Emergent Airway Management

2013

Agenda:Agenda:Agenda:Agenda:

• Airway Anatomy Adult vs. Pediatric• Review of basic equipment• Approach to the Difficult Airway• RSI• Post-Intubation Management• Ventilator Settings• The Crashing Asthmatic

• Airway Anatomy Adult vs. Pediatric• Review of basic equipment• Approach to the Difficult Airway• RSI• Post-Intubation Management• Ventilator Settings• The Crashing Asthmatic

Important take home points

The search for the epiglottis

Are kids Are kids just just small small adults?adults?

Are kids Are kids just just small small adults?adults?

• ExternallyExternally– Larger head/occiput– Head flexes forward and can obstruct

• InternallyInternally– Intra-oral tongue – Large, floppy epiglottis

• ExternallyExternally– Larger head/occiput– Head flexes forward and can obstruct

• InternallyInternally– Intra-oral tongue – Large, floppy epiglottis

• Further differences– “Pinker” vocal cords worsen visualization

– Different location of narrowest point• Peds cuffed tubes?

– Smaller cricothyroid membrane• No surgical crics in children

• Further differences– “Pinker” vocal cords worsen visualization

– Different location of narrowest point• Peds cuffed tubes?

– Smaller cricothyroid membrane• No surgical crics in children

Other ConsiderationsOther Considerations

•More gastric insufflation with BVM

•Quicker desats during intubation Different• 10 kg will drop to 90% in <4 minutes (vs. 8 for adult)

•Vagal response (not significant)• Consider Pre-treatment with Atropine (though not literature supported and not the standard of care)

•More gastric insufflation with BVM

•Quicker desats during intubation Different• 10 kg will drop to 90% in <4 minutes (vs. 8 for adult)

•Vagal response (not significant)• Consider Pre-treatment with Atropine (though not literature supported and not the standard of care)

10% 10%

80%

Hypoxia and Hypercarbia

Bradycardia

Self ConfidentIf he can, you can

Avoid the “cookie-cutter” approach to every airway you encounter.

Be familiar with your equipment…

What tools do I have ?

Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment

• Oxygen and Suction

• BVM / OPA / NPA

• ETT / Bougie / LMA / King LT

• Stylet

• Magill forceps

• End-tidal CO2 monitoring and securing devices

• Surgical Airway Devices

• Oxygen and Suction

• BVM / OPA / NPA

• ETT / Bougie / LMA / King LT

• Stylet

• Magill forceps

• End-tidal CO2 monitoring and securing devices

• Surgical Airway Devices

Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment

Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment

C-E technique is WRONG

CE

Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment

Use the Two Thumbs Downtechnique

Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment

Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment

OPA NPA

King LT

Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment

Endotracheal tube

stylet

Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment

Eschmann Stylet, a.k.a “Gum elastic bougie”

Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment

MAGILL FORCEPS

LMA

Airway EquipmentAirway EquipmentAirway EquipmentAirway EquipmentLMA – Laryngeal Mask Airway

Are extraglottic airways harmful in cardiac arrest ?

Airway EquipmentAirway EquipmentAirway EquipmentAirway Equipment

“Yellow” = YES

“Purple” = Pathologic

Airway Equipment:Airway Equipment:Airway Equipment:Airway Equipment:

• What equipment do we have in our departments?

• Where is it located?

• What equipment do we have in our departments?

• Where is it located?

Broselow TapeThe

• Can’t Protect Airway

• Can’t Maintain Ventilation / Oxygenation

• Expected Decline in Clinical Status

3 Emergent Indications for Intubation

Gag reflex is absent in up to 37% of population, and is a poor predictor of airway protection

•Can they talk?

•Can they swallow and manage secretions?

Can’t Protect Airway

• SaO2 <90% on High Flow O2 or PaO2<60 on FiO2>40%

• PaCO2 >55 if baseline is normal, or >10 increase from baseline

• Respiratory Rate

Can’t Maintain Ventilation or Oxygenation

• Deterioration/Impending Compromise Transport

• Airway protection during procedures (ie. endoscopy)

Expected Decline in Clinical Status

DEFINITIONSDEFINITIONSDEFINITIONSDEFINITIONS

Rapid Sequence Intubation (RSI)

INDUCTION AGENT

PARALYTIC

UNCONSCIOUSNESS

MOTOR PARALYSIS

DEFINITIONSDEFINITIONSDEFINITIONSDEFINITIONS

Delayed Sequence Intubation (DSI)

DSI consists of the administration of

specific sedative agents, which do not

blunt spontaneous ventilations or airway

reflexes; followed by a period of

preoxygenation before the

administration of a paralytic agent.

