The document appears to be notes from an airway management seminar that discusses various topics related to intubation including indications for intubation, preparation for difficult airways and intubation, choices around rapid sequence intubation versus awake intubation, induction agents, and paralysis agents. Case studies are presented and questions are provided about how to manage each case.

1. Airway Management Emergency Medicine Seminar Series

2. Michael Ha Section of Emergency Medicine 4th year Resident John Sokal Health Sciences Centre 12 years Bob Sweetland Health Sciences Centre 15 years

3. April 25, 2002 CHURCHILL ASHERN PINE FALLS

4. April 26, 2002 STEINBACH BOUNDARY TRAILS

5. May 2, 2002 BRANDON KILLARNEY PORTAGE

6. May 3, 2002 RUSSELL DAUPHIN SWAN RIVER

7. May 14, 2002 FLIN FLON LYNN LAKE THE PAS

8. eMEDiUM Emergency Medicine in the U of M emergency.mb.ca Back

9. CAEP ACEP

10. CME Objectives To discuss: the indications for intubation the approach to RSI capnometry bougies

11. Intubate? RSI vs. Awake Preparing for patient Difficult BVM Difficult Intubation Capnography Laryngoscopy Tips Bougies Lightwand - LMA Master Preoxygenation Pretreatment O 2 Delivery Thiopental Ketamine Propofol Succinylcholine Rocuronium Finish

12. Intubation Indications Is there a failure of airway maintenance or protection? Is there a failure of ventilation or oxygenation? What is the anticipated clinical course ? Back

13. HR 125 BP 98/40 RR 20 GCS 8 O 2 Sats 100% (PRB) no injuries Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases 45 female alcoholic beverages empty pill bottles

14. Cases 60 VF 44 MVA 25 asthma 15 fall 28 bull 16 pencil 40 fire 22 TCA 54 CRF 67 HTN 51 melena 45 overdose

15. 60 male IHD AMI VF - defibrillated 3x HR 110 BP 68 / 40 RR 10 O 2 Sats 90% (BVM) Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases

16. 44 female MVA 100 kph HR 130 BP 100 / 70 RR 28 O 2 Sats 99% (BVM) GCS 6 Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases

17. 25 female asthma SOB 2 days severe distress HR 145 BP 98 / 42 RR 30 O 2 Sats 80% (PRB) Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases

18. 15 female fell from tree HR 110 BP 100 / 50 RR 20 O 2 Sats 99% (BVM) GCS 8 Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases

19. 28 male playing with bull blunt trauma HR 130 BP 80 / 60 RR 28 O 2 Sats 99% (PRB) abdomen rigid pelvic fracture Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases

20. 16 male pencil oropharynx 'buddy' pulled it out HR 80 BP 115 / 60 RR 16 O 2 Sats 99% (room) voice change hematoma visible Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases

21. 40 female house fire prolonged exposure HR 115 BP 130 / 60 RR 28 O 2 Sats 96% (PRB) singed facial hair soot in mouth Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases

22. 22 female ingestion amitryptyline quantity unknown HR 145 BP 100 / 42 RR 14 O 2 Sats 99% (PRB) GCS 8 Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases

23. 54 male CRF DM on dialysis holiday respiratory distress HR 115 BP 200 / 120 RR 36 O 2 Sats 88% (NRB) peaked T's Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases

24. 67 female HTN on ACE inhibitor oral angioedema HR 85 BP 150 / 80 RR 20 O 2 Sats 99% (room) slight stridor Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases

25. 51 male cirrhosis melena 2 days hematemesis HR 165 BP 50 palpation RR 28 O 2 Sats 92% (NRB) vomiting red blood Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases

26. 68 male CHF HR 125 BP 180 / 100 RR 32 O 2 Sats 86% (NRB) SOB over 3 days worsened overnight Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases

27. Intubate? Custom Shows

28. Intubate? HR 125 BP 98/40 RR 20 GCS 8 O 2 Sats 100% (PRB) no injuries Indication? 45 female alcoholic beverages empty pill bottles

29. Intubation Indications Is there a failure of airway maintenance or protection?

30. Intubate? HR 135 BP 150/90 RR 10 O 2 Sats 86% (NRB) 'tight' wheezes bilaterally Indication? 50 yo male SOB over 2 days worsened overnight

31. Intubation Indications Is there a failure of ventilation or oxygenation ?

32. Intubate? HR 100 BP 105/60 RR 20 GCS 10 O 2 Sats 100% (PRB) multiple injuries transfering to HSC Indication? 34 yo male MVA ejected from car

33. Intubation Indications What is the anticipated clinical course ?

34. Intubation Indications Is there a failure of airway maintenance or protection? Is there a failure of ventilation or oxygenation? What is the anticipated clinical course ? Back

35. RSI vs Awake? Custom Shows

36. Rapid Sequence Intubation a potent induction agent followed immediately by the patient has not fasted at risk of aspiration a rapidly-acting NMB to induce unconsciousness and motor paralysis for intubation.

