Emergent Airway Management
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Transcript of Emergent Airway Management
2013
Agenda:Agenda:Agenda:Agenda:
• Airway Anatomy Adult vs. Pediatric• Review of basic equipment• Approach to the Difficult Airway• RSI• Post-Intubation Management• Ventilator Settings• The Crashing Asthmatic
• Airway Anatomy Adult vs. Pediatric• Review of basic equipment• Approach to the Difficult Airway• RSI• Post-Intubation Management• Ventilator Settings• The Crashing Asthmatic
Important take home points
The search for the epiglottis
Are kids Are kids just just small small adults?adults?
Are kids Are kids just just small small adults?adults?
• ExternallyExternally– Larger head/occiput– Head flexes forward and can obstruct
• InternallyInternally– Intra-oral tongue – Large, floppy epiglottis
• ExternallyExternally– Larger head/occiput– Head flexes forward and can obstruct
• InternallyInternally– Intra-oral tongue – Large, floppy epiglottis
• Further differences– “Pinker” vocal cords worsen visualization
– Different location of narrowest point• Peds cuffed tubes?
– Smaller cricothyroid membrane• No surgical crics in children
• Further differences– “Pinker” vocal cords worsen visualization
– Different location of narrowest point• Peds cuffed tubes?
– Smaller cricothyroid membrane• No surgical crics in children
Other ConsiderationsOther Considerations
•More gastric insufflation with BVM
•Quicker desats during intubation Different• 10 kg will drop to 90% in <4 minutes (vs. 8 for adult)
•Vagal response (not significant)• Consider Pre-treatment with Atropine (though not literature supported and not the standard of care)
•More gastric insufflation with BVM
•Quicker desats during intubation Different• 10 kg will drop to 90% in <4 minutes (vs. 8 for adult)
•Vagal response (not significant)• Consider Pre-treatment with Atropine (though not literature supported and not the standard of care)
10% 10%
80%
Hypoxia and Hypercarbia
Bradycardia
Self ConfidentIf he can, you can
Avoid the “cookie-cutter” approach to every airway you encounter.
Be familiar with your equipment…
What tools do I have ?
Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment
• Oxygen and Suction
• BVM / OPA / NPA
• ETT / Bougie / LMA / King LT
• Stylet
• Magill forceps
• End-tidal CO2 monitoring and securing devices
• Surgical Airway Devices
• Oxygen and Suction
• BVM / OPA / NPA
• ETT / Bougie / LMA / King LT
• Stylet
• Magill forceps
• End-tidal CO2 monitoring and securing devices
• Surgical Airway Devices
Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment
Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment
C-E technique is WRONG
CE
Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment
Use the Two Thumbs Downtechnique
Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment
Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment
OPA NPA
King LT
Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment
Endotracheal tube
stylet
Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment
Eschmann Stylet, a.k.a “Gum elastic bougie”
Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment
MAGILL FORCEPS
LMA
Airway EquipmentAirway EquipmentAirway EquipmentAirway EquipmentLMA – Laryngeal Mask Airway
Are extraglottic airways harmful in cardiac arrest ?
Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment
“Yellow” = YES
“Purple” = Pathologic
Airway Equipment:Airway Equipment:Airway Equipment:Airway Equipment:
• What equipment do we have in our departments?
• Where is it located?
• What equipment do we have in our departments?
• Where is it located?
Broselow TapeThe
• Can’t Protect Airway
• Can’t Maintain Ventilation / Oxygenation
• Expected Decline in Clinical Status
3 Emergent Indications for Intubation
Gag reflex is absent in up to 37% of population, and is a poor predictor of airway protection
•Can they talk?
•Can they swallow and manage secretions?
Can’t Protect Airway
• SaO2 <90% on High Flow O2 or PaO2<60 on FiO2>40%
• PaCO2 >55 if baseline is normal, or >10 increase from baseline
• Respiratory Rate
Can’t Maintain Ventilation or Oxygenation
• Deterioration/Impending Compromise Transport
• Airway protection during procedures (ie. endoscopy)
Expected Decline in Clinical Status
DEFINITIONSDEFINITIONSDEFINITIONSDEFINITIONS
Rapid Sequence Intubation (RSI)
INDUCTION AGENT
PARALYTIC
UNCONSCIOUSNESS
MOTOR PARALYSIS
DEFINITIONSDEFINITIONSDEFINITIONSDEFINITIONS
Delayed Sequence Intubation (DSI)
DSI consists of the administration of
specific sedative agents, which do not
blunt spontaneous ventilations or airway
reflexes; followed by a period of
preoxygenation before the
administration of a paralytic agent.
