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Emergency Airway Management

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Emergency Airway Management Powered By Docstoc
					    Rob Dickson, M.D. FAAEM, FACEP
    Good Shepherd Health System
    Longview, Texas



Emergency Airway Management
Clinical Questions
• What is different about emergency airways
  from those done in the anesthesia suite?
• Are there reliable signs of airway
  compromise and at what point do we
  intervene?
• How can we screen for potential airway
  disasters?
• What are the best management strategy for
  difficult airways?
• What are the newest airway devices and are
  they worth the investment?
Unique issues in the Emergency
Department
     We don’t pre-select cases




Unique issues in the Emergency
Department
     We don’t pre-select cases
     Can never cancel a case




Unique issues in the Emergency
Department
The patient we want
The patients we get
Closed claims paper
• Review paper of closed anesthesia claims
  resulting in death or disability
• Take home points
• Emergency airways are the riskiest!
• Difficult BVM ventilation increased risk of
  bad outcome
• Highest predictor of bad outcome was
  persistent attempts before rescue method
  employed- have a plan B!

                     Peterson GN. Management of the difficult airway: A closed claims analysis.
                     Anesthesiology 2005; 103:33.
Unique issues in the Emergency
Department
Unique issues in the Emergency
Department
• Deteriorating cardio -respiratory status
Unique issues in the Emergency
Department
• Deteriorating cardio -respiratory status
• High aspiration risks
Unique issues in the Emergency
Department
• Deteriorating cardio -respiratory status
• High aspiration risks
• Altered mental states
Unique issues in the Emergency
Department
•   Deteriorating cardio -respiratory status
•   High aspiration risks
•   Altered mental states
•   Anatomical variants
Unique issues in the Emergency
Department
•   Deteriorating cardio -respiratory status
•   High aspiration risks
•   Altered mental states
•   Anatomical variants
•   Upper airway structural and mechanical
    considerations (vomit, angioedema)
Clinical signs of airway compromise

• Snoring respirations
• Inspiratory stridor
• Drooling
• Hoarseness
• Retractions/tracheal tugging/paradoxical
  breathing patterns
• Mass effects
When to intervene?
• Hypoxic/hypercapnic respiratory failure
• Shock states (decreases cardiac load)
• Altered mental states and unable to maintain
  patent airway
• Potential decompensation
Continuum of airway management

• Upper airway obstruction (airway positioning)
• Head positions- jaw thrust, head tilt-chin lift
• Oropharyngeal/nasopharyngeal airway
• Bag-valve-mask ventilation
• Supra-glottic airways- LMA, combitube, king
  device
• Difficult intubations- bougie, video assisted
  laryngoscopy, cricothyrotomy, needle
  cricothyrotomy
Predictors of difficult Airway

• History of airway problems- tracheostomy
  scars
• Physical assessment- obesity
• Mouth opening
• Tongue to pharyngeal size
• Hyo-mental distance
• Neck flexion/head extension(mobility issues)
Mallampatti/Cormack-Lehane
Mallampatti views
Bag-valve mask
• Essential skill to managing the airway
• The most important airway skill
• Almost every case can be managed or
  rescued with good BVM technique
• Never abandon until using a 2 person
  technique with NP/OP airway
• This skill is necessary before attempting to
  master other techniques/devices
One person BVM
Two person BVM
Direct laryngoscopy
Rapid Sequence Intubation
• Use of sedation and chemical paralysis to
  facilitate intubation
• 70-84% of all intubations
• High success rates for experience operators
• In comparison to non-paralysis intubations
  RSI had 15% less aspiration, 25% less
  airway trauma, 3% less death
Steps in RSI
•   Preparation: T-10 minutes
•   Preoxygenation: T-5m
•   Premedication: T-3m
•   Paralysis: T-0
•   Placement of tube T+45s
•   Post intubation management:T+2m
Blades
• Miller (straight)
• Macintosh(curved)
• Main criteria is blade long enough to
  effectively fit into the valecula space (curved)
• Reach the epiglottis to lift (straight)
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Best laryngoscopy techniques
• Proper alignment auditory meatus with
  suprasternal notch
• Flex neck by placing pillow under occiput
• Extend head maximal
• Insert laryngoscope, visualize epiglottis by
  sweeping tongue to the left
• Must see this landmark
• Glottic opening lies just distal to this
  structure
Proper alignment
Picture correct axis positioning
Positioning in the obese patient
Technique for difficult airway


