10/27/2009
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Gerald Wydro, MD
Clinical Associate Professor Emergency Medicine
Temple University School of Medicine
When I started….
When I started…. When I started….
When I started…. When I started….
How To Make A Fertile Polyploid Hybrid
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When I started….
In the beginning….EMS & Airway Management…..
In the beginning….EMS & Airway Management…..
In the beginning….EMS & Airway Management…..
In the beginning….EMS & Airway Management…..
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In the beginning….EMS & Airway Management…..
In the beginning….EMS & Airway Management…..
Look at us now….
So what have we really learned?
A lot of advancement… New Equipment…. New Medications…
But???
The goal has not changed in a century, Has EMS evolved?? Objectives
Brief Anatomy / Physiology Review
Intubation Indications and Techniques
Preintubation Airway Assessment
Alternative Airways
Confirmation of placement
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Anatomy
Upper airway
Larynx
Trachea
Cartilage ringsCartilage rings
Carina
Mainstem bronchi
Left and right
Bronchioloes
Alveoli
Mediastinal Structures
Tracheal Rings Alveolar Sacs
Physiology
Prepare the air
Warm
Humidify
Clean
Physiology
Prepare the air
Warm
Humidify
Clean
Exchange
Capillary exchange
CO2
O2.
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Indications for IntubationIndications for Intubation
Failure to maintain / protect the airway Value of intact gag
Never really studied May induce vomiting
More realistic handle secretions handle secretions swallowing mechanism
Remember reversible causes Hypoglycemia Opiate intoxication
Failure of Ventilation or Oxygenation
Clinical assessment Not reversible
Increased oxygen
CPAP / BiPAP
D50 / Narcan5
Overall status VS
Mental status Be careful not to manage the numbers
Clinical Situation Mandates“They are only getting sicker”
Potential for badness Status epilepticus
Penetrating torso / neck trauma
Closed head injury SDH SAH
Serious Overdoses TCA’s
Endotracheal Intubation
These are NOT Indications
Because I can
Because they are unresponsive
Because the ED staff will expect it
Endotracheal IntubationComplications
Soft tissue trauma/bleeding
Dental injury
L l d
Barotrauma
Hypoxia
Aspiration
Esophageal intubation Laryngeal edema
Laryngospasm
Vocal cord injury
Esophageal intubation
Mainstem bronchus intubation
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Pre‐Intubation Technique
Position, ventilate patient
Monitor patient / Safety Net Cardiac monitor
Pulse oximeter
Preintubation Airway Assessment
Assemble, check equipment (suction)
Hyperventilate patient (30‐120 sec)
It seems easy enough
Sobering statistics
Intubation success rate
Intubation Success???Author Misplaced / total Misplaced
%
Jenkins
Bozeman
2/39
1/100
5.1%
1.0%
Stewart
Sayre
Pointer
3/779
3/103
5/383
0.4%
2.9%
1.3%
verification of tube placement was performed in the field.
Does it make a difference??
Out-of-hospital endotracheal intubation: where are we?Wang HE - Ann Emerg Med - 01-JUN-2006; 47(6): 532-41
Frequency of Prehospital Intubation in PA
How would minimum experience standards affect the distribution of out-of-hospital endotracheal intubations?Wang HE - Ann Emerg Med - 01-SEP-2007; 50(3): 246-52
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Sobering Statistics
Intubation success rate
Undetected esophageal bintubations
Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Katz SH ‐ Ann Emerg Med ‐ 01‐Jan‐2001; 37(1): 32‐7
Purpose: The purpose of our study was to determine the incidence of unrecognized misplaced ETTs that had been inserted in the field, in an emergency
( )medical services (EMS) community in which ETCO2
monitoring was not consistently used.
Results: 108 intubated patients who were brought by paramedics to the ED d i th 8 th t d ED during the 8‐month study period. . The overall rate of improperly placed ETTs was 25%
Sobering Statistics
Intubation success rate
Undetected esophageal intubationsintubations
Frequency of performing the skill
Effect of out‐of‐hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial JAMA ‐ 2000 Feb 9; 283(6): 783‐90
OBJECTIVE: To compare the survival and neurological outcomes of pediatric patients treated with bag‐valve‐mask ventilation (BVM) with those of patients treated mask ventilation (BVM) with those of patients treated with BVM followed by ETI.
