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Emergency Airway Management 2014: Mark P. Brady PA-C
- 1. 013 2
- 2. Agenda: • Airway Anatomy Adult vs. Pediatric • Review of basic equipment • Approach to the Difficult Airway • RSI • Post-Intubation Management • Ventilator Settings • The Crashing Asthmatic
- 3. Important take home points
- 4. The search for the epiglottis
- 11. • Externally – Larger head/occiput – Head flexes forward and can obstruct • Internally – Intra-oral tongue – Large, floppy epiglottis
- 12. • Further differences – “Pinker” vocal cords worsen visualization – Different location of narrowest point • Peds cuffed tubes? – Smaller cricothyroid membrane • No surgical crics in children
- 13. Other Considerations • More gastric insufflation with BVM • Quicker desats during intubation Different • 10 kg will drop to 90% in <4 minutes (vs. 8 for adult) • Vagal response (not significant) • Consider Pre-treatment with Atropine (though not literature supported and not the standard of care)
- 15. Cardiorespiratory Arrests Hypoxia and Hypercarbia Bradycardia
- 16. Self Confident If he can, you can
- 19. Avoid the “cookie-cutter” approach to every airway you encounter.
- 21. What tools do I have ?
- 23. Airway Equipment • Oxygen and Suction • BVM / OPA / NPA • ETT / Bougie / LMA / King LT • Stylet • Magill forceps • End-tidal CO2 monitoring and securing devices • Surgical Airway Devices
- 24. Airway Equipment
- 25. Airway Equipment C-E technique is WRONG E
- 26. Airway Equipment Use the Two Thumbs Down technique
- 27. Airway Equipment
- 30. King LT
- 36. Airway Equipment Eschmann Stylet, a.k.a “Gum elastic bougie”
- 38. Airway Equipment LMA – Laryngeal Mask Airway Are extraglottic airways harmful in cardiac arrest ?
- 39. Airway Equipment “Yellow” = YES “Purple” = Pathologic
- 40. Airway Equipment: • What equipment do we have in our departments? • Where is it located?
- 47. 3 Emergent Indications for Intubation • Can’t Protect Airway • Can’t Maintain Ventilation / Oxygenation • Expected Decline in Clinical Status
- 48. Can’t Protect Airway Gag reflex is absent in up to 37% of population, and is a poor predictor of airway protection • Can they talk? • Can they swallow and manage secretions?
- 49. Can’t Maintain Ventilation or Oxygenation • SaO2 <90% on High Flow O2 or PaO2<60 on FiO2>40% • PaCO2 >55 if baseline is normal, or >10 increase from baseline • Respiratory Rate
- 50. Expected Decline in Clinical Status • Deterioration/Impending Compromise Transport • Airway protection during procedures (ie. endoscopy)
- 51. DEFINITIONS Rapid Sequence Intubation (RSI) INDUCTION AGENT PARALYTIC UNCONSCIOUSNESS MOTOR PARALYSIS
- 52. DEFINITIONS Delayed Sequence Intubation (DSI) DSI consists of the administration of specific sedative agents, which do not blunt spontaneous ventilations or airway reflexes; followed by a period of preoxygenation before the administration of a paralytic agent.
- 56. RATIONALE - Secondary Blunting ↑ in ICP / IOP
- 59. ↓ Pain ↓ Discomfort ↓ Recall
- 62. The 7 “P’s”of RSI t – 10 minutes PREPARATION PREOXYGENATION PRETREATMENT TIME ZERO PARALYSIS WITH INDUCTION PROTECTION AND POSITIONING PLACEMENT AND PROOF t + 90 seconds POST-INTUBATION MANAGEMENT
- 64. PREPARATION t – 10 minutes 1. EQUIPMENT PRESENT AND WORKING INCLUDING EQUIPMENT FOR PLAN “B”
- 65. PREPARATION t – 10 minutes 2. Ask yourself: CAN I… BAG THE PATIENT TUBE THE PATIENT CRIC THE PATIENT
- 67. “Evaluate for signs of a difficult intubation” -Obesity -
- 69. CAN I TUBE THIS PATIENT? Look at the general anatomy Evaluate the 3-3-2 rule Mallampati score Obstruction Neck mobility Saturation Reserve
- 70. Look at the general anatomy
- 71. Evaluate the 3-3-2 rule
- 72. Mallampati score
- 73. Obstruction
- 74. Neck mobility
- 76. Saturation Reserve At 92% the patient’s oxygen saturation falls off a cliff….