37. Rapid Sequence Intubation take nothing that you cannot return or replace approach every airway as a potential difficult airway be prepared

38. The 7 P’s P reparation P reoxygenation P retreatment P aralysis with induction P ositioning with protection P lacement with proof P ostintubation management

39. Awake Intubations “ Awake” means that patient can: follow simple instructions provide feedback can respond to events sedation – versed, fentanyl topical lidocaine oral, nasotracheal, fiberoptic

40. Choices… paralyze? Paralysis contraindications prediction of difficulty difficult BVM difficult intubation lack of equipment unnecessary inexperience

41. Preparation Difficult Airways Custom Shows

42. Preparation STOP IC BARS S staff, suction T tube O oxygen P pharmacology (meds)

43. Preparation I intravenous lines C connect to monitors B blades, bougies A alternate (lightwand) R rescue (LMA, combitube) S surgical (cricothyroidotomy) STOP IC BARS Back

44. Difficult Mask Ventilation B eard

45. Difficult Mask Ventilation O bese

46. Difficult Mask Ventilation O lder T oothless

47. Difficult Mask Ventilation S nores

48. Preparation Assessment for Difficult Mask Ventilation BOOTS B beard O obese O older T toothless S snores Back

49. Difficult Mask Ventilation reposition OP / NP airway 2 person change mask ? obstruction Back

50. Repositioning Oral – Pharyngeal - Laryngeal Axes

51. Repositioning Head extended on neck

52. Repositioning “ Sniffing” position

53. Repositioning “ Sniffing” with extension Back

54. Preparation Assessment for a difficult intubation Lemon Law L look E evaluate (3-3-1 rule) M Mallampati O obstruction N neck mobility Back

55. 3-3-1 Rule Back 3 3 fingers mouth opening 1 finger anterior jaw subluxation 3 1 3 fingers hyomental distance (room for tongue)

56. Mallampati Back

57. Preparation Preoxygenation Pretreatment

58. Preoxygenation is the establishment of an oxygen reservoir. “ no bagging ” principle of RSI “ apnea time ” concept 100% O 2 for 5 minutes effect of body size & metabolic demands

59. Apnea Time Back

60. Pretreatment is the administration of drugs to mitigate the adverse effects associated with intubation. L idocaine O piodes A tropine D efasciculation Back

61. Induction Agents

62. Paralysis after induction thiopental ketamine propofol etomidate versed succinylcholine rocuronium skip drug section

63. Thiopental cerebroprotective potent vasodilator myocardial depressant Contraindication: porphyria INDUCTION

64. Thiopental Back INDUCTION Onset: 15 - 30 seconds Dose: 3 - 5 mg / kg (euvolemic) 1 - 3 mg / kg (hypovolemic) Duration: 5 - 10 minutes

65. Ketamine analgesia - amnesia bronchodilation catecholamine release hypovolemic - hypotensive agent of choice INDUCTION ICP (significance ?) ( cerebroprotective ??) stimulating effects: laryngeal reflexes secretions

66. Ketamine lower dose if profound shock: maximal sympathetic stimulation already - ketamine has intrinsic CV depression Back INDUCTION Onset: 15 - 30 seconds Dose: 1 - 2 mg / kg Duration: 15 - 30 minutes

67. Propofol dose-dependant sedation - amnesia no analgesic properties airway reflexes: dose-dependant depression potent vasodilator , myocardial depressant (effect may exceed that of thiopental) cardiac & respiratory depression related to rate of administration as well as dose INDUCTION cerebroprotective ICP CPP

68. Propofol Onset: 30 - 40 seconds 1 - 3 mg / kg (induction) Dose: Duration: 5 - 10 minutes Combo: ketamine 50 mg propofol 50 mg Back Contraindication: egg, soybean allergies INDUCTION

69. Etomidate most hemodynamically stable minimal cardiac & respiratory depression cortisol suppression ( no ED cases) myoclonus / hiccups 30% - 40% nausea / vomiting does not block BP response to intubation INDUCTION cerebroprotective ICP

