Airway Management

1
Airway Management

• Philip Ukrainetz, MD, PGY5
• Gord McNeil, MD, FRCPS
• Core Rounds, July 18, 2002

2
Case

• 6 year old girl, MVA victim. She is stuporous,
  has a suspected head injury and is hypotensive.
  You have an IV and are giving a 20cc/kg NS bolus.
  What do you want to do?

3
Three indications to intubate

• Failure to protect airway
• Failure to oxygenate or ventilate
• Anticipated course

4
Anatomy

• Pediatric Airway Differences
• Larger tongue
• Large occiput
• Anterior larynx
• Larger epiglottis/floppier
• Subglottic area narrowest
• Less musculature
• Shorter trachea
• Narrower airway

5
Pediatric Pointers

• Broselow tape
• Avoid 2nd dose of sux
• infants/children exquisitely sensitive ?
  intractable brady/arrest
• Pierre Robin and Treacher Collins syndrome
• Small mandibles and posteriorly fixed tongues
• Down syndrome - large tongue

6
Four Types of Airways

• BVM
• Crash - intubate
• RSI the 8 Ps
• Difficult no paralytic, have a backup

7
8 Steps to a Successful RSI

• RSI 8 ps
• Preparation
• Peruse
• Preoxygenate
• Pretreatment
• Paralysis
• Protection
• Placement
• Post intubation management

8
Basic Airway Management - 8 PsPrepare SIGMA
D

• What do you need for intubation?
• SIGMA D
• S Suction
• I Intravenous
• G Gas
• M Mask/Bag
• A airway equipment (oral airway, laryngoscope,
  tubes, alternative)
• D Drugs

9
Peruse - LEMON LAW

• L Look face, neck, chest
• E Examine mouth, thyromental, floor of mouth
  to thyroid
• M Mallampatti huge tongue?, back of throat?
• O Obstruction tumor, epiglottitis
• N Neck mobility OA, RA, syndromic

10
LEMON - Look

• Look
• Evaluate the pt.
• Obesity
• Micrognathia
• High arched palate
• Narrow face
• Short or thick neck
• Neck trauma
• Large tongue
• Presence of facial hair
• Dentures
• Large teeth

11
LEMON Evaluate 3-3-2

• Evaluate 3-3-2
• Evaluate the anatomy
• 3 fingerbreadths of mouth opening
• 3 fingerbreadths between front of chin and hyoid
• 2 fingerbreadths from mandible to thyroid
  cartilage
• CAN I DISPLACE TISSUE SUB-MENTALLY?

12
LEMON Mallampati score

• Mallampati score
• Grade 1 entire post. Pharynx, visualized to
  tonsillar pillars
• No difficulty
• Grade 2 hard palate, soft palate and top of
  uvula only
• No difficulty
• Grade 3 hard and soft palate only
• Moderate difficulty
• Grade 4 no visualization post pharynx or uvula
  (hard palate only
• Severe difficulty

13
LEMON -Obstruction

• Obstruction
• Look for upper and lower airway obstruction
• foreign body aspiration
• Epiglottitis
• croup
• Abscesses
• others surgery,tumors, radiation

14
LEMON Neck Mobility

• Neck Mobility
• Collar, RA, degenerative arthritis, history of
  surgery
• Note get significant movement with BVM
  ventilation also!!

15
Pre-oxygenate - no bagging

• Preoxygenate (nitrogen washout)
• Saturate O2 reservoir, tissues and blood
• 100 NRB (70)
• 5 min healthy adult
• 2.5 min children
• 8 VC breaths

16
How much time do I have?

• 70kg adult maintains O2 sat gt90 for 8 min
• From 90 - 0 lt 120 seconds
• Obese adult (gt120kg) desaturate to 0 in less
  than 3 min
• 10kg child desaturate lt90 in 4 min
• From 90 to 0 in 45 seconds

17

• Walls graph

18
Pre- medicate - LOAD

• Lidocaine tight heads, tight lungs
• Opioid for blunting sympathetic response (ICP,
  IOP, aortic dissection, aneurysm, IHD)
• Atropine children lt 10
• Defasiculate for increased ICP

19
Lidocaine ?

• Premise
• Laryngoscopy and Intubation
• afferent stim. in post pharynx/ larynx
• increased central stim
• increased ICP
• stim of autonomic system
• increased HR / BP
• upper and lower resp. tract leading to increased
  airway resistance

20
Lidocaine ?

• Literature (supports)
• suppresses cough reflex
• attenuates increase in airway resistance (from
  ET tube irritation)
• prevents increased ICP
• prevents increased IOP
• decreases dysrhythmias by 30-40

21
Lidocaine ?

• Literature (?doesnt support)
• use to attenuate sympathetic response to
  laryngoscopy
• Use tight lungs / tight brains
• 1.5mg/kg 3 min prior
• Topical 4 lidocaine and ICP ????

