Airway management in ER.

1. Emergency Airway
Management
Pat Melanson, MD

2. Safe airway management
 airway evaluation
 identification of the difficult airway
 assessment of other clinical factors
 selection of the likely most successful
plan of action
 reasonable alternative plan

3. Algorithmic Approach to Airway
Management
 Have a precompiled plan of airway
management ready for implementation
as clinical airway difficulties are
encountered
 develop a plan and a back-up plan
 Practice guidelines for management of
the difficult airway
– ASA taskforce
– Anesthesiology 78 : 597 - 602, 1993

4. Emergency Airway
 full stomach
 altered level of consciousness
 deteriorating cardiorespiratory
physiology
 abnormal or distorted upper airway
anatomy
 no time for pre-assessment or plan

5. Airway Assessment
 compromise or threats
 potentially difficult airway

6. The Three Pillars of Airway
Management
 Patency ( airflow integrity )
 Protection against aspiration
 Assurance of oxygenation and
ventilation

7. Indications for Active Airway
Intervention
 Patency - relief of obstruction
 Protection from aspiration
 Hypoxic/ hypercapnic respiratory failure
 Airway access for pulmonary toilet, drug
delivery,therapeutic hyperventilation
 Shock

8. Clinical Signs of Airway Compromise
: Patency
 Inspiratory stridor
 Snoring ( pharyngeal obstruction )
 Gurgling ( foreign matter/ secretions )
 Drooling ( epiglottitis )
 Hoarseness ( laryngeal edema/ vc
paralysis)
 Paradoxical chest wall movement
 Tracheal tug

9. Clinical Signs of Airway Compromise
: Protection
 Blood in upper airway
 Pus in upper airway
 persistant vomiting
 Loss of protective airway reflexes

10. Clinical Signs of Airway Compromise:
Oxygenation and Ventilation
 Central cyanosis
 Obtundation and diaphoresis
 rapid shallow respirations
 Accessory muscle use
 Retractions
 Abdominal paradox

11. The Difficult Airway
 Difficult laryngoscopy
 Difficult bag-mask ventilation
 Lower airway difficulty

12. Techniques for the
Compromised Airway
 Bag-Valve-Mask Ventilation
 Endotracheal Intubation
 Rapid Sequence Intubation
 Alternate techniques for the difficult
airway

13. Golden Rules of Bagging
 “ Anybody ( almost ) can be oxygenated
and ventilated with a bag and a mask “
 The art of bagging should be mastered
before the art of intubation
 Manual ventilation skill with proper
equipment is a fundamental premise of
advanced airway management

14. Frequent Errors with BVM
 failure to recognize its importance
 forget to bag ( focussed on ETT )
 give up on bagging too early
 bag but don’t assess efficacy
 failure to assign one person to airway
management only

15. Difficult Airway : BVM
 Upper airway obstruction
 Lack of dentures
 Beard
 Midfacial smash
 facial burns, dressings, scarring
 poor lung mechanics

16. Difficult Airway : BVM
 degree of difficulty from zero to infinite
 zero = no external effort/internal device
 one person jaw thrust/ face seal
 oropharyngeal or nasopharyngeal AW
 two person jaw thrust / face seal
– both internal airway devices
 infinite -no patency despite maximal
external effort and full use of OP/NP

17. Difficult Airway : BVM
 Remove FB - Magill forceps
 Triple maneuver if c-spine clear
– Head tilt, jaw lift, mouth opening
 Nasopharyngeal or oropharyngeal
airway
 two-person, four-hand technique

18. Prediction of the difficult
airway (Intubation)
 1200 prospectively studied patients
 of 84 patients predicted to have
problem, only 22 (25%) actually had a
problem
 of 43 actual difficult intubations
incurred, only 22 (51%) were predicted
– Latto IP. and Rosen M

19. Prediction of the difficult
airway
 history of past airway problems
 Careful physical assessment
 knowledge and experience to
overcome the "unpredicted difficult
airway".
 learning practical airway management
skills in an environment that is not
urgent, stressful or life threatening

22. Difficult Airway :
Laryngoscopy
 Short thick neck
 Receding mandible
 Buck teeth
 Poor mandibular mobility/ limited jaw
opening
 Limited head and neck movement
– ( including trauma )

23. Difficult Airway :
Laryngoscopy
 Tumor, abscess or hematoma
 Burns
 Angioneurotic edema
 Blunt or penetrating trauma
 Rheumatoid arthritis, ankylosing
spondylitis
 Congenital syndromes
 Neck surgery or radiation

24. Difficult Airway :
Laryngoscopy
 3 fingerbreadths mentum to hyoid
 3 fb chin to thyroid notch
 3 fb upper to lower incisors
 Head extension and neck flexion
 Mallimpadi classification
 Previous history of difficult intubation

25. Mallimpadi Classification
( Tongue to Pharyngeal Size )
 I - soft palate, uvula, tonsillar pillars
– 99 % have grade I laryngoscopic view
 II - soft palate, uvula
 III - soft palate, base of uvula
 IV - soft palate not visible
– 100% grade III or grade IV views

26. Unsuccessful Intubation
 Bag the patient
 Maximize neck flexion/ head extension
 Move tongue out of line of site
 Maximize mouth opening
 Look for landmarks and adjust blade
 BURP maneuver
 increasing lifting force
 consider Miller blade
 Bag the patient

