Pre-hospital and ER Management of Difficult Airway In

8/16/2019 Pre-hospital and ER Management of Difficult Airway In

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Pre-hospital and ER

Management of DicultAirway in Trauma Patientพญ!"#$%&'() *+ญ%,#./+"

#พ0+120ญ3


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Airway Decision Scheme


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*+#45#'(678*#&)9suction: ;< : laryngoscope: =MA : surgical >needlecricothyroidotomy ? protect @-pine ? PreoBygenate

Co "+6+#2077*FG4%,H10#I7H63 DeJnitiKe airway > urgical

airway LesDicult

#.46G,+N41G,0+(2%O3+(+*0#I7H63 2 =EM;CEasy

2"3373O(0+(2%!1(2(+ Q cricoid pressure 7SO+63O(40I7 UnsuccessfulพG%+#&+78*#&)4"#G6 V =MA: =TA:WEXY awaZe intu[ation

พ(+(+62 DeJnitiKe airway> urgical airway


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Encountered Dicult

Airway algorithm


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*+#พ(+(+62"3373O(0+(2%S#$ \N]#*640O

20^+ [ag masZ Kentilation V XM_Y

*#&'' ` 9 "+6+#3O(0+(2%+N0,+*+*77*FG4%,H1 *#&'' `< 9 H63"+6+#3O(0+(2%+N0,+*+*77*FG4%, H1


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($N"+6+##7H1 ,$ `,SI7($Nพ76'4O+

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"+̂4#%

203O(0+(2%3+, XM_ %,*O3+%.1'


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+H63"+̂4#% *+#2"3373O(0+(2%S#$ \N' "̀+6

5+6]พ()' `6'#."*+#&) : alternatiKe intu[ationtechnibues

+H63"+̂4#%

*+#2"3373O(0+(2%H63#.""+̂4#%"+6S#$ \N Vfailedintu[ationY

20*$6+2 XM_ 0#I7 EWD


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*#&'' `< 9 H63"+6+#3O(0+(2%+N0,+*+*77*FG4%,H1

4,/+O.4#3N13O,' `#7H63 H1

/+O. ailed ;Bygenation V at j ]62 XM_ Y 2,#.0O3+N#745#'(6+̂ cricothyrotomy "+6+#7N2"3 EWD 7(3+N#O14#O"$*S#$ \N

+H63"+̂4#% +7N2"3 EWD ]OH63#.""+̂4#% SO##'+̂ cricothyrotomy204#O' "̀81


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+"+6+#%$1*+#4#I `7N*+#0+(2%H14#'(#7(

*#&'' 4̀+"3 k"618]. k3O(H1#$77*FG4%,7(3+N4พ'(Nพ7SO##'+̂ deJnitiKe care

].4#G 6̀*+#1k]0$N%+**+#2"3373O(0+(2%537H


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4,I \70+ Y Airway

- #+7+*+#]"1N7N7+*+#0+(2%781*$ \,

- $ญ0++N41G,0+(2%' `พ2, k3 O(78$5G4058,G153+N


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4,I \70+ Y Airway Management - @hin-=ift ManeuKer - aw-

Thrust ManeuKer- ;ropharyngeal Airway -Casopharyngeal Airway

- =aryngeal masZ Airway - Wum

Elastic Xougie- DeJnitiKe airway


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4,I \70+Y Dicult intu[ation - =EM;C

- Airway Decision cheme - Technibue for rapid

sebuence intu[ation V RY - urgical Airway


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Airway


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7+*+#]"1N7N7+*+#0+(2%781*$ \,


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7+*+#]"1N7N7+*+#0+(2%781

*$ \, Y =ooZ /+O.*#."$*#."3+(0#I7Fq6

/+O.GO0,$N!1(4พ+.#G4O#G6'+*].44,"'4'(O/+O.0+(2%!1(2*+64,I \73O(

0+(2% > 0+(2%*#.]* /+O.0+(2%4#O


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7+*+#]"1N7N7+*+#0+(2%781*$ \,


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7+*+#]"1N7N7+*+#0+(2%781*$ \,

0+* k3O("+6+#พk157S^++6

]พ() ].0+(2%H11'

+N41G,0+(2%!3N1'


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$ญ0++N41G,0+(2%' พ̀ 2, k3 O(78$5G4058