22
Drugs to Decrease Sympathetic Response to
Intubation (LOAD)

• Fentanyl
• high dose 5-10 ug/kg (will unequivocally block
  sympathetic response - hypotension, apnea , chest
  wall rigidity)
• 1.5-3ug/kg (2 min prior) blocks increase BP but
  no effect on HR
• Beta-blockers
• will decrease sympathetic response
• prob neg ionotrope, bronchoconstriction

23
Drugs to Decrease Sympathetic Response to
Intubation

• Helfman et al
• compared 200 lido, 200 fentanyl, 150 esmolol
• esmolol only reliably agent in preventing rise in
  HR and BP
• Chung et al
• combination esmolol and fentanyl (2ug/kg and
  2mg/kg) best combo with limited side-effects

24
LOAD - Atropine

• Use with SUX in children under the age of 8 and
  when giving repeat doses
• Sinus brady, junctional, sinus arrest usually
  after a second dose
• Reason Sch mimicks action of Ach at the cardic
  muscarinic receptors
• Dose 0.02mg/kg (no less than 0.1mg), 3 min prior
  to induction

25
LOAD - Atropine

• Literature
• Prevents brady in children
• Reduces BUT doesnt eliminate them in infants
• No effect on older children
• Anesthesia literature volatile anesthetics in
  combination with atropine - increased risk of
  arrhythmias
• Bottomline Use atropine on children in the ED

26
Defasiculation

• Decrease the rise in ICP from Sch induced
  fasciculation (animal data, limited human)
• Does not attenuate the sympathetic response to
  intubation
• Does not attenuate the increase in airway
  resistance with intubation
• 1/10 intubating dose

27
RSI in Adults With Elevated Intracranial
Pressure A Survey of EmergencyMedicine
Residency Programs

• Am J Emerg Med 1995
• 100 programs surveyed
• 67 responses, 65 used RSI in their programs!!!
• Top NMB agents Sux and vecuronium
• Top induction agents - midazolam and thiopental
• Lidocaine - was routine
• Fentanyl - other pretreatment agent
• Defasciculating dose used by most programs

28
Paralysis with induction

• Rapid sequence - intubation before aspiration
• Do not titrate
• Midazolam, ketamine or thiopental
• Succinylcholine

29
Case

• A 6 year old has been seizing for 30 minutes and
  you have a vial of etomidate in your hand -
  should you use it?

30
Etomidate

• Ultrashort acting non-barbiturate hypnotic agent
  (no analgesic effects)
• Adv
• rapid onset and rapid recovery
• hemodynamic stability
• minimal resp depression
• cerebral protection
• Induction Dose 0.3 mg/kg

31
Etomidate

• Onset one arm-brain circulation (within 1 min)
• Duration 3-5 min
• Cerebral
• decreases CBF by 35 - decr ICP
• no change MAP
• CPP increases (increased cerebral oxygen/demand
  ratio) - decr ICP

32
Etomidate

• Resp
• minimal effects
• doesnt release histamine
• CV
• no change in HR/ MAP/ CI/ PAWP
• Endocrine
• concern re steroid depression

33
Etomidate

• Dose dependant reversible inhibition of 11-beta-
  hydroxylase (converts 11-deoxycortisol to
  cortisol)
• Studies
• transient drop in cortisol levels with induction
  of anesthesia (6hrs), back to normal in 20 hrs
• no reported adverse outcomes

34
Etomidate

• CI lt 10, known seizure disorder, pregnant
• Adverse effects
• nausea and vomiting (30-40)
• pain on injection (similar to propofol)
• myoclonic movement
• Pregnancy category C
• embryocidal in rats

35
Case

• A brittle asthmatic comes in obtunded and has a
  silent chest - you needed to intubate him
  yesterday?
• What inductionagent shall you use?

