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Difficult Airway in Polytrauma.pptx

Anatomical difficult airway has been emphasised immensely in poly trauma management . But we very often forgot to look into the correctable physiological airway difficulties ...this presentation is exploring this aspect of airway management . This session was done in Nepal emergency medicine conference in October 2023 at Kathmandu

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Poly Trauma Airway
management : An area
which always forgets to
look into!
Dr.Venugopalan .P P
HOD & Sr.Consultant
Emergency Medicine
Aster MMS -Calicut
NEMCON
2023
“The Case”
• A 45-year-old man was brought to the ED by
following RTA. He had been involved in a high
mechanism injury , BP: 70/40 mm Hg ,HR :
136/minute R R: 45/minute
• Saturation: 78% on RA , GCS :7
• POCUS- Bleed in Morrison pouch
• ABG- PH 7.1 , BE 18 , PaO2 55 ,PaCO2 25 ,Lactate 9
• Planning for RSI – LEMON Score suggests an easy
Intubation
• Do you think ,RSI going to be an Easy job ?
Background
• Airway management in critically ill patients
involves the identification and management of
the potentially difficult airway in order to
avoid untoward complications
• Traditionally referred to identifying anatomic
characteristics of the patient that make
either “visualizing the glottic opening or
placement of the tracheal tube” through
the vocal cords
West J Emerg Med. 2015;16(7):1109-1117
Evidence based facts…
1.Heffner AC, Swords DS, Neale MN, et al. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013;84(11):1500-1504.
2.Reynolds SF, Heffner J. Airway management of the critically ill patient: rapid-sequence intubation. Chest. 2005;127(4):1397-1412.
3.Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004;99(2):607-613.
4.Bodily JB, Webb HR, Weiss SJ, et al. Incidence and duration of continuously measured oxygen desaturation during emergency department intubation. Ann Emerg Med. 2016;67(3):389-
• Surgical airway in ED
following anatomically
difficult Airway -0.5 %
• Incidence of hypoxaemia
19.2 %
• Hypotension – 25%
• Cardiac arrest - 4 to 11 %
• Success with first attempt intubation
reduces complication dramatically
• 20 % associated with physiological
derangements which is amenable for
optimization
• Potential to deteriorate in the presence
of altered physiological parameters
• This brings the concept of
“Physiologically Difficult Airway”
ATLS : Airway assessments
for Anatomical difficulties
•MOANS
•LEMON
•RODS
•SMART
Attempts to add Physiological parameters in
airway assessment
• LEMONS – S- Saturation : An early
attempt to add one physiological
variant
• HEAVEN- Added Hypoxemia and
Blood loss
HEAVEN
• Hypoxemia
• Extremes of size
• Anatomic abnormalities
• Vomit/blood/fluid
• Exsanguination/anaemia
• Neck mobility issues

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Difficult Airway in Polytrauma.pptx

  • 1. Poly Trauma Airway management : An area which always forgets to look into! Dr.Venugopalan .P P HOD & Sr.Consultant Emergency Medicine Aster MMS -Calicut NEMCON 2023
  • 2. “The Case” • A 45-year-old man was brought to the ED by following RTA. He had been involved in a high mechanism injury , BP: 70/40 mm Hg ,HR : 136/minute R R: 45/minute • Saturation: 78% on RA , GCS :7 • POCUS- Bleed in Morrison pouch • ABG- PH 7.1 , BE 18 , PaO2 55 ,PaCO2 25 ,Lactate 9 • Planning for RSI – LEMON Score suggests an easy Intubation • Do you think ,RSI going to be an Easy job ?
