Challenges of airway management in Emergency Department

1. Airway Management
Anupam Ghimire
GP-EM Resident

2. Objectives
• Case scenario
• Airway management
• Challenges in difficult airway management

3. Case scenario
• 70 yr/F
- COPD , HTN and Post TB fibrosis of Lung
• Coughing up of blood for 2 hrs
- Around 750 ml , fresh red
- Similar episode 1 day back ~ 50 ml

4. • No history of :
- Fever
- Chest pain
- Weight loss, anorexia
- Rashes , bleeding from other sites
- Antiplatelet or Anticoagulant
• Former Smoker

5. Examination
• Anxious , alert , short stature and obese
• Pallor +, ILCCOD-
• Vitals :
Bp : 80/40 mmhg Pulse : 120 bpm
RR: 20 breath/min Spo2: 91 % on RA
T: Afebrile

6. • Chest examination
- Air entry – decreased in lt side
- Vesicular Breath sound
- Conducted sound over lt lung field
• Other system examinations grossly normal

7. Emergency Management
- Airway
- Breathing
- Circulation
- Position: Lt lateral decubitus
- Fluid resustication
- Drugs : Tranxemic acid , Ondansetron
- Blood arranged and cross-matched

8. After 10 min
• Hemoptysis continues  next 250 ml
• Drowsy , Sweating
• MAP : 60 , P: 136-140/min
Spo2 : 88% on 10 L Oxygen
ECG : Sinus Tachycardia
WHAT NEXT ….

9. • Discussion on airway management strategy
• Equipments : Oxygen
- Mask - Monitoring
- Airway ( Oral and nasal ) - Emergency Drugs
- Laryngoscope - Suction
- Endotracheal tube - Self inflating bag
valve resusticator

10. • Airway assessment:
– L- Look externally ( No facial trauma, large incisors,
large tongue)
– E- Evaluate the 3-3-2 rule
• Incisor opening distance: 2 fingerbreadths
• Hyoid-mental distance: 2 fingerbreadths
• Thyroid-to-mouth distance: 1 fingerbreadths
– M- Mallampati score 4
– O- Obstruction: No epiglottitis, peritonsillar abscess,
or trauma
– N- Neck mobility ( neck mobility)

11. • Preoxygenation , Positioning
• Sedative agent :
- Ketamine 50 mg
• Immediately followed by Muscle relaxant
- Succinylcholine 50 mg

12. • Intubation field not seen despite suctioning
• Intubation with size 7 ET tube done  failed
- Cormack Lehane grade 4
• Second attempt done with Preloaded stylet
- Glottic exposure : BURP manaeuver
- Rt lung intubation done , confirmed
- Tube fixed at 28 cm, secured
- Kept in lateral decubitis position

13. • Post intubation sedation given, Bag and mask
ventillation continued
• Spo2 – 97 % with 10 L oxygen
• BP : 110/80 mmhg
• Pulse : 100/ min
• Urine output : 300 ml , clear

14. After 10 min
• Spo2: 34 % on 15 L oxygen
• Bp : ??
• HR: 38 bpm , decreasing
• Pulse : not palpable
What NEXT……

15. • CPR Started, ET tube suctioning done in between
• Injection Adrenaline every 5 min ( 3 doses )
• Injection Atropine 1ml ( 2doses )
• Noradrenaline started
• NO Improvement
What NEXT…..

16. • Flushing of ET tube done
- NS 10 ml
• After 2 minute
- Sp02 : 98% on 10 L oxygen, P: 92 bpm
- ROSC , CPR stopped
- Post resustication care done
- Referred to CTVS center

17. Learning points
• Airway assessment :
– L- Look externally (facial trauma, large incisors, beard,
large tongue)
– E- Evaluate the 3-3-2 rule
• Incisor opening distance: 3 fingerbreadths
• Hyoid-mental distance: 3 fingerbreadths
• Thyroid-to-mouth distance: 2 fingerbreadths
– M- Mallampati score ≥3
– O- Obstruction: Presence of condition such as
epiglottitis, peritonsillar abscess, or trauma
– N- Neck mobility (limited neck mobility)

18. Mallampati Score

20. Rapid Sequence Induction (RSI)
• Sequential administration of an induction
agent and neuromuscular blocking agent to
facilitate endotracheal intubation
• The goal of RSI- facilitate rapid insertion of the
ETT while minimizing physiologic
perturbations

21. RSI Steps
• Discuss airway management strategy with the team
• Set up IV access, cardiac monitor, oximetry, and
capnography/capnometry
• Plan procedure. Assess physiologic status and airway
difficulty.
• Prepare equipment, suction, and potential rescue devices
• Preoxygenate
• Consider pretreatment agents
• Give sedative agent immediately followed by neuromuscular
blocking agent.
• Intubate trachea
• Confirm tube placement.
• Secure tube
• Adjust mechanical ventilation and provide postintubation
sedation.

22. RSI
• Pre treatment agents- Lidocaine, Fentanyl
• Induction agents- Etomidate, Propofol,
Ketamine
• Neuromuscular Blocking- Rocuronium,
Vecuronium, Succinylcholine

23. PEA causes:
• M: massive pulmonary embolism
• A: acidosis
• D: drug overdose
• H: HYPOXIA/hypothermia
• H: hypovolemia
• H: hypokalemia/hyperkalemia
• C: cardiac tamponade
• A: acute MI
• T: tension pneumothorax

24. Troubleshooters: Post intubation
• D - Displacement of tube or cuff
– Auscultate / look etco2
• O - Obstruction of tube/circuit
– Use suction catheter to remove mucus/blood, or
make sure patient not biting down, look for kink in
tube
• P - Pneumothorax
– Verify via USG , CXR, or Needle
thoracocenthesis (high suspicion)
• E - Equipment failure
– ReConnect to Bag mask ventillator

25. Summary
• Anticipation of difficult airway
• Single lung ventillation
• Emergency intubation : RSI
• Troubleshooters of postintubation should be
promptly managed

26. THANK YOU