Emergency lectures - Emergency airway management
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Transcript of Emergency lectures - Emergency airway management
Emergency Airway ManagementEmergency Airway Management
Rob Dickson, M.D. FAAEM, FACEP
Good Shepherd Health System
Longview, Texas
Rob Dickson, M.D. FAAEM, FACEP
Good Shepherd Health System
Longview, Texas
Clinical QuestionsClinical Questions
• What is different about emergency airways from those done in the anesthesia suite?
• Are there reliable signs of airway compromise and at what point do we intervene?
• How can we screen for potential airway disasters?
• What are the best management strategy for difficult airways?
• What are the newest airway devices and are they worth the investment?
Unique issues in the Emergency DepartmentUnique issues in the Emergency Department
Unique issues in the Emergency DepartmentUnique issues in the Emergency Department
We don’t pre-select casesWe don’t pre-select cases
Unique issues in the Emergency DepartmentUnique issues in the Emergency Department
We don’t pre-select cases
Can never cancel a case
We don’t pre-select cases
Can never cancel a case
The patient we wantThe patient we want
The patients we getThe patients we get
Closed claims paperClosed claims paper
• Review paper of closed anesthesia claims resulting in death or disability
• Take home points• Emergency airways are the riskiest!• Difficult BVM ventilation increased risk of
bad outcome• Highest predictor of bad outcome was
persistent attempts before rescue method employed- have a plan B!
Peterson GN. Management of the difficult airway: A closed claims analysis.Anesthesiology 2005; 103:33.
Unique issues in the Emergency DepartmentUnique issues in the Emergency Department
Unique issues in the Emergency DepartmentUnique issues in the Emergency Department
• Deteriorating cardio -respiratory status
Unique issues in the Emergency DepartmentUnique issues in the Emergency Department
• Deteriorating cardio -respiratory status• High aspiration risks
Unique issues in the Emergency DepartmentUnique issues in the Emergency Department
• Deteriorating cardio -respiratory status• High aspiration risks• Altered mental states
Unique issues in the Emergency DepartmentUnique issues in the Emergency Department
• Deteriorating cardio -respiratory status• High aspiration risks• Altered mental states• Anatomical variants
Unique issues in the Emergency DepartmentUnique issues in the Emergency Department
• Deteriorating cardio -respiratory status• High aspiration risks• Altered mental states• Anatomical variants• Upper airway structural and mechanical
considerations (vomit, angioedema)
Clinical signs of airway compromiseClinical signs of airway compromise
• Snoring respirations• Inspiratory stridor• Drooling• Hoarseness• Retractions/tracheal tugging/paradoxical
breathing patterns• Mass effects
When to intervene?When to intervene?
• Hypoxic/hypercapnic respiratory failure• Shock states (decreases cardiac load)• Altered mental states and unable to maintain
patent airway• Potential decompensation
Continuum of airway management Continuum of airway management
• Upper airway obstruction (airway positioning)
• Head positions- jaw thrust, head tilt-chin lift• Oropharyngeal/nasopharyngeal airway• Bag-valve-mask ventilation• Supra-glottic airways- LMA, combitube, king
device• Difficult intubations- bougie, video assisted
laryngoscopy, cricothyrotomy, needle cricothyrotomy
Predictors of difficult AirwayPredictors of difficult Airway
• History of airway problems- tracheostomy scars
• Physical assessment- obesity• Mouth opening• Tongue to pharyngeal size• Hyo-mental distance• Neck flexion/head extension(mobility issues)
Mallampatti/Cormack-LehaneMallampatti/Cormack-Lehane
Mallampatti viewsMallampatti views
Bag-valve maskBag-valve mask
• Essential skill to managing the airway• The most important airway skill• Almost every case can be managed or
rescued with good BVM technique• Never abandon until using a 2 person
technique with NP/OP airway• This skill is necessary before attempting to
master other techniques/devices
One person BVMOne person BVM
Two person BVMTwo person BVM
Direct laryngoscopy Direct laryngoscopy
Rapid Sequence IntubationRapid Sequence Intubation
• Use of sedation and chemical paralysis to facilitate intubation
• 70-84% of all intubations• High success rates for experience operators• In comparison to non-paralysis intubations
RSI had 15% less aspiration, 25% less airway trauma, 3% less death
Steps in RSISteps in RSI
• Preparation: T-10 minutes• Preoxygenation: T-5m• Premedication: T-3m• Paralysis: T-0• Placement of tube T+45s• Post intubation management:T+2m
BladesBlades
• Miller (straight)• Macintosh(curved)• Main criteria is blade long enough to
effectively fit into the valecula space (curved) • Reach the epiglottis to lift (straight)
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Best laryngoscopy techniquesBest laryngoscopy techniques
• Proper alignment auditory meatus with suprasternal notch
• Flex neck by placing pillow under occiput• Extend head maximal• Insert laryngoscope, visualize epiglottis by
sweeping tongue to the left• Must see this landmark• Glottic opening lies just distal to this
structure
Proper alignment Proper alignment
Picture correct axis positioningPicture correct axis positioning
Positioning in the obese patientPositioning in the obese patient
Technique for difficult airwayTechnique for difficult airway
Bimanual laryngoscopy
What is looks like in a perfect worldWhat is looks like in a perfect world
Supraglottic airwaysSupraglottic airways
LMALMA
• Peripharyngeal sealers• Seats over the pyriform fossae• Sizes 1(infant) to 5(large adult)• At least as effective as other airway
management choices in CPR• Does not prevent aspiration
Laryngeal Mask AirwaysLaryngeal Mask Airways
King airwayKing airway
• Isolates the hypopharynx and laryngeal inlet• Pediatric sizes 2 and 2.5• Adult sizes 3-5 (sized by height 4-5 ft,5-6,
>6)• Pass tube exchanger/bronchoscope through
ports• No documented tracheal placements• Insertion technique
King airwayKing airway
CombitubeCombitube
• High success rates of 98-100 %• Esophageal and oropharyngeal balloons• Most common placement in the esophagus• Tracheal placements ventilate thru distal port• No pediatric sizes• Distal cuff #2(white)-15cc air• Proximal cuff #1(blue)-85 cc air
OTHER AIRWAY ADJUNCTSOTHER AIRWAY ADJUNCTS
Gum Elastic BougieGum Elastic Bougie
• Used to facilitate endotracheal intubation• Essentially a plastic ETT changer with
curved tip• For use when unable to visualize the glottic
opening or the view is impaired• Place the tip up and aim just past the
epiglottis• “Feel bumps” or hit resistance• Continue using laryngoscope and slide tube
over the bougie for placement
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What is a difficult airway?What is a difficult airway?
