The Unexpected Difficult Airway

A/Prof John VassiliadisSenior Staff Specialist Emergency Medicine

Deputy Director Sydney Clinical Skills & Simulation Centre, RNSH

I am NOT an anaesthetist!!!

Intubating In ED

• Why it is a danger zone

• Role of Checklists

• Pre-oxygenation and Apnoeic Oxygenation

• Laryngoscopy

Danger Zone

ED Patient Airways are Different

• They are emergent

– Usually for airway +/- breathing failure

– Limited history

– Limited opportunity to predict difficult airway or difficult

laryngoscopy

– They are sick… Really sick (ie high metabolic demands)

Oh S!!!I knew I should have called in sick today!!

I LOVE it when I have a registrar!!

I have a bad feeling about this one!!!

Our training and Skill Level

Our Training and Skill Level

Adequate supervision and supportAnaesthetics and ICU experienceE-learning and simulation training to practice drillsCredentialling process and guidelines on who should be allowed to intubate in ED and other critical care environments

Suggested parameters for predicting the difficult airway

Long upper incisors and/or prominent overbiteInter-incisor distance <3 finger breathsMandibular floor distance < 3 finger breathsThyromental distance < 2 finger breathsMallampati score > 2High arched palateLarge, thick tongueShort, thick neckPatient unable to touch the chin to the chest

Are they any good?

In 2003 ASA Difficult Airway Task force after a

review of literature found there was

insufficient evidence to recommend any

predictive tool, however some of these

markers were associated with difficult

airways!

So..What Do We Do?

Ron Walls and Difficult Airway Team

The JV Method

Looks Bloody Hard!!Looks Bloody Hard!!

ED Physician GestaltED Physician Gestalt

Have an Approach and A Plan

ED appropriate assessment, checklist and difficult airway algorithm

Meticulous preparation, pre-oxygeation, positioning, apnoeic

oxygenation

Excellent laryngoscopy

Plan B and C and D....

Ramping and Positioning

Preoxygenation

Weingart & Levitan, Annals of EM Weingart & Levitan, Annals of EM Volume 59, No. 3, March 2012 pp 165-Volume 59, No. 3, March 2012 pp 165-175175

C-MAC

C-MAC

Take Home Messages

ED Intubations are DifficultNeed Experience and TrainingPrepare and PlanPreoxygenate and Apnoeic VentilationC-MAC and bougie