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Emergency Medicine <ul><li>And the Difficult Airway </li></ul><ul><li>Jordan Barnett, MD FACEP FAAEM </li></ul>
Disclaimer This presentation is free of commercial bias
Dichotomy  <ul><li>Anesthesiologists usually have time to prepare </li></ul><ul><li>Anesthesiologists often can defer care...
What Does the ED Contend with?
 
 
 
 
 
 
 
Initial Assessment <ul><li>Be comfortable calling for help </li></ul><ul><li>Surgical airway endpoint of all algorithms </...
Intubation Plan <ul><li>In crash situation, may intubate without paralytics </li></ul><ul><li>Difficult airway cart to bed...
Predictors of a Difficult Airway LEMON RULE LEMON RULE <ul><li>L ook at the Anatomy </li></ul><ul><li>E valuate using 3-3-...
L OOK for predictors of Difficult Airway <ul><li>Abnormal,jagged, or protruding teeth </li></ul><ul><li>Receding chin </li...
Other Items to  L OOK for include <ul><li>No Teeth </li></ul><ul><li>Elderly </li></ul><ul><li>Snoring </li></ul><ul><li>L...
E valuate THE AIRWAY
Evaluate with the 3-3-2 Rule <ul><li>Can you get 3 fingers in mouth?  If So there is room for insertion of tube and laryng...
M allampati Classification <ul><li>Grades I and II high success rate at intubation </li></ul><ul><li>Grade III can only se...
How to Mallampati Score <ul><li>Have Patient seated, extend neck, open mouth and stick out tongue </li></ul><ul><li>Visual...
No obstruction Complete obstruction
O BSTRUCTIONS
Types of Obstructions
N eck Mobility? <ul><li>Fracutre? </li></ul><ul><li>Arthritis? </li></ul><ul><li>Surgical hardware? </li></ul><ul><li>Can’...
Always <ul><li>Try not to utilize medications too quickly.  Evaluate airway first.  Gives time to call for help </li></ul>
All the predictors are fine theoretically but .......
 
Difficult Airway Cart <ul><li>Recommended items include drawer for medications and basic equipment </li></ul><ul><li>Intub...
Intubation equipment <ul><li>Options to avoid intubation include CPAP </li></ul><ul><li>Consider intubation in OR </li></u...
 
 
The Bougie
How to use the Bougie <ul><li>Bougie acts as guide wire </li></ul><ul><li>Gets Passed Blindly </li></ul><ul><li>Feel for t...
Lighted Intubation Stylet
VIDEO
Laryngeal Mask Airway
Note: This video provided to demonstrate LMA use.  No financial interest with the Solus Brand
 
Airway Alternatives <ul><li>Supraglottic: Combitube; blind nasotracheal intubation still has role </li></ul><ul><li>Infrag...
Combitube
Combitube Details <ul><li>Two Lumens </li></ul><ul><li>Filling one blocks the esophagous </li></ul><ul><li>Second Lumen ac...
VIDEO
Tracheal position
Esophageal Position
EMS using King LT  <ul><li>Easier field insertion </li></ul><ul><li>Simpler to change to ETT </li></ul><ul><li>Can Place K...
 
Additional options <ul><li>Wire guided Seldinger technique </li></ul><ul><li>Keep option to use open techinique if wire un...
Retrograde Endotracheal Intubation
Technique In Detail  <ul><li>Needle through Cricothyroid Membrane </li></ul><ul><li>Retreive End of Wire </li></ul><ul><li...
VIDEO
Anterograde Seldinger
Pass wire through hub
Pass Over Wire
Fiberoptics
Two Types Available <ul><li>Flexible </li></ul><ul><li>Rigid </li></ul>
Flexible Fiberoptic Intubation <ul><li>Used if Neck Extension Not desirable </li></ul><ul><li>Risk of Dental Damage </li><...
Advantages of Fiberoptics <ul><li>Excellent visualization </li></ul><ul><li>Minimal hemodynamic stress when performed prop...
Disadvantages <ul><li>Expensive </li></ul><ul><li>Requires maintenance </li></ul><ul><li>Blood or secretions impairs visua...
Video
Rigid Fiberoptics <ul><li>Indicated for limited mouth opening </li></ul><ul><li>Indicated for reduced neck movment </li></ul>
Advantages <ul><li>Allows for visualization of the larynx with little neck movement and mouth opening </li></ul><ul><li>Ca...
Disadvantages <ul><li>Skill </li></ul><ul><li>External light source for some devices </li></ul><ul><li>Wu Scope requires c...
Levitan Scope
Bullard Scope
Wu Scope
Upsher Scope
New Laryngoscope blades <ul><li>Utilize video camera at end of laryngoscope </li></ul><ul><li>Complications including fogg...
GlideScope <ul><li>Preferred over Laryngoscope </li></ul><ul><li>Gets around Tongue Easily </li></ul><ul><li>Insert with p...
 
