AIRWAY MANAGEMENT IN THE EMERGENCY DEPARTMENT

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					AIRWAY MANAGEMENT IN
   THE EMERGENCY
    DEPARTMENT




   Christ Kyriakedes DO FACOEP
Airway Emergencies
 Emergency Physicians
 must be Airway Experts:
 – The most difficult problems
   present in the ED
 – No help or only delayed
   help from other specialties
 – No other specialty has our
   general overview and
   ability to use all modes of
   airway control
GOAL:
Establish an airway without doing harm
Cervical Spine protection
Avoid aspiration
No dental trauma
Minimize changes in Intracranial Pressure
Cervical Spine Controversy:
 Can a patient with a cervical
 spine injury be orally intubated
 without worsening the injury ?
        YES
 Definite movement (small)
 during intubation does occur
 Solution: In-line-stabilization
EQUIPMENT:
Oxygen: 100%
Laryngoscope handle: need 2 available
Laryngoscope blades
E.T. tubes
Stylet
Suctioning
Bag-Valve-Mask (know how to use it)
            Bag Valve Mask
May be the single most important skill in airway management.
Even in cases where a patient can not be intubated, patient may
be maintained for long periods of time with BVM support.
Practice of this skill is critical and frequently overlooked
Ensure tongue and secretions clear of airway.
Ensure a good seal of the face mask.
Practice it!
Laryngoscope Blade:
 Macintosh:
  – Curved
  – Adult size is 3 or 4
  – Inserted in vallecula
Laryngoscope Blade:
Miller:
– Straight
– Adult size 3 or 4
– Picks up the epiglottis
Laryngoscope Blade:
Pediatric:
– Miller is used, but placed in vallecula

– Miller 0 for infants

– Miller 2 for children over 1 year
      Endotracheal Tube:
       Adult female: 7.0 or 7.5
       (Internal Diameter)

       Adult male: 8.0

       Insert to 24 cm (oral;
       +2-3 cm for nasal)


ACOEP Lecture Series in Emergency Medicine
Endotracheal Tube:

Pediatric:
– Newborns 3.5
– Uncuffed Tubes up to age 8
– Size: Tube Diameter = 4 + (age/4)
– Pediatric length: ( age in years / 2 ) + 12
     MACINTOSH VS. MILLER




MACINTOSH       MILLER
The Difficult Airway:
Immobilized trauma patient
Combative patient
Short neck
Prominent incisors
Receding mandible
The Difficult Airway
Limited jaw opening
Upper airway conditions
(edema, enlarged uvula..)
Facial trauma
Laryngeal trauma
TECHNIQUE: ORAL
Have equipment ready
Adjust head (sniffing position)
Open mouth with right hand and
advance laryngoscope with left
hand starting right side of mouth
(push tongue over) to midline
and then down to epiglottis
Keep eyes on intubation
Nasotracheal Intubation
Patient needs to breath spontaneously

Complication: epistaxis

Use for difficult oral intubations (no
   paralysis) and when pt. has difficulty
   laying down ( Pulmonary Edema )
Relative Contraindications:
Increased intracranial pressure (stimulation)
Combative patients
Facial trauma with possible basal skull Fx
 – inadvertent intracranial placement of tube
Coagulopathy ( epistaxis )
Anterior neck injuries
 – Anatomy changes
 – Injuries may prevent placement
Technique (nasal):
Inspect nostril ( patency )
Vasoconstriction and anesthesia
– neosynephrine and xylocaine
Lubricate tube and nostril
Advance tube until breath sounds heard
   through it
On inspiration or expiration advance tube
   3-4 cm
          COMBITUBE

Airway Rescue Device
Most common use is by pre-hospital
providers when unable to establish
endotracheal tube
Dual Lumen – Dual Cuff design
Easy to insert
2 Sizes 37F for small patients and 41F for
large patients
          Combitube Insertion

Lift tongue and jaw upward to clear posterior pharynx
Insert tube following the curve of the airway until
bands on teeth reach alveolar ridge
Inflate proximal lumen (blue) with air 100 cc for large
tube and 85 cc for small tube
Inflate distal lumen (white) with air --5 to 15 cc for
large tube and 5 to 12 cc for small tube
Do not force the tube against excessive resistance or
over inflate lumens against excessive resistance
Combitube
Combitube Ventilation Esophageal

