Emergency Airway Management

1
Emergency Airway Management

• Kevin Ferguson, MD FACEP
• Assistant Professor
• Department of Emergency Medicine
• University of Florida-Gainesville

2
Lung Association motto

• If you cant breathe, nothing else matters!
• All resuscitation algorithms (ACLS, ATLS, APLS,
  PALS) start with A,B,Cs

3
My Philosophy is

• The emergency physician bears the primary
  responsibility for resuscitative airway
  management.
• Therefore, emergency physicians must be skilled
  in multiple methods of assessing and controlling
  the airway.
• Furthermore

4
Emergency Airway Management

• Comprises the skills and techniques required to
  cope with many different events that precipitate
  respiratory failure requiring immediate and
  definitive action to prevent tissue hypoxia.

5
For Everything a Purpose

• The purpose of the cardio-pulmonary system is the
  transport of oxygen to tissues, and CO2 to the
  atmosphere

6
Indications for Intubation

• Failure to protect airway
• Inadequate oxygenation
• Inadequate ventilation
• Problem not reversible with the amount of time
  resources available

7
Anatomy
8
Equipment

• Nasal Cannula
• Non-rebreathing Face Mask
• Venturi face Mask

9
Equipment

• Laryngocopes
• Millers Macs
• Endotracheal tubes
• End Tidal CO2 detectors
• Gum Bougie

10
Adjuncts Aids

• LMA
• Combitube
• Bougie
• Lighted stylet
• Fiberoptic intubating bronchoscope
• Retrograde intubation
• Surgical airway
• Melker
• Open

11
The Drugs

• Neuromusular Blockers
• Succinylcholine-depolarizing, rapid, brief
• Vecuronium- Depolarizing, rapid onset, 1- 1.5
  hours duration
• Atracurium- Depolarizing, rapid onset, rapid
  metabolism

12
Drugs II
13
Assessing Airway

• Mallampati
• 3-3-2 rule

14
Intubating Conditions

• Optimize view of Vocal cords
• If you see VCs, its a straight line Eye ? cords
  (Einstein et al)
• Place in sniffing position unless concerns for
  c-spine injury
• Chin lift
• B.U.R.P. for anterior airway

15
6 Ps 1

• Prepare-gather equipment staff
• Pre-oxygenate- high flow NRFM
• Pre-treat- case dependent
• lidocaine, atropine, NDNMBs
• Paralyze-Succinylcholine preferred
• Sedation preceding Sch
• Pass the Tube
• Position confirmation
• Procedure Note

16
The Times

• Pre-Oxygenate/ Prepare 500 minutes
• PreTreat
• Lidocaine 1mg/kg IVP 05 sec
• Vecuronium 3mg IVP.. 05 sec
• WAIT 200 min
• Paralyze (begin Sellecks Maneuver)
• Succinylcholine1.0-1.5mg/kg IVP.. 05
  sec
• Methohexital 1.0mg/kg IVP. 10 sec
• WAIT 100 min
• Pass Tube. 35 sec
• Position Confirmation 30 sec
• RSI Time.. 900 min

17
The CRASH Technique

• Pre-Oxygenate prepare equipment 500 minutes ?
  200
• Lidocaine 1mg/kg IVP.. 005 sec
• Vecuronium 3mg IVP... 005 sec
• WAIT....200 min
• Succinylcholine1.0-1.5mg/kg IVP 005 sec
• Etomidate 0.5 mg/kg IVP. 010 sec
• Sellecks Maneuver (begin)
• WAIT... 100 min
• Intubate Patient. 035 sec
• End Selick Maneuver
• Crash RSI Time 450 min

Can be omitted -210 - 410
900 -410
18
Variations on a Theme

• Congestive heart failure
• Barbituates are hypotensive agents. They are
  contraindicated in hypotensive patients and
  failing hearts. Substitute short acting
  benzodiazepine, or Etomidate
• Acute Bronchospasm
• Since ketamine is a potent bronchodilator, it is
  the preferred induction agent in asthmatic crisis
• Renal failure and dialysis holiday
• If the patient is hyperkalemic Sch is
  contraindicated. Substitue Vecuronium as
  neuromuscular blocker.
• Head trauma
• Sch is theoretically contraindicated, though many
  use it without difficulty. Vecuronium is a
  reasonable substitute.

