cases, however, unlikely that reversal of paralysis is needed immediately after
intubation
Succinylcholine (dose of 1.5mg/kg) is favoured by the Cochrane database for RSI due to better
intubating conditions and less post‐paralysis pain, but contraindications need to be remembered:
hyperkalemia (eg, dialysis); burns, crush injuries and neurological dysfunction (eg, stroke) starting at 5
days after the insult
Positioning

Optimal position: bed at the level of the intubator’s belt line, straight back and arms at a distance from
the patient, holding the laryngoscope blade at the base of the handle, with the appropriate blade type
(curved blade allows for better tongue control, but straight may be used if attempt is unsuccessful with
straight blade)
Optimal patient position: sniffing position (although simple head extension without lower C‐spine
flexion may be just as good); for trauma patients, C‐collar removed while assistant is providing manual
in‐line stabilization from below, to allow for movement of the mandible forward and optimization of the
glottic view
Consider using adjuncts – Video laryngoscope (which may lead to less C‐spine mobilization than direct
laryngoscopy), Trach light (light wand), intubating LMA or fiberoptic scope – and don’t repeat the exact
same sequence twice if you fail: something has to be changed to provide better intubating condition and
be successful

emcases-update

Update 2017: A recent prospective observational study by Turner et al. (2017) has shown elevating the
head of the bed, particularly to ≥45degrees, helps facilitate first-pass success for endotracheal intubation
performed by residents in the ED. This correlates with recent literature questioning the traditional supine
method – which suggests head-elevated positioning improves pre-oxygenation, glottic view, and reduces
risk of intubation complications. Abstract

emergency airway controversies

Medications for Airway Management card PDF 2017

Placement with proof

Reference standards: End‐tidal CO2 monitoring, either with capnography (number and waveform) or
colorimetric (Yellow color = “Yes”, and purple = “The colour of the patient when tube in the wrong
place”, but has a 4‐7% failure rate) – ETCO2 will be negative in ⅓ of cardiac arrests due to lack of
cardiac output; anotherconfirmation method is confidently seeing the endotracheal tube going through
the vocal cords confirmation method is confidently seeing the endotracheal tube going through the vocal
cords
Other methods: Esophageal detector device (squeeze the bulb and apply to tube – it will stay collapsed if
in the esophagus, but pop open if in the trachea), auscultation, misting of the tube
Placement of the tube at 21cm of length at the upper teeth (or alveolar ridge if edentulous) in women
will result in the tip being at 3cm from the carina in 95% of individuals; the number in males is 23cm
Immediate postintubation management

First step: adequate analgesia with fentanyl 25‐50μg IV q5min PRN based on vital signs
Second step: sedation (especially if patient paralyzed) with midazolam 5mg (±2mg depending on
patient’s weight and hemodynamics) or lorazepam 1‐2mg IV puss; assess degree of sedation with facial
muscle tension, movements and increased heart rate and blood pressure
Third step: start propofol or midazolam drip, volume resuscitation, NG tube, consider using ketamine or
phenylephrine IV push for hypotension, and wrist restraints in case the patient wakes up

Tips for emergency airway management of obese patients

Optimize preoxygenation because of RAPID desaturation (decreased FRC and increased metabolic rate,
with resting hypoxemia and hypercapnia even without underlying lung pathology), higher likelihood for
and worse consequences from aspiration (larger gastric volumes with lower pH); all of BVM,
laryngoscopy, intubation and surgical airway will be difficult, so prepare plans B and C (and D)
Consider putting a “ramp of blankets” under obese patients (eg, 7 blankets under the occiput, 5 under the
shoulder and 3 under the scapula) so that the external auditory canal is on an horizontal line with the
sternum, as well as reverse Trendelenburg position (to push the abdominal content away from the lungs)
Remember that other types of patients also desaturate quickly: pregnant, extremes of age, CHF, COPDIn
the setting of severe asthma:
In the setting of severe asthma:
Intubate only if all treatment modalities have been optimized and are still unsuccessful – getting the air
out of the lungs is the patient’s problem and a ETT will likely not help so much for that; eg, patient is
peri‐arrest and will go into PEA if not intubated (have ENT or anesthesia back‐up present), and consider
using ketamine

For EM Cases main episode on Managing Obese Patients with Rich Levitan, Andrew Sloas and David
Barbic go to Episode 69

Ventilation of the asthmatic or COPD patient

Permissive hypercapnia: low tidal volume, low plateau pressure and low peak inspiratory pressure in
order to protect the lungs from barotrauma and ventilator‐induced lung injury, with low respiratory rate
and long expiratory phase in order prevent air trapping, hyperinflation and subsequent cardiovascular
compromise; results in higher than normal CO2 and lower than normal pH (down to 7.2)
If an episode of hypotension occurs, you should (1) disconnect the patient from the ventilator to allow
for full exhalation of the air that is likely trapped (manual chest pressure may help), (2) assess the DOPE
mnemonic – Displacement of tube, Obstruction of tube, Pneumothorax and Equipment failure
Do not forget to continue standard therapies such as volume resuscitation, inhaled bronchodilators, and
consider using inhaled anesthetics in the OR as a last ditch effort

Airway poster for your ED by Dr. Caroline Shooner summarizing all EM Cases airway related resources

Dr. Sherbino, Dr. Helman, Dr. Healy and Dr. Mensour have no conflicts of interest to declare.

Key References
Walls RM, Murphy MF. Manual of Emergency Airway Management. Lippincott Williams & Wilkins;
2008.

Ovassapian A, Salem MR. Sellick’s maneuver: to do or not do. Anesth Analg. 2009;109(5):1360-2.

Snider DD et al. The “BURP” maneuver worsens the glottic view when applied in combination with
cricoid pressure. Can J Anaesth 2005 Jan; 52:100-4.
El-Orbany M, Woehlck HJ. Difficult mask ventilation. Anesth Analg. 2009 Dec;109(6):1870-80.

Ni chonghaile M, Higgins B, Laffey JG. Permissive hypercapnia: role in protective lung ventilatory
strategies. Curr Opin Crit Care. 2005;11(1):56-62.

https://emergencymedicinecases.com/episode-8-emergency-airway-controversies/
Tactical Medicine TACMED España
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