Ventilate the blue--long tube 1st
Air entry into lung by auscultation indicated
by absence of gastric insufflation
Most common placement is in the
esophagus
Continue ventilation through the blue tube
Combitube Ventilation Tracheal

Ventilate longer blue tube 1st
Absence of breath sounds indicates tracheal
intubation
Ventilate through the clear-shorter tube
Less common to place in trachea
If breath or gastric sounds are not heard,
device has been placed too far down and
needs to be pulled back
Laryngeal Mask Airway (LMA)

Mask/tube combination slid into posterior pharynx
and advanced along palate with laryngeal surface
against tongue with insertion
Inflate the cuff until no leak with ventilation
Can place ETT through the LMA by sliding ETT
through metal port and into the esophagus
LMA alone will not protect against aspiration but
will allow ventilation
Verification of Placement:
 Watch the E.T. go
 through the "cords" and
 let everyone know
 Auscultation
 Chest motion
 End Tidal CO2 ( no
 CO2 in stomach )
 Pulse Oximeter
 CXR
Cricoid Pressure:
 Sellick's Maneuver

 Digital pressure on the cricoid cartilage

 Improved observation of anterior airway

 Prevent aspiration
Rapid Sequence Intubation

  Rapid controlled induction of
      anesthesia to facilitate
           intubation.
The Decision to Intubate
 Is there failure of airway maintenance
 or protection?
 – Gag vs. Swallow
 Is there failure of ventilation or
 oxygenation?
 What is the expected clinical course?
 – Multiple trauma
 – Impending airway obstruction
 – Facility transport
 – Fatigue
R.S.I. – The Seven “P’s”
 Preparation
 Pre-oxygenation
 Pretreatment
 Paralysis with induction
 Protection and positioning
 Placement with proof
 Post-intubation management
RSI - Preparation
 Equipment
 – Suction
 – Laryngoscope(s) and blade(s)
 – Endotracheal tube and stylet – cuff tested
 – Monitoring – cardiac and pulse oximetry
 – BVM, O2 source, O2 mask
 – Medications – drawn and labeled
 – Airway cart
RSI - Preparation
Predicting the difficult airway – “LEMON”
– L – Look
– E – Evaluation of airway – the “3-3-2” rule
– M – Mallampati
– O – Observation?
– N – Neck mobility
RSI Protocol:
Pre-oxygenate, IV, Monitor, Equipment
Lidocaine 1 mg/kg
Atropine 0.01 mg/kg
Pancuronium 0.01 mg/kg or Vecuronium 0.01
mg/kg
Amidate 0.2-0.3 mg/kg or Midazolam 0.3-0.35
mg/kg or Ketamine 1.0-1.5 mg/kg
Succinylcholine 1.5 mg/kg or Rocuronium 0.6
mg/kg
Intubation
Preoxygenation:
 100 % oxygen
 Do not bag patient
 5 minutes if possible
 Get everything ready
 during this phase
Preoxygenation:
 Nonrebreather mask = 70-75% oxygen
 BVM with assist = 90-100% oxygen
 “Crash preoxygenation: 8 vital capacity
 breaths
Pretreatment
 Drugs to mitigate adverse effects of
 intubation
 – L - (Lidocaine)
 – O - (Opiates) to blunt sympathetic response
 – A - (Atropine)
 – D - (Defasiculating dose when using
   depolarizing paralytic (succinylcholine)
Lidocaine:
 1 mg/kg IV push
 Lowers ICP or prevents increase
 in ICP during intubation
 Controversial
 Given 60-90 seconds before succinylcholine
Atropine
 Prevents succinylcholoine
 induced bradycardia
 .01 mg/kg
 Always:
 – in pediatrics
 – if patient has underlying
   bradycardia
 – if succinylcholine is repeated
Defasiculating Dose
Non-depolarizing neuromuscular blocker
Prevents fasciculations due to
succinylcholine
1/10th of usual dose
Infrequently can cause paralysis
Pancuronium or vecuronium
Sedation:
 Neither depolarizing nor non-depolarizing
 agents cause sedation
 Need sedation in conscious patient
 Midazolam/Amidate/Ketamine
 Agents adjusted to individual clinical
 situation
Midazolam (Versed)
 Most commonly used
 Amnesia, anxiolysis, sedation,
 anticonvulsant effects and hypnosis
 Dose for induction, 0.3-0.35 mg/kg
 Causes myocardial depression
 Long half-life (2 hours)
Amidate (Etomidate)
Primarily a hypnotic agent
Best agent for most situations
Minimal myocardial or respiratory depression
Decreases intracranial pressure
Onset in 20-30 seconds, duration 7-14 min.
Dose 0.2 to 0.3 mg/kg
Decreases serum cortisol and aldosterone levels
Ketamine
Provides excellent analgesia, anesthesia,
and amnesia
Releases catecholamines
Relaxes bronchial smooth muscle, agent of
choice for bronchospasm patients
Consider in hypotensive/hypovolemic
patients without CAD or head injury
Succinylcholine:
 Depolarizing muscle relaxant
 Inactivate post-synaptic receptor
 An initial activation causes fasciculations
 Degraded by pseudo cholinesterase
 Onset: < 60 seconds
 Duration: < 10 minutes
 1 mg/kg to 1.5 mg/kg
Succinylcholine
 Disadvantage:
 – Increased intraocular pressure
 – Increased ICP
 – Increased intragastric pressure
 – Increased in potassium
 – Bradycardia
Succinylcholine
 Prior administration of a small dose of
 non-depolarizing agent can probably
 prevent above problems