70. Etomidate Back Onset: 20 - 30 seconds Dose: 0.2 - 0.3 mg / kg INDUCTION Duration: 5 - 15 minutes

71. NMB

72. Choices… paralyze? Paralysis contraindications prediction of difficulty difficult BVM difficult intubation lack of equipment unnecessary inexperience

73. Choices… SUX or ROC? SUX contraindications difficult BVM or intubation neuromuscular disorders hyperkalemia 24 hours post-burns 7 days post-crush 7 days post-denervation malignant hyperthermia

74. Succinylcholine duration of action is dependant on: rapid hydrolysis - pseudocholinesterase diffusion away from motor end plate (no pseudocholinesterase at end plate) only a fraction of dose ever reaches end plate give large doses no harm giving too much problem when incompletely paralyzed give extra 20% (2 mg / kg) PARALYSIS depolarizing NMB fasciculations

75. Succinylcholine Onset: 10 - 15 seconds (fasciculations) 45 - 60 seconds (paralysis) Dose: 1 - 2 mg / kg (adults) 2 mg / kg (children) 3 mg / kg (newborns) Duration: 3 - 5 minutes (some resps) 8 - 10 minutes (adequate) PARALYSIS

76. Succinylcholine Side- Effects fasciculations hyperkalemia bradycardia malignant hyperthermia prolonged blockade trismus - masseter muscle spasm Back PARALYSIS

77. Succinylcholine Fasciculations nicotinic receptor stimulation inhibiting fasciculations - little evidence side-effects occurs same time as ICP PARALYSIS

78. Succinylcholine SUX-induced Hyperkalemia under normal situations, increase of: 0.5 mEq/L K + small risk of dysrythmia: CRF severe acidosis rhabdomyolysis Preexistent K + PARALYSIS

79. Succinylcholine increased extrajunctional receptors: 5 - 10 mEq/L K + prolonged depolarization refractory to non-depolarizing NMB, may require large doses Exaggerated release of K + PARALYSIS

80. Succinylcholine Exaggerated release of K + functional denervation of muscle: stroke spinal cord injury extensive burns massive crush injuries neuromuscular disorders side-effects PARALYSIS

81. Succinylcholine PARALYSIS Receptor Recruitment & Sensitization Onset: 7 days Duration: 2 - 3 months Crush: Onset: 7 days Duration: 6 months Denervation: Onset: 24 hours Duration: 2 years Burns: (% burn does not determine response)

82. Succinylcholine Neuromuscular disorders: SUX contraindicated side-effects PARALYSIS Receptor Recruitment & Sensitization If give SUX: intractable cardiac arrest may occur (even if recognize and treat K +)

83. Succinylcholine Bradycardia cardiac muscarinic receptor stimulation succinylmonocholine (a metabolite) sensitizessinus node receptors to repeat doses consider atropine if: age < 10 repeating dose side-effects children have vagal tone PARALYSIS

84. Succinylcholine Prolonged Neuromuscular Blockade congenital absence of pseudocholinesterase presence of an atypical form may last hours PARALYSIS

85. Succinylcholine acquired absence: cocaine metoclopramide (Maxeran) CRF severe liver disease hypothyroidism malnutrition pregnancy cytotoxic drugs organophosphates Prolonged Neuromuscular Blockade PARALYSIS

86. Succinylcholine acquired absence: even worst of acquired not reported to last > 25 minutes SUX not contraindicated Prolonged Neuromuscular Blockade side-effects PARALYSIS

87. Succinylcholine mortality 60% onset can be acute or delayed for hours Malignant Hyperthermia genetic skeletal muscle abnormality can be triggered by: SUX stress vigorous exercise halothane PARALYSIS

88. Succinylcholine muscle rigidity autonomic instability hypotension hypoxia severe lactic acidosis myoglobinemia DIC fever - late manifestation Malignant Hyperthermia side-effects PARALYSIS

89. Succinylcholine prevents Ca ++ release from sarcoplasmic reticulum of skeletal muscle Dantrolene for MH essential to resuscitation give as soon as Dx suspected free of serious side-effects side-effects Dose: 2.5 mg/kg IV q5min until muscle relaxation, or max 4 doses PARALYSIS

90. Succinylcholine Trismus - Masseter Muscle Spasm rise in jaw muscle tension is normal should not affect laryngoscopy pretreatment will not prevent if severe, or progresses to other muscles: consider malignant hyperthermia spasm is not pathonomonic for MH if occurs - administer non-depolarizing NMB (Rocuronium) side-effects PARALYSIS

