Microsoft PowerPoint - AALS講義.ppt

AALS Training Course Advanced Airway Life Support 實用高級氣道處置 Airway anatomy RA & RF Prediction of difficult airway Open airway Algorithm RSI, Sellick maneuver Airway devices One lung ventilation BVM, Basic Airway LMA Intubation, Tube Exchanger Combitube Trachlight, FOB Retrograde Cricothyrotomy PTIS Airway Anatomy Airway Anatomy C6 T5 Airway Anatomy Vallecula AE fold RA vs RF RA : Respiratory Arrest RF : Respiratory Failure, Distress Dyspnea Cuniform Corniculate 呼吸停止呼吸窘迫 Arytenoid 1

Check Breathing 依基本氣道處理原則, 必須先打開呼吸道, 再評估有無呼吸 RA 需緊急處理 Open airway 3L (Look, Listen, Feel ) 無呼吸有呼吸 RF 評估呼吸功能 Stable Unstable bradypnea tachypnea 呼吸型態改變意識形態改變血氧濃度降低血壓心跳變化發生氣道阻塞理學檢查發現 Unstable 淺快 Prediction of difficult airway Difficult Mask 費力 RF 不協調 Difficult Laryngoscopy 痰多 Difficult Intubation 困難氣道處置發生機率困難氣道處置種類發生機率 LEMON Rule 單純困難面罩通氣困難插管 (difficult intubation) 無法插管或插管失敗 (failed intubate or impossible intubate) 無資料 1%-4% 0.13%-0.3% L E Look externally Evaluate 3-3-2 rule 困難面罩通氣且困難插管 (difficult ventilate 且 difficult intubate) 1.5 % M Mallampati classification 困難面罩通氣且無法插管 (difficult ventilate, impossible intubate) 0.01-0.03% O Obstruction? 無法面罩通氣且無法插管 (cannot ventilate 且 cannot intubate) 約五千分之一 N Neck mobility 2

Attempts > 3 times or more Difficult Intubation More than 10 min SaO 2 < 90% 大舌頭 Receding mandible 正面像暴牙 Normal Patient 粗短頸側面像 overbite Post op Klipple Feil syndrome 3

下巴內縮正常 Thyromental Distance < 6 cm 9 cm Sternomental Distance < 11.5 cm 15 cm Open Airway 三軸合一 Opening the Airway Jaw thrust: 壓, 提, 推 Head tilt chin lift Opening the Airway Jaw thrust: 壓, 提, 推 Head tilt chin lift Opening the Airway 難易度頸椎保護使用時機 4

Opening the Airway Oropharyngeal airway;oral airway 正確位置與長度太短 Sniffing Position Wedge Shape Nasopharyngeal Airway Insertion Nasal vs Oral airway 長度 : 鼻尖至耳垂或下頷骨角之距離管徑大小 : 恰可塞滿鼻孔, 不致太緊男性 7.5-8# 女性 6.5-7# 氣道處理流程 ASA Difficult Airway Algorithm RA/RF Algorithm Difficult Mask Algorithm Intubate-Ventilate Algorithm All in one Algorithm 5

BVM (Bag-Valve Valve-Mask) 插得進擠得進 Normal Practice 插不進擠得進 Other airway device 插得進擠不進 Bronchodilator, Steroid 插不進擠不進 Combitube, Cricothyrotomy Tracheostomy PMR II BVM 3 C Bagging 單人操作 skill less effective 700 cc Difficult Mask Ventilation Obesity Use airway 雙人操作 easy more effective 1200-1500 cc Snoring Beard Lack of teeth Laryngospasm size Two hands Mask strap Special method 6

AALS Laryngeal Mask Airway LMA 喉罩口罩眼罩面罩胸罩喉罩 LMA Dr. Brain LMA 大事記 LMA Series 1981 LMA 第一次在人體使用 1983 第一篇醫學文獻發表 1990 全英國開刀房開始使用 1991 美國 FDA 認可使用 1993 美國麻醉醫學會 (ASA) 列入困難氣道處置流程 Unique Classic Fastrach Proseal Flexible 2000 ACLS 列為 class IIa 氣道處理 Purpose Size Volume Ventilation device Fastrach Intubation assist Blind FOB As suggested Pediatric: #3 Female : #3-#4 #4 Male: #5 Max. Volume: (size 1) x 10 ml Large size, Less pressure 7

Advantage Limitation Complicaiton Endotracheal Intubation Simple Easy to learn Easy to use Fast Reuse Intubaton Mouth open < 2 cm Regurgitation Obstruction Poor compliance Tumor Surgery Trauma Bleeding Laryngospasm Aspiration Leakage Supraglottic edema ETT Oral Awake or sedated Laryngoscopy LMA, Fastrach FOB Trachlight Retrograde Nasal Awake or sedated Laryngoscopy Blind FOB Trachlight Retrograde Stylet BURP Backward Backward-Upward Upward-Rightward Pressure Over Thyroid Cartilage 4.7 % 1.8 % Upward Rightward 8