 
Transtracheal Jet <ul><li>If under 8 and no airway, surgical airway of choice </li></ul><ul><li>Temporary /Stabilizing </l...
Cricothyrotomy  <ul><li>Taught as the “Final Pathway” to all ER physicians as a last resort for failed airway access </li>...
video
Ready for some Cases?
 
Difficult Airway Case 1 <ul><li>34 year old chronic alcoholic enters the ER “not feeling well.”  History of “back pain” fo...
Case 1 continued <ul><li>Monitor shows patient become bradycardic.  </li></ul><ul><li>Patient is rolled into rescue positi...
Case 1 continued <ul><li>Must protect airway! </li></ul><ul><li>Despite attempts at direct visualization with laryngoscope...
Options? <ul><li>Blind digital intubation? </li></ul><ul><li>Fiberoptics NOT an option </li></ul><ul><li>Reverse Selinger?...
 
Case 2 <ul><li>73 year old female presents with history of hemoptysis.  </li></ul><ul><li>Hasn’t seen a doctor for “years”...
Case 2 continued <ul><li>During the episodes of hemoptysis, patient vagals.  </li></ul><ul><li>Airway protection paramount...
 
Case 3 <ul><li>35 year old male presented after dental extraction placed on antibiotics </li></ul><ul><li>Patient presente...
Discussion <ul><li>Conventional laryngoscope blade would probably be ineffective </li></ul><ul><li>Fiberoptics ideal </li>...
 
Case 4 <ul><li>85 year old female presents via Fire Rescue tachypnic, with only 2-3 word sentences </li></ul><ul><li>Medic...
Case 4 continued <ul><li>Patient tachypnic with rales 2/3 up </li></ul><ul><li>JVD </li></ul><ul><li>Pedal Edema at 2+ </l...
Discussion <ul><li>Most ED docs today would trial patient on BiPAP with airway cart on standby </li></ul><ul><li>Preload r...
 
Case 5 <ul><li>27 year old male leaped from burning 2 story dwelling landing on back </li></ul><ul><li>Arrives collared an...
Discussion <ul><li>Have to assume potential neck fracture </li></ul><ul><li>Carbonateous sputum and singed nasal hairs tau...
Management <ul><li>2nd helper holds inline stabalization of neck during attempted intubation </li></ul><ul><li>BURP maneuv...
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Emergency Respiratory Medicine and the Difficulty Airway, Jordan Barnett MD

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Presented as a Faculty member of the Deborah Heart and Lung Center\’s, &quot;What\’s Up Dock,&quot; on Friday, September 11th 2009, at the Independence Seaport Museum in Philadelphia. This conference\’s purposes was to review the most current developments and advances in medicine as they pertain to practicing physicians and allied health professionals alike. Jordan Barnett MD

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Transcript of "Emergency Respiratory Medicine and the Difficulty Airway, Jordan Barnett MD"

