By the end of the rotation the resident should have acquired the following cognitive objectives and technical skills:
- Recognition of airway compromise, including recognition and management of upper airway obstruction including foreign bodies and infections. Describe how to assess an airway for signs of compromise using the concept of the three "pillars" or cornerstones of airway management - patency. protection, and gas exchange.
- Establishment and maintenance of the airway. 'List the indications for an artificial airway including endotracheal intubation. Describe the indications for airway intervention with special emphasis on the indications for intubation, but also describing the indications for BVM ventilation, and oral-pharyngeal and nasopharyngeal airways.
- Discuss the concept of the difficult airway and divide this into the difficult laryngoscopy and the difficult patient to bag. Describe which factors may make a patient more difficult to bag. Describe which anatomical factors and which disease states may make laryngoscopy more difficult. Describe the brief pre-intubation examination to identify the difficult laryngoscopy including the Mallimpadi classification.
- Describe proper preparation for intubation. Describe or demonstrate the act of laryngoscopy including proper patient positioning and the sequential steps in using a laryngoscope.
- Emergency airway management including use of Bag-Mask-Ventilation, oropharyngeal and nasopharyngeal airways. Emphasize the importance of good bagging technique and describe in sequence the step wise use of maximal internal devices ( OP and NP airways ) and maximal external force when a patient is difficult to bag.
- Outline indications and contraindications of various routes of tracheal intubation icluding Rapid Sequence Intubation: Knowledge of the principles, indications, contraindications, and medications. Describe and define Rapid Sequence Intubation. Discuss its advantages and disadvantages as compared to awake intubation, use of iv sedation only, and blind nasotracheal intubation. Describe the full technique of RSI ( the 6 P's).
- Know potential complications of tracheal intubation and appropriate management. What are the hemodynamic consequences to intubation. Describe the Reflex Sympathetic Response to Laryngoscopy ( RSRL ) or "intubation reflex" and list clinical scenarios where pharmacologic blunting of this reflex is desirable. What are the causes of post-intubation hypotension?
- Airway pharmacology. Discuss the choice of neuromuscular blockers. Describe the contraindications to Succinylcholine. Discuss the use of the following induction agents and their respective advantages and disadvantages; Thiopental, midazolam, fentanyl, propafol, etomidate, ketamine.
- Describe alternate methods for establishing an airway when endotracheal intubation cannot be accomplished. Discuss the management of the failed airway ( can't intubate, can't bag ventilate ). Describe the difficult airway kit and its contents including the procedure for cricothyroidotomy (Surgical establishment of an airway), the LMA, Combitube, light wand, transtracheal jet ventilation.
Patrick Melanson, MD, FRCPC