Advanced Emergency Airway Management

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					    Advanced
 Emergency Airway
   Management
• RSI
• Techniques for the Difficult
  or Failed Airway
          Dilemmas:
• Intubate Awake or Asleep
• Oral or Nasal
• Laryngoscopy or Blind
  Intubation
• To Paralyze or Not
            Techniques
•   DL without pharmacologic aids
•   Awake Direct Laryngoscopy
•   Awake Blind Nasal
•   Rapid Sequence Intubation (RSI)
•   Fiberoptic
•   Surgical Cricothyroidotomy
    Blind Nasal Intubation
• success rates 65 - 80 % in most series
• high complication rates
   – epistaxis
   – pharyngeal/ esophageal perforations
   – increased incidence of O2 desaturation
• Considered second line approach only
• reserved for when RSI contraindicated
Oral Intubation Without Drugs
• Reserved for the completely unconscious,
  unresponsive, and apneic
• Arrest situations only
 Oral Intubation with Sedation
• proponents argue use of BZ or opioids
  – improves airway access
  – decreases patient resistance
  – avoids risks of neuromuscular blockade
• Generally obtunds patient to point of loss
  of protective reflexes and respiratory
  drive
• lower success rate, higher complications
  compared with RSI
 Oral Intubation with Sedation
• “ In general, the technique of
  administering a potent sedative agent to
  obtund the patient’s responses and
  permit intubation in the absence of NMB
  is hazardous and to be discouraged… is
  not an appropriate alternative to
  properly conducted RSI and affords
  neither the success rate or the minimal
  complication rate of RSI.”
  – RM Walls, page 4, Chapter 1, Rosen
     Oral Intubation with
      Sedation:Use for the
  Anticipated Difficult Airway

• if time permits
  – topical anesthesia
  – careful titrated sedation
  – avoid obtundation
• ‘Awake” intubation technique
    Emergency Airway Concerns
•   “full” stomach
•   minimal respiratory reserve
•   hemodynamic instability
•   acute myocardial ischemia
•   increased intracranial pressure
•   The “Difficult” Airway
    – Laryngoscopy
    – bag-mask difficulty
      The “Intubation Reflex “
• Catecholamine release in response to
  laryngeal manipulation
• Tachycardia, hypertension, raised ICP
• Attenuated by beta-blockers, fentanyl
• ICP rise possibly attenuated by lidocaine
• Midazolam and thiopental have no effect
  Rapid Sequence Intubation :
          Definition
• The near simultaneous administration of
  a sedative-hypnotic agent and a
  neuromuscular blocker in the presence of
  continuous cricoid pressure to facilitate
  endotracheal intubation and minimize
  risk of aspiration
• modifications are made depending upon
  the clinical scenario
  Rapid Sequence Intubation :
         Advantages
• Optimizes intubating conditions/
  facilitates visualization
• Increased rate of successful intubation
• Decreased time to intubation
• Decreased risk of aspiration
• Attenuation of hemodynamic and ICP
  changes
  Rapid Sequence Intubation :
      Contraindications
• Anticipated difficulty with endotracheal
  intubation
  – anatomic distortion
• Lack of operator skill or familiarity
• inability to preoxygenate
    Rapid Sequence Intubation:
            Principles
•   Emergency intubation is indicated
•   The patient has a “full” stomach
•   Intubation is predicted to be successful
•   If intubation fails, ventilation is predicted
    to be successful
    Rapid Sequence Intubation :
            Procedure
•   Pre-intubation assessment
•   Pre-oxygenate
•   Prepare ( for the worst )
•   Premedicate
•   Paralyze
•   Pressure on cricoid
•   Place the tube
•   Post intubation assessment
             Pre-oxygenate
          ( Time - 5 Minutes)
•   100 % oxygen for 5 minutes
•   4 conscious deep breaths of 100 % O2
•   Fill FRC with reservoir of 100 % O2
•   Allows 3 to 5 minutes of apnea
•   Essential to allow avoidance of bagging
•   If necessary bag with cricoid pressure
             Preparation
         ( Time - 5 Minutes )
•   ETT, stylet, blades, suction, BVM
•   Cardiac monitor, pulse oximeter, ETCO2
•   One ( preferably two ) iv lines
•   Drugs
•   Difficult airway kit including cric kit
•   Patient positioning
        Pre-treatment/ Prime
         ( Time - 2 Minutes )
• Lidocaine 1.5 mg/kg iv
• Defasciculating dose of non-depolarizing
  NMB
• Beta-blocker or fentanyl
• Induction agent
  –   Thiopental 3 - 5 mg/kg
  –   Midazolam 0.1 - 0.4mg/kg
  –   Ketamine 1.5 - 2.0 mg/kg
  –   Fentanyl 2 - 30 mcg/kg
      Paralyze ( Time Zero )
• Succinylcholine 1.5 mg/kg iv
• Allow 45 - 60 seconds for complete
  muscle relaxation
• Alternatives
  – Vecuromium 0.1 - 0.2 mg/kg
  – Rocuronium o.6 - 1.2 mg/kg
                 Pressure
•   Sellick maneuver
•   initiate upon loss of consciousness
•   continue until ETT balloon inflation
•   release if active vomiting
         Place the Tube
     ( Time Zero + 45 Secs )
• Wait for optimal paralysis
• Confirm tube placement with ETCO2
    Post-intubation Hypotension
•   Loss of sympathetic drive
•   Myocardial infarction
•   Tension pneumothorax
•   Auto-peep
          Succinylcholine
        : Contraindications
• Hyperkalemia - renal failure
• Active neuromuscular disease with
  functional denervation ( 6 days to 6
  months)
• Extensive burns or crush injuries
• Malignant hyperthermia
• Pseudocholinesterase deficiency
• Organophosphate poisoning
         Succinylcholine :
          Complications
• Inability to secure airway
• Increased vagal tone ( second dose )
• Histamine release ( rare )
• Increased ICP/ IOP/ intragastric
  pressure
• Myalgias
• Hyperkalemia with burns, NM disease
• malignant hyperthermia
        Difficult Airway Kit
• Multiple blades and ETTs
• ETT guides ( stylets, bougé, light wand)
• Emergency nonsurgical ventilation
  ( LMA, Combitube, TTJV )
• Emergency surgical airway access
  ( cricothyroidotomy kit, cricotomes )
• ETT placement verification
• Fiberoptic and retrograde intubation
  Emergency Surgical Airway
          Maxims
• they are usually a bloody mess, but ...
• a bloody surgical airway is better than an
  arrested patient with a nice looking neck

				
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