 Advantage is quick onset and short
 duration
Rocuronium(Zemuron):
 Non-depolarizing agent
 Onset 70 seconds (fastest non-depolarizer)
 Duration: 14-30 minutes
 Dose: 0.6-1.0 mg/kg
 No cardiovascular effects
 No increased ICP, IOP, IGP
 RSI Protocol:
TIME (min)
 -5.00 -Pre-oxygenate ,IV, Monitor, Equipment
*1.00 -Lidocaine 1 mg/kg
*1.25 -Atropine 0.01 mg/kg
 1.50 -Midazolam 0.3 mg/kg
 1.55 - Pancuronium/Vecuronium 0.01mg/kg
 2.00 - Start Sellick Maneuver
 2.25 -Succinylcholine 1.5 mg/kg
 3.00 -Intubation
 *=optional
Non-Depolarizing Protocol
  Time (min)
   -5.00 -Pre-oxygenate/IVs/monitoring/Equipment
  *1.00 -Lidocaine 1 mg/kg
  *1.30 -?Atropine
   2.00 - Midazolam 0.3-0.35 mg/kg
   2.10 -Rocuronium 0.6-1.0 mg/kg
   2.15 - Start Sellick maneuver
   3.00 -Intubate
   *=optional
Alternative Airway Management

  Transtracheal oxygenation

  Cricothyroidotomy

  Fiberoptic
Translaryngeal Ventilation

14 gauge IV catheter through inferior
aspect of cricothyroid membrane

High flow intermittent oxygen
Cricothyroidotomy (equipment):
  Scalpel with 11 blade
  Tracheal hook
  Trousseau dilator
  Cuffed tracheostomy tube
  Small vascular clamps
“HOCKEY STICK” ETT FOR
   ANTERIOR AIRWAY
        Intubation Success
Best predictor that the ETT is in place
Direct Visualization!
    SURGICAL AIRWAY
CRICOTHYROTOMY
– NEEDLE
– SURGICAL
TRACHEOSTOMY
ONLY TO BE DONE BY THOSE TRAINED AND
PROFICIENT IN THE PROCEDURE
SURGEONS (TRAUMA, GENERAL, ENT)
EMERGENCY PHYSICIANS
SOME ANESTHESIOLOGISTS & CRITICAL
CARE PHYSICIANS
Cricothyroidotomy (technique):
 Immobilize larynx with non-dominant hand by
 grasping upper poles of thyroid cartilage with
 thumb and middle finger

 Initial incision is vertical and midline 2-3 cm skin
 incision

 Use index finger of non-dominant hand to palpate
 cricothyroid membrane
Cricothyroidotomy
 Cricothyroid membrane is incised transversely (1.5
cm)
Insert tracheal hook and pull at 45 degree and cephalad
Insert Dilator
Insert tracheostomy tube through dilator
Remove Dilator and Hook
Secure tube.
      Airway Management

Airway needs to be continually monitored
Blood gasses checked
Physical examination is key element of
ongoing airway management including
auscultation, observation, and palpation
Original Contribution of This
          Lecture


  Jerry Balentine DO FACOEP

            Thank You!