36
Ketamine

• Phencyclidine derivative (similar to Angel Dust)
• Dissociative anesthetic (dissociation between the
  thalmus and limbic system)
• Sympathomimetic (increased HR and BP)
• Increases cerebral blood flow by 60 potentially
  elevating ICP!
• Reduces airway resistance
• Dose 1-2mg/kg IV, 4-5mg/kg IM
• Onset within 60s

37
Case

• Head injured, hemodynamically stable 34 year old.
  Needs to be intubated what will you pre-medicate
  with and what is currently your induction agent
  of choice?

38
Thiopental

• Barbituate, potentiates GABA
• Cerebroprotective
• Dose related potent venodilator and myocardial
  and resp depressant
• Adult 1-4 mg/kg, child 1- 6 mg/kg
• Onset 15 - 30 secs, duration 3- 5 min
• Do not use in hypotension

39
Case

• One hour ago a zoo keeper was welding in the
  elephant cage when the elephant panicked, sat on
  him, and they were both burnt severely. The
  patient has been crushed, paralyzed, head
  injured, has an open globe injury, but manages to
  squeak out that he had a stroke 4 days ago. You
  cannot get an IV - can you use succinylcholine?

40
Succinylcholine CI

• History of MH
• Burns gt 24 hrs old until healed
• Muscle damage (crush) gt 7 days - completely
  healed
• Spinal cord injury, stroke (denervation UMN, LMN)
  gt 7 days - 6 months
• Neuromuscular disease, myopathies indefinately
  as long as disease is active
• Intra-abdominal sepsis gt 7 days - resolution of
  infection

41
Succinylcholine

• Depolarizing NM agent
• Onset 30-45s
• Duration 5-10 min
• Dosage (IV)
• 1-1.5mg/kg adult
• 2mg/kg child
• 3mg/kg neonate
• Can give IM at twice the dose

42
Succinylcholine

• Side-effects?
• Incr IOP, ICP
• Bradycardia
• Trismus-masseter muscle spasm
• Fasciculations
• Malignant Hyperthermia
• Hyperkalemia
• Prolonged blockade

43
Sux - Hyperkalemia

• Literature
• Case reports since 1960s
• No case reports of hyperkalemia in the ED
  (multiple trauma, burns, neurological disease)
• Literature poor with chronic renal failure
• Zink et al
• 100 pts (no risk factors)
• Max increase 1.0 meq/L (K increased in 46pts,
  dropped in 46 pts and unchanged in 8)
• 1 pt found to be in a wheelchair!, K dropped from
  4.6 to 4.1

44
Sux - Hyperkalemia

• Mechanism ? Increased receptor density
  (extra-junctional), more sensitive, depolarize
  for long periods, release of K
• ? Increased K of approx 0.5 meq/L
• Risk factors/guidelines
• Burn victims gt24hrs to 1-2 yrs post healing?
• Crush injuries gt7 days post lasting up to 60-90
  days
• Spinal cord injury/ stroke (denervation injury)
  gt7 days to 6 months
• Neuromuscular disorders (MS, ALS) indefinitely

45
Sux - Hyperkalemia

• Conclusion
• Non high risk pts
• No problems with administration
• High risk pts
• CRF probably okay
• Others literature is not great but we have good
  NDNM blockers, therefore no point to take risk

46
Sux Raised IOP

• Thought to be a contraindication to an open globe
  injury!
• Pressure elevations do occur, are transient,
  maximal for 2-4 min post administration
• Pressure elevations of 3-8mmHg (never been shown
  to worsen globe injury
• Comparison normal blink increases IOP by
  10-15mmHg, forceful closure of the eyelid gt70
  mmHg
• Anesthesia continues to use Sux in OR with globe
  injuries
• Chiu et al
• if you want to prevent increase in IOP, can give
  defasciculating dose of a NDNM blocker
  (rocuronium 2 min pre RSI)

47
Case

• During the G8 summit a cocaine addict comes in
  SLUDGING. Is it safe to use succinylcholine?

48
Sux Prolonged blockade

• Pseudocholinesterase Deficiency
• Congenital
• Heterozygous up to 25 min, homozygous up to 5
  hrs after a single dose
• Homozygous 1 in 3000 pts
• Acquired
• Organophosphate poisoning
• Cocaine use
• CRF, severe liver disease, hypothyroidism,malnutri
  tion, pregnancy, cytotoxic drugs, metoclopramide,
  bambuturol(long acting beta 2 anonist)
• Note above none have prolonged blockade over
  20-25 min

49
Sux Trismus/Masseter muscle Spasm

• Occasionally can get spasm
• Especially in children
• Transient
• If prolonged, severe and other muscle involved
  should think of MH

50
Malignant Hyperthermia

• Genetic skeletal muscle membrane abnormality -
  never been an ED case reported
• Onset acute or delayed - 60 mortality
• Clinically
• Muscle rigidity
• Autonomic instability
• Hypoxia
• Hypotension
• Hyperkalemia
• Lactic acidosis
• Temp. elevation is a late sign

51
Case

• You need a paralytic, however the patient was
  severely burnt 48 hours ago ago. You can see the
  epiglottis but you need just a little more
  relaxation - what would be your paralytic of
  choice?