CONTRAINDICATIONSCONTRAINDICATIONSCONTRAINDICATIONSCONTRAINDICATIONS
INDICATIONINDICATION
RISKRISK
RSI RATIONALERSI RATIONALERSI RATIONALERSI RATIONALE
Increasedsuccess
Decreasedaspiration
BetterC-spinecontrol
RATIONALE - SecondaryRATIONALE - Secondary
Blunting ↑ in ICP / IOP
RATIONALE - SecondaryRATIONALE - Secondary
Avoid airway trauma
RATIONALE - SecondaryRATIONALE - Secondary
Avoid Avoid airway airway traumatrauma
RATIONALE - SecondaryRATIONALE - Secondary
↓ ↓ PainPain↓ ↓ Discomfort Discomfort ↓ ↓ RecallRecall
Adverse Drug Events
HAZARDSHAZARDS
May force crash airway scenario
HAZARDSHAZARDS
The 7 “P’s”of RSIThe 7 “P’s”of RSIThe 7 “P’s”of RSIThe 7 “P’s”of RSI
PPREPARATION
PPREOXYGENATION
PPRETREATMENT
PPARALYSIS WITH INDUCTION
PPROTECTION AND POSITIONING
PPLACEMENT AND PROOF
PPOST-INTUBATION MANAGEMENT
PPREPARATION
PPREOXYGENATION
PPRETREATMENT
PPARALYSIS WITH INDUCTION
PPROTECTION AND POSITIONING
PPLACEMENT AND PROOF
PPOST-INTUBATION MANAGEMENT
TIME ZEROTIME ZERO
t – 10 minutes
t + 90 seconds
PREPARATIONPREPARATIONt – 10 minutest – 10 minutes
PREPARATIONPREPARATIONt – 10 minutest – 10 minutes
1. EQUIPMENT PRESENT AND WORKING
INCLUDING EQUIPMENT
FOR PLAN “B”
1. EQUIPMENT PRESENT AND WORKING
INCLUDING EQUIPMENT
FOR PLAN “B”
PREPARATIONPREPARATIONt – 10 minutest – 10 minutes
PREPARATIONPREPARATIONt – 10 minutest – 10 minutes
2. Ask yourself: CAN I…
BAGBAG THE PATIENT
TUBETUBE THE PATIENT
CRICCRIC THE PATIENT
2. Ask yourself: CAN I…
BAGBAG THE PATIENT
TUBETUBE THE PATIENT
CRICCRIC THE PATIENT
““Evaluate for signs of Evaluate for signs of a difficult intubationa difficult intubation””
-Obesity-Obesity--
LLook at the general anatomyEEvaluate the 3-3-2 ruleMMallampati scoreOObstructionNNeck mobilitySaturation Reserve
LLook at the general anatomyEEvaluate the 3-3-2 ruleMMallampati scoreOObstructionNNeck mobilitySaturation Reserve
CAN I TUBETUBE THIS PATIENT?
Look at the general anatomyLook at the general anatomy
Evaluate the 3-3-2 rule
Mallampati score
Obstruction
Neck mobility
Saturation Reserve
Saturation Reserve
At 92% the patient’s oxygen saturation falls off a cliff….
CAN I CAN I BAGBAG THIS PATIENT? THIS PATIENT?
Maybe. Maybe Not.
Approximate normal ventilation rates:
• 10 bpm Adult
• 20 bpm Child
• 25 bpm Infant
Approximate normal ventilation rates:
• 10 bpm Adult
• 20 bpm Child
• 25 bpm Infant
VENTILATE (BLS)
Squeeze.....Release - Release
Keep Dentures in when using a BVM
CAN I CAN I CRICCRIC THIS PATIENT?THIS PATIENT?
IndicationsIndications
• ObstructionObstruction
• Facial TraumaFacial Trauma
• Intubation or other Intubation or other alternatives impossiblealternatives impossible
• Trismus (clenching)Trismus (clenching)
• > 8 years old > 8 years old
(for open procedures) (for open procedures)
SURGICAL AIRWAYS
LAST RESORT!LAST RESORT!
