Airway Management 3

5,850 views
5,638 views

Published on

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
5,850
On SlideShare
0
From Embeds
0
Number of Embeds
39
Actions
Shares
0
Downloads
148
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • EM rotation is an opportunity to refine approach. Learning is by discussion & review around cases seen while in ED. “ hit & miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment & management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  • EM rotation is an opportunity to refine approach. Learning is by discussion & review around cases seen while in ED. “ hit & miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment & management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  • EM rotation is an opportunity to refine approach. Learning is by discussion & review around cases seen while in ED. “ hit & miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment & management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  • EM rotation is an opportunity to refine approach. Learning is by discussion & review around cases seen while in ED. “ hit & miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment & management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  • EM rotation is an opportunity to refine approach. Learning is by discussion & review around cases seen while in ED. “ hit & miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment & management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  • EM rotation is an opportunity to refine approach. Learning is by discussion & review around cases seen while in ED. “ hit & miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment & management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  • EM rotation is an opportunity to refine approach. Learning is by discussion & review around cases seen while in ED. “ hit & miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment & management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  • EM rotation is an opportunity to refine approach. Learning is by discussion & review around cases seen while in ED. “ hit & miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment & management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  • EM rotation is an opportunity to refine approach. Learning is by discussion & review around cases seen while in ED. “ hit & miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment & management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • 332 rule – geometry of oral intubation chin/mentum – hyhoid - thyroid Is the mandible large enough to accommodate tongue? (3-4 cm or 3 fingers) a very long mandible elongates the oral axis Length of neck – position of larynx
  • 332 rule – geometry of oral intubation chin/mentum – hyhoid - thyroid Is the mandible large enough to accommodate tongue? (3-4 cm or 3 fingers) a very long mandible elongates the oral axis Length of neck – position of larynx
  • 332 rule – geometry of oral intubation chin/mentum – hyhoid - thyroid Is the mandible large enough to accommodate tongue? (3-4 cm or 3 fingers) a very long mandible elongates the oral axis Length of neck – position of larynx
  • 332 rule – geometry of oral intubation chin/mentum – hyhoid - thyroid Is the mandible large enough to accommodate tongue? (3-4 cm or 3 fingers) a very long mandible elongates the oral axis Length of neck – position of larynx
  • 332 rule – geometry of oral intubation chin/mentum – hyhoid - thyroid Is the mandible large enough to accommodate tongue? (3-4 cm or 3 fingers) a very long mandible elongates the oral axis Length of neck – position of larynx
  • 332 rule – geometry of oral intubation chin/mentum – hyhoid - thyroid Is the mandible large enough to accommodate tongue? (3-4 cm or 3 fingers) a very long mandible elongates the oral axis Length of neck – position of larynx
  • 332 rule – geometry of oral intubation chin/mentum – hyhoid - thyroid Is the mandible large enough to accommodate tongue? (3-4 cm or 3 fingers) a very long mandible elongates the oral axis Length of neck – position of larynx
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • DRUG SUPPLIED: COST Metabolism SUX 20 mg/ml 20 ml $ 0.88 plasma pseudocholinesterase ROC 10 mg/ml 5 ml $ 12.75 hepatic - major renal - 33% unchanged VEC 10 mg vial $ 16.03 hepatobiliary - 50% renal 30% PAN 2 mg/ml 5 ml $ 2.58 renal - unchanged (major) 2 mg/ml 2 ml $ 1.10 biliary - 2% 1 mg/ml 5 ml $ 2.74 ATRA 10 mg vial $ 7.85 Hoffman elimination hydrolysis - nonspecific enzymatic
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Demonstration & explanation of equipment and technique
  • Demonstration & explanation of equipment and technique
  • Demonstration & explanation of equipment and technique
  • Demonstration & explanation of equipment and technique
  • Demonstration & explanation of equipment and technique
  • Demonstration & explanation of equipment and technique
  • Demonstration & explanation of equipment and technique
  • Accuracy: older generation oximeters – corresponded to oxyhemoglobin dissociation curve – 1-2% on flat portion, 5-6% on steep portion (<90%) More recent generation – above Newer generation – 1-2% across oxyhemoglobin dissociation curve All are kept well calibrated by our RT’s.
  • Accuracy: older generation oximeters – corresponded to oxyhemoglobin dissociation curve – 1-2% on flat portion, 5-6% on steep portion (<90%) More recent generation – above Newer generation – 1-2% across oxyhemoglobin dissociation curve All are kept well calibrated by our RT’s.