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Maxillofacial Trauma

Trauma to the midface การหกหรอมการเล อนท บรเว

!a"o#har$!% หรอ oro#har$!% มเลอ&ออก ' มการเ( ม)* +น)อ,-าร.&หล,


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Maxillofacial Trauma

/racture of ma!di01e 23าหกท บรเว 0o!$ fracture ท +,-อ,&3าน

อา4ม5าว6-78เ-9ร6บบการ.วบ.:มการหา9;4 ว9อา4มอาการ)อ,ทา,เ&นหา9;4อ:&ก +น

หรอ?ม>-ามาร2นอนราบ?&3 บ>,ว>าน>า46มทา,เ&นหา9;4


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Neck Trauma

Penetrating inury 7+%!1,4",4I71#G4O&S7 SI76'

*+#781*$ \,+N41G,0+(2%


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Neck Trauma

Xlunt inury 7+%+̂20 H1#$+14%' ̀#G4O&

larynB 0#I7 trachea 9 6'+N41G,0+(2%781*$ \,

9 6'4I7177*#G4O&tracheo[ronchial tree


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Neck Trauma

*+#1k]1+,+N41G,0+(2% 2"3373O(0+(2%

fails

surgical airway


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Laryngeal Trauma

Clinical signs ' ̀3N7*O3+7+%6'$ญ0+537*+#+14%7Nlarynx

1) Hoarseness

2) Subcutaneous emphysema

3) alpable fracture


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Laryngeal Trauma

/+O.,' \57N#.6$1#.O$N4#I `7N airwayo[struction

*+#+14%#G4O&,' \6$*4*G1#3O6*$*+#+14%#G4O&0717+0+# : ugular Kein: carotid artery *#&'5#O%#3+N*+(H636$

`,2% @T


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Ventilation


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7+*+#]"1N7N7+*+#0+(2%H634พ'(Nพ7

2 H


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7+*+#]"1N7N7+*+#0+(2%H634พ'(Nพ7

Y=ooZ %$N0O.*+#0+(2%H63"6^ `+4"67

*+#(+(5$O7N#ON7*H6343+*$, 0+(2%5I \,0#I707q* 2*+64,I \73O(0+(2% 43,*+#

(*H03 67N40,#7( 840,I7 H0+#+ '*%6k*+,

2 H


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7+*+#]"1N7N7+*+#0+(2%H634พ'(Nพ7

Y=ooZ k3 O(6$*,$ `N5$O5#N4N(0,+q \,

,7,#+H63 H1 +N#+(0+(2%!1(6'*+#"$!(*#.0O3+N*+64,I \70,+7N*$

#ON7* 0+(2%4vI7*0#I70+(2%พ.N+

2 H


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7+*+#]"1N7N7+*+#0+(2%H634พ'(Nพ7


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7+*+#]"1N7N7+*+#0+(2%H634พ'(Nพ7

Y *+#2 pulse oBimeter4พI `71k oBygen saturation

]. peripheral perfusion ]536G H11k Kentilation

2 H 3


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7+*+#]"1N7N7+*+#0+(2%H634พ'(Nพ7

Y eel 5#O%1k trachea shift

5#O%0+/+O. 9 *#.1k*F' `!S#N0$*

9 su[cutaneousemphysema


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$ญ0+*+##.+(7+*+x

V_entilationY' พ̀2, k3O(78$5G4058


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!ib "racture

O14O+0+(2%

0+(2%4#O].5I \,

/+O.+177*FG4%,2,4I71


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#ntracranial #n$ury

#k]*+#0+(2%' `G1#*5G

*+#]*4' (̀,*+FG1*5G

/+O.+177*FG4%,2,4I71


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%er&ical Spinal %or' #n$ury

($N7+%"+6+#0+(2%!1(2*+64,I \7

*#.$N6

/+O.+177*FG4%,2,4I71


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@omplete @erKical @ord

Transection *+#+14%' 5̀$13+,#G4O& phrenicnerKesV @ ]. @Y

0+(2%!1(2*+64,I \70,+7N

57N3O(0+(2%


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Airway Maintenancetechniques


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Chin-lift Maneuver


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aw-thrustManeuKer


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Orophayngeal Airway


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(rophayngeal ir*ay

+ 4I7*2 2, k3O(' 0̀61"5G ' `H636' gag reflex 0#I7 cough reflex+ SO+6(+O' 4̀06+."6tip corner of mouth

flange angle of mandile


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itfall


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!asopharyngeal Airway


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!asopharyngeal Airway

+ 4I7*2 2, conscious "semiconscious

+ ,+14",3+,xk,()*+N ,+1,G \O*7(7N k3O(

+ SO+6(+O +(%6k* - 5G Ǹ0k


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#itfall


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,xtraglottic 'e&ice -,./)


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4#'(*7'*I `7O3+ supraglottic deKices *+#+̂N+,SI73O(207+*+x3+,