CONCLUSION: These results indicate that the addition of out‐of‐hospital ETI to a paramedic scope of practice that already includes p yBVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system.
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So maybe it is time to change our thought
process!process!
Can we ever consider an Alternative Airway Algorithm as our initial Intervention?
Would you get this patient? Multitude of reasons to consider alternative airway from the initial assessment
Must be confident in your Must be confident in your skill level and more importantly know the limitations of laryngoscopy!
No teeth… No problem?? What challenges might this patient provide?
Mask Seal
Landmarks Landmarks
BLS Airways
Securing the tube
Open the MouthDon’t be surprised! External characteristics are key
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LEMON Rule L=Look externally (facial trauma, large incisors, beard or moustache,
and large tongue)
E=Evaluate the 3‐3‐2 rule (incisor distance <3 fingerbreadths, hyoid/mental distance <3 fingerbreadths, thyroid‐to‐mouth distance <2 fingerbreadths)<2 fingerbreadths)
M=Mallampati Score
O=Obstruction (presence of any condition that could cause an obstructed airway)
N=Neck mobility (limited neck mobility).
Pre‐Intubation Airway Assessment
Jaw opening
3 fingers
Pre‐Intubation Airway Assessment
Jaw opening
3 fingers
Hyoid Mental distance Hyoid‐Mental distance
3 fingers
Pre‐Intubation Airway Assessment
Jaw opening
3 fingers
Hyoid‐Mental distance
3 fingers3 g
Thyro‐Mental distance
2 fingers
Pre‐Intubation Airway Assessment
Jaw opening
3 fingers
Hyoid Mental distance Hyoid‐Mental distance
3 fingers
Thyro‐Mental distance
2 fingers
Prominent Upper Incisors
Airway Assessment
Cormack / Lehane Grade
Mallampati’s classification
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Neck Mobility
Align axis to facilitate orotracheal intubation
Decreased mobility
C‐Spine immobilization
Extend Back – Flex Forward
Rheumatoid arthritis
Quick Test
Put chin on chest then move toward ceiling
Assumes no trauma
Is there an optimal position? Sniffing position
the neck must be flexed on the chest by elevating the head with a cushion under the occiput and the under the occiput and the head extended at the atlanto‐occipital joint.
Extension position The neck is placed into simple extension
What is the problem?
Ventilate and Visualize This is the perfect candidate
What is the problem?
Ventilate and Visualize
This is the perfect candidate
Ventilate but cannot Ventilate but cannot Visualize
Consider alternative methods
What is the problem?
Ventilate and Visualize
This is the perfect candidate
Ventilate cannot Visualize
C id l i h d Consider alternative methods
Cannot Ventilate or Visualize
Your worst nightmare
What we do now!Pre-hospital Intubation
Determine need for IntubationHypoventilationSecure Airway
Potential deterioration
Alternative AirwayBVM
LMA / CombitubeNeedle / Surgical Cric
Unsuccessful
Successful IntubationSubjective Confirmation
Secure Tube
Determine MethodOral / Nasal
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What we do now!Pre-hospital Intubation
Determine need for IntubationHypoventilationSecure Airway
Potential deterioration
Alternative AirwayBVM
LMA / CombitubeNeedle / Surgical Cric
Unsuccessful
Successful IntubationSubjective Confirmation
Secure Tube
Determine MethodOral / Nasal
Most prehospital intubations are: Dead / Nearly dead
There are others
Awake
Facilitated
Rapid Sequence
Awake Intubation Used in the awake patient with a full stomach.
Topical anesthesia with lidocaine, cetocaine or other agent.
Careful oral insertion of tube.
Generally used in the OR.
Facilitated IntubationMedication Assisted
Used for patients who need definitive airway, but require some sedative.
P i l d Patient not paralyzed.
Requires use of sedatives / induction agents.
Rapid Sequence Induction Take the patient from a state of conscious and breathing to complete unconsciousness with apnea.
Emergency intubation indicated
P i h f ll h Patient has a full stomach
Predicted to be successful
If fail, manual ventilation will be successful
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Sellick Maneuver Cricoid Pressure!
Lessens the chance of aspiration??