  • Accuracy: older generation oximeters – corresponded to oxyhemoglobin dissociation curve – 1-2% on flat portion, 5-6% on steep portion (<90%) More recent generation – above Newer generation – 1-2% across oxyhemoglobin dissociation curve All are kept well calibrated by our RT’s.
  • Accuracy: older generation oximeters – corresponded to oxyhemoglobin dissociation curve – 1-2% on flat portion, 5-6% on steep portion (<90%) More recent generation – above Newer generation – 1-2% across oxyhemoglobin dissociation curve All are kept well calibrated by our RT’s.
  • Accuracy: older generation oximeters – corresponded to oxyhemoglobin dissociation curve – 1-2% on flat portion, 5-6% on steep portion (<90%) More recent generation – above Newer generation – 1-2% across oxyhemoglobin dissociation curve All are kept well calibrated by our RT’s.
  • Accuracy: older generation oximeters – corresponded to oxyhemoglobin dissociation curve – 1-2% on flat portion, 5-6% on steep portion (<90%) More recent generation – above Newer generation – 1-2% across oxyhemoglobin dissociation curve All are kept well calibrated by our RT’s.
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Demonstration & explanation of equipment and technique
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  • EM rotation is an opportunity to refine approach. Learning is by discussion & review around cases seen while in ED. “ hit & miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment & management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  • EM rotation is an opportunity to refine approach. Learning is by discussion & review around cases seen while in ED. “ hit & miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment & management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  • EM rotation is an opportunity to refine approach. Learning is by discussion & review around cases seen while in ED. “ hit & miss” - may not seen many critically ill patients / resuscitations. The purpose of this seminar is to review the basic aspects of critically ill patient assessment & management and to allow you to practice these skills with simulated cases. Afterwards, hopefully you will feel more comfortable and confident when such patients require your attention on this rotation and subsequently.
  • Airway Management 3

    1. 1. Airway Management Emergency Medicine Seminar Series
    2. 2. Michael Ha Section of Emergency Medicine 4th year Resident John Sokal Health Sciences Centre 12 years Bob Sweetland Health Sciences Centre 15 years
    3. 3. April 25, 2002 CHURCHILL ASHERN PINE FALLS
    4. 4. April 26, 2002 STEINBACH BOUNDARY TRAILS
    5. 5. May 2, 2002 BRANDON KILLARNEY PORTAGE
    6. 6. May 3, 2002 RUSSELL DAUPHIN SWAN RIVER
    7. 7. May 14, 2002 FLIN FLON LYNN LAKE THE PAS
    8. 8. eMEDiUM Emergency Medicine in the U of M emergency.mb.ca Back
    9. 9. CAEP ACEP
    10. 10. CME Objectives To discuss: <ul><ul><li>the indications for intubation </li></ul></ul><ul><ul><li>the approach to RSI </li></ul></ul><ul><ul><li>capnometry </li></ul></ul><ul><ul><li>bougies </li></ul></ul>
    11. 11. <ul><li>Intubate? </li></ul><ul><li>RSI vs. Awake </li></ul><ul><li>Preparing for patient </li></ul><ul><li>Difficult BVM </li></ul><ul><li>Difficult Intubation </li></ul><ul><li>Capnography </li></ul><ul><li>Laryngoscopy Tips </li></ul><ul><li>Bougies </li></ul><ul><li>Lightwand - LMA </li></ul>Master Preoxygenation Pretreatment O 2 Delivery Thiopental Ketamine Propofol Succinylcholine Rocuronium Finish
    12. 12. Intubation Indications <ul><li>Is there a failure of </li></ul><ul><li>airway maintenance or protection? </li></ul><ul><li>Is there a failure of </li></ul><ul><li>ventilation or oxygenation? </li></ul><ul><li>What is the </li></ul><ul><ul><li>anticipated clinical course ? </li></ul></ul>Back
    13. 13. HR 125 BP 98/40 RR 20 GCS 8 O 2 Sats 100% (PRB) no injuries Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases <ul><li>45 female </li></ul><ul><li>alcoholic beverages </li></ul><ul><li>empty pill bottles </li></ul>