CONTRAINDICATIONSCONTRAINDICATIONSCONTRAINDICATIONSCONTRAINDICATIONS

INDICATIONINDICATION

RISKRISK

RSI RATIONALERSI RATIONALERSI RATIONALERSI RATIONALE

Increasedsuccess

Decreasedaspiration

BetterC-spinecontrol

RATIONALE - SecondaryRATIONALE - Secondary

Blunting ↑ in ICP / IOP

RATIONALE - SecondaryRATIONALE - Secondary

Avoid airway trauma

RATIONALE - SecondaryRATIONALE - Secondary

Avoid Avoid airway airway traumatrauma

RATIONALE - SecondaryRATIONALE - Secondary

↓ ↓ PainPain↓ ↓ Discomfort Discomfort ↓ ↓ RecallRecall

Adverse Drug Events

HAZARDSHAZARDS

May force crash airway scenario

HAZARDSHAZARDS

The 7 “P’s”of RSIThe 7 “P’s”of RSIThe 7 “P’s”of RSIThe 7 “P’s”of RSI

PPREPARATION

PPREOXYGENATION

PPRETREATMENT

PPARALYSIS WITH INDUCTION

PPROTECTION AND POSITIONING

PPLACEMENT AND PROOF

PPOST-INTUBATION MANAGEMENT

PPREPARATION

PPREOXYGENATION

PPRETREATMENT

PPARALYSIS WITH INDUCTION

PPROTECTION AND POSITIONING

PPLACEMENT AND PROOF

PPOST-INTUBATION MANAGEMENT

TIME ZEROTIME ZERO

t – 10 minutes

t + 90 seconds

PREPARATIONPREPARATIONt – 10 minutest – 10 minutes

PREPARATIONPREPARATIONt – 10 minutest – 10 minutes

1. EQUIPMENT PRESENT AND WORKING

INCLUDING EQUIPMENT

FOR PLAN “B”

1. EQUIPMENT PRESENT AND WORKING

INCLUDING EQUIPMENT

FOR PLAN “B”

PREPARATIONPREPARATIONt – 10 minutest – 10 minutes

PREPARATIONPREPARATIONt – 10 minutest – 10 minutes

2. Ask yourself: CAN I…

BAGBAG THE PATIENT

TUBETUBE THE PATIENT

CRICCRIC THE PATIENT

2. Ask yourself: CAN I…

BAGBAG THE PATIENT

TUBETUBE THE PATIENT

CRICCRIC THE PATIENT

““Evaluate for signs of Evaluate for signs of a difficult intubationa difficult intubation””

-Obesity-Obesity--

LLook at the general anatomyEEvaluate the 3-3-2 ruleMMallampati scoreOObstructionNNeck mobilitySaturation Reserve

LLook at the general anatomyEEvaluate the 3-3-2 ruleMMallampati scoreOObstructionNNeck mobilitySaturation Reserve

CAN I TUBETUBE THIS PATIENT?

Look at the general anatomyLook at the general anatomy

Evaluate the 3-3-2 rule

Mallampati score

Obstruction

Neck mobility

Saturation Reserve

Saturation Reserve

At 92% the patient’s oxygen saturation falls off a cliff….

CAN I CAN I BAGBAG THIS PATIENT? THIS PATIENT?

Maybe. Maybe Not.

Approximate normal ventilation rates:

• 10 bpm Adult

• 20 bpm Child

• 25 bpm Infant

Approximate normal ventilation rates:

• 10 bpm Adult

• 20 bpm Child

• 25 bpm Infant

VENTILATE (BLS)

Squeeze.....Release - Release

Keep Dentures in when using a BVM

CAN I CAN I CRICCRIC THIS PATIENT?THIS PATIENT?

IndicationsIndications

• ObstructionObstruction

• Facial TraumaFacial Trauma

• Intubation or other Intubation or other alternatives impossiblealternatives impossible

• Trismus (clenching)Trismus (clenching)

• > 8 years old > 8 years old

(for open procedures) (for open procedures)

SURGICAL AIRWAYS

LAST RESORT!LAST RESORT!