  1. 1. Emergency Medicine <ul><li>And the Difficult Airway </li></ul><ul><li>Jordan Barnett, MD FACEP FAAEM </li></ul>
  2. 2. Disclaimer This presentation is free of commercial bias
  3. 3. Dichotomy <ul><li>Anesthesiologists usually have time to prepare </li></ul><ul><li>Anesthesiologists often can defer care </li></ul><ul><li>Anesthesiologists can obtain information and history from patient </li></ul><ul><li>Anesthesiologists have non chaotic environment </li></ul>
  4. 4. What Does the ED Contend with?
  5. 12. Initial Assessment <ul><li>Be comfortable calling for help </li></ul><ul><li>Surgical airway endpoint of all algorithms </li></ul><ul><li>BVM to buy time. Not always imperative to intubate immediately </li></ul><ul><li>Have a difficult airway cart and be familiar with it! </li></ul>
  6. 13. Intubation Plan <ul><li>In crash situation, may intubate without paralytics </li></ul><ul><li>Difficult airway cart to bedside </li></ul><ul><li>What is your skill set, tools available? </li></ul>
  7. 14. Predictors of a Difficult Airway LEMON RULE LEMON RULE <ul><li>L ook at the Anatomy </li></ul><ul><li>E valuate using 3-3-2 rule </li></ul><ul><li>M allampati </li></ul><ul><li>O bstructions </li></ul><ul><li>N eck Mobility </li></ul>
  8. 15. L OOK for predictors of Difficult Airway <ul><li>Abnormal,jagged, or protruding teeth </li></ul><ul><li>Receding chin </li></ul><ul><li>Facial hair </li></ul><ul><li>Full stomach </li></ul><ul><li>Obesity </li></ul>
  9. 16. Other Items to L OOK for include <ul><li>No Teeth </li></ul><ul><li>Elderly </li></ul><ul><li>Snoring </li></ul><ul><li>Large Tongue </li></ul><ul><li>False Teeth </li></ul><ul><li>Narrow Face </li></ul>
  10. 17. E valuate THE AIRWAY
  11. 18. Evaluate with the 3-3-2 Rule <ul><li>Can you get 3 fingers in mouth? If So there is room for insertion of tube and laryngoscope </li></ul><ul><li>Can you fit three fingers between the angle of the jaw and mentum? If so, you can probably lift the tongue forward </li></ul><ul><li>Can you fit two fingersers between the top of the thyroid cartilage and bottom of jaw? If not, high anterior cord probably present </li></ul>
  12. 19. M allampati Classification <ul><li>Grades I and II high success rate at intubation </li></ul><ul><li>Grade III can only see arytenoid cartilage </li></ul><ul><li>Grade IV cannot visualize anything </li></ul>
  13. 20. How to Mallampati Score <ul><li>Have Patient seated, extend neck, open mouth and stick out tongue </li></ul><ul><li>Visualize Mouth, tongue, faucial pillars, uvula, and pharynx </li></ul>
  14. 21. No obstruction Complete obstruction
  15. 22. O BSTRUCTIONS
  16. 23. Types of Obstructions
  17. 24. N eck Mobility? <ul><li>Fracutre? </li></ul><ul><li>Arthritis? </li></ul><ul><li>Surgical hardware? </li></ul><ul><li>Can’t Align Axises For Visualization! </li></ul>
  18. 25. Always <ul><li>Try not to utilize medications too quickly. Evaluate airway first. Gives time to call for help </li></ul>
  19. 26. All the predictors are fine theoretically but .......
  20. 28. Difficult Airway Cart <ul><li>Recommended items include drawer for medications and basic equipment </li></ul><ul><li>Intubating stylet or bougie </li></ul><ul><li>Intubating laryngeal mask airway </li></ul><ul><li>Light Wand </li></ul><ul><li>Fiberoptics </li></ul><ul><li>surgical airway kit - essential </li></ul>
  21. 29. Intubation equipment <ul><li>Options to avoid intubation include CPAP </li></ul><ul><li>Consider intubation in OR </li></ul><ul><li>For blind intubations consider LMA or Bougie </li></ul><ul><li>Digital intubation? </li></ul>
  22. 32. The Bougie
  23. 33. How to use the Bougie <ul><li>Bougie acts as guide wire </li></ul><ul><li>Gets Passed Blindly </li></ul><ul><li>Feel for tracheal rings </li></ul>