  • 3. Background • Airway management in critically ill patients involves the identification and management of the potentially difficult airway in order to avoid untoward complications • Traditionally referred to identifying anatomic characteristics of the patient that make either “visualizing the glottic opening or placement of the tracheal tube” through the vocal cords West J Emerg Med. 2015;16(7):1109-1117
  • 4. Evidence based facts… 1.Heffner AC, Swords DS, Neale MN, et al. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013;84(11):1500-1504. 2.Reynolds SF, Heffner J. Airway management of the critically ill patient: rapid-sequence intubation. Chest. 2005;127(4):1397-1412. 3.Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004;99(2):607-613. 4.Bodily JB, Webb HR, Weiss SJ, et al. Incidence and duration of continuously measured oxygen desaturation during emergency department intubation. Ann Emerg Med. 2016;67(3):389- • Surgical airway in ED following anatomically difficult Airway -0.5 % • Incidence of hypoxaemia 19.2 % • Hypotension – 25% • Cardiac arrest - 4 to 11 % • Success with first attempt intubation reduces complication dramatically • 20 % associated with physiological derangements which is amenable for optimization • Potential to deteriorate in the presence of altered physiological parameters • This brings the concept of “Physiologically Difficult Airway”
  • 5. ATLS : Airway assessments for Anatomical difficulties •MOANS •LEMON •RODS •SMART
  • 6. Attempts to add Physiological parameters in airway assessment • LEMONS – S- Saturation : An early attempt to add one physiological variant • HEAVEN- Added Hypoxemia and Blood loss HEAVEN • Hypoxemia • Extremes of size • Anatomic abnormalities • Vomit/blood/fluid • Exsanguination/anaemia • Neck mobility issues
  • 7. Four Physiologically Difficult Airways plus One Hypoxemia Severe metabolic Acidosis Hypotension Right Ventricular failure Raised ICP
  • 8. CRASH for Physiologically Difficult Airway C- Consumption of Oxygen R-Rt Ventricular Failure A-Acidosis ( Metabolic) S-Saturation H- Hypotension/ Volume
  • 9. Considering Polytrauma --- 6 Physiological Parameters are prevalent 1. Hypovolemia -Blood loss 2. Hypotension – Blood loss , Tension pneumothorax , Cardiac Tamponade, Spinal cord injuries 3. Hypoxia – Airway obstruction, OMF , Chest injuries , Aspiration 4. Raised ICP – Head injuries 5. Metabolic Acidosis – Lethal triad in Trauma 6. RV Dysfunction – Fat Embolism in Fracture femur, Pre-existing heart diseases
  • 10. Burns and Five physiological difficulties • Hypoxia – Inhalation injuries • Hypovolemia - Extensive burns • Oxygen consumption – Pain and Anxiety • Metabolic Acidosis • RV dysfunction : Late phase in sepsis
  • 11. CRASH - Consumption • Paediatrics & Pregnancy • Excitation / Delirium / Agitation • Convulsion • Malignant Hyperthermia • Sepsis ( Late presentation) • Acute respiratory distress syndrome • Thyrotoxicosis( Co-Existing ) 1. Meticulous preoxygenation 2. Improving low cardiac output 3. Correcting anaemia (Preserve adequate oxygen delivery)
  • 12. CRASH- Right Ventricular Failure • Right ventricle (RV) has limited ability to increase contractility and output in response to increased demand • RV dilation and tricuspid regurgitation occur quickly when RV afterload is increased • Worsened by fluids administered in an attempt to increase the preload 1. R S I & Paralysis may lead to Hypercapnia, Atelectasis, and Hypoxemia 2. All the 3 independently increase pulmonary vascular resistance and right ventricular afterload—often leads to cardiovascular collapse
  • 13. CRASH: Acidosis- Metabolic • Major trauma • Diabetic ketoacidosis • Severe sepsis • CKD • Salicylate poisoning Increased risk for life-threatening acidosis 1. Interruption of ventilation 2. Inability to match the necessary compensatory minute ventilation A recent study showed that, with 60 seconds of apnoea, pH drops 0.15 and PaCO2 increases by 12.5 mmHg, which can be devastating to fragile patients West JR, Scoccimarro A, Kramer C, et al. The effect of the apneic period on the respiratory physiology of patients undergoing intubation in the ED. Am J Emerg Med. 2017;35(9):1320-1323.