27. Dilemmas:
 Awake or Asleep
 Oral or Nasal
 Laryngoscopy or Blind Intubation
 To Paralyze or Not

28. Case #1
 43 year old female, day 12 post SAH
 5 unclipped cerebral aneurysms
 vasospasm with left hemiparesis
 hydrocephalus with clotted IV drain
 rising ICP and BP
 decreasing LOC
 ate breakfast

29. Techniques
 DL without pharmacologic aids
 Awake Direct Laryngoscopy
 Awake Blind Nasal
 Rapid Sequence Intubation (RSI)
 Fiberoptic
 Surgical Cricothyroidotomy

30. Anesthesia Airway Maxims
 the awake airway is the safest to
manage
 spontaneous breathing is generally
safer than paralysis with PPV by mask
 have a low threshold to wake the
patient up and cancel the case
 call for help early

31. The “Intubation Reflex “
 Catecholamine release in response to
laryngeal manipulation
 Tachycardia, hypertension, raised ICP
 Attenuated by beta-blockers, fentanyl
 ICP rise possibly attenuated by
lidocaine
 Midazolam and thiopental have no
effect

32. Rapid Sequence Intubation :
Definition
 The near simultaneous administration of
a sedative-hypnotic agent and a
neuromuscular blocker in the presence
of continuous cricoid pressure to
facilitate endotracheal intubation and
minimize risk of aspiration
 modifications are made depending upon
the clinical scenario

33. Rapid Sequence Intubation :
Advantages
 Optimizes intubating conditions/
facilitates visualization
 Increased rate of successful intubation
 Decreased time to intubation
 Decreased risk of aspiration
 Attenuation of hemodynamic and ICP
changes

34. Rapid Sequence Intubation :
Contraindications
 Anticipated difficulty with endotracheal
intubation
– anatomic distortion
 Lack of operator skill or familiarity
 inability to preoxygenate

35. Rapid Sequence Intubation :
Procedure
 Pre-intubation assessment
 Pre-oxygenate
 Prepare ( for the worst )
 Premedicate
 Paralyze
 Pressure on cricoid
 Place the tube
 Post intubation assessment

36. Pre-oxygenate
( Time - 5 Minutes)
 100 % oxygen for 5 minutes
 4 conscious deep breaths of 100 % O2
 Fill FRC with reservoir of 100 % O2
 Allows 3 to 5 minutes of apnea
 Essential to allow avoidance of bagging
 If necessary bag with cricoid pressure

37. Preparation
( Time - 5 Minutes )
 ETT, stylet, blades, suction, BVM
 Cardiac monitor, pulse oximeter, ETCO2
 One ( preferably two ) iv lines
 Drugs
 Difficult airway kit including cric kit
 Patient positioning

38. Pre-treatment/ Prime
( Time - 2 Minutes )
 Lidocaine 1.5 mg/kg iv
 Defasciculating dose of non-
depolarizing NMB
 Beta-blocker or fentanyl
 Induction agent
– Thiopental 3 - 5 mg/kg
– Midazolam 0.1 - 0.4mg/kg
– Ketamine 1.5 - 2.0 mg/kg
– Fentanyl 2 - 30 mcg/kg

39. Paralyze ( Time Zero )
 Succinylcholine 1.5 mg/kg iv
 Allow 45 - 60 seconds for complete
muscle relaxation
 Alternatives
– Vecuromium 0.1 - 0.2 mg/kg
– Rocuronium o.6 - 1.2 mg/kg

40. Pressure
 Sellick maneuver
 initiate upon loss of consciousness
 continue until ETT balloon inflation
 release if active vomiting

41. Place the Tube
( Time Zero + 45 Secs )
 Wait for optimal paralysis
 Confirm tube placement with ETCO2

42. Post-intubation Hypotension
 Loss of sympathetic drive
 Myocardial infarction
 Tension pneumothorax
 Auto-peep

43. Succinylcholine
: Contraindications
 Hyperkalemia - renal failure
 Active neuromuscular disease with
functional denervation ( 6 days to 6
months)
 Extensive burns or crush injuries
 Malignant hyperthermia
 Pseudocholinesterase deficiency
 Organophosphate poisoning

44. Succinylcholine :
Complications
 Inability to secure airway
 Increased vagal tone ( second dose )
 Histamine release ( rare )
 Increased ICP/ IOP/ intragastric
pressure
 Myalgias
 Hyperkalemia with burns, NM disease
 malignant hyperthermia

45. Difficult Airway Kit
 Multiple blades and ETTs
 ETT guides ( stylets, bougé, light wand)
 Emergency nonsurgical ventilation
( LMA, combitube, TTJV )
 Emergency surgical airway access
( cricothyroidotomy kit, cricotomes )
 ETT placement verification
 Fiberoptic and retrograde intubation

46. Emergency Surgical Airway
Maxims
 they are usually a bloody mess, but ...
 a bloody surgical airway is better than
an arrested patient with a nice looking
neck

47. Case # 2
 42 year old female
 right Pancoast tumor
 RUL, RML, RLL collapse
 ARDS on left
 hypoxemic respiratory failure
 cord compression C7 - T4