Ems difficult airway lecture symposium

2. Approach to the Pre-Hospital Difficult Airway Andrew Schmidt, DO, MPH Assistant Professor, Emergency Med Deputy Medical Director, TraumaOne

7. Normal Airway Difficult Airway Failed Airway

10. This is:

11. This is NOT:

13. Indications for intubation Consider intubation

14. Indications for intubation Consider intubation Airway protection

15. Indications for intubation Consider intubation Airway protection Failure to ventilate

16. Indications for intubation Consider intubation Airway protection Failure to ventilate Failure to oxygenate

17. Indications for intubation Consider intubation Airway protection Failure to ventilate Failure to oxygenate Impending clinical course

18. Difficult Airway predicted Forced to act? Failure to oxygenate? BMV or EGD predicted success? Consider scoop and run Predict successful ETI? Give RSI drugs One best attempt successful? RSI with double setup Y Y Y YN N N Y FAILED AIRWAY PIM Fig 30-1: The EMS Difficult Airway Algorithm (Manual of Emergency Airway Management)

19. Difficult Airway predicted? Forced to act? Failure to oxygenate? BMV or EGD predicted success? Consider scoop and run Predict successful ETI? Give RSI drugs One best attempt successful? RSI with double setup Y Y Y YN N N Y FAILED AIRWAY PIM Fig 30-1: The EMS Difficult Airway Algorithm (Manual of Emergency Airway Management)

20. Difficult Airway predicted? Is he easy to tube?

21. Difficult Airway predicted? If I can’t tube him, can I bag him? Is he easy to tube?

22. Difficult Airway predicted? If I can’t tube him, can I bag him? Is he easy to tube? If I can’t bag him, can I place an EGD?

23. Difficult Airway predicted? If I can’t tube him, can I bag him? Is he easy to tube? If I can’t bag him, can I place an EGD? If all else fails, can I cric him?

24. Difficult Airway predicted? Difficult BVM? Difficult Laryngoscopy? Difficult EGD? Difficult Cric?

25. Difficult Airway predicted? Difficult BVM? Difficult Laryngoscopy? Difficult EGD? Difficult Cric? LEMON(S) M O A N S R O D S S M A R T L E M O N

26. Difficult Airway predicted? Difficult Laryngoscopy? L ook Externally E valuate 3-3-2 Mallampati O bstruction/Obesity N eck Mobility (S)pace

27. Look Externally “Gestalt”

28. Evaluate 3-3-2 3 2 3 patient fingers chin hyoid3 hyoid Thyroid cart 2

29. Seriously?

30. Evaluate 3-3-2

31. Evaluate 3-3-2 • Short mandible – Less room to displace the tongue

32. Mallampati Primarily for use in OR Difficult in field DIFFICULTY

33. Shhhhh

35. Obstruction/Obesity

36. Neck Mobility

37. Space

38. Airway Axis

39. Airway Axis

44. Questions so far?

45. Difficult Airway predicted? Difficult BVM? M ask O besity A ge N o teeth S tiff lungs

46. Mask

47. Obesity

48. Age • Elderly have decreased airway muscle tone

49. No Teeth

50. No Teeth

51. Stiff Lungs

52. Difficult Airway predicted? Difficult EGD? R estricted opening O besity/obstruction D istorted airway S tiff lungs

53. Restricted Mouth Opening

54. Obesity/Obstruction

55. Obesity/Obstruction

56. Disrupted/distorted airway

57. Stiff Lungs Obesity COPD Asthma Pulm edema

58. Difficult Airway predicted? Difficult Cric? S urgery M ass A cess/anatomy R adiation T umor

59. Surgery

60. Mass

61. Access/Anatomy

62. Radiation

63. Tumor

65. Difficult Airway predicted Forced to act? Failure to oxygenate? BMV or EGD predicted success? Consider scoop and run Predict successful ETI? Give RSI drugs One best attempt successful? RSI with double setup Y Y Y YN N N Y FAILED AIRWAY PIM

66. Scoop and Run • Factors to consider – Available manpower – Available equipment – Local protocols – Provider experience – Hospital location – Amount of trauma – Patient vitals – Number of patients – Mechanism of injury – Medical history – Response to treatment – Weather – Phase of the moon – Patient’s Zodiac sign – Insurance provider – Local legal environment – Your officer’s mood that day – Whether patient is nice – Number of runs that day – Whether patient is on fire – If you are left or right handed – Would you rather get the cric

68. Recent Evidence TBI 124 severe TBI Better outcomes with basic airways OHCA 10,000 patients Better outcome with no airway placement TBI Case Control (55 vs 165) Higher mortality for ETI group

70. House Fire/Stridor GCS 15 1 Hour Transport SaO2=70% Stroke Alert GCS 6 10 minute transport SaO2=99% on room air

75. Failed Airway Cannot intubate, Can oxygenate Scoop and run BVM Cannot intubate, Cannot Oxygenate EGD while preparing for cric Cric if EGD not adequate

81. Difficult Airway predicted? If I can’t tube him, can I bag him? Is he easy to tube? If I can’t bag him, can I place an EGD? If all else fails, can I cric him?

82. Difficult Airway predicted? Difficult BVM? Difficult Laryngoscopy? Difficult EGD? Difficult Cric? LEMON(S) M O A N S R O D S S M A R T L E M O N

86. BP 80/30

88. D O P E S

89. D isplacement O P E S

90. D isplacement O bstruction P E S

91. D isplacement O bstruction P neumothorax E S

92. D isplacement O bstruction P neumothorax E quip failure S

93. D isplacement O bstruction P neumothorax E quip failure S tacking breaths

94. Displacement

95. Tube depth

96. Pediatrics Flex  Tube down Extend Tube Up

97. Pediatrics

98. End-Tidal CO2 Loss of wave form

99. Direct Visualization

100. Obstruction

104. Tube Biting Blood Secretions Vomit

105. Pneumo

109. Equip Failure

114. Breath Stacking

115. Normal Asthma Air trapped in alveoli by airway constriction

117. Unable to exhale Impaired gas exchange Decreased venous return

121. RR

122. QUIZ • Question What is the greatest airway device ever invented?

124. The Bougie

128. Proper, Prior, Planning Prevents Piss Poor Performance

130. D O P E S

131. The End www.JaxEMS.com

Ems difficult airway lecture symposium

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