91. Rocuronium Nondepolarizing, does not stimulate receptor no fasciculations minimal hemodynamic effects do not need priming dose PARALYSIS

92. Rocuronium Dose: 0.6 - 1.2 mg / kg PARALYSIS Onset: 60 - 90 seconds Duration: 30 - 60 minutes Defasiculating: 0.05 mg / kg

93. Comparing NMB SUX ROC PARALYSIS ONSET 30 - 60 60 - 90 sec DURATION 3 - 10 20 - 60 min rapid rapid no priming CVS stability advantages precautions K +

94. Comparing NMB PARALYSIS sec min VEC 150 - 180 25 - 30 no histamine release PAN 120 - 180 60 - 90 histamine release ATRA 120 - 150 20 - 35 histamine release

95. Positioning Proof

96. Positioning with protection You are asked to apply: cricoid pressure (Sellick’s maneuver)

97. BURP B ackwards U pwards R ightward P ressure distinct from Sellick’s maneuver second assistant first assistant’s other hand

98. Maneuvers Back

99. Laryngoscopy

100. Laryngoscopy

101. Laryngoscopy

102. Laryngoscopy

103. Laryngoscopy

104. Placement with proof methods of confirmation chest rise air entry fogging of ETT 60 cc syringe * capnometer

105. Colorimetric Capnometry exhaled CO2 simple color change from purple to yellow

106. Colorimetric Capnometry NEGATIVE POSITIVE

107. Colorimetric Capnometry ETCO 2 < 4 mm Hg ETT not in trachea inadequate perfusion (ineffective CPR)

108. Colorimetric Capnometry ETCO 2 15 - 38 mm Hg ETT in trachea

109. Colorimetric Capnometry ETCO 2 4 to < 15 mm Hg retained CO 2 in esophagus low perfusion deliver 6 more breaths

110. Colorimetric Capnometry Standard of Care Limitations: Back decreased cardiac output low metabolic CO 2 production ex. hypothermia

111. Bougie Lightwand LMA

112. Bougie

113. Epiglottis

114. Laryngoscopy Grades Cormack Lehane

115. Bougie

116. Lightwand

117. Lightwand Source: Laerdal

118. Lightwand Source: Laerdal

119. Laryngeal Mask Airway Source: LMA North America skip insertion technique

120. Laryngeal Mask Airway Source: LMA North America deflate the cuff apply water-soluble lubricant to the posterior surface place index finger at the junction of the cuff skip insertion technique

121. Laryngeal Mask Airway Source: LMA North America press the tip of the cuff upward against the hard palate and flatten the cuff against it skip insertion technique

122. Laryngeal Mask Airway Source: LMA North America use the index finger to guide the LMA, press backward toward the other hand, which exerts counter-pressure (do not use force) skip insertion technique

123. Laryngeal Mask Airway Source: LMA North America advance the LMA into the hypopharynx until a definite resistance is felt. inflate the cuff skip insertion technique

124. 7. Postintubation mgmt fix tube in place CXR nasogastric / orogastric tube lab etc Back

125. O2 Delivery Systems

126. O 2 Delivery Systems Nasal cannulae Double rate - add to room air FiO 2 ex. 3 L / min + 21 % FiO 2 = 27 % Limitations: rates > 3 L / min uncomfortable mouth breathing

127. O 2 Delivery Systems Simple Face Mask 6 – 10 L / min flow 35 – 55 % FiO 2 entrainment of room air through exhalation ports

128. O 2 Delivery Systems Partial Rebreathing Face Mask reservoir bag first ~ 1/3 of exhaled gas is directed into bag (that which was in patient’s upper airway) up to 60 % FiO 2

129. O 2 Delivery Systems Non-Rebreathing Face Mask reservoir bag one-way valves up to 80 % FiO 2 (realistically)

130. O 2 Delivery Systems Bag Valve Mask (BVM) up to 100 % FiO 2

131. Summary

132. Airway Management ? ?

133. eMEDiUM Emergency Medicine in the U of M emergency.mb.ca Back

134. HSC ED Maryann Cromwell MCromwell @ exchange.hsc.mb.ca phone: 787-2934 fax: 787-2231 Department of Emergency Medicine Health Sciences Centre GF 201-800 Sherbrook Street Winnipeg, MB R3A 1R9 Back

135. CAEP ACEP