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9/20/18
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James M. Rich, CRNA, MADepartment of Anesthesiology & Pain Management
Baylor University Medical Center, Dallas, [email protected]
SLAM Rescue Airway Flowchart
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The SLAM Universal Emergency Airway Flowchart
•A thorough understanding of the flowchart is necessary prior to its use.•Algorithms by their very nature cannot be all-
encompassing and need to be interpreted, modified, and applied according to individual patient assessment and good clinical judgment
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Airway Assessment & Evaluation
The Devil is in the Details!!!
Ross Perot
Winner PGA 2003: Best Exhibit for Clinical Application
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SLAM Flowchart
Fills a dual role as both an emergency and difficult airway algorithm. Manages difficult airway situations through practical methods to modify failed intubation attempts, While providing the emergency airway practitioners with clinical guidance on:1. When tracheal intubation is appropriate,2. When to stop attempting tracheal intubation, or3. When to undertake rescue ventilation.
SLAM Universal Emergency Airway Flowchart
Four Clinical Care Pathways Decision Points:Determines thedirection of theflow based upona “yes” or “no”answer.
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Action Blocks:Tells you when to proceed with a therapeutic intervention.üCall for help,üAssess patient,üObserveüIntubate,üVentilate,üModify technique,üSwitch technique,üEtc.
Explanatory Blocks:üProvides explanationüGives options (T.I. & R.V.)
Consideration Borders:üDashed LinesüReminder of a clinical
consideration
Critical or Danger Blocks:üCrash airwayüCritical Airway EventüLike the 3-second zone in
basketball – stay here andyou will lose the patient,
üAlways leads to RescueVentilation Pathway
• Crash airway: Describes patients who have severe acute respiratory failure andtypically 1) exhibit reduced responsiveness or are unresponsive; 2) have a respiratoryrate of <10 or >30 breaths per minute; and 3) have severely depleted oxygen levels.Such patients are usually close to death and require either rapid tracheal intubation orimmediate rescue ventilation.• Critical airway event: Indicated by 1) any CMVCI situation; 2) three or more failedintubation attempts or attempted intubation for >10 minutes by an experienced laryngoscopist; or 3) sustained hypoxemia that is refractory to positive-pressure ventilation with 100% O2.
SAFE BLOCKS:üPost-Intubation ManagementüT.I. is confirmedüRescue Ventilation is
effective
Recognition and Management of the Crash Airway
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Why choose an SpO2 of 92%?Why choose an SpO2 of 92%?
Why choose an SpO2 of 92%? Rescue Ventilation &Cricothyrotomy Pathways
• Rescue Ventilation with any FDA Approved SAD.
• Cric can be TTJV, PDC or Surgical Cricothyrotomy
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What is Rescue Ventilation
Administration of 100% oxygen and positive pressure ventilation, preferably via an FDA approved alternative airway device: •Combitube, Easytube• LMA, •King LT, •Cobra PLA, •Easytube
Critical Airway EventThresholds for Switching to R.V.
• CMVCI• Refractory Hypoxemia• PU ≤ 92• Failed Intubation ≥ 3 times or• T.I. attempted for > 10 minutes.
OBSERVE, ASSESS, DECIDE!!!!
• BEWARE OF CLOSED-SPACE RESCUE SITUATIONS.• WHAT OR WHO IS YOUR WEAKEST LINK?• ASSESS THE AIRWAY AS THOROUGHLY AS POSSIBLE• EASIER TO STAY OUT OF TROUBLE THAN TO GET INTO TROUBLE – DON’T BE A COWBOY – CONSIDER RESCUE VENTILATION FIRST (DARV).
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Oxygenation – Ventilation Pathway Oxygenation – Ventilation Pathway
ç YES
ç YES
ç NO
Oxygenation – Ventilation Pathway
• Non-rebreathing Mask with OPA/NPA• PPMV with OPA/NPA• Supraglottic Airway Device
Difficult Mask Ventilation: FACES
• F-Facial Hair• A-Age > 55• C-Chubby BMI>26• E-Edentulous• S-Snoring
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No – RSI Pathway
Yes – Difficult Intubation Pathway
Yes – RSI Pathway or Difficult Intubation Pathway
No – Primary Ventilation or Rescue Ventilation Pathway
Intubation Pathways
• RSI, DSI• Difficult Intubation
Thresholds for Stopping T.I. and Proceeding With R.V.:�D.L. X 3�D.L. > 10 min. �Cannot attain
or maintain SpO2 ≥ 92%
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Confirmation of Tracheal Intubation
•Use what you have: Waveform EtCO2; Colorimetric CO2 Detector, Self Inflating Bulb, stethoscope, SaO2, 2nd Look D.L., & VL
ALWAYS Have a Backup Plan!} Always assess the airway for
difficulty – 6 D method} Promotes Oxygenation &
Ventilation over Tracheal Intubation
} Promotes simple techniques to prevent and overcome failed T.I.
} Thresholds for when to stop attempting T.I.
} Always overcome difficult mask ventilation and hypoxia with rescue ventilation
SLAM Flowchart
ASADifficultAirway Algorithm
James M. Rich, CRNA, MADepartment of Anesthesiology & Pain Management
Baylor University Medical Center, Dallas, TXwww.slamairway.com
THE UPPER AIRWAY:THE LARYNX
THE UPPER AIRWAY:THE LARYNX
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THE UPPER AIRWAY:POSTERIOR VIEWS OF THE LARYNX Direct Glottic Exposure: Straight Blade
Indirect Glottic Exposure: Curved BladeGRADING THE LARYNGOSCOPIC VIEW
• GRADE I - ENTIRE LARYNGEAL APERATURE• GRADE II - POSTERIOR
LARYNGEAL APERATURE• GRADE III - EPIGLOTTIS
ONLY• GRADE IV - SOFT
TISSUE ONLY
Cormack & Lehane Grade I Cormack & Lehane Grade II
ESOPHAGUS
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Cormack & Lehane Grade IIIEPIG
LOTIS IN
TERA
RY
TENO
ID N
OTC
H
ASSESING THE UPPER AIRWAY:THE ORAL CAVITY
Assess the Airway6-D METHOD – D IS FOR DIFFICULT
• Look for the 6 D’s:1. Disproportion2. Distortion3. Decreased Range of Motion4. Decreased Thyromental Distance5. Decreased Interincisor Gap6. Dental Overbite
• Upper Lip Bite Test: (A and A February 2003 by Dr. Khan et. Al)• Demonstrated a high degree of reliability
Airway Assessment 6-D METHOD
Disproportion = Mallampati Test
Airway Assessment6-D METHODDistortion
AIRWAY ASSESSMENT6-D METHODDecreased Interincisor Gap
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Airway Assessment6-D METHODDECREASED ROMAirway Range of Motion
AIRWAY ASSESSMENT6-D METHODDECREASED A/O ROM
AIRWAY ASSESSMENT:DECREASED THYROMENTAL DISTANCE Dental Overbite
Upper Lip Bite Test
•Place lower teeth beyond the vermillion of the upper lip.•Highly reliable in patients who:• Have teeth• Have no pharyngeal pathology• Can follow commands• No C-spine precautions
GENERAL OBSERVATION OF THE HEAD AND NECK
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GENERAL OBSERVATION OF THE HEAD AND NECK
Induced, Ventilated, Paralyzed Intubated after Multiple Blades & Maximal ELM
Easy Intubation
Take Home Message
•Done to move the patient from the dangerous to the safe road•High Incidence of False Positives•Occasional occurrence of false negatives•Always be prepared with backup plans A – B – C – etc.