- 77. CAN I BAG THIS PATIENT? Maybe. Maybe Not.
- 78. VENTILATE (BLS) Approximate normal ventilation rates: • 10 bpm Adult • 20 bpm Child • 25 bpm Infant Squeeze.....Release - Release
- 79. Keep Dentures in when using a BVM
- 80. CAN I CRIC THIS PATIENT?
- 81. SURGICAL AIRWAYS Indications • Obstruction • Facial Trauma • Intubation or other alternatives impossible • Trismus (clenching) • > 8 years old (for open procedures) LAST RESORT!
- 82. DEFense Readiness CONdition Maximum readiness Armed Forces ready to deploy and engage in less than 6 hours Air Force ready to mobilize in 15 minutes Above normal readiness Normal readiness
- 83. Perform Cric Make Skin Cut & Find Membrane Inject / Prep / Open & Set Kit Scalpel in Hand Mark / Kit Bedside Discuss / Feel / See Kit
- 85. Open Cricothyrotomy 1. 2. 3. 4. Vertical Incision over membrane Pierce membrane in horizontal plane Open and spread to insert 4.0 or 5.0 tube Secure tube in place and ventilate
- 87. PREOXYGENATION t – 5 minutes 1. “First, do not bag!” 2. Avoid “Sellick’s” maneuver (cricoid pressure)
- 90. PREOXYGENATION t – 5 minutes 1. Well-fitting mask 2. 8 vital capacity breaths
- 91. PREOXYGENATION t – 5 minutes
- 93. PREOXYGENATION t – 5 minutes NIV CPAP for Pre-Oxygenation
- 94. Summary of LOAD PRETREATMENT L idocaine à optional O piates à optional A tropine à for infants consider for kids < 8 D efasciculating à optional dose
- 95. DEFASCICULATING DOSE 1/10 th the RSI dose Traditional Indications 1. Blunt rise in ICP 2. Decrease risk of aspiration 3. Prevent muscular pain
- 96. PRETREATMENT t – 3 minutes If you’re going to give these drugs: …at least give them some time to circulate (3 minutes)
- 97. PARALYSIS WITH INDUCTION Time “0” PARALYTIC AGENTS INDUCTION AGENTS Etomidate Ketamine Propafol Midazolam + DEPOLARIZING Succinylcholine NON-DEPOLARIZING Vecuronium Rocuronium
- 99. PARALYSIS WITH INDUCTION Time “0” Use of Apneic oxygenation
- 100. Etomidate – Rapid onset/offset – Minimal hemodynamic and respiratory effects – Pediatrics – not approved for patients under 10
- 101. Succinylcholine • When: Immediately after Etomidate • Onset: Rapid, usually 30-90 secs • Duration: Short acting, 3-5 mins
- 102. When Sux Really “Sucks” CONTRAINDICATIONS 1. HYPERKALEMIA RENAL FAILURE RHABDOMYOLYSIS 2. RECEPTOR UPREGULATION SUBACUTE BURNS (>1 day) SUBACUTE DENERVATING DISORDER HISTORY OF MALIGNANT HYPERTHERMIA
- 103. SUX IS STILL KING
- 104. SUX versus ROC 45 seconds ONSET 1 minute 9 minutes 1-1.5 mg/kg DURATION 45 minutes 1 mg/kg
- 105. PROTECTION AND POSITIONING t + 20 seconds May NOT be helpful
- 107. C Spine Precautions
- 108. C Spine Precautions
- 109. Positioning Adult vs Pedi
- 113. Cormack & Lehane Grading
- 114. Orotracheal Intubation Procedure Sweep Left and Look
- 117. PLACEMENT AND PROOF t + 45 seconds
- 118. POST-INTUBATION MANAGEMENT t + 90 seconds
- 119. More to come next month……….