  24. 34. Lighted Intubation Stylet
  25. 35. VIDEO
  26. 36. Laryngeal Mask Airway
  27. 37. Note: This video provided to demonstrate LMA use. No financial interest with the Solus Brand
  28. 39. Airway Alternatives <ul><li>Supraglottic: Combitube; blind nasotracheal intubation still has role </li></ul><ul><li>Infraglottic; Cannot BVM or intubate if access required below cords; Prepare for Cricothyrotomy In peds, consider transtracheal jet ventilation </li></ul>
  29. 40. Combitube
  30. 41. Combitube Details <ul><li>Two Lumens </li></ul><ul><li>Filling one blocks the esophagous </li></ul><ul><li>Second Lumen acts like a standard cuffed tube </li></ul><ul><li>Blind insertion </li></ul><ul><li>90% Esophageal insertion </li></ul><ul><li>100 cc for proximal balloon inflation </li></ul><ul><li>10 ml for distal balloon inflation </li></ul><ul><li>Listen as you inflate through each port </li></ul>
  31. 42. VIDEO
  32. 43. Tracheal position
  33. 44. Esophageal Position
  34. 45. EMS using King LT <ul><li>Easier field insertion </li></ul><ul><li>Simpler to change to ETT </li></ul><ul><li>Can Place King without Interupting CPR </li></ul><ul><li>Placement Edema </li></ul>
  35. 47. Additional options <ul><li>Wire guided Seldinger technique </li></ul><ul><li>Keep option to use open techinique if wire unsuccessful </li></ul>
  36. 48. Retrograde Endotracheal Intubation
  37. 49. Technique In Detail <ul><li>Needle through Cricothyroid Membrane </li></ul><ul><li>Retreive End of Wire </li></ul><ul><li>Tube Changer over wire </li></ul><ul><li>Slide in ETT </li></ul>
  38. 50. VIDEO
  39. 51. Anterograde Seldinger
  40. 52. Pass wire through hub
  41. 53. Pass Over Wire
  42. 54. Fiberoptics
  43. 55. Two Types Available <ul><li>Flexible </li></ul><ul><li>Rigid </li></ul>
  44. 56. Flexible Fiberoptic Intubation <ul><li>Used if Neck Extension Not desirable </li></ul><ul><li>Risk of Dental Damage </li></ul><ul><li>Abnormal airway </li></ul><ul><li>Compromised Airway </li></ul>
  45. 57. Advantages of Fiberoptics <ul><li>Excellent visualization </li></ul><ul><li>Minimal hemodynamic stress when performed properly </li></ul><ul><li>oral or nasal intubation is possible </li></ul><ul><li>ability to apply topical anesthesia insufflate oxygen during intubation </li></ul>
  46. 58. Disadvantages <ul><li>Expensive </li></ul><ul><li>Requires maintenance </li></ul><ul><li>Blood or secretions impairs visualization </li></ul><ul><li>Requires “Practiced Expertise” for use in acute situations </li></ul>
  47. 59. Video
  48. 60. Rigid Fiberoptics <ul><li>Indicated for limited mouth opening </li></ul><ul><li>Indicated for reduced neck movment </li></ul>
  49. 61. Advantages <ul><li>Allows for visualization of the larynx with little neck movement and mouth opening </li></ul><ul><li>Can overcome difficult view </li></ul><ul><li>Sturdy and Durable instruments </li></ul>
  50. 62. Disadvantages <ul><li>Skill </li></ul><ul><li>External light source for some devices </li></ul><ul><li>Wu Scope requires considerable mouth opening </li></ul>
  51. 63. Levitan Scope
  52. 64. Bullard Scope
  53. 65. Wu Scope
  54. 66. Upsher Scope
  55. 67. New Laryngoscope blades <ul><li>Utilize video camera at end of laryngoscope </li></ul><ul><li>Complications including fogging and inability to visualize airway after intubation </li></ul>
  56. 68. GlideScope <ul><li>Preferred over Laryngoscope </li></ul><ul><li>Gets around Tongue Easily </li></ul><ul><li>Insert with patient in neutral position </li></ul><ul><li>Can see even in presence of blood and vomit </li></ul><ul><li>Will probably replace Laryngoscope in 5 to 10 years </li></ul>
  57. 71. Transtracheal Jet <ul><li>If under 8 and no airway, surgical airway of choice </li></ul><ul><li>Temporary /Stabilizing </li></ul>