19
AWESOME Tube Dude!Now what?
20
Ventilator Settings

• MODE
• Control
• Assist Control
• SIMV
• CPAP

21
Oxygen Delivery and Consumption

• DO2 cao2 x Q x 10
• Cao2 is the O2 content of arterial blood or
• (Hgb x 1.39)/sao2 (pao2 x0.003)
• Q cardiac output
• VO2 Q x(a-vdo2) x 10
• Where avdo2 is the arterial-venous O2 content
  difference cao2 cvo2
• Under basal conditions..Vo2 250ml/min
• DO2 900-1200ml/min..Extraction ratio
  25

22
Oxygenation

• If there is any doubt about the patients ability
  to oxygenate initial fio2 should 90-100. Get
  ABGs after 10-15 minutes on constant ventilator
  settings.
• If the initial pco2 gt 35 , lt45, po2 gt200 Lower
  the fio2 10 every 10 minutes until the
  pulse-oximeter O2 sat lt96 or fio2 lt50
• Repeat ABG
• If the patients able to oxygenate adequately
  start fio2 at 50
• ABG in 15 minutes

23
Problems with Oxygenation

• PEEP
• Ramp waveform
• Inspiratory Pause
• Paralysis
• Treat underlying disease

24
Problems with Ventilation

• Hypoventilation occurs because of inadequate gas
  exchange and is manifested as hypercapnea and
  Respiratory Acidosis
• ASSUMING the ventilator settings are confirmed
  examine the pulmonary circuit from Ventilator ?
  Patient. Look for a break or obstruction in the
  circuit.

25
Problems with Ventilation

• Low peak pressure and exhaled volume implies a
  leak in the circuit a loose connection,
  bronchopleural fistula, ruptured ETT cuff.
• High peak inspiratory pressures imply obstruction
  or restriction blood or vomit in the ETT or
  airway, tension pneumothorax, kinked ETT,
  pulmonary edema, chest wall burn with escar

26
Difficult Airway Management
27
Goal and Objective

• Goal To be able to handle difficult airways in
  resuscitation.
• Objective To develop personal difficult Airway
  algorithm
• Doesnt matter how anyone else does it.
• Utilize multiple techniques to solve specific
  problems.
• Write it down and MEMORIZE it
• Practice, practice, practice!!!

28
Prepare, Practice, Predict

• Cant wait until youre in trouble to figure out
  how to get out.
• Practice the thought process, and the techniques.
• Know what youll have to do BEFORE it needs
  doing.

29
Park the EGOs at the door.

• Airway skills part of multiple specialties
• Anesthesia
• Emergency
• Trauma surgery
• Critical Care / Pulmonary
• Respiratory Therapy
• Assign roles PTA of patient
• Go up the ladder of experience when problems
  arise

30
Problem Airways

• 1 cant see cords
• Epiglottis Obstructicus
• Anterior airway
• Dysmorphic Airwway
• Trauma, Burn, Edema, Surgery, Tumor, Congenital

31
Can See em but...

• Too tight to pass tube
• Cant direct tube to cords

32
Options

• Change Blades- Miller for big epiglottis
• Gum Bougie
• Intubating Fiberoptic Bronchoscope
• Cricothyrotomy
• Intubating LMA
• Good for short term airway control
• Still need definitive Airway

33
My Personal Algorithm
RSI w/ Mac
Anterior Airway
Epiglotticus Obstructicus
RUB -Modified Selleck Maneuver right, up,and
back
Miller blade
34
My Personal Algorithm
Still Cant find em
Get prepare Intubating bronchoscope
Attempt Blind airway with Gum Bougie
Prep Neck for surgical airway
Fiberoptic Intubation
Cricothyrotomy
35
My Personal Algorithm
Can see cords but cant pass tube
Due to edema, Trauma, surgery
Very anterior
Cricothyrotomy
Hockey stick ETT, Gum Bougie, Fiberoptic
bronchoscope
36
Pearls From the Pit

• Prepare, Practice, Predict
• Go to simulator and practice!!!
• Thought process
• Techniques especially bronchoscopic and
  cricothyrotomy
• Consider LMA for temp airway while preparing for
  advanced technique
• When gt1 Provider available, progress up ladder of
  EXPERIENCE
• Experience NOT Rank

37
Thanks for Your Attention