    14. 14. Cases <ul><li>60 VF </li></ul><ul><li>44 MVA </li></ul><ul><li>25 asthma </li></ul><ul><li>15 fall </li></ul><ul><li>28 bull </li></ul><ul><li>16 pencil </li></ul>40 fire 22 TCA 54 CRF 67 HTN 51 melena 45 overdose
    15. 15. 60 male IHD <ul><li>AMI </li></ul><ul><li>VF - defibrillated 3x </li></ul>HR 110 BP 68 / 40 RR 10 O 2 Sats 90% (BVM) Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
    16. 16. 44 female <ul><li>MVA </li></ul><ul><li>100 kph </li></ul>HR 130 BP 100 / 70 RR 28 O 2 Sats 99% (BVM) GCS 6 Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
    17. 17. 25 female asthma <ul><li>SOB 2 days </li></ul><ul><li>severe distress </li></ul>HR 145 BP 98 / 42 RR 30 O 2 Sats 80% (PRB) Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
    18. 18. 15 female <ul><li>fell from tree </li></ul>HR 110 BP 100 / 50 RR 20 O 2 Sats 99% (BVM) GCS 8 Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
    19. 19. 28 male <ul><li>playing with bull </li></ul><ul><li>blunt trauma </li></ul>HR 130 BP 80 / 60 RR 28 O 2 Sats 99% (PRB) abdomen rigid pelvic fracture Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
    20. 20. 16 male <ul><li>pencil oropharynx </li></ul><ul><li>'buddy' pulled it out </li></ul>HR 80 BP 115 / 60 RR 16 O 2 Sats 99% (room) voice change hematoma visible Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
    21. 21. 40 female <ul><li>house fire </li></ul><ul><li>prolonged exposure </li></ul>HR 115 BP 130 / 60 RR 28 O 2 Sats 96% (PRB) singed facial hair soot in mouth Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
    22. 22. 22 female <ul><li>ingestion amitryptyline </li></ul><ul><li>quantity unknown </li></ul>HR 145 BP 100 / 42 RR 14 O 2 Sats 99% (PRB) GCS 8 Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
    23. 23. 54 male CRF DM <ul><li>on dialysis holiday </li></ul><ul><li>respiratory distress </li></ul>HR 115 BP 200 / 120 RR 36 O 2 Sats 88% (NRB) peaked T's Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
    24. 24. 67 female HTN <ul><li>on ACE inhibitor </li></ul><ul><li>oral angioedema </li></ul>HR 85 BP 150 / 80 RR 20 O 2 Sats 99% (room) slight stridor Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
    25. 25. 51 male cirrhosis <ul><li>melena 2 days </li></ul><ul><li>hematemesis </li></ul>HR 165 BP 50 palpation RR 28 O 2 Sats 92% (NRB) vomiting red blood Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
    26. 26. 68 male CHF HR 125 BP 180 / 100 RR 32 O 2 Sats 86% (NRB) <ul><li>SOB over 3 days </li></ul><ul><li>worsened overnight </li></ul>Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
    27. 27. Intubate? Custom Shows
    28. 28. Intubate? HR 125 BP 98/40 RR 20 GCS 8 O 2 Sats 100% (PRB) no injuries Indication? <ul><li>45 female </li></ul><ul><li>alcoholic beverages </li></ul><ul><li>empty pill bottles </li></ul>
    29. 29. Intubation Indications <ul><li>Is there a failure of </li></ul><ul><li>airway maintenance or protection? </li></ul>
    30. 30. Intubate? HR 135 BP 150/90 RR 10 O 2 Sats 86% (NRB) 'tight' wheezes bilaterally Indication? <ul><li>50 yo male </li></ul><ul><li>SOB over 2 days </li></ul><ul><li>worsened overnight </li></ul>
    31. 31. Intubation Indications <ul><li>Is there a failure of </li></ul><ul><li>ventilation or oxygenation ? </li></ul>
    32. 32. Intubate? HR 100 BP 105/60 RR 20 GCS 10 O 2 Sats 100% (PRB) multiple injuries transfering to HSC Indication? <ul><li>34 yo male </li></ul><ul><li>MVA </li></ul><ul><li>ejected from car </li></ul>
    33. 33. Intubation Indications <ul><li>What is the </li></ul><ul><ul><li>anticipated clinical course ? </li></ul></ul>
    34. 34. Intubation Indications <ul><li>Is there a failure of </li></ul><ul><li>airway maintenance or protection? </li></ul><ul><li>Is there a failure of </li></ul><ul><li>ventilation or oxygenation? </li></ul><ul><li>What is the </li></ul><ul><ul><li>anticipated clinical course ? </li></ul></ul>Back
    35. 35. RSI vs Awake? Custom Shows
    36. 36. Rapid Sequence Intubation a potent induction agent followed immediately by <ul><ul><li>the patient has not fasted </li></ul></ul><ul><ul><ul><ul><ul><li>at risk of aspiration </li></ul></ul></ul></ul></ul>a rapidly-acting NMB to induce unconsciousness and motor paralysis for intubation.