  58. 72. Cricothyrotomy <ul><li>Taught as the “Final Pathway” to all ER physicians as a last resort for failed airway access </li></ul>
  59. 73. video
  60. 74. Ready for some Cases?
  61. 76. Difficult Airway Case 1 <ul><li>34 year old chronic alcoholic enters the ER “not feeling well.” History of “back pain” for which he has been seen and treated in the past (err....with Motrin?!) </li></ul><ul><li>Suddenly, during evaluation and obtaining history and physical, patient begins to profusely vomit blood and becomes obtunded. </li></ul>
  62. 77. Case 1 continued <ul><li>Monitor shows patient become bradycardic. </li></ul><ul><li>Patient is rolled into rescue position and airway cart called for while multiple peripheral large bore IVs are established </li></ul>
  63. 78. Case 1 continued <ul><li>Must protect airway! </li></ul><ul><li>Despite attempts at direct visualization with laryngoscope blade and vigorous suctioning, there is just too much blood to see the cords </li></ul>
  64. 79. Options? <ul><li>Blind digital intubation? </li></ul><ul><li>Fiberoptics NOT an option </li></ul><ul><li>Reverse Selinger? </li></ul><ul><li>Crich? </li></ul><ul><li>Lighted stylet? </li></ul>
  65. 81. Case 2 <ul><li>73 year old female presents with history of hemoptysis. </li></ul><ul><li>Hasn’t seen a doctor for “years” yet has been loosing weight. Has come to the ER now on the behest of family because of coughing up blood </li></ul>
  66. 82. Case 2 continued <ul><li>During the episodes of hemoptysis, patient vagals. </li></ul><ul><li>Airway protection paramount </li></ul><ul><li>Best Management? </li></ul>
  67. 84. Case 3 <ul><li>35 year old male presented after dental extraction placed on antibiotics </li></ul><ul><li>Patient presented complaining of pain and swelling of the jaw </li></ul><ul><li>Uvula shift to the left and swollen elevated tongue limit visualization. Sonorous respirations </li></ul>
  68. 85. Discussion <ul><li>Conventional laryngoscope blade would probably be ineffective </li></ul><ul><li>Fiberoptics ideal </li></ul><ul><li>Crich kit on standby </li></ul><ul><li>Call to anesthesia to ED on standby if situation not of immediate“Crash” type. </li></ul>
  69. 87. Case 4 <ul><li>85 year old female presents via Fire Rescue tachypnic, with only 2-3 word sentences </li></ul><ul><li>Medics report “flash pulmonary Edema” while “at your back door” </li></ul><ul><li>“ Doc, we only had time to place her on oxygen and get an IV when we pulled up!” </li></ul>
  70. 88. Case 4 continued <ul><li>Patient tachypnic with rales 2/3 up </li></ul><ul><li>JVD </li></ul><ul><li>Pedal Edema at 2+ </li></ul>
  71. 89. Discussion <ul><li>Most ED docs today would trial patient on BiPAP with airway cart on standby </li></ul><ul><li>Preload reduction with nitrates </li></ul><ul><li>Afterload reduction with Captopril </li></ul><ul><li>Intubation Equipment on standby! </li></ul>
  72. 91. Case 5 <ul><li>27 year old male leaped from burning 2 story dwelling landing on back </li></ul><ul><li>Arrives collared and back boarded, unconscious with a Glascow Coma Scale of 5 </li></ul><ul><li>Singed nasal hairs with carbonatious sputum </li></ul>
  73. 92. Discussion <ul><li>Have to assume potential neck fracture </li></ul><ul><li>Carbonateous sputum and singed nasal hairs taught as signs of pending airway edema </li></ul><ul><li>Head injuries (which have to be assumed) preclude nasal intubation </li></ul>
  74. 93. Management <ul><li>2nd helper holds inline stabalization of neck during attempted intubation </li></ul><ul><li>BURP maneuver </li></ul><ul><li>Anesthesia on standby if can respond timely </li></ul><ul><li>Too much edema? Can’t seen cords? Surgical option of crich. </li></ul>
  75. 94. ?
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