Advanced Emergency Airway Management

1
Advanced Emergency Airway Management

• RSI
• Techniques for the Difficult or Failed Airway

2
Dilemmas

• Intubate Awake or Asleep
• Oral or Nasal
• Laryngoscopy or Blind Intubation
• To Paralyze or Not

3
Techniques

• DL without pharmacologic aids
• Awake Direct Laryngoscopy
• Awake Blind Nasal
• Rapid Sequence Intubation (RSI)
• Fiberoptic
• Surgical Cricothyroidotomy

4
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

5
Oral Intubation Without Drugs

• Reserved for the completely unconscious,
  unresponsive, and apneic
• Arrest situations only

6
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

7
Oral Intubation with Sedation

• In general, the technique of administering a
  potent sedative agent to obtund the patients
  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

8
Oral Intubation with SedationUse for the
Anticipated Difficult Airway

• if time permits
• topical anesthesia
• careful titrated sedation
• avoid obtundation
• Awake intubation technique

9
Emergency Airway Concerns

• full stomach
• minimal respiratory reserve
• hemodynamic instability
• acute myocardial ischemia
• increased intracranial pressure
• The Difficult Airway
• Laryngoscopy
• bag-mask difficulty

10
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

11
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

12
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

13
Rapid Sequence Intubation Contraindications

• Anticipated difficulty with endotracheal
  intubation
• anatomic distortion
• Lack of operator skill or familiarity
• inability to preoxygenate

14
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

15
Rapid Sequence Intubation Procedure

• Pre-intubation assessment
• Pre-oxygenate
• Prepare ( for the worst )
• Premedicate
• Paralyze
• Pressure on cricoid
• Place the tube
• Post intubation assessment

16
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

17
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

18
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

19
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

20
Pressure

• Sellick maneuver
• initiate upon loss of consciousness
• continue until ETT balloon inflation
• release if active vomiting

21
Place the Tube (
Time Zero 45 Secs )

• Wait for optimal paralysis
• Confirm tube placement with ETCO2

22
Post-intubation Hypotension

• Loss of sympathetic drive
• Myocardial infarction
• Tension pneumothorax
• Auto-peep

23
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

24
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

25
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
  

26
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