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Airway management in ED - Basics and advanced
1. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Airway management in ER settings
“Basic & Advanced”
Updated with recent advances
Dr.Venugopalan. P.P
DA,DNB,MNAMS,MEM-GWU
Director , Emergency Medicine
Aster DM Healthcare
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
2. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Why airway management in
Emergency Room ?
» Airway management is the cornerstone of
resuscitation
» A defining skill for the specialty of
emergency medicine
» The emergency physician has primary
responsibility for management of the airway
» All airway management techniques lie
within the domain of emergency medicine
3. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
When to intubate ?
» 1.Failure to maintain or protect the airway
» 2.Failure of ventilation or oxygenation
» 3.Anticipated clinical course and likelihood
of deterioration.
Clinical Decision
4. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
How do you know airway is patent?
» 1.Level of consciousness
» 2.Ability to phonate in response to voice
command or query (Integrity of the upper
airway and the level of consciousness)
» 3. Ability to manage his or her own
secretions ( pooling of secretions in the
oropharynx, absence of swallowing
spontaneously or on command)
5. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Intubation?
A patient who requires a maneuver to
establish a patent airway or who
easily tolerates an oral airway
probably requires intubation for
protection of that airway, unless
temporary or readily reversible
condition, such as opioid overdose, is
present.
7. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
The decision to intubate
intubate, and intubate early
especially in dynamic airways
Bullets - neck trauma
Bites- anaphylaxis /
angioedema thermal and
Burns -caustic airway
injuries
• 3 Bs
Bullets
Bites
Burns
#
8. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
ABCDEF
Airway - mouth and neck infections, tumors,
foreign bodies, bleeds
]exam: stridor, phonation, swallowing, secretions, dyspnea
Breathing failure of oxygenation or ventilation
often amenable to medical and non-invasive therapies – think NIV
Circulation supporting tissue oxygen delivery by
unloading the muscles of respiration
sepsis
9. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
ABCDEF
Disability : CNS catastrophes and CNS depression, ongoing
seizures, weakness
exam: avoid gag – assess ability to swallow and handle secretions (pooling, drooling,
gurgling) for neuromuscular weakness: FVC < 12 ml/kg and NIF < 20 cm H20
vomiting in the obtunded patient is a particular concern
Expected course :anticipated decline, transfer to radiology
or another institution
» Feral -need for prompt, aggressive sedation to protect
patient/others
especially with potential or undiagnosed medical instability
11. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Anticipated clinical deterioration
» Certain overdoses
» Significant multiple trauma, with or without head
injury
» Multiple trauma with hypotension, an open femur
fracture, and diffuse abdominal tenderness
» Aggressive resuscitation, pain control,invasive
procedures and imaging outside of the emergency
department ,inevitable operative management
» Evidence of vascular or direct airway injury in the
neck
34. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
RSI Defined
“Virtually simultaneous administration of a
potent sedative agent and a
neuromuscular blocking agent to induce
unconsciousness and motor paralysis
for tracheal intubation”
47. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Double set up
» Neuromuscular paralysis
generally should be
avoided in patients for
whom a high degree of
intubation difficulty is
predicted, unless the
administration of the
neuromuscular blocking
agent (NMBA) is part of
a planned approach to
the difficult airway
49. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Look Externally
» Severely bruised
» Bloodied face of a combative trauma patient
» Immobilized in a cervical collar on a spine
board
» Anatomical deformities
» Subjective clinical judgment can be highly
specific (90%) but insensitive and so should
be augmented by other evaluations.
52. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Obstruction or obesity
» Visualization of the glottis, or intubation
itself, mechanically impossible
» Epiglottitis, head and neck cancer,
Ludwig’s angina, neck hematoma, or glottic
polyps
» Examine the patient for airway obstruction
and assess the patient’s voice to satisfy
this evaluation step
53. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Neck mobility
» Neck mobility is desirable for any
intubation technique and is essential for
positioning the patient for optimal direct
laryngoscopy. Neck mobility is assessed
with the patient’s flexion and extension of
the head and neck through a full range of
motion
58. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Cormack and Lehane[CL]
» The most widely used system for grading
laryngoscopic view of the glottis is that of
Cormack and Lehane (CL)
» Grades laryngoscopy according to the
extent to which laryngeal and glottic
structures can be seen.
59. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
CL grading
» Grade 1 laryngoscopy, all or nearly all of the
glottic aperture is seen.
» Grade 2 laryngoscopy visualizes only a portion
of the glottis (arytenoid cartilages alone or
arytenoid cartilages plus part of the vocal cords).
» Grade 3 laryngoscopy visualizes only the
epiglottis.
» Grade 4 laryngoscopy, not even the epiglottis is
visible.
62. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Confirmation of Endotracheal Tube
Placement
» Direct visualisation
» Chest auscultation
» Gastric auscultation
» Bag resistance
» Exhaled volume
» Visualization of condensation within the ETT
» Chest radiography
» All are prone to failure as means of confirming
tracheal intubation.
63. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
ETCO2
» End-tidal carbon dioxide (ETCO2)
detection device to the ETT and assess it
through six manual ventilations
» Disposable, colorimetric ETCO2 detectors
are highly reliable, convenient, and easy to
interpret, indicating adequate CO2
detection by color change
70. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Chest X ray
» Although chest radiography is universally
recommended after ETT placement, its
primary purpose is to ensure that the tube
is well positioned below the cords and
above the carina.
77. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Equipments Needed
❑ Laryngoscope with different types of
blade.
❑ ET tube with proper size and type.
Average adult male: 8.5 mm
Average adult female: 7.5 mm
Low pressure cuff tubes above 8 years
Uncuffed tubes below 8 years
< 4 Age + 3.5
3
> 4 Age + 4.5
4
87. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Laryngeal Mask Airway
❑A silicone rubber device that combines.
Tracheal intubation and the use of a face
mask.
❑Used for situations when intubation
attempts have failed, bag-valve mask
ventilation is unsuccessful, and the patient
needs immediate airway management.
91. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
LMA- Sizes
Size Description Weight
1 Neonates Upto 5 Kg
1 ½ Pediatric 5 - 10 Kg
2 Infant 10 – 20 Kg
2 ½ Child 20-30 Kg
3 Large child/ Small Adult 30 – 50 Kg
4 Adult 50 – 70 Kg
5 Adult > 70 Kg
99. Blind Nasotracheal
Intubation
• BNTI remains a valid method of intubation in the
out-of-hospital setting, where it occasionally is
used. In the ED, BNTI rarely, if ever, should be
used and is reserved for patients in whom the
presence of a narrowly defined type of difficult
airway makes RSI undesirable or contraindicated
and alternatives
100. Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Awake Oral Intubation
» Awake oral intubation is a technique in which
sedative and topical anesthetic agents are
administered to permit management of a difficult
airway without neuromuscular blockade.
» Topical anesthesia may be achieved by spray,
nebulization, or local anesthetic nerve block. After
the patient is sedated and topical anesthesia has
been achieved, gentle direct, video, or flexible
endoscopic laryngoscopy is performed to determine
whether the glottis is visible and intubation possible