    37. 37. Rapid Sequence Intubation <ul><li>take nothing that </li></ul><ul><li>you cannot return or replace </li></ul><ul><li>approach every airway as </li></ul><ul><li>a potential difficult airway </li></ul><ul><li>be prepared </li></ul>
    38. 38. The 7 P’s <ul><li>P reparation </li></ul><ul><li>P reoxygenation </li></ul><ul><li>P retreatment </li></ul><ul><li>P aralysis with induction </li></ul><ul><li>P ositioning with protection </li></ul><ul><li>P lacement with proof </li></ul><ul><li>P ostintubation management </li></ul>
    39. 39. Awake Intubations <ul><li>“ Awake” means that patient can: </li></ul><ul><ul><ul><li>follow simple instructions </li></ul></ul></ul><ul><ul><ul><li>provide feedback </li></ul></ul></ul><ul><ul><ul><li>can respond to events </li></ul></ul></ul><ul><ul><ul><ul><li>sedation – versed, fentanyl </li></ul></ul></ul></ul><ul><ul><ul><ul><li>topical lidocaine </li></ul></ul></ul></ul><ul><ul><ul><ul><li>oral, nasotracheal, fiberoptic </li></ul></ul></ul></ul>
    40. 40. Choices… paralyze? Paralysis contraindications <ul><li>prediction of difficulty </li></ul><ul><ul><ul><li>difficult BVM </li></ul></ul></ul><ul><ul><ul><li>difficult intubation </li></ul></ul></ul><ul><li>lack of equipment </li></ul><ul><li>unnecessary </li></ul><ul><li>inexperience </li></ul>
    41. 41. Preparation Difficult Airways Custom Shows
    42. 42. Preparation STOP IC BARS S staff, suction T tube O oxygen P pharmacology (meds)
    43. 43. Preparation I intravenous lines C connect to monitors B blades, bougies A alternate (lightwand) R rescue (LMA, combitube) S surgical (cricothyroidotomy) STOP IC BARS Back
    44. 44. Difficult Mask Ventilation B eard
    45. 45. Difficult Mask Ventilation O bese
    46. 46. Difficult Mask Ventilation O lder T oothless
    47. 47. Difficult Mask Ventilation S nores
    48. 48. Preparation Assessment for Difficult Mask Ventilation BOOTS B beard O obese O older T toothless S snores Back
    49. 49. Difficult Mask Ventilation reposition OP / NP airway 2 person change mask ? obstruction Back
    50. 50. Repositioning Oral – Pharyngeal - Laryngeal Axes
    51. 51. Repositioning Head extended on neck
    52. 52. Repositioning “ Sniffing” position
    53. 53. Repositioning “ Sniffing” with extension Back
    54. 54. Preparation Assessment for a difficult intubation Lemon Law L look E evaluate (3-3-1 rule) M Mallampati O obstruction N neck mobility Back
    55. 55. 3-3-1 Rule Back 3 3 fingers mouth opening 1 finger anterior jaw subluxation 3 1 3 fingers hyomental distance (room for tongue)
    56. 56. Mallampati Back
    57. 57. Preparation Preoxygenation Pretreatment
    58. 58. Preoxygenation is the establishment of an oxygen reservoir. <ul><ul><li>“ no bagging ” principle of RSI </li></ul></ul><ul><ul><li>“ apnea time ” concept </li></ul></ul><ul><ul><li>100% O 2 for 5 minutes </li></ul></ul><ul><ul><li>effect of body size & metabolic demands </li></ul></ul>
    59. 59. Apnea Time Back
    60. 60. Pretreatment is the administration of drugs to mitigate the adverse effects associated with intubation. L idocaine O piodes A tropine D efasciculation Back
    61. 61. Induction Agents
    62. 62. Paralysis after induction thiopental ketamine propofol etomidate versed succinylcholine rocuronium skip drug section
    63. 63. Thiopental <ul><li>cerebroprotective </li></ul><ul><li>potent vasodilator </li></ul><ul><li>myocardial depressant </li></ul>Contraindication: porphyria INDUCTION