AALS BURP 向前上提手腕旋轉 AALS Laryngoscope Set Call Help BURP Sniffing Position 白色 Stylet Difficult Intubation Algorithm Change Position 再墊頭 FOB, LMA, combitube,, surgical airway Laryngoscope Handle Series Laryngoscope Blades Series Green Spec. Handle Dolphin(Water Proof) Handle Fiber - GS System(No Lamp) Fiber - Dolphin System(Lamp in Blade) Traditional Blade-Lamp on blade 9

Dolphin VS Green Spec. System Laryngoscope Flex-Tip(McCoy) Laryngoscope Set Truview Laryngoscope Set Adapter for Photography Dophin Handle The Truview Laryngoscope Visual Field Pediatric Blade: Overall Length 78mm #2.5 Adult Blade: Overall Length 111mm #3.8 22 Degree more then Normal Blade The Truview Laryngoscope Blade TruView Blade vs Normal Blade Width 15mm 15mm = + + 28mm 21mm 28mm 15mm Machintosh Blade FiberClip Bundle with Halogen Lamp Optical View Tube 10

The Laryngoscope Intubating TruView Laryngoscope Intubating Truview Laryngoscope Intubating Normal Far-Sightedness Intibating Intubating Photos took by Digital Camera TruView Laryngoscope Application Truview + CCD Camara System 適用於開刀房內各種廠牌的影像放大系統臨床及教學兩相宜 TruView Laryngoscope Application Truview + Digital Camera 數位相機螢幕可放大影像, 讓插管更容易隨時可照相錄影與記錄插管過程建立與教學相機螢幕可隨操作者的習慣, 可轉至操作者的左邊或右邊組裝簡單輕巧易攜帶超值型插管教學工具數位相機規格 : 1. 317 萬畫數 2. 蔡司鏡片 3. Zoom 光學 3 倍數位 2 倍 =6 倍 4. 1.5 TFT monitor 5. 適用 SD 或 MMC 記憶卡 6. 錄影功能像數 : 最高 640*480 (30fps) 7. Monitor 角度可旋轉 270, 可任意調整位置及適合的插管角度 8. 體積小重量輕 ; 只有 125g, 不會增加插管的負擔 TruView Laryngoscope Intubating Video Tube Exchanger 彰化基督教醫院麻醉科提供情境模擬 : 呼吸加護中心病患, 先前插管時非常困難, 因氣管內管氣囊破裂, 導致使用呼吸器時異常漏氣, 必須更換氣管內管如何處理 11

舊管 Tube Exchanger 新管 Tube Exchanger Advantage Ventilation, oxygenation Easy use Safe Blunt tip Length marker Limitation Lubrication Limit in same route Pull out EET Push down sputum Rapi-Fit connector Confirmation of EET 2000 ACLS Bulb type Capnography EID ETCO 2 Bulb type Synrige Capnography Detector 12

RSI Rapid Sequence Intubation 快速插管 RSI : 6 P Prepare Preoxygenation Premedicaiton Pressure Paralysis Pass tube IV, monitor, instrument, suction 100 % O 2, Denitrogenation BZD, barbiturate, lidocaine Sellick maneuver Muscle relaxant Direct vision, BURP Sellick Maneuver Cricoid Cartilage the movable one Cricoid Pressure Prevent Aspiration Sellick Maneuver Sellick Maneuver Mechanism Prevention : regurgitation aspiration 100 cmh 2 O Priority Not NPO Pregnancy Intra-abdominal abdominal P. Hiatal hernia Achalasia Post gastrectomy SARS Complication C spine injury Laryngeal trauma Active vomiting 13

Lighted Stylet Trachlight Insertion Trachlight Advantage Priority Complication Retrograde intubation Fast Intubation As intubation Easy practice Failure intubation Easy learning Simple instrument CPR Cannot intubate Can Ventilate Less trauma Retrograde Intubating Retrograde intubation CVP set Retrograde set 14

Retrograde Cricothyrotomy Limitation Experience Priority C spine Complication Laceration Cricothyroidotomy Time consuming Skillful Local infection Local tumor Not identify Difficult airway Cannot intubate -Can ventilate infection Trauma, hematoma Pneumo Nerve damage 找不到洞打洞 Cricothyrotomy Cricothyrotomy cannot intubate cannot ventilate Melker Emergent cricothyrotomy IV catheter Cricothyrotomy Patil Emergent cricothyrotomy Surgical airway 15

Cricothyrotomy Separate Lung Ventialtion Limitation Priority Complication < 12 y/o Difficult airway Laryngeal stenosis Laryngeal Fx Inaccessible airway Voice change Trauma, infection tumor Facial Fx Oral bleeding Cannot intubate infection Trauma, hematoma Pneumo One Lung Ventialtion -Can ventilate Nerve damage One lung ventilation One Lung Ventialtion SimMan ACLS AALS 水電工氣 Let s s Play! volume rate pump airway 16