  • 14. CRASH: Saturation Failure to maintain adequate arterial oxygenation • Shunt • Ventilation/perfusion (V/Q) mismatch Critically ill patients are at high risk for rapid desaturation • Reduced functional residual capacity (FRC) • V/Q mismatch • Shunt • All can be acutely worsened by induction
  • 15. CRASH: Hypotension / Hemorrhage • Critically ill patients are at significant risk of hypotension in the peri-intubation period • Many critically ill patients can lead to deleterious states and precipitate arrest 1. Volume depleted 2. Vasoplegic 3. Primary or comorbid cardiomyopathy 4. Induction agents 5. Transition to positive pressure ventilation can amplify these • Fluid resuscitation • Vasopressors • Inotropes Indicated prior to intubation, depending on the clinical scenario
  • 16. SAM Recommendations to manage Physiologically Difficult Airway
  • 17. Recommendations to handle hypoxia 1. Adequate preoxygenation – 3minutes High flow or 8 vital capacity breaths @ FiO2 1 2. Oxygenation during apneic period- Prolong safe apnea period 3. Apneic oxygenation – Nasal Canula with 15 L flow or HFNO at 60 to 70 l/mt 4. Pre-Oxygenation with assisted spontaneous ventilation with BVM and PEEP valve or one way exhalation valve
  • 18. Recommendations to handle hypoxia Patients with significant shunt use 1. PEEP Valve and NIV or BVM 2. Inhaled pulmonary vasodilators 3. Extra glottic devices if high level of PEEP is required
  • 19. Recommendations to handle hypoxia • Awake intubation in refractory hypoxia • Pre-Oxygenation in Upright position or RAMP position • Delayed sequence intubation Ketamine / Dexmedetomidine
  • 20. Recommendations to handle Hypotension Adequate I.V Line Stroke Index > 0.7 Fluid Tolerant- Preload Fluid Intolerant Preinduction Vasopressor infusion Infusion not possible Bolus Vasopressor Induction Haemodynamically Neutral Agents Obstructive Shock RV Failure Guideline
  • 21. Recommendations for RV Dysfunction Pre-Intubation RV Screening Assess- 1.RV Systolic Function 2.Fluid and Vasopressor Tolerance Tolerant : Fluid & Pressors Intolerant: Inhaled/ IV Pulmonary Vasodilators
  • 22. Recommendations for RV Dysfunction • Pre-Intubation • ECMO cannulation(pts with RV Induced shock ) • Pre-Intubation diuresis • Avoid hypercapnia • Keep high mean arterial pressure • Post intubation 1. Low mean airway pressure 2. High PEEP
  • 23. Recommendations for Severe Metabolic Acidosis High risk for post intubation decompensation due to 1. Volume depletion 2. Inadequate alveolar ventilation Patients with high minute ventilation 1. Awake intubation 2. Maintain spontaneous respiration 3. Spontaneous breathing mode in post intubation
  • 24. Recommendations for Neurologically injured patients –Raised ICP 1. Normocapnia 2. Neutral induction agents 3. Position 30 degree upright 4. Post intubation – limited PEEP 5. Avoid 3 Bs : Bucking , Blocking & Biting 6. Avoid tube tie 7. Adequately Sedate and Paralyze 8. Avoid Mosquito Doses
  • 25. End point of Pre-Oxygenation ( Objectively) The end points of maximal preoxygenation and denitrogenation • End-tidal Oxygen (EtO2) concentration of approximately 90% • End-tidal Nitrogen (EtN2) concentration of 5% 1. Berry CB, Myles PS. Preoxygenation in healthy volunteers: a graph of oxygen “washin” using end-tidal oxygraphy. Br J Anaesth. 1994;72:116–118. 2. Campbell IT, Beatty PC. Monitoring preoxygenation. Br J Anaesth. 1994;72:3–4. New
  • 26. “The Case” • A 45-year-old man was brought to the ED by following RTA. He had been involved in a high mechanism injury , BP: 70/40 mm Hg ,HR : 136/minute R R: 45/minute • Saturation: 78% on RA , GCS :7 • POCUS- Bleed in Morrison pouch • ABG- PH 7.1 , BE 18 , PaO2 55 ,PaCO2 25 ,Lactate 9 • Planning for RSI – LEMON Score suggests an easy Intubation • Do you think ,RSI going to be an Easy job ?
  • 27. Take home points Physiologically difficult airway is rather neglected or not considered seriously in trauma airway management Physiologically challenged airway contributes significant morbidity and mortality Majority are preventable crashes on preparation and pre optimization When considering “7 Ps of RSI”- Add Physiological Preparation and Pre- Intubation optimization as “Eighth P"
  • 28. Beware of “Two death Spiral”
  • 29. Further reading • https://www.acepnow.com/article/crash-a- mnemonic-for-the-physiological-difficult- airway/?singlepage=1&theme=print-friendly • https://journals.lww.com/anesthesia- analgesia/Fulltext/2021/10000/Difficult_Airway_Ma nagement_in_Adult_Coronavirus.10.aspx • https://journals.lww.com/anesthesia- analgesia/Fulltext/2021/02000/Evaluation_and_Man agement_of_the_Physiologically.16.aspx
  • 30. Thank you So much … • drvenugopalpp@gmail.com • 9847054747 • www.drvenu.blogspot.com • www.drvenu.net