• Three components may co-exist• Difficult BVM ventilation• Difficult laryngoscopy• Difficult surgical airway
ASA Difficult Airway Task Force. Anesthesiology 2003; 93:1269-1277.
Failed airwayFailed airway
• Occurs when one or mores exists• Inability to ventilate or intubate paralyzed
patients• 3 or more attempts at intubation by most
experienced operator
ASA Difficult Airway Task Force. Anesthesiology 2003; 93:1269-1277.
Failed emergency airwaysFailed emergency airways
• NEAR database• N= 7212• Patients were enrolled if first technique failed
and a rescue was required• Overall 2.7% failed airways• Surgical airway in 0.5% of cases
Bair AE. The failed intubation attempt in the emergency department: analysis ofprevalence, techniques, and personnel. Journal of Emergency Medicine 2002; 23:131.
Failed airway algorithmFailed airway algorithm
Normal anatomy and oxygen Abnormal anatomy normal oxygen
Normal anatomy abnormal oxygen Abnormal anatomy abnormal oxygen
Failed airway algorithmFailed airway algorithm
Normal anatomy and oxygen
•Obese overdose patient with unfavorable anatomy- able to BVM to 95% saturation
•First choice: video laryngoscope•Second choice: bougie or supraglottic device
Abnormal anatomy normal oxygen
Normal anatomy abnormal oxygen Abnormal anatomy abnormal oxygen
Failed airway algorithmFailed airway algorithm
Normal anatomy and oxygen
•Obese overdose patient with unfavorable anatomy- able to BVM to 95% saturation
•First choice: video laryngoscope•Second choice: bougie or supraglottic device
Abnormal anatomy normal oxygen
Normal anatomy abnormal oxygen
•Obese paralyzed RSI patient with failed intubation and falling sats, unable to oxygenate with BVM
•First choice: Supraglottic device or limited attempt with video device•Second choice: Cricothyrotomy
Abnormal anatomy abnormal oxygen
Failed airway algorithmFailed airway algorithm
Normal anatomy and oxygen
•Obese overdose patient with unfavorable anatomy- able to BVM to 95% saturation
•First choice: video laryngoscope•Second choice: bougie or supraglottic device
Abnormal anatomy normal oxygen
•Severe angioedema with normal oxygen saturation
•First choice: Intubating bronchoscope or video device•Second choice: Cricothyrotomy
Normal anatomy abnormal oxygen
•Obese paralyzed RSI patient with failed intubation and falling sats, unable to oxygenate with BVM
•First choice: Supraglottic device or limited attempt with video device•Second choice: Cricothyrotomy
Abnormal anatomy abnormal oxygen
Failed airway algorithmFailed airway algorithm
Normal anatomy and oxygen
•Obese overdose patient with unfavorable anatomy- able to BVM to 95% saturation
•First choice: video laryngoscope•Second choice: bougie or supraglottic device
Abnormal anatomy normal oxygen
•Severe angioedema with normal oxygen saturation
•First choice: Intubating bronchoscope or video device•Second choice: Cricothyrotomy
Normal anatomy abnormal oxygen
•Obese paralyzed RSI patient with failed intubation and falling sats, unable to oxygenate with BVM
•First choice: Supraglottic device or limited attempt with video device•Second choice: Cricothyrotomy
Abnormal anatomy abnormal oxygen
•Obese patient with severe angioedema and falling oxygen saturation with bradycardia
•First choice: cricothyrotomy
Difficult airway algorithmDifficult airway algorithm
• 2674 pre-hospital intubations (France)• Difficult airway algorithm BAI, ILMA,
Cricothyrotomy• 6% failed airways• 98% adherence to algorithm• BAI successful rescue in 114/151 attempts• Remainder successfully managed with ILMA• Cricothyrotomy in 1 patient
Anesthesiology:January 2011 - Volume 114 - Issue 1 - pp 105-110
Back to our questionsBack to our questions
• What is different about emergency airways from those done in the anesthesia suite?
• Are there reliable signs of airway compromise and at what point do we intervene?
• How can we screen for potential airway disasters?
• What are the best management strategy for difficult airways?
• What are the newest airway devices and are they worth the investment?
DISCUSSIONDISCUSSION