- 120. POST-INTUBATION MANAGEMENT t + 90 seconds CONFIRM PLACEMENT & SECURE TUBE
- 121. Capnography
- 122. Post-intubation CXR
- 123. INTUBATION HURTS! And it keeps on hurting once the tube is in…
- 124. POST-INTUBATION MANAGEMENT Achieve Adequate Analgesia and Sedation
- 125. POST-INTUBATION MANAGEMENT Raise the Head of the Bed to at Least 30°
- 126. POST-INTUBATION MANAGEMENT Confirm Lung Protective Vent Settings Standard Ventilator Settings • Mode AC • VT 6-8 cc/kg • Rate 12-16 • PEEP 5 • FiO2 100% then titrate down
- 127. POST-INTUBATION MANAGEMENT Continuous waveform ETCO2 NG / OG tube Empty the stomach to reduce the chances of aspiration and to improve lung mechanics
- 128. POST-INTUBATION MANAGEMENT Nebulizers/MDI If they were intubated for reactive airway disease, then they need frequent nebs
- 129. Acute Deterioration after Intubation D.O.P.E.S: Displacement Obstruction Pneumothorax Equipment failure Stacked Breaths
- 131. Basics of Ventilator Management Lung Injury Use as Default Obstructive Lung Disease
- 132. Basics of Ventilator Management Lung Injury Lung Protective Management 1. Mode: use A/C (assist control)
- 133. Basics of Ventilator Management Vt IFR RR FiO2 PEEP
- 134. Basics of Ventilator Management Vt Tidal Volume 6-8 cc/kg IBW
- 135. Basics of Ventilator Management Inspiratory Flow Rate = how quickly the breath is delivered 60-80 LPM IFR
- 136. Basics of Ventilator Management RR = Ventilation 16-18 BPM RR Respiratory Rate
- 137. Basics of Ventilator Management FiO2 1. 2. 3. 4. Start @ 100% Wait 5 min Get ABG Drop to 40% Goal: Saturation of 88-95% FiO2 PEEP
- 138. Basics of Ventilator Management Positive End-Expiratory Pressure - PEEP Start with 5 FiO2 PEEP
- 139. Basics of Ventilator Management FiO2 + PEEP = Oxygenation FiO2 PEEP
- 140. Inspiratory Plateau Pressure _________________________________________________ Plateau Pressure < 30 Peak Plateau cmH2O Must find and hold Inspiratory Hold button Ventilator will then display Plateau Pressure
- 141. Basics of Ventilator Management Vt IFR RR FiO2 PEEP
- 142. Basics of Ventilator Management Analgesia 1st Sedation 2nd
- 145. Crashing Asthmatic Maximal O2 (NRB) Inhaled Albuterol Inhaled Atrovent IV Steroids IV Magnesium SC Terbutaline Epinephrine drip THE KITCHEN SINK – Maximal Rx
- 147. Crashing Asthmatic Early Too o Late To WHEN TO INTUBATE
- 148. Crashing Asthmatic KEEP IT SIMPLE! Etomidate Succinylcholine OPTIONS... Lidocaine Ketamine GO FAST! HOW TO INTUBATE
- 149. Crashing Asthmatic Reason #1 Mucous Plugs Use a Big ETT AGGRESSIVE TOILET
- 150. Crashing Asthmatic Reason #2 Dehydration IV FLUID BOLUS
- 151. Crashing Asthmatic Reason #3 Breath Stacking Squeeze Chest Low Vent Settings
- 153. Cardiac Arrest Post-Intubation Summary 1 Disconnect ventilator 2 Squeeze chest 3 Bilateral chest tubes 4 Fluid bolus
- 154. Crashing Asthmatic Last Chance……… Anesthetic Gases
- 155. ECMO
- 156. Extracorporeal Membrane Oxygenation (ECMO)
- 157. Pearls
- 158. • Can’t see the cords …try BURP • Another attempt needed – …change something
- 159. Call for help !
- 160. Have a backup plan – “Prior planning prevents poor performance”
- 161. Don’t panic!
- 162. Thank you! Mark P. Brady PA-C Dept.of Emergency Medicine Cambridge Health Alliance Cambridge, MA