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Dr.

Alan Bazn Farfn

Anestesilogo Jefe SAMU Regin de Los Lagos Dipl. Gestin Instituciones de Salud Dipl. Medicina Aeroespacial Sin conflicto de intereses

El paciente no se muere porque no fue intubado, sino porque no fue oxigenado

Con estas maniobras se obtiene la permeabilidad de la va area en el 97% de los casos

Estmago lleno Potencial dao columna cervical Mala iluminacin y trabajo en espacios confinados

Riesgo Aspiracin Pulmonar Dificultad manejo V.A. Dificultad manejo V.A. Morbilidad por desconocer condicin real del dao Morbimortalidad por recursos insuficientes

Dao multisistmico
Mltiples vctimas

Caractersticas

Consecuencias

Profesionales universitarios no mdicos Cumplen labores propias de la formacin mdica:


Diagnstico Decisin Manipulacin y colocacin de dispositivos en va area Administracin de frmacos Etc.

Competencias no entregadas en sus mallas curriculares de pregrado

Cdigo Sanitario

ATLS

ASA
RCP: 5:1 15:2

Intubacin Endotraqueal y proteccin columna cervical

Medicina Basada en la Evidencia:


30:2 200:2 ???? Guas RCP AHA 2005:
la experiencia con dispositivos avanzados para la va area muestra claramente

que la intubacin traqueal realizada por personal inexperto puede asociarse con alta tasa de complicaciones

Guas AHA 2010:


Nos cambia el A B - C por C A B RCP mnimas interrupciones

1. 2.

IOT interrumpe el aporte de Oxigeno durante la RCP Uso de hipnoinductores y BNM. Riego/beneficio llegar a no puedo

intubar, no puedo ventilar

3.

2 ms intentos fallidos de IOT, traumatiza va area, edema y sangrado dificultad progresiva hasta prdida de la ventilacin Bolsa-Mscara
A mayor expertice del personal en manejo de la va area, mayor sobrevida y outcome del paciente La sobrevida de los pacientes crticos es similar en aquellos IOT y los ventilados Bolsa mscara

4.

5.

Benumof JL, Anesthesiology 1991:75: 1087-1110 Practice Guidelines for Management of the Difficult Airway. Anesthesiology 1993:78:597-602 An update report by ASA Task Force Management of the Difficult Airway. Anesthesiology

2003:95: 1269-1277

Nivel de educacin y entrenamiento necesario para el uso seguro de una tcnica especfica.

La herramienta correcta en las manos correctas

Entrenamiento Avanzado:

Entrenamiento Intermedio:

Ventilacin Bolsa Mscara Dispositivos Supraglticos IOT IOT ISR Mdicos entrenados Especialistas

Entrenamiento Bsico:

Pocket Mask Ventilacin Bolsa Mscara Dispositivos Supraglticos Reanimadores-Mdicos generales

Pocket mask Ventilacin Bolsa Mascarilla TENS

Berlac P, Hyldmo PK, Kongstad P, et Al. Pre-Hospital airway management guidelines a task force from Scandinavian Society for Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2008; 52: 897-907

1.

Cnulas farngeas

2.

Mscara facial
Mscara larngea

3.

4.

Tubos endotraqueales

Kurolan JO, Turunen MJ, Laakso JP et al. A comparison of the laryngeal tube and bagvalve mask ventilation by emergency medical technicians: a feasibility study in anesthetized patients. Anesth Analg 2005; 101: 1577-81 Doerges V, Sauer C, Ocker H et al. Airway management durin cardiopulmonary resuscitation a comparative study of bagvalve-mask, laryngeal mask airway and combitube ina a bench model. Resuscitation 1999; 41: 63-9

Stone BJ, Chantler PJ, Baskett PJ. The incidence of regurgitation during cardiopulmonary resuscitation: a comparinson between the bag valve mask and laryngeal mask airway. Resuscitation 1998; 38: 3-6.

Fcil aprendizaje

Distensin gstrica Regurgitacin

Brain AIJ, Verghese C, Addy EV, Kapila A. The intubating laryngeal mask, I: development of a new device for intubation of the trachea. Br. J Anasth 1997; 79:699-703.

Davies PR, Tigue SQ, Greenslade GL et al. Laryngeal mask airway and tracheal tube insertion by unskilled personnel. Lancet 1990; 336: 977-9.

Pennant JH, Walker MB. Comparision of the endotracheal tube and laryngeal mask in airway management by paramedical personnel. Anesth Analg 1992: 74: 531-4. Martin PD, Cyna AM, Hunter WA et al. Training nursing staff in airway management for resuscitation. A clinical comparision of the facemask and laryngeal mask. Anaesthesia 1993; 48: 33-7.

97% xito 1 intento


Kurola J, Pere P, Niemi-Murola L et al. Comparison of airway mangement with the intubating laringeal mask, laryngeal tube an Cobra PLA by paramedical students ina anaesthetized patients. Acta Anaesthsiol Scand 2006; 50:40-4.

Brain AIJ, Verghese C, Strube PJ. The LMA ProSeal- a laryngeal mask with an oesophageal vent. Br. J Anasth 2000; 84:650-654.

