9. Conocimiento del Mercado
9.2. Investigación de mercado
fauces, pillars visible uvula, fauces visibleClass II: soft palate, Class III: soft palate,base of uvula visible Class IV: hard palateonly visible
Mallampati Classifications. These classifications are used to visualize the hypopharynx. Class I: soft palate, uvula, fauces, pillars entirely visible; Class II: soft palate, uvula, fauces partially visible; Class III: soft palate, base of uvula visible; Class IV: hard palate only visible.
n FIGURE 2-4 Airway Decision
Scheme. Clinicians use this algorithm
to determine the appropriate route of airway management. Note: The ATLS Airway Decision Scheme is a general approach to airway management in trauma. Many centers have developed other detailed airway management algorithms. Be sure to review and learn the standard used by teams in your trauma system.
30 CHAPTER 2 n Airway and Ventilatory Management
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algorithm applies only to patients who are in acute respiratory distress or have apnea, are in need of an immediate airway, and potentially have a c-spine injury based on the mechanism of injury or physical examination findings. (Also see functional Airway
Decision Scheme on MyATLS mobile app.)
The first priority of airway management is to ensure continued oxygenation while restricting cervical spinal motion. Clinicians accomplish this task initially by positioning (i.e., chin-lift or jaw-thrust maneuver) and by using preliminary airway techniques (i.e., nasopharyngeal airway). A team member then passes an endotracheal tube while a second person manually restricts cervical spinal motion. If an endotracheal tube cannot be inserted and the patient’s respiratory status is in jeopardy, clinicians may attempt ventilation via a laryngeal mask airway or other extraglottic airway device as a bridge to a definitive airway. If this measure fails, they should perform a cricothyroidotomy. These methods are described in detail in the following sections. (Also see Airway Management Tips video on MyATLS
mobile app.)
airway MaintenanCe teCHniqUes
In patients who have a decreased level of conscious- ness, the tongue can fall backward and obstruct the hypopharynx. To readily correct this form of ob- struction, healthcare providers use the chin-lift or jaw-thrust maneuvers. The airway can then be maintained with a nasopharyngeal or oropharyngeal airway. Maneuvers used to establish an airway can produce or aggravate c-spine injury, so restriction of cervical spinal motion is mandatory during these procedures.Chin-Lift Maneuver
The chin-lift maneuver is performed by placing the fingers of one hand under the mandible and then gently lifting it upward to bring the chin anterior. With the thumb of the same hand, lightly depress the lower lip to open the mouth (nFIGURE 2-5). The
thumb also may be placed behind the lower incisors while simultaneously lifting the chin gently. Do not hyperextend the neck while employing the chin-lift maneuver.
Jaw-Thrust Maneuver
To perform a jaw thrust maneuver, grasp the angles of the mandibles with a hand on each side and then
displace the mandible forward (nFIGURE 2-6). When used
with the facemask of a bag-mask device, this maneuver can result in a good seal and adequate ventilation. As in the chin-lift maneuver, be careful not to extend the patient’s neck.
Nasopharyngeal Airway
Nasopharyngeal airways are inserted in one nostril and passed gently into the posterior oropharynx. They should be well lubricated and inserted into the nostril that appears to be unobstructed. If obstruction is encountered during introduction of the airway, stop and try the other nostril. Do not attempt this procedure in patients with suspected or potential cribriform plate fracture. (See Appendix G: Airway Skills and
Nasopharyngeal Airway Insertion video on MyATLS
mobile app.)
n FIGURE 2-6 The Jaw-Thrust Maneuver to Establish an Airway.
Avoid extending the patient’s neck.
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n FIGURE 2-5 The Chin-Lift Maneuver to Establish an Airway. Providers
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Oropharyngeal Airway
Oral airways are inserted into the mouth behind the tongue. The preferred technique is to insert the oral airway upside down, with its curved part directed upward, until it touches the soft palate. At that point, rotate the device 180 degrees, so the curve faces downward, and slip it into place over the tongue
(n FIGURE 2-7; also see Oropharyngeal Airway Insertion
video on MyATLS mobile app).
Do not use this method in children, because rotating the device can damage the mouth and pharynx. Instead, use a tongue blade to depress the tongue and then insert the device with its curved side down, taking care not to push the tongue backward, which would block the airway. Both of these techniques can induce gagging, vomit- ing, and aspiration; therefore, use them with caution in conscious patients. Patients who tolerate an oropharyngeal airway are highly likely to require intubation. (See
Appendix G: Airway Skills.)
Extraglottic and Supraglottic Devices
The following extraglottic, or supraglottic, devices have a role in managing patients who require an advanced airway adjunct, but in whom intubation has failed or is unlikely to succeed. They include laryngeal mask airway, intubating laryngeal mask airway, laryngeal tube airway, intubating laryngeal tube airway, and multilumen esophageal airway.
Laryngeal Mask Airway and Intubating LMA The laryngeal mask airway (LMA) and intubating laryngeal mask airway (ILMA) have been shown to be effective in the treatment of patients with difficult airways, particularly if attempts at endotracheal intubation or bag-mask ventilation have failed. An example of an LMA appears in (nFIGURE 2-8). Note that
the LMA does not provide a definitive airway, and proper placement of this device is difficult without appropriate training.
The ILMA is an enhancement of the device that allows for intubation through the LMA (see Laryngeal Mask
Airway video on MyATLS mobile app). When a patient
has an LMA or an ILMA in place on arrival in the ED, clinicians must plan for a definitive airway.
Other devices that do not require cuff inflation, such as the i-gel® supraglottic airway device, can be used in place of an LMA if available (nFIGURE 2-9).
Laryngeal Tube Airway and Intubating LTA
The laryngeal tube airway (LTA) is an extraglottic airway device with capabilities similar to those of the LMA in providing successful patient ventilation
(n FIGURE 2-10). The ILTA is an evolution of the device
AIRWAY MANAGEMENT 31
n FIGURE 2-7 Alternative Technique for Inserting Oral Airway.
A. In this technique, the oral airway is inserted upside down until
the soft palate is encountered. B. The device is then rotated 180 degrees and slipped into place over the tongue. Do not use this method in children. Note: Motion of the cervical spine must be
restricted, but that maneuver is not shown in order to emphasize the airway insertion technique.
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n FIGURE 2-8 Example of a laryngeal mask airway.
A
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that allows intubation through the LTA. The LTA is not a definitive airway device, so plans to provide a definitive airway are necessary. As with the LMA, the LTA is placed without direct visualization of the glottis and does not require significant manipulation of the head and neck for placement.
Multilumen Esophageal Airway
Some prehospital personnel use multilumen eso- phageal airway devices to provide oxygenation and ventilation when a definitive airway is not feasible.
(n FIGURE 2-11). One of the ports communicates with the
esophagus and the other with the airway. Personnel using this device are trained to observe which port occludes the esophagus and which provides air to the trachea. The esophageal port is then occluded with a
balloon, and the other port is ventilated. Using a CO2 detector provides evidence of airway ventilation. The multilumen esophageal airway device must be removed and/or a definitive airway provided after appropriate assessment. End tidal CO2 should be monitored, as it provides useful information regarding ventilation and perfusion.