DEFense Readiness CONdition

Maximum readiness

Armed Forces ready to deploy and engage in less than 6 hours

Air Force ready to mobilize in 15 minutes

Above normal readiness

Discuss / Feel / See Kit

Mark / Kit Bedside

Inject / Prep / Open & Set KitScalpel in Hand

Perform Cric

Open CricothyrotomyOpen CricothyrotomyOpen CricothyrotomyOpen Cricothyrotomy

1.1. Vertical Incision over membraneVertical Incision over membrane2.2. Pierce membrane in horizontal planePierce membrane in horizontal plane3.3. Open and spread to insert 4.0 or 5.0 Open and spread to insert 4.0 or 5.0

tubetube4.4. Secure tube in place and ventilateSecure tube in place and ventilate

1.1. Vertical Incision over membraneVertical Incision over membrane2.2. Pierce membrane in horizontal planePierce membrane in horizontal plane3.3. Open and spread to insert 4.0 or 5.0 Open and spread to insert 4.0 or 5.0

tubetube4.4. Secure tube in place and ventilateSecure tube in place and ventilate

Open CricothyrotomyOpen CricothyrotomyOpen CricothyrotomyOpen Cricothyrotomy

PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes

PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes

1. “First, do not bag!”

2.Avoid “Sellick’s”

maneuver (cricoid pressure)

1. “First, do not bag!”

2.Avoid “Sellick’s”

maneuver (cricoid pressure)

PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes

PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes

1. Well-fitting mask

2. 8 vital capacity breaths

1. Well-fitting mask

2. 8 vital capacity breaths

PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes

PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes

PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes

PREOXYGENATIONPREOXYGENATIONt – t – 55 minutes minutes

NIV CPAP for Pre-Oxygenation

Summary of Summary of LOADLOADPRETREATMENTPRETREATMENT

Summary of Summary of LOADLOADPRETREATMENTPRETREATMENT

LL idocaine optional

OO piates optional

AA tropine for infants consider for kids < 8

DD efasciculating optional dose

LL idocaine optional

OO piates optional

AA tropine for infants consider for kids < 8

DD efasciculating optional dose

DEFASCICULATING DOSEDEFASCICULATING DOSE1/10 1/10 th th the RSI dosethe RSI dose

DEFASCICULATING DOSEDEFASCICULATING DOSE1/10 1/10 th th the RSI dosethe RSI dose

Traditional Indications

1. Blunt rise in ICP

2. Decrease risk of aspiration

3. Prevent muscular pain

Traditional Indications

1. Blunt rise in ICP

2. Decrease risk of aspiration

3. Prevent muscular pain

PRETREATMENTPRETREATMENTt – 3 minutest – 3 minutes

PRETREATMENTPRETREATMENTt – 3 minutest – 3 minutes

If you’re going to give these drugs:

…at least give them some time to circulate (3 minutes)

If you’re going to give these drugs:

…at least give them some time to circulate (3 minutes)

PARALYSIS WITH PARALYSIS WITH INDUCTIONINDUCTION

Time Time ““00””

PARALYSIS WITH PARALYSIS WITH INDUCTIONINDUCTION

Time Time ““00””INDUCTION AGENTS

EtomidateEtomidate

Ketamine

Propafol

Midazolam

INDUCTION AGENTS

EtomidateEtomidate

Ketamine

Propafol

Midazolam

PARALYTIC AGENTS

DEPOLARIZINGDEPOLARIZING

Succinylcholine

NON-DEPOLARIZINGNON-DEPOLARIZING

Vecuronium Rocuronium

PARALYTIC AGENTS

DEPOLARIZINGDEPOLARIZING

Succinylcholine

NON-DEPOLARIZINGNON-DEPOLARIZING

Vecuronium Rocuronium

+

PARALYSIS WITH PARALYSIS WITH INDUCTIONINDUCTION

Time Time ““00””

PARALYSIS WITH PARALYSIS WITH INDUCTIONINDUCTION

Time Time ““00””

Sedation then Paralysis

PARALYSIS WITH PARALYSIS WITH INDUCTIONINDUCTION

Time Time ““00””

PARALYSIS WITH PARALYSIS WITH INDUCTIONINDUCTION

Time Time ““00””