    64. 64. Thiopental Back INDUCTION Onset: 15 - 30 seconds Dose: 3 - 5 mg / kg (euvolemic) 1 - 3 mg / kg (hypovolemic) Duration: 5 - 10 minutes
    65. 65. Ketamine <ul><li>analgesia - amnesia </li></ul><ul><li>bronchodilation </li></ul><ul><li>catecholamine release </li></ul>hypovolemic - hypotensive agent of choice INDUCTION <ul><li>ICP (significance ?) </li></ul><ul><li>( cerebroprotective ??) </li></ul><ul><li>stimulating effects: laryngeal reflexes </li></ul><ul><ul><ul><ul><ul><li>secretions </li></ul></ul></ul></ul></ul>
    66. 66. Ketamine lower dose if profound shock: maximal sympathetic stimulation already - ketamine has intrinsic CV depression Back INDUCTION Onset: 15 - 30 seconds Dose: 1 - 2 mg / kg Duration: 15 - 30 minutes
    67. 67. Propofol <ul><li>dose-dependant sedation - amnesia </li></ul><ul><li>no analgesic properties </li></ul><ul><li>airway reflexes: dose-dependant depression </li></ul><ul><li>potent vasodilator , myocardial depressant </li></ul><ul><li>(effect may exceed that of thiopental) </li></ul><ul><li>cardiac & respiratory depression related to </li></ul><ul><li>rate of administration as well as dose </li></ul>INDUCTION <ul><li>cerebroprotective </li></ul>ICP CPP
    68. 68. Propofol Onset: 30 - 40 seconds 1 - 3 mg / kg (induction) Dose: Duration: 5 - 10 minutes Combo: ketamine 50 mg propofol 50 mg Back Contraindication: egg, soybean allergies INDUCTION
    69. 69. Etomidate <ul><li>most hemodynamically stable </li></ul><ul><li>minimal cardiac & respiratory depression </li></ul><ul><li>cortisol suppression ( no ED cases) </li></ul><ul><li>myoclonus / hiccups </li></ul><ul><li>30% - 40% nausea / vomiting </li></ul><ul><li>does not block BP response to intubation </li></ul>INDUCTION <ul><li>cerebroprotective </li></ul>ICP
    70. 70. Etomidate Back Onset: 20 - 30 seconds Dose: 0.2 - 0.3 mg / kg INDUCTION Duration: 5 - 15 minutes
    71. 71. NMB
    72. 72. Choices… paralyze? Paralysis contraindications <ul><li>prediction of difficulty </li></ul><ul><ul><ul><li>difficult BVM </li></ul></ul></ul><ul><ul><ul><li>difficult intubation </li></ul></ul></ul><ul><li>lack of equipment </li></ul><ul><li>unnecessary </li></ul><ul><li>inexperience </li></ul>
    73. 73. Choices… SUX or ROC? SUX contraindications <ul><li>difficult BVM or intubation </li></ul><ul><li>neuromuscular disorders </li></ul><ul><li>hyperkalemia </li></ul><ul><li>24 hours post-burns </li></ul><ul><li>7 days post-crush </li></ul><ul><li>7 days post-denervation </li></ul><ul><li>malignant hyperthermia </li></ul>
    74. 74. Succinylcholine <ul><li>duration of action is dependant on: </li></ul><ul><ul><ul><li>rapid hydrolysis - pseudocholinesterase </li></ul></ul></ul><ul><ul><ul><li>diffusion away from motor end plate (no pseudocholinesterase at end plate) </li></ul></ul></ul><ul><li>only a fraction of dose ever reaches end plate </li></ul><ul><ul><ul><li>give large doses </li></ul></ul></ul><ul><ul><ul><li>no harm giving too much </li></ul></ul></ul><ul><ul><ul><li>problem when incompletely paralyzed </li></ul></ul></ul><ul><ul><ul><li>give extra 20% (2 mg / kg) </li></ul></ul></ul>PARALYSIS <ul><li>depolarizing NMB fasciculations </li></ul>
    75. 75. Succinylcholine Onset: 10 - 15 seconds (fasciculations) 45 - 60 seconds (paralysis) Dose: 1 - 2 mg / kg (adults) 2 mg / kg (children) 3 mg / kg (newborns) Duration: 3 - 5 minutes (some resps) 8 - 10 minutes (adequate) PARALYSIS