Bimanual laryngoscopy
What is looks like in a perfect world
Supraglottic airways
LMA
• Peripharyngeal sealers
• Seats over the pyriform fossae
• Sizes 1(infant) to 5(large adult)
• At least as effective as other airway
  management choices in CPR
• Does not prevent aspiration
Laryngeal Mask Airways
King airway
• Isolates the hypopharynx and laryngeal inlet
• Pediatric sizes 2 and 2.5
• Adult sizes 3-5 (sized by height 4-5 ft,5-6,
  >6)
• Pass tube exchanger/bronchoscope through
  ports
• No documented tracheal placements
• Insertion technique
King airway
Combitube
•   High success rates of 98-100 %
•   Esophageal and oropharyngeal balloons
•   Most common placement in the esophagus
•   Tracheal placements ventilate thru distal port
•   No pediatric sizes
•   Distal cuff #2(white)-15cc air
•   Proximal cuff #1(blue)-85 cc air
OTHER AIRWAY ADJUNCTS
Gum Elastic Bougie
• Used to facilitate endotracheal intubation
• Essentially a plastic ETT changer with
  curved tip
• For use when unable to visualize the glottic
  opening or the view is impaired
• Place the tip up and aim just past the
  epiglottis
• “Feel bumps” or hit resistance
• Continue using laryngoscope and slide tube
  over the bougie for placement
surgeryencyclopedia.com
lungpro.com
     Click link below to watch video



http://youtu.be/umLs2V1A9i0
http://austhink.com/critical/pages/teaching.html
What is a difficult airway?
•   Three components may co-exist
•   Difficult BVM ventilation
•   Difficult laryngoscopy
•   Difficult surgical airway




                    ASA Difficult Airway Task Force. Anesthesiology 2003; 93:1269-1277.
Failed airway
• Occurs when one or mores exists
• Inability to ventilate or intubate paralyzed
  patients
• 3 or more attempts at intubation by most
  experienced operator




                     ASA Difficult Airway Task Force. Anesthesiology 2003; 93:1269-1277.
Failed emergency airways
• NEAR database
• N= 7212
• Patients were enrolled if first technique failed
  and a rescue was required
• Overall 2.7% failed airways
• Surgical airway in 0.5% of cases




              Bair AE. The failed intubation attempt in the emergency department: analysis of
              prevalence, techniques, and personnel. Journal of Emergency Medicine 2002; 23:131.
      Failed airway algorithm
Normal anatomy and oxygen        Abnormal anatomy normal oxygen




Normal anatomy abnormal oxygen   Abnormal anatomy abnormal
                                 oxygen
       Failed airway algorithm
Normal anatomy and oxygen           Abnormal anatomy normal oxygen

•Obese overdose patient with
unfavorable anatomy- able to BVM
to 95% saturation

•First choice: video laryngoscope
•Second choice: bougie or
supraglottic device

Normal anatomy abnormal oxygen      Abnormal anatomy abnormal
                                    oxygen
       Failed airway algorithm
Normal anatomy and oxygen               Abnormal anatomy normal oxygen

•Obese overdose patient with
unfavorable anatomy- able to BVM
to 95% saturation

•First choice: video laryngoscope
•Second choice: bougie or
supraglottic device

Normal anatomy abnormal oxygen          Abnormal anatomy abnormal
                                        oxygen
•Obese paralyzed RSI patient with
failed intubation and falling sats,
unable to oxygenate with BVM

•First choice: Supraglottic device or
limited attempt with video device
•Second choice: Cricothyrotomy
       Failed airway algorithm
Normal anatomy and oxygen               Abnormal anatomy normal oxygen

•Obese overdose patient with            •Severe angioedema with normal
unfavorable anatomy- able to BVM        oxygen saturation
to 95% saturation

•First choice: video laryngoscope       •First choice: Intubating
•Second choice: bougie or               bronchoscope or video device
supraglottic device                     •Second choice: Cricothyrotomy

Normal anatomy abnormal oxygen          Abnormal anatomy abnormal
                                        oxygen
•Obese paralyzed RSI patient with
failed intubation and falling sats,
unable to oxygenate with BVM

•First choice: Supraglottic device or
limited attempt with video device
•Second choice: Cricothyrotomy
       Failed airway algorithm
Normal anatomy and oxygen             Abnormal anatomy normal oxygen

•Obese overdose patient with          •Severe angioedema with normal
unfavorable anatomy- able to BVM      oxygen saturation
to 95% saturation

•First choice: video laryngoscope     •First choice: Intubating
•Second choice: bougie or             bronchoscope or video device
supraglottic device                   •Second choice: Cricothyrotomy

Normal anatomy abnormal oxygen        Abnormal anatomy abnormal
                                      oxygen
•Obese paralyzed RSI patient with
failed intubation and falling sats,   •Obese patient with severe
unable to oxygenate with BVM          angioedema and falling oxygen
                                      saturation with bradycardia
•First choice: Supraglottic device or
limited attempt with video device     •First choice: cricothyrotomy
•Second choice: Cricothyrotomy
Difficult airway algorithm
• 2674 pre-hospital intubations (France)
• Difficult airway algorithm BAI, ILMA,
  Cricothyrotomy
• 6% failed airways
• 98% adherence to algorithm
• BAI successful rescue in 114/151 attempts
• Remainder successfully managed with ILMA
• Cricothyrotomy in 1 patient



                   Anesthesiology:January 2011 - Volume 114 - Issue 1 - pp 105-110
Back to our questions
• What is different about emergency airways
  from those done in the anesthesia suite?
• Are there reliable signs of airway
  compromise and at what point do we
  intervene?
• How can we screen for potential airway
  disasters?
• What are the best management strategy for
  difficult airways?
• What are the newest airway devices and are
  they worth the investment?
DISCUSSION

				
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