Use of Apneic oxygenation

EtomidateEtomidateEtomidateEtomidate

– Rapid onset/offset

– Minimal hemodynamic and respiratory effects

– Pediatrics – not approved for patients under 10

– Rapid onset/offset

– Minimal hemodynamic and respiratory effects

– Pediatrics – not approved for patients under 10

SuccinylcholineSuccinylcholineSuccinylcholineSuccinylcholine

• When: Immediately after Etomidate

• Onset: Rapid, usually 30-90 secs

• Duration: Short acting, 3-5 mins

• When: Immediately after Etomidate

• Onset: Rapid, usually 30-90 secs

• Duration: Short acting, 3-5 mins

When Sux Really When Sux Really ““SucksSucks””CONTRAINDICATIONSCONTRAINDICATIONS

When Sux Really When Sux Really ““SucksSucks””CONTRAINDICATIONSCONTRAINDICATIONS

1. HYPERKALEMIAHYPERKALEMIARENAL FAILURERHABDOMYOLYSIS

2. RECEPTOR UPREGULATIONRECEPTOR UPREGULATIONSUBACUTE BURNS (>1 day)SUBACUTE DENERVATING DISORDERHISTORY OF MALIGNANT HYPERTHERMIA

1. HYPERKALEMIAHYPERKALEMIARENAL FAILURERHABDOMYOLYSIS

2. RECEPTOR UPREGULATIONRECEPTOR UPREGULATIONSUBACUTE BURNS (>1 day)SUBACUTE DENERVATING DISORDERHISTORY OF MALIGNANT HYPERTHERMIA

SUX IS STILL KINGSUX IS STILL KINGSUX IS STILL KINGSUX IS STILL KING

SUXSUX versusversus ROCROCSUXSUX versusversus ROCROC

45 seconds ONSET 1 minute

9 minutes DURATION 45 minutes

45 seconds ONSET 1 minute

9 minutes DURATION 45 minutes

1 mg/kg1-1.5 mg/kg

PROTECTION AND POSITIONINGPROTECTION AND POSITIONING t + 20 secondst + 20 seconds

PROTECTION AND POSITIONINGPROTECTION AND POSITIONING t + 20 secondst + 20 seconds

May NOT be helpful

Positioning:Positioning:MedicalMedicalvs.vs.TraumaTrauma

Positioning:Positioning:MedicalMedicalvs.vs.TraumaTrauma

C Spine PrecautionsC Spine Precautions

C Spine PrecautionsC Spine Precautions

Positioning Adult vs PediPositioning Adult vs PediPositioning Adult vs PediPositioning Adult vs Pedi

Cormack & Lehane GradingCormack & Lehane GradingCormack & Lehane GradingCormack & Lehane Grading

SweepSweep LeftLeft

and and

LookLook

Orotracheal Intubation ProcedureOrotracheal Intubation Procedure

AdultAdult vs vs PediPedi AdultAdult vs vs PediPedi

Normal TracheaNormal Trachea

PLACEMENT AND PROOFPLACEMENT AND PROOF t + 45 secondst + 45 seconds

PLACEMENT AND PROOFPLACEMENT AND PROOF t + 45 secondst + 45 seconds

POST-INTUBATION POST-INTUBATION MANAGEMENT MANAGEMENT t + 90 secondst + 90 seconds

POST-INTUBATION POST-INTUBATION MANAGEMENT MANAGEMENT t + 90 secondst + 90 seconds

More to come next month……….More to come next month……….

POST-INTUBATION MANAGEMENTPOST-INTUBATION MANAGEMENT t + 90 secondst + 90 seconds

POST-INTUBATION MANAGEMENTPOST-INTUBATION MANAGEMENT t + 90 secondst + 90 seconds

CONFIRM PLACEMENT

&SECURE

TUBE

CONFIRM PLACEMENT

&SECURE

TUBE

Capnography

Post-intubation CXR

INTUBATION HURTS!INTUBATION HURTS!INTUBATION HURTS!INTUBATION HURTS!And it keeps on hurting once the tube is in…And it keeps on hurting once the tube is in…

POST-INTUBATION MANAGEMENTPOST-INTUBATION MANAGEMENT

Achieve Adequate Analgesia and Sedation

POST-INTUBATION MANAGEMENTPOST-INTUBATION MANAGEMENT

Raise the Head of the Bed to at Least 30°

Confirm Lung Protective Vent Settings

POST-INTUBATION MANAGEMENTPOST-INTUBATION MANAGEMENT

• Mode AC• VT 6-