    76. 76. Succinylcholine Side- Effects <ul><li>fasciculations </li></ul><ul><li>hyperkalemia </li></ul><ul><li>bradycardia </li></ul><ul><li>malignant hyperthermia </li></ul><ul><li>prolonged blockade </li></ul><ul><li>trismus - masseter muscle spasm </li></ul>Back PARALYSIS
    77. 77. Succinylcholine Fasciculations <ul><li>nicotinic receptor stimulation </li></ul><ul><li>inhibiting fasciculations - little evidence </li></ul>side-effects <ul><li>occurs same time as ICP </li></ul>PARALYSIS
    78. 78. Succinylcholine SUX-induced Hyperkalemia <ul><li>under normal situations, increase of: 0.5 mEq/L K + </li></ul><ul><li>small risk of dysrythmia: </li></ul><ul><ul><ul><li>CRF </li></ul></ul></ul><ul><ul><ul><li>severe acidosis </li></ul></ul></ul><ul><ul><ul><li>rhabdomyolysis </li></ul></ul></ul>Preexistent K + PARALYSIS
    79. 79. Succinylcholine <ul><li>increased extrajunctional receptors: </li></ul><ul><li>5 - 10 mEq/L K + </li></ul><ul><ul><li>prolonged depolarization </li></ul></ul><ul><ul><li>refractory to non-depolarizing NMB, may require large doses </li></ul></ul>Exaggerated release of K + PARALYSIS
    80. 80. Succinylcholine Exaggerated release of K + <ul><li>functional denervation of muscle: </li></ul><ul><ul><ul><li>stroke </li></ul></ul></ul><ul><ul><ul><li>spinal cord injury </li></ul></ul></ul><ul><li>extensive burns </li></ul><ul><li>massive crush injuries </li></ul><ul><li>neuromuscular disorders </li></ul>side-effects PARALYSIS
    81. 81. Succinylcholine PARALYSIS Receptor Recruitment & Sensitization Onset: 7 days Duration: 2 - 3 months Crush: Onset: 7 days Duration: 6 months Denervation: Onset: 24 hours Duration: 2 years Burns: (% burn does not determine response)
    82. 82. Succinylcholine Neuromuscular disorders: SUX contraindicated side-effects PARALYSIS Receptor Recruitment & Sensitization <ul><li>If give SUX: </li></ul><ul><ul><li>intractable cardiac arrest may occur </li></ul></ul><ul><ul><li>(even if recognize and treat K +) </li></ul></ul>
    83. 83. Succinylcholine Bradycardia <ul><li>cardiac muscarinic receptor stimulation </li></ul><ul><li>succinylmonocholine (a metabolite) sensitizessinus node receptors to repeat doses </li></ul><ul><li>consider atropine if: age < 10 </li></ul><ul><li>repeating dose </li></ul>side-effects <ul><li>children have vagal tone </li></ul>PARALYSIS
    84. 84. Succinylcholine Prolonged Neuromuscular Blockade <ul><li>congenital absence </li></ul><ul><li>of pseudocholinesterase </li></ul><ul><li>presence of an atypical form </li></ul><ul><ul><ul><ul><li>may last hours </li></ul></ul></ul></ul>PARALYSIS
    85. 85. Succinylcholine <ul><li>acquired absence: </li></ul><ul><ul><ul><li>cocaine </li></ul></ul></ul><ul><ul><ul><li>metoclopramide (Maxeran) </li></ul></ul></ul><ul><ul><ul><li>CRF </li></ul></ul></ul><ul><ul><ul><li>severe liver disease </li></ul></ul></ul><ul><ul><ul><li>hypothyroidism </li></ul></ul></ul><ul><ul><ul><li>malnutrition </li></ul></ul></ul><ul><ul><ul><li>pregnancy </li></ul></ul></ul><ul><ul><ul><li>cytotoxic drugs </li></ul></ul></ul><ul><ul><ul><li>organophosphates </li></ul></ul></ul>Prolonged Neuromuscular Blockade PARALYSIS
    86. 86. Succinylcholine <ul><li>acquired absence: </li></ul><ul><ul><ul><li>even worst of acquired not reported </li></ul></ul></ul><ul><ul><ul><li>to last > 25 minutes </li></ul></ul></ul><ul><ul><ul><li>SUX not contraindicated </li></ul></ul></ul>Prolonged Neuromuscular Blockade side-effects PARALYSIS