52
Rocuronium

• Aminosteroid, non-depolarizing neuromuscular
  blocker
• Agent of choice when sux is CI
• Onset 1.2-1.8 min (sux 0.8-1.2)
• Dose 0.6 mg/kg
• Duration of action 30 -45min

53
Rocuronium

• Cannot depend on neostigmine in failed intubation
  - time to recovery will be too long
• Histamine related hypotension
• Primary use of non-depolarizing agents is for
  defasiculation and paralytic maintenance
  post-intubation
• Rapacuronium1.5 mg/kg, onset 60 sec, neostigmine
  could reverse from 24min duration to 11min looked
  ideal, however.

54
Rapacuronium

• HOLD THE PRESSES!!!
• March 27, 2001
• Injectable Anesthesia Drug Being Withdrawn From
  The Market
• Bronchospasm in 3.4
• 5 case reports of death (? severe bronchospasm)
• Other drugs also given
• Voluntary withdrawal by the company pending
  investigation

55
Paralytics (table)
Agent Class Dose(mg/kg) Onset Duration
Vecuronium Intem. 0.1 3-5 30-45
Atracurium Intem. 0.5 3-5 30-45
Pancuronium Long 0.1 3-5 60-90
Rocuronium Intem. 0.6 1-2 30-45
Mivacurium Short 0.15 2.5-4 10-20
Rapacuronium Short 1.5 1-2 10-15
56
Case

• You are ready to intubate the RT is screaming in
  your ear to push all the meds and get the
  !_at_ tube in. The RT is bagging the patient
  and the nurses have drawn up the appropriate
  medications for this head injured,
  hemodynamically stable patient - what is your
  timeline to intubate?

57
Timing

• 10 minutes out
• Prepare (SIGMA D) Peruse (LEMON)
• 5 minutes out Pre-oxygenate
• 3 minutes out Pre-treat (LOAD)
• Zero Paralysis with induction
• Zero 30 sec Pressure and position
• Zero 45 sec Pass tube - jaw flaccidity
• Zero 1 minute Post-tube mngmt

58
RSI Sequence
59
Case

• As you go to intubate a child, you get a
  beautiful view of the cords and then it
  disappears. You cannot seem to direct the RT to
  give the right amount of BURP to get the same
  view. What can you do?

60
Pressure and position

• Sellicks maneuver BURP
• Sniffing position - cervical extension and
  atlanto-occipital flexion

61
BURP

• The Efficacy of the "BURP" Maneuver During a
  Difficult Laryngoscopy. Takahata O Anesth Analg
  - 1997 Feb 84(2) 419-21

The difficult intubation. The value of BURP and
3 predictive tests of difficult intubation
Ulrich B - Anaesthesist - 1998 Jan 47(1) 45-50
62
Case

• You have somewhat blindly intubated a cardiac
  arrest patient. You are quite confident it went
  in. However, the end tidal CO2 monitor is not
  registering wave form. By all other measures the
  tube appears in - should you yank it?

63
Pass tube with proof

• Thru cords
• Misting
• ETCO2
• Chest rising and falling
• Esophageal detector

64
Basic Airway ManagementPositioning
65
Pass tube with proof

• Position of Tube During Intubation

66
End Tidal CO2

• Qualitative
• Colorimetric
• When color change (yellow yes) virtually 100
  specific
• False negative with cardiac arrest
• Quantitative
• Capnography
• Measures amount of CO2 in the expired air (direct
  indicator of CO2 elimination by the lungs)
• Again false negative with cardiac arrest

67
Esophageal Detection Devices (EDD)

• Premise
• Esophagus will collapse with suction
• Trachea rigid structure with lots of air (no
  collapse
• Not as reliable as end tidal CO2 therfore should
  be used as a 2nd line device to confirm tube
  placement

68
Bulb Aspiration

• Turkey baster
• Round compressible ball
• Deflate the bulb and attach to end of ETT
• Esophagus delayed or sluggish inflation
• Trachea expands rapidly (within 2 seconds)

69
Syringe Technique

• Same principle
• Use larger volume of air
• Withdraws 30 cc of air
• Use rapid aspiration os syringe

70
Case

• You have successfully intubated a Cormack-
  Lehane grade IV airway while telling the trauma
  team about a 67 foot putt you drained at McCall
  Lake. As you are doing your end-zone dance the
  patient grabs for his tube. The nurse screams
  Dr. Hotshot - what would you like for
  maintenance of sedation and paralysis?