Evans NR, Gardner SV, James MFM, ProSeal laryngeal mask protects against aspitration of fuid in the pharinx. Br. J Anaesth 2002; 88: 584-587.

No recomendado por la Task Force Sacandinavian por mayor dificultad de insercin frente a cLMA

Ferson DZ, Chi L, Zambare S Brown D. The effectiveness of the LMA Supreme in patients with

normal and difficult to manage airway. Anesthesiology 2007; 107: A 592


Pearson D, Young P. Use of the LMA- Supreme for airway rescue.

Anesthesiology 2008; 109: 356-357.

Timmermann A. Cremer S. Heuer J, et al. Laryngeal mask LMA Supreme. Application by

medical personnel inexperienced in airway management. Anaesthesist 2008; 57: 970-975.

Drges V, Ocker H, Wenzel V et al. The Laryngeal Tube S: a modified simple airway device. Anesth Analg 2003; 96: 618-621.

78-100% xito en paciente anestesiado

Kurolan JO, Turunen MJ, Laakso JP et al. A comparison of the laryngeal tube and bag-valve mask ventilation by emergency medical technicians: a feasibility study in anesthetized patients. Anesth Analg 2005; 101: 1577-81

83% xito en PCR

Kette F, Reffo I, Giordani G et al. The use of laryngeal tube by nurses in out of hospital emergencies: preliminary experiences. Resuscitation 2005; 66: 21-5

Ningn estudio, ctedra , fabricante u opinin de expertos avala su insercin en pacientes con reflejos de va area presentes. Aumenta riesgo de nuseas, vmitos y aspiracin. Laringoespasmo.

Gold Standard

fcil o exento de riesgo

Intubacin esofgica no detectada Ambiente prehospitalario desplazamiento TOT

Gausche M, Lewis RJ, Stratton SJ et al. Effect of out of hospital pediatric endotracheal intubation on survival and neurological outcome: a controled clinical trial. JAMA 2000; 283: 783-90. Davis DP, Dunford JV, Poste JC et al. The impact of hypoxia an hyperventilation on outcome after paramedic rapid sequence intubation of severely head injured patients. J Trauma 2004; 57:1-8. DiRusso SM, sullivan T, Risucci D et al. Intubation of pediatric trauma patients in the field: predictor of negative outcome despite risk stratification. J trauma 2005; 59: 84-90. Bochiccio GV, Ilahi O, Joshi M et al. Endotracheal intubation in the field does not improve outcome in trauma patienst who present without an acutely lethal traumatic brain injury. J trauma 2003, 54: 307-11

Klemen P, Grmec S, Effect of prehospital advanced life support with rapid sequence intubation on outcome of severe traumatic brain injury. Acta Anaesthesiol Scand 2006; 50: 1250-4

En contra

A favor

53-63% IOT exitosa Intubacin esofgica no advertida:


6- 16,7 % 37 %
Rocca B, Crosby E, Maloney J et al. An assessment of paramedic perfomance during invasive airway mangement. Prehosp Emerg Care 2000; 4: 1350-7 Wang HE, Sweeney TA, OConnor RE et al. Failed prehospital intubations: an anlysis of emergency department courses and outcomes. Prehosp Emerg Care 2001; 5: 134-41 Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med 2001; 37: 32-7.

99,1% xito Intubacin esofgica no advertida:


0,4 %

8% uso BNM
Adnet F, Jouriles NJ, Le TP et al. Survey of out of hospital emergency intubations in

N= 691
the French prehospital medical system: a multicenter study. Ann Emerg Med 1998; 32: 454-60.

N= 147 nios
Meyer G, Orliatguet G, Blanot S et al. Complications of emergency tracheal

intubation in severely head injury children. Paediatr Anaesth 2000; 10: 253-60.

xito 62,5 85%


Wang HE, OConnor RE, Megargel RE et al. The utilization of midazolam as a

pharmacolologicadjunct to endotracheal intubation by paramedics. Prehosp Emerg Care 2000; 4: 14-8.

Dickinson ET, Cohen JE, Mechem CC. The effectiveness of midazolam as a

pharmacologic agent to facilitate endotracheal intubation by paramedics. Prehosp Emerg Care 1999; 3: 191-3

Sedacin insuficiente: Aumento PIC Taquicardia Reflejos va area

Mayor dao en TEC


Isquemia miocrdica Laringoespasmo Broncoespasmo Vmito Aspiracin

Produccin de CO2 Ventilacin alveolar Posicin TOT

Perfusin pulmonar Patrn respiratorio Gasto Cardaco


Donald MJ, Paterson B. End tidal carbon dioxide monitoring in prehospital and retrieval medicine: a review. Emerg Med J 2006; 23:728-30

Reduce el riesgo de hiper o hipoventilacin inadvertida.


Helm M, Schuster R, Hauke J et al. Tight control of

prehospital ventilation by capnography in major trauma victims. Br j Anaesth 2003; 90: 327-32.

PaCO2

Flujo Sanguneo Cerebral

Presin IntraCraneana

Operador Paciente

Dispositivos