Direct pressure over i id h cricoid to compress the
esophagus against the anterior vertebral bodies. BURP Maneuver
Alternatives
Any patient that mayrequire intubation must undergo a Pre‐intubation Ai AAirway Assessment
Think of Alternative Airway maneuvers in a parallel fashion.
Positive Pressure VentilationWidely available
High flow oxygen
Requires precise airway control
No protection from aspiration
Can be used with other airway adjuncts
SupraglotticLaryngeal Mask Airway
Tube with a large ring at distal end
Low pressure to fill around glottis
Allows trachea to be ventilated
Limited Aspiration Protection
Not approved on PA for EMS use!
SupraglotticCombitube
Double lumen / Port
Place in esophagus or trachea
Blind placementBlind placement
Ventilate with BVM
Limited Aspiration Protection
Combitube
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Supraglottic King LT
Single Lumen / Port
Distal Esophageal placement
Blind PlacementBlind Placement
Ventilate with BVM
Limited Aspiration Protection
Bougie Semi‐rigid stylette‐like device
Advanced into the larynx and through the cords until the tip rubs cartilage irings
Thread an ETT over the end of the bougie, into the larynx. Once the ETT is in place, the bougie is removed.
Lighted Stylet
ETT placed on stylet
When in the trachea, the light will shine though the skin.
Area of thyroid cartilage
adjunct to blind intubation
Transtracheal Jet Ventilation Needle inserted through the cricothyroid membrane allows for
doxygenation and minimal ventilation of a patient
Rescue Technique!!!
Cricothyroidotomy Surgical airway !!!!!
Utilized when unable to secure airway with other means.
Can’t ventilate, Can’t visualize
Opening made in the cricothyroid membrane.
Tube placed into opening.
Expensive ToysShikani
GlideScope
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Confirmation of Tube Placement Subjective
Visualization
Breath Sounds
Misting in tube
Objective ETCO2
Waveform preferred – breath to breath
Esophageal devices EDD
Confirmation of Tube Placement
Document
Misting
Equal excursion
Equal BS
Absent Gastric
EDD
ETCO2
Continous Pulse‐ox
Confirmation of Tube Placement
Need confirmation Initial placement
Every patient move.
C bi Combine Subjective and Objective
ETCO2 limited value in arrest NAEMSP
Use ETCO2 and EDD for cardiac arrest.
Before intubation
Is there another means of getting our desired results BEFORE we attempt intubation? (Especially if we RSI) CPAP
PPV with BVM or Demand Valve?
Nasal ETT?
Do we have all the help we need, all Airway equipment with us? (Suction?)
Do not forget non‐invasive ventilation
Intrinsic positive end expiratory pressure is the concept that in patients with severe lung disease, the lung does not fully empty due to the obstruction in the airway resulting in a positive pressure in the airways at end expiration.
The patient must first overcome this positive airway pressure before generating a negative pressure to inhale more air
CPAPContinuous Positive Airway Pressure
Support spont. Resp Provide continuous
pressure throughout respiratory cycle
usually 10 cm H2Oy Counteract intrinsic
PEEP
decrease preload and afterload
improve lung compliance
decrease the work of breathing
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Contraindications
Patients unable to tolerate the increased work of breathing
Increased ICP
Hemodynamic instability Hemodynamic instability
Recent facial, oral, or skull surgery or trauma
Active epistaxis
Recent Esophageal surgery
Active hemoptysis
Untreated pneumothorax
Does it help! Less intubation
Down 16%*
Decreased Mortality
Down 18%*
Reduce
ICU admit
Patient discomfort
Cost
*Hubble MW, Richards ME and Wilfong DA: "Estimates of cost*Hubble MW, Richards ME and Wilfong DA: "Estimates of cost--effectiveness of prehospital continuous effectiveness of prehospital continuous positive airway pressure in the management of acute pulmonary edema." Prehospital Emergency Care. positive airway pressure in the management of acute pulmonary edema." Prehospital Emergency Care.
12(3):27712(3):277--85, 2008. 85, 2008.
Remember The Pre‐intubation Airway Assessment is Critical
Sometimes Less is More
Noninvasive ventilation when possible
Confirmation of placement always
Waveform capnography is gold standard!
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