71
Post-intubation

• Use a one third therapeutic dose of benzo and
  non-depolarizing paralytic when any signs of
  patient awareness detected
• Appropriate vent settings PEEP, rate, volume
• Post-intubation bradycardia is an esophageal
  intubation until absolutely proven otherwise.

72
Case

• You have successfully intubated a child. Sixty
  seconds later the child becomes hypotensive.
  What could be the cause?

73
Postintubation Hypotension

• Tension pneumothorax
• Incr PIP, difficulty bagging, decr B/S, poor sats
• Rx Chest tube
• Induction agents
• Exclude other causes
• Rx Fluid bolus, expectant

74
Postintubation Hypotension

• Decreased venous return
• High PIPS secondary to high intrathoracic
  pressure
• Rx Fluid bolus, bronchodilator, incr exp time,
  decr tidal volume and rate
• Cardiogenic
• Usually in compromised patient EKG exclude
  other causes
• Rx cautious fluid bolus. pressors

75
Post-tube complication

• A patient becomes hypoxemic 2 minutes after you
  intubate him. What is your differential?

76
Post-intubation Hypoxia

• D Dislodged
• O Obstruction
• P PTX
• E Equipment failure

77
Mr. Pierre Robin

• Your called to a 2 year old child who is flat,
  mom says he has been unwell for a few days. She
  found him unresponsive. You note he has a tiny
  mandible and a large tongue. How are you going
  to prepare for this airway?

78
Difficult Airway

• Emergency Physicians
• National Emergency Airway Registry
• 6294 intubations
• 85 successful on first attempt
• 99 ultimately successful
• 1 failed airway requiring rescue maneuvers

79
Difficult Airway

• Sakles Jc et al Ann Emergency Med 1998
• Intubations over 1 yr in their ED (N610)
• 569 (93)by staff/residents
• 515(84) used RSI
• 98.9 intubated successfully

80
Difficult Airway

• Paralytics and Aeromedical Transport
• Program A (RSI) success rate 93.5
• Program B (no RSI) 66.7
• Same program after institution if RSI
• Success 90.5

81
Difficult Airway BARF

• B(5) Best view, Best person, Bougie, Blade
  change, BURP manueuver
• Alternative airway LMA, lighted stylet
• Rescue BMV with BURP
• Failed airway TTJV if lt8 years old, crich if gt8

82
Best View

• Cormack-Lehane laryngoscopy grading system
• Grade 1 2 low failure rates
• Grade 3 4 high failure rates

83
Blade Change

• Macintosh (curved)
• McCoy articulating tip
• Miller (straight)
• Use with children younger than 8y/o, and people
  with anterior larynx (short mental- hyoid
  distance)
• Wisconsin and Guedel blades
• Larger more rounded barrel

84
Blade Change

• Laryngoscopy and Intubation
• the single greatest obstacle to successful
  intubation is the tongue the tongue is the
  enemy
• Paraglossal technique
• Step 1 (blind) insert blade blindly into the
  esophagus
• Step 2 (visual) withdraw blade until you
  visualize the cords /epiglottis

85
Alternative Airway technique

• LMA
• Orotracheal or nasotracheal
• Lighted stylet
• Digital
• Retrograde
• Fibreoptic

86
Alternative Airway - Laryngeal Mask

• Does not constitute definitive airway management
• Temporizing measure in the ED
• Size
• 3 teenagers and small female adults
• 4 average size adult
• 5 large adults

87
Alternative Airway-Laryngeal Mask

• Inflate cuff
• 3 20cc
• 4 30cc
• 5 40cc
• Or until no leak
• Note no literature describing the
• success rate in the ED(OR success gt95)

88
Alternative Airway - LMA

• Zideman D - Ann Emerg Med - 01-Apr-2001 37(4
  Suppl) S126-36
• Not studied in infant/child resuscitation
• Complications more frequent in peds
• Correct size
• 1 smallest 3-4 adult female 4-5 adult
  male
• May be dislodged during transport/CPR
• Aspiration little protection