DEFense Readiness CONdition
Maximum readiness
Armed Forces ready to deploy and engage in less than 6 hours
Air Force ready to mobilize in 15 minutes
Above normal readiness
Discuss / Feel / See Kit
Mark / Kit Bedside
Inject / Prep / Open & Set KitScalpel in Hand
Perform Cric
Open CricothyrotomyOpen CricothyrotomyOpen CricothyrotomyOpen Cricothyrotomy
1.1. Vertical Incision over membraneVertical Incision over membrane2.2. Pierce membrane in horizontal planePierce membrane in horizontal plane3.3. Open and spread to insert 4.0 or 5.0 Open and spread to insert 4.0 or 5.0
tubetube4.4. Secure tube in place and ventilateSecure tube in place and ventilate
1.1. Vertical Incision over membraneVertical Incision over membrane2.2. Pierce membrane in horizontal planePierce membrane in horizontal plane3.3. Open and spread to insert 4.0 or 5.0 Open and spread to insert 4.0 or 5.0
tubetube4.4. Secure tube in place and ventilateSecure tube in place and ventilate
Open CricothyrotomyOpen CricothyrotomyOpen CricothyrotomyOpen Cricothyrotomy
PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes
PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes
1. “First, do not bag!”
2.Avoid “Sellick’s”
maneuver (cricoid pressure)
1. “First, do not bag!”
2.Avoid “Sellick’s”
maneuver (cricoid pressure)
PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes
PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes
1. Well-fitting mask
2. 8 vital capacity breaths
1. Well-fitting mask
2. 8 vital capacity breaths
PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes
PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes
PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes
PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes
NIV CPAP for Pre-Oxygenation
Summary of Summary of LOADLOADPRETREATMENTPRETREATMENT
Summary of Summary of LOADLOADPRETREATMENTPRETREATMENT
LL idocaine optional
OO piates optional
AA tropine for infants consider for kids < 8
DD efasciculating optional dose
LL idocaine optional
OO piates optional
AA tropine for infants consider for kids < 8
DD efasciculating optional dose
DEFASCICULATING DOSEDEFASCICULATING DOSE1/10 1/10 th th the RSI dosethe RSI dose
DEFASCICULATING DOSEDEFASCICULATING DOSE1/10 1/10 th th the RSI dosethe RSI dose
Traditional Indications
1. Blunt rise in ICP
2. Decrease risk of aspiration
3. Prevent muscular pain
Traditional Indications
1. Blunt rise in ICP
2. Decrease risk of aspiration
3. Prevent muscular pain
PRETREATMENTPRETREATMENTt – 3 minutest – 3 minutes
PRETREATMENTPRETREATMENTt – 3 minutest – 3 minutes
If you’re going to give these drugs:
…at least give them some time to circulate (3 minutes)
If you’re going to give these drugs:
…at least give them some time to circulate (3 minutes)
PARALYSIS WITH PARALYSIS WITH INDUCTIONINDUCTION
Time Time ““00””
PARALYSIS WITH PARALYSIS WITH INDUCTIONINDUCTION
Time Time ““00””INDUCTION AGENTS
EtomidateEtomidate
Ketamine
Propafol
Midazolam
INDUCTION AGENTS
EtomidateEtomidate
Ketamine
Propafol
Midazolam
PARALYTIC AGENTS
DEPOLARIZINGDEPOLARIZING
Succinylcholine
NON-DEPOLARIZINGNON-DEPOLARIZING
Vecuronium Rocuronium
PARALYTIC AGENTS
DEPOLARIZINGDEPOLARIZING
Succinylcholine
NON-DEPOLARIZINGNON-DEPOLARIZING
Vecuronium Rocuronium
+
PARALYSIS WITH PARALYSIS WITH INDUCTIONINDUCTION
Time Time ““00””
PARALYSIS WITH PARALYSIS WITH INDUCTIONINDUCTION
Time Time ““00””
Sedation then Paralysis
PARALYSIS WITH PARALYSIS WITH INDUCTIONINDUCTION
Time Time ““00””