+N1+,,7*7NKocal cord 7%+̂*$1SI7H63SO#246I `76'/+O.' `*37204*G1*+#781*$ \,' ̀#G4O&1+,3+N7N Kocal cord


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H1]*3 =aryngeal masZ airway:@om[itu[e : =aryngeal Tu[e Airway 4#+,+̂6+2*#&' failed intu[ation

20*$6+20,+*+*77*FG4%,0#I7

พG%+#&+3O(0+(2%!1(2 EWD 0$N278*#&),' \57NพG%+#&+^+deJnitiKe airway 4"67


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$aryngeal Mas% Airway


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&he 'sophageal-&racheal

Comitue ( '&C)

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http://images.google.co.th/imgres?imgurl=http://belkmk.narod.ru/ems/combitube/Cbt1.jpg&imgrefurl=http://belkmk.narod.ru/ems/combitube/link1.htm&usg=__IrcAnvnzNuJqr_EgteUleMkAfm8=&h=726&w=663&sz=58&hl=th&start=34&um=1&tbnid=64Jdp_sLBDRIGM:&tbnh=141&tbnw=129&prev=/images%3Fq%3Dcombitube%26ndsp%3D20%26hl%3Dth%26sa%3DN%26start%3D20%26um%3D1


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$aryngeal &ue Airway


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lternati&e #ntubation Techni0ues


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lternati&e #ntubation Techni0ues

*+#พ(+(+62"3373O(0+(2%0+(S#$ \N 4,*+#4พG 6̀!7*+"4*G1*+#+14%' `#.+N41G,0+(2% ? 5+66+7+%

+̂203O(0+(2%+̂+* /+(0$N%+**+#' 4̀#+2"3373O(0+(2% !1(2OGz'*+# {[est looZ| ($NH63

"+6+#2"3373O(0+(2%H12,0,q `N0#I7"7NS#$ \N 20,+̂OGz' alternatiKe intu[ationtechnibues 6+2


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LM "astrach


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Light*an' - egTrachlight)


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_ideolaryngoscopy

V egWlidescopeY


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Definitive Airway


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Definitive Airway

1 (rotracheal tube

2 Nasotracheal tube3 Surgical air*ay

cricothroi'otomy

tracheostomy


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Manual in line staili*ation


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Surgical Cricothyroidotomy


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73N' \ 2,*+#2"3

deJnitiKe airway

73N'\2,*+#2"3 definitive


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7N 2,*+#2" definitiveairway

k3O( apnea


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ขอบงช ในการใช

}@losed head inury ' ̀VWlasgow@oma score ~Y

• H63"+6+#6' oBygenation H14พ'(Nพ71O( face masZ

€€€€ #.O$N7+%4*G17$,5#+(537cerKical spine €€€€


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=EM;C Assessmentfor Dicult ntu[ation

L,M(N assesment for


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L,M(N assesment for

'ifficult intubation

L,M(N

L look externally

, e&aluate the 332 rule

M mallampati

( obstruction

N neck mobility

L L k t ll


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L Look externally

+ 1k$*&./+(,7*O3++N41G,

0+(2%].*+#3O(0+(2%#*5G0#I7H63

, , l t th 3 3 2 l


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, ,&aluate the 332 rule

• #.(.03+N#.0O3+Nincisor SO#6+**O3+

Jnger [reaths V"+6+#4G1+*H1 Y• #.(.03+N#.0O3+N hyoid [one qN chin SO#6+**O3+ Jnger [reaths

•#.(.03+N#.0O3+N thyroid notch qN ‚oorof mouth SO#6+**O3+ < Jnger [reaths


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Mallampati ir*ay %lassification


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Mallampati ir*ay %lassification

%lass 1 soft palate4 u&ula4 fauces4 pillars

%lass 2 soft palate4 u&ula4 fauces &isible

%lass 3 soft palate 4base of u&ula &isible

%lass 5har' palate only &isible


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(b t ti


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(bstruction

+ 6'/+O.' 7̀+%+̂20+N41G,

0+(2%781*$ \,H1Fq `N7+%+̂20 2"3 laryngoscopy ? *+# Kentilation+̂H1(+*

• 43,/+O. epiglottitis: trauma

N k M bilit


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Neck Mobility

+ !1(*+#20 k3O(*60,+S+NG17*0#I7]0N,0,+q \,67NพI \,+ 4,"G Ǹ' `#.46G,H1N3+(' "̀81


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Rapid ebuencenduction


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ขนตอนการทา


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ข นตอนการทา

45#'(678*#&)"+̂0#$̂+ surgicalairway 20พ#76


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ellicZ maneuKer

ขนตอนการทา


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ข นตอนการทา

• 20 succinylcholine -< mg>Zgƒ 0$N%+*(+0(37,*+64,I \777*

„zG … 20 2"3373O(0+(2%~ Xlow cu† ].$N711kS3+ @;< 37(6I7%+**+#*1 cricoid

pressure3O(0+(2% k3O(


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@omponents ;f {XET =;;‡|=aryngoscopy


