11/5/2013 1 Topics 2013 The Difficult Airway Anatomy • Visualization • Difficult BVM / LMA ventilation Physiology • Unable to oxygenate • Unable to ventilate • Severe Acidosis • Hypotension The Difficult Airway Deciding which patient to intubate Timing • Stable – semi-elective • Crashing • Crashed Drama BUT ‘REAL’ May be the single most important topic in Emergency Medicine Airway management The area of EM with the greatest immediate breadth of outcomes within minutes: life and death
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17SimonDifficultAirway · Delayed Sequence Intubation ... Percutaneous transtracheal intubation Cricothyrotomy – traditional Cricothyrotomy – needle guided Video laryngoscopes.
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11/5/2013
1
Topics 2013
The Difficult Airway� Anatomy
• Visualization• Difficult BVM / LMA ventilation
� Physiology• Unable to oxygenate• Unable to ventilate• Severe Acidosis• Hypotension
The Difficult Airway� Deciding which patient to intubate� Timing
• Stable – semi-elective• Crashing• Crashed
Drama BUT ‘REAL’
� May be the single most important topic in Emergency Medicine
Airway management
The area of EM with the greatest immediatebreadth of outcomes within minutes: life and death
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Sexy
HEROIC
Dramatic Life Saving
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� Forethought� Planning� Attention to detail� Knowledge
Plan Ahead� Equipment� Drugs� Positioning � Check lists…
An intervention to dec complications related to EI in the ICU…..Int Care Med 2010
Severe Mild to Moderate
Death Difficult tube
Cardiac Arrest Esophageal
Severe Hypoxemia Aspiration
Severe Cardiovascular Collapse Arrhythmia requiring RX
Dangerous agitation
� Presence of two operators� Fluid Loading� Pre-oxygenation� RSI drug prep� Sellick� Placement confirmation – capnography� Pressor support� Longer term sedation� Protective low volume vent
trendelenberg• Delay time to desat by about 100 seconds
� Jaw thrust
Apneic Oxygenation� Prolong time to desat:
• Normal BMI – by 2-3 minutes• BMI > 30 – by about 100 seconds
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Journal of Clinical Anesthesia 2010
Preoxygenation Strategies� NIV
• USE NIV mask or BVM• 5cm of PEEP / 100% O2 / High flow• Sat >95% for >3 min• Leave Mask in place while pushing drugs• Leave NC on at all times
strategies� Ventilator to drive the BVM
• Oral airway• Standard BVM vent• Ventilator on AC at 550ml• Flow at 30 L /min• 12 vent / min + 5-15 PEEP• Attach the vent to the mask
strategies� Ventilator Vs. Bagging� Peep� Atelectasis� Saturation
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Delayed Sequence Intubation
• Ketamine 1mg/kg slow push (glycopyrrolate)• NIV / non-rebreather / LMA…….• Sat >95% for >3 min• Paralytic – leave mask while inducing• Leave nasal cannula and intubate
Hydration before induction� Most critically ill are dry� Loss of sympathetic support� Loss of muscle tone� Peep / Pos Pressure vent� Drugs
� Hydration� Phenylephrine
PLAN AHEAD� What drugs do you have available
� What tools do you have
� What are you experienced and comfortable to perform
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Can you bag – valve –mask ventilate this patient?Will you be able to see cords?Oral endotracheal intubation fails – what next? This pt develops stridor and sat’s begin to fall??
This asthmatic becomes agitated –her PH is 6.8 PCO2 = 110
Difficult AirwayManagement Steps (7)
1. Always assume the intubation will be difficult! **
2. Familiarize yourself: **Where are your airway tools locatedWhat devices are at your disposal
3. Have backup plans A B & Cdeveloped before the scairway arrives **
** MAJOR TAKE HOME POINTS
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Airway Plans A B & COptimize Oral Endotracheal Intubation
conditions
LMA – Combitube – Stylet guided Intubation
Surgical: Needle, Seldinger, or Traditional
A
B
C
More Steps4. Consider the urgency of the case
Airway control is needed:NOW!!Within minutesSemi – elective
5.Can the patient be bag-valve-mask ventilated?
More Steps
4. Consider the urgency of the case5. Can the patient be bag-valve-mask ventilated?
6. Assess airway anatomy7. How great is the risk of aspiration?
1ST ATTEMPT HAS FAILED
� Start with back up plan A
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Preparing for the second attempt� Positioning can make a huge difference
• Raise the bed • Top of patients head at very end of gurney• Flex neck 30o - extend head / ramp up
� Change blades – or use the Mac like a Miller� BURP maneuver