PARALYSIS WITH PARALYSIS WITH INDUCTIONINDUCTION
Time Time ““00””
Use of Apneic oxygenation
EtomidateEtomidateEtomidateEtomidate
– Rapid onset/offset
– Minimal hemodynamic and respiratory effects
– Pediatrics – not approved for patients under 10
– Rapid onset/offset
– Minimal hemodynamic and respiratory effects
– Pediatrics – not approved for patients under 10
SuccinylcholineSuccinylcholineSuccinylcholineSuccinylcholine
• When: Immediately after Etomidate
• Onset: Rapid, usually 30-90 secs
• Duration: Short acting, 3-5 mins
• When: Immediately after Etomidate
• Onset: Rapid, usually 30-90 secs
• Duration: Short acting, 3-5 mins
When Sux Really When Sux Really ““SucksSucks””CONTRAINDICATIONSCONTRAINDICATIONS
When Sux Really When Sux Really ““SucksSucks””CONTRAINDICATIONSCONTRAINDICATIONS
1. HYPERKALEMIAHYPERKALEMIARENAL FAILURERHABDOMYOLYSIS
2. RECEPTOR UPREGULATIONRECEPTOR UPREGULATIONSUBACUTE BURNS (>1 day)SUBACUTE DENERVATING DISORDERHISTORY OF MALIGNANT HYPERTHERMIA
1. HYPERKALEMIAHYPERKALEMIARENAL FAILURERHABDOMYOLYSIS
2. RECEPTOR UPREGULATIONRECEPTOR UPREGULATIONSUBACUTE BURNS (>1 day)SUBACUTE DENERVATING DISORDERHISTORY OF MALIGNANT HYPERTHERMIA
SUX IS STILL KINGSUX IS STILL KINGSUX IS STILL KINGSUX IS STILL KING
SUXSUX versusversus ROCROCSUXSUX versusversus ROCROC
45 seconds ONSET 1 minute
9 minutes DURATION 45 minutes
45 seconds ONSET 1 minute
9 minutes DURATION 45 minutes
1 mg/kg1-1.5 mg/kg
PROTECTION AND POSITIONINGPROTECTION AND POSITIONING t + 20 secondst + 20 seconds
PROTECTION AND POSITIONINGPROTECTION AND POSITIONING t + 20 secondst + 20 seconds
May NOT be helpful
Positioning:Positioning:MedicalMedicalvs.vs.TraumaTrauma
Positioning:Positioning:MedicalMedicalvs.vs.TraumaTrauma
C Spine PrecautionsC Spine Precautions
C Spine PrecautionsC Spine Precautions
Positioning Adult vs PediPositioning Adult vs PediPositioning Adult vs PediPositioning Adult vs Pedi
Cormack & Lehane GradingCormack & Lehane GradingCormack & Lehane GradingCormack & Lehane Grading
SweepSweep LeftLeft
and and
LookLook
Orotracheal Intubation ProcedureOrotracheal Intubation Procedure
AdultAdult vs vs PediPedi AdultAdult vs vs PediPedi
Normal TracheaNormal Trachea
PLACEMENT AND PROOFPLACEMENT AND PROOF t + 45 secondst + 45 seconds
PLACEMENT AND PROOFPLACEMENT AND PROOF t + 45 secondst + 45 seconds
POST-INTUBATION POST-INTUBATION MANAGEMENT MANAGEMENT t + 90 secondst + 90 seconds
POST-INTUBATION POST-INTUBATION MANAGEMENT MANAGEMENT t + 90 secondst + 90 seconds
More to come next month……….More to come next month……….
POST-INTUBATION MANAGEMENTPOST-INTUBATION MANAGEMENT t + 90 secondst + 90 seconds
POST-INTUBATION MANAGEMENTPOST-INTUBATION MANAGEMENT t + 90 secondst + 90 seconds
CONFIRM PLACEMENT
&SECURE
TUBE
CONFIRM PLACEMENT
&SECURE
TUBE
Capnography
Post-intubation CXR
INTUBATION HURTS!INTUBATION HURTS!INTUBATION HURTS!INTUBATION HURTS!And it keeps on hurting once the tube is in…And it keeps on hurting once the tube is in…
POST-INTUBATION MANAGEMENTPOST-INTUBATION MANAGEMENT
Achieve Adequate Analgesia and Sedation
POST-INTUBATION MANAGEMENTPOST-INTUBATION MANAGEMENT
Raise the Head of the Bed to at Least 30°
Confirm Lung Protective Vent Settings
POST-INTUBATION MANAGEMENTPOST-INTUBATION MANAGEMENT
• Mode AC• VT 6-8 cc/kg• Rate 12-16• PEEP 5• FiO2 100% then titrate down
Standard Ventilator Settings
POST-INTUBATION MANAGEMENTPOST-INTUBATION MANAGEMENT
Continuous waveform ETCO2
NG / OG tubeEmpty the stomach to reduce the chances of aspiration and to improve lung mechanics