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Sniffing #osition

Sniffing #osition


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Sniffing #osition

*+#*67N7537#.0O3+N cerKicalspine ]. thoracic spine ? *+#4N(' `7 atlantoocipital 20 k3O(,7,0N+(0,8,+0#I7067,"kN ƒ- 4F,5G465#25+(7(

2,3+,' \+̂20 ],O7N oral caKity:pharynB: larynB 5#N*$,^+2067N40,+N4+ glottis H1


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XURP ManeuKer

XURP ManeuKer


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XURP ManeuKer •SI7 technibue 2,*+#+̂laryngealmanipulation 4พI `73O(2040, Kocal cord1'q \,

X XacZward U Upward RP RightwardPressure


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$aryngoscope +lade

$aryngoscope +lade


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$aryngoscope +lade

Xlade ,G15#N V MillerY 9 O+N+( [lade 25537]3,

epiglottis9 ,G(62 2,41*4*

$aryngoscope +lade


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$aryngoscope +lade

Xlade ,G1!SN V MacintoshY9 O+N+( [lade #G4O&

Kallecular 0,+537]3, epiglottis 9 ,G(62 2, k 20ญ3


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,um 'lastic +ougie

,um 'lastic +ougie


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,um 'lastic +ougie


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Airway Management


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Airway Decision Scheme


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*+#45#'(678*#&)9suction: ;< : laryngoscope: =MA : surgical >needle cricothyroidotomy ?protect @-pine ? PreoBygenate


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ygCo

"+6+#2077*FG4%,H10#I7H63 DeJnitiKe airway > urgical airway

Les Dicult

#.46G,+N41G,0+(2%O3+(+*0#I7H63 2 =EM;C

Easy

2"3373O(0+(2%!1(2(+ Q cricoid pressure 7SO+63O(40I7

UnsuccessfulพG%+#&+78*#&)4"#G6 V =MA: =TA:WEXY awaZe intu[ation

พ(+(+62 DeJnitiKe airway> urgical airway


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Encountered Dicult

Airway algorithm


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*+#พ(+(+62"3373O(0+(2%S#$ \N]#*640O


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20+̂ [ag masZ Kentilation V XM_Y

*#&'' ̀ 9 "+6+#3O(0+(2%+N0,+*+*77*FG4%,H1

*#&''


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*#&'' ` 9 "+6+#3O(0+(2%+N0,+*+*77*FG4%,H1

($N"+6+##7H1 ,$ `,SI7($Nพ76'4O+

*+#2"3373O(0+(2%S#$ \N' `"7N

[est looZ: 4' (̀,,G1 [lade:2 alternatiKe intu[ation technibues +H63"+̂4#%

203O(0+(2%3+, XM_ %,*O3+%.1'

+H63"+̂4#%

2 3 3 3 2 $\ '`


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*+#2"3373O(0+(2%S#$ N' "+6 5+6]พ()' `6'#."*+#&) : alternatiKe intu[ationtechnibues

+H63"+̂4#%

*+#2"3373O(0+(2%H63#.""+̂4#%"+6S#$ \N Vfailedintu[ationY

20*$6+2 XM_ 0#I7 EWD

*#&'' `< 9 H63"+6+#3O(0+(2%+N0,+*+*77*FG4%,H1


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4,/+O.4#3N13O,' `#7H63 H1

/+O. ailed ;Bygenation V at j ]62 XM_ Y 2,#.0O3+N#745#'(6+̂ cricothyrotomy "+6+#7N2"3 EWD 7(3+N#O14#O"$*S#$ \N +H63"+̂4#%

+7N2"3 EWD ]OH63#.""+̂4#% SO##'+̂ cricothyrotomy204#O' "̀81

+"+6+#%$1*+#4#I `7N*+#0+(2%H14#'(#7(


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4#(#7(

*#&'' 4̀+"3 k"618]. k3O(H1#$77*FG4%,7(3+N4พ'(Nพ7SO##'+̂ deJnitiKe care

].4#G 6̀*+#1k]0$N%+**+#2"3373O(0+(2%537H

Pre-hospital and ER Management of Difficult Airway In

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Transcript of Pre-hospital and ER Management of Difficult Airway In