89
Alternative Airway - Combitube

• Double lumen, double cuff airway
• Insert in the midline
• Inflate proximal large oropharyngeal balloon
  ( 100mls of air) via blue pilot balloon
• Inflate white distal balloon with 5-15mls air
• Ventilate first through the long blue port if
  air in lungs the tube in the esophagus (majority
  of time in esophagus)
• If air in stomach then tube in the trachea (rare
  event) then ventilate through the short clear
  port

90
Alternative Airway - Combitube

• Effective airway management device
• Higher success rate than LMA in the prehospital
  setting
• High rate of success and few complications when
  used for prehospital cardiac arrest

91
Alternative Airway Nasotracheal Intubation

• Advantages
• Very few over RSI
• Disadvantages
• Takes a long time
• Higher failure rate
• Higher complication rate
• Use smaller tube size

92
Alternative Airway Nasotracheal Intubation

• Indication
• A potentially difficult intubation who is
  spontaneously breathing - epiglottitis
• Pt you do not want to paralyze
• Contraindicated
• Combative pts
• Anatomically deranged airway
• Neck hematomas
• Raised ICP
• Severe facial trauma
• Coagulopathy

93
Alternative Airway Nasotracheal Intubation

• Pearls
• Sniffing position
• Pull tongue forward by grasping with gauze
• Only 60-70 successful on first attempt (10-20
  of NTIs are simply not possible

94
Alternative Airway Lighted Stylet

• Use if cannot directly visualize the larynx with
  laryngoscopy
• Relies on transillumination of the soft tissues
  of the neck
• Trachea well defined glow
• Esophagus diffuse light glow

95
Alternative Airway Lighted Stylet

• Success rates consistent with or exceed that of
  conventional laryngoscopy

96
Alternative Airway Digital Intubation

• Tactile intubation technique
• Use of fingers to direct the tube into the larynx
• Not easy to perform (if have small hands)
• Indications
• No laryngoscopy equipment
• Visualization of the larynx is impossible (blood,
  secretions)
• Best for premature and newborn infants

97
Rescue Airway

• BVM with BURP
• BONES - predicts difficult mask ventilation
• B Beard
• O Obese
• N No teeth
• E Elderly (gt55 y/o)
• S Snores

98
Failed Airway

• Surgical
• Needle crich TTJV, cricothyrotomy, retrograde
  intubation
• Difficult crich SHORT
• S Surgery
• H Hematoma
• O Obese
• R Radiation
• T Tumor

99
Failed Airway

• Cricothyroidodomy not recomm. age lt8
• complication rate 10-40
• Retrograde?
• Transtracheal jet ventilation
• surgical method of choice in emergency
• allows ventilation for 45-60 mins
• risk aspiration, subcutaneous emphysema,
  barotrauma, bleeding, catheter dislodgment, CO2
  retention

100
Failed Airway Retrograde Intubation

• Puncture the cricothyroid membrane then thread a
  wire retrograde to the mouth, the tube is then
  inserted over the wire
• Use as rescue technique
• Do not use if infection at the site of the needle
  puncture
• Note does take time to do

101
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102
Failed Airway Surgical Airway

• Cricothyrotomy
• NEAR Study
• Only 1 of 4000 Ed intubations required cric.
• 20 complication rate (mostly minor)
• 4 step process
• Pediatrics age gt8 y/o
• 4 Shiley cuffed tube
• Needle cricothyrotomy (age lt8)

103
Failed Airway Surgical Airway

• Needle cricothyrotomy/ TTJV
• Temporizing measure
• Surgical airway of choice for age lt8 y/o
• Need supraglottic patency (exhalation)
• No airway protection

104
Failed Airway Surgical Airway

• Needle cricothyrotomy/ TTJV
• 12-16G needle
• lt5 y/o ventilation only by bag
• 5-12 y/o 30 psi
• 12 adult 30-50 psi

105
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106
Case

• A lucid, perfectly well 20 year old has been hit
  in the throat with a 67 foot putt. He is
  stridorous and sats are fine. He has a large
  hematoma externally. He is slowly getting worse.
  How would you like to intubate him?

107
Awake intubation

• Lidocaine spray
• 4 lidocaine on pledgets
• Titrated dose of midazolam and fentanyl
• Take a look - can turn into a formal RSI

108
Thanks

• Idan Khan MD, FRCPS
• Gord McNeil MD, FRCPS