    87. 87. Succinylcholine <ul><li>mortality 60% </li></ul><ul><li>onset can be acute or delayed for hours </li></ul>Malignant Hyperthermia <ul><li>genetic skeletal muscle abnormality </li></ul><ul><li>can be triggered by: </li></ul><ul><ul><ul><ul><li>SUX </li></ul></ul></ul></ul><ul><ul><ul><ul><li>stress </li></ul></ul></ul></ul><ul><ul><ul><ul><li>vigorous exercise </li></ul></ul></ul></ul><ul><ul><ul><ul><li>halothane </li></ul></ul></ul></ul>PARALYSIS
    88. 88. Succinylcholine <ul><ul><li>muscle rigidity </li></ul></ul><ul><ul><li>autonomic instability </li></ul></ul><ul><ul><li>hypotension </li></ul></ul><ul><ul><li>hypoxia </li></ul></ul><ul><ul><li>severe lactic acidosis </li></ul></ul><ul><ul><li>myoglobinemia </li></ul></ul><ul><ul><li>DIC </li></ul></ul><ul><ul><li>fever - late manifestation </li></ul></ul>Malignant Hyperthermia side-effects PARALYSIS
    89. 89. Succinylcholine <ul><li>prevents Ca ++ release from sarcoplasmic reticulum of skeletal muscle </li></ul>Dantrolene for MH <ul><li>essential to resuscitation </li></ul><ul><li>give as soon as Dx suspected </li></ul><ul><li>free of serious side-effects </li></ul>side-effects Dose: <ul><li>2.5 mg/kg IV q5min </li></ul><ul><li>until muscle relaxation, or max 4 doses </li></ul>PARALYSIS
    90. 90. Succinylcholine Trismus - Masseter Muscle Spasm <ul><li>rise in jaw muscle tension is normal </li></ul><ul><ul><ul><li>should not affect laryngoscopy </li></ul></ul></ul><ul><li>pretreatment will not prevent </li></ul><ul><li>if severe, or progresses to other muscles: </li></ul><ul><ul><ul><li>consider malignant hyperthermia </li></ul></ul></ul><ul><ul><ul><li>spasm is not pathonomonic for MH </li></ul></ul></ul><ul><li>if occurs - administer non-depolarizing NMB (Rocuronium) </li></ul>side-effects PARALYSIS
    91. 91. Rocuronium <ul><li>Nondepolarizing, </li></ul><ul><li>does not stimulate receptor </li></ul><ul><ul><ul><ul><li>no fasciculations </li></ul></ul></ul></ul><ul><li>minimal hemodynamic effects </li></ul><ul><li>do not need priming dose </li></ul>PARALYSIS
    92. 92. Rocuronium Dose: 0.6 - 1.2 mg / kg PARALYSIS Onset: 60 - 90 seconds Duration: 30 - 60 minutes Defasiculating: 0.05 mg / kg
    93. 93. Comparing NMB SUX ROC PARALYSIS ONSET 30 - 60 60 - 90 sec DURATION 3 - 10 20 - 60 min rapid rapid no priming CVS stability advantages precautions K +
    94. 94. Comparing NMB PARALYSIS sec min VEC 150 - 180 25 - 30 no histamine release PAN 120 - 180 60 - 90 histamine release ATRA 120 - 150 20 - 35 histamine release
    95. 95. Positioning Proof
    96. 96. Positioning with protection You are asked to apply: cricoid pressure (Sellick’s maneuver)
    97. 97. BURP B ackwards U pwards R ightward P ressure <ul><li>distinct from Sellick’s maneuver </li></ul><ul><ul><li>second assistant </li></ul></ul><ul><ul><li>first assistant’s other hand </li></ul></ul>
    98. 98. Maneuvers Back
    99. 99. Laryngoscopy
    100. 100. Laryngoscopy
    101. 101. Laryngoscopy
    102. 102. Laryngoscopy
    103. 103. Laryngoscopy
    104. 104. Placement with proof methods of confirmation chest rise air entry fogging of ETT 60 cc syringe * capnometer
    105. 105. Colorimetric Capnometry exhaled CO2 simple color change from purple to yellow
    106. 106. Colorimetric Capnometry NEGATIVE POSITIVE
    107. 107. Colorimetric Capnometry ETCO 2 < 4 mm Hg ETT not in trachea inadequate perfusion (ineffective CPR)
    108. 108. Colorimetric Capnometry ETCO 2 15 - 38 mm Hg ETT in trachea
    109. 109. Colorimetric Capnometry ETCO 2 4 to < 15 mm Hg retained CO 2 in esophagus low perfusion deliver 6 more breaths