POST-INTUBATION MANAGEMENTPOST-INTUBATION MANAGEMENT
Nebulizers/MDIIf they were intubated for reactive airway disease, then they need frequent nebs
Acute Deterioration Acute Deterioration after Intubationafter IntubationAcute Deterioration Acute Deterioration after Intubationafter Intubation
D.O.P.E.SD.O.P.E.S: :
DDisplacementisplacement
OObstructionbstruction
PPneumothoraxneumothorax
EEquipment failurequipment failure
SStacked Breathstacked Breaths
Basics of Ventilator Management
Lung Injury Obstructive Lung Disease
Use as Default
Basics of Ventilator Management
Lung Injury
Lung Protective Management
1. Mode: use A/C (assist control)
Basics of Ventilator Management
Vt IFR
FiO2
PEEP
RR
Basics of Ventilator Management
VtTidal Volume
6-8 cc/kg IBW
Basics of Ventilator Management
IFRInspiratory Flow Rate
= how quickly the breath is delivered
60-80 LPM
Basics of Ventilator Management
RRRespiratory Rate
16-18 BPM
RR = Ventilation
Basics of Ventilator Management
FiO2
PEEP
1. Start @ 100%2. Wait 5 min3. Get ABG4. Drop to 40%
FiO2
Goal: Saturation of 88-95%
Basics of Ventilator Management
FiO2
PEEPStart with 5
Positive End-Expiratory Pressure - PEEP
Basics of Ventilator Management
FiO2
PEEP
FiO2 + PEEP =Oxygenation
Inspiratory Plateau Pressure_________________________________________________
PeakPlateauPlateau Pressure
< 30 cmH2O
Must find and hold Inspiratory Hold buttonVentilator will then display Plateau Pressure
Basics of Ventilator Management
Vt IFR
FiO2
PEEP
RR
Basics of Ventilator Management
Analgesia 1stSedation 2nd
The Crashing AsthmaticThe Crashing Asthmatic
Crashing Asthmatic
SweatyCan’t TalkTachypneicTripoding
Maximal O2 (NRB)Inhaled AlbuterolInhaled AtroventIV SteroidsIV MagnesiumSC TerbutalineEpinephrine drip
Crashing Asthmatic
THE KITCHEN SINK – Maximal Rx
Crashing Asthmatic
BiPAPCPAP
NON-INVASIVE VENTILATION
Too EarlyToo EarlyToo LateToo Late
Crashing Asthmatic
WHEN TO INTUBATE
Crashing Asthmatic
EtomidateSuccinylcholine
GO FAST!GO FAST!
EtomidateSuccinylcholine
GO FAST!GO FAST!
LidocaineKetamineLidocaineKetamine
KEEP IT SIMPLE! OPTIONS...
HOW TO INTUBATEHOW TO INTUBATE
Crashing Asthmatic
Use a Big ETT AGGRESSIVE TOILET
Reason #1 Reason #1 Mucous PlugsMucous Plugs
Crashing AsthmaticCrashing Asthmatic
Reason #2 Reason #2 DehydrationDehydration
IV FLUID BOLUS
Reason #3 Reason #3 Breath StackingBreath Stacking
Crashing AsthmaticCrashing Asthmatic
Squeeze ChestSqueeze Chest Low Vent SettingsLow Vent Settings
Crashing AsthmaticCrashing Asthmatic
Chest TubesChest Tubes
Reason #4Reason #4BarotraumaBarotrauma
Cardiac Arrest Post-IntubationCardiac Arrest Post-Intubation
11 Disconnect ventilatorDisconnect ventilator 22 Squeeze chest Squeeze chest 33 Bilateral chest tubes Bilateral chest tubes 44 Fluid bolus Fluid bolus
11 Disconnect ventilatorDisconnect ventilator 22 Squeeze chest Squeeze chest 33 Bilateral chest tubes Bilateral chest tubes 44 Fluid bolus Fluid bolus
SummarySummary
Crashing AsthmaticCrashing Asthmatic Last Chance………Last Chance………
Anesthetic Gases
ECMO
Extracorporeal Membrane Oxygenation (ECMO)
Pearls
• Can’t see the cords -
…try BURP
• Another attempt needed – …change something
Call for Call for helphelp ! !
Have a backup plan– “Prior planning prevents poor performance”
Have a backup plan– “Prior planning prevents poor performance”
Don’t panic!Don’t panic!
Thank you!Thank you!
Mark P. Brady PA-CDept.of Emergency MedicineCambridge Health AllianceCambridge, MA