    110. 110. Colorimetric Capnometry Standard of Care Limitations: Back <ul><li>decreased cardiac output </li></ul><ul><li>low metabolic CO 2 production </li></ul><ul><ul><li>ex. hypothermia </li></ul></ul>
    111. 111. Bougie Lightwand LMA
    112. 112. Bougie
    113. 113. Epiglottis
    114. 114. Laryngoscopy Grades Cormack Lehane
    115. 115. Bougie
    116. 116. Lightwand
    117. 117. Lightwand Source: Laerdal
    118. 118. Lightwand Source: Laerdal
    119. 119. Laryngeal Mask Airway Source: LMA North America skip insertion technique
    120. 120. Laryngeal Mask Airway Source: LMA North America <ul><li>deflate the cuff </li></ul><ul><li>apply water-soluble lubricant to the posterior surface </li></ul><ul><li>place index finger at the junction of the cuff </li></ul>skip insertion technique
    121. 121. Laryngeal Mask Airway Source: LMA North America <ul><li>press the tip of the cuff upward against the hard palate and flatten the cuff against it </li></ul>skip insertion technique
    122. 122. Laryngeal Mask Airway Source: LMA North America <ul><li>use the index finger to guide the LMA, </li></ul><ul><li>press backward toward the other hand, which exerts counter-pressure (do not use force) </li></ul>skip insertion technique
    123. 123. Laryngeal Mask Airway Source: LMA North America <ul><li>advance the LMA into the hypopharynx until a definite resistance is felt. </li></ul><ul><li>inflate the cuff </li></ul>skip insertion technique
    124. 124. 7. Postintubation mgmt fix tube in place CXR nasogastric / orogastric tube lab etc Back
    125. 125. O2 Delivery Systems
    126. 126. O 2 Delivery Systems <ul><li>Nasal cannulae </li></ul><ul><ul><ul><ul><li>Double rate - add to room air FiO 2 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>ex. 3 L / min + 21 % FiO 2 </li></ul></ul></ul></ul><ul><ul><li>= 27 % </li></ul></ul><ul><li>Limitations: </li></ul><ul><ul><li>rates > 3 L / min uncomfortable </li></ul></ul><ul><ul><li>mouth breathing </li></ul></ul>
    127. 127. O 2 Delivery Systems <ul><li>Simple Face Mask </li></ul><ul><ul><li>6 – 10 L / min flow </li></ul></ul><ul><ul><li>35 – 55 % FiO 2 </li></ul></ul><ul><li>entrainment of room air </li></ul><ul><li>through exhalation ports </li></ul>
    128. 128. O 2 Delivery Systems <ul><li>Partial </li></ul><ul><li>Rebreathing </li></ul><ul><li>Face Mask </li></ul><ul><li>reservoir bag </li></ul><ul><li>first ~ 1/3 of exhaled gas </li></ul><ul><li>is directed into bag </li></ul><ul><ul><li>(that which was in patient’s upper airway) </li></ul></ul><ul><li>up to 60 % FiO 2 </li></ul>
    129. 129. O 2 Delivery Systems <ul><li>Non-Rebreathing Face Mask </li></ul><ul><ul><li>reservoir bag </li></ul></ul><ul><ul><li>one-way valves </li></ul></ul><ul><ul><li>up to 80 % FiO 2 </li></ul></ul><ul><li>(realistically) </li></ul>
    130. 130. O 2 Delivery Systems <ul><li>Bag Valve Mask </li></ul><ul><li>(BVM) </li></ul><ul><li>up to 100 % FiO 2 </li></ul>
    131. 131. Summary
    132. 132. Airway Management ? ?
    133. 133. eMEDiUM Emergency Medicine in the U of M emergency.mb.ca Back
    134. 134. HSC ED <ul><li>Maryann Cromwell </li></ul><ul><li>MCromwell @ exchange.hsc.mb.ca </li></ul><ul><li>phone: 787-2934 </li></ul><ul><li>fax: 787-2231 </li></ul><ul><ul><ul><li>Department of Emergency Medicine </li></ul></ul></ul><ul><ul><ul><li>Health Sciences Centre </li></ul></ul></ul><ul><ul><ul><li>GF 201-800 Sherbrook Street </li></ul></ul></ul><ul><ul><ul><li>Winnipeg, MB </li></ul></ul></ul><ul><ul><ul><li>R3A 1R9 </li></ul></ul></ul>Back
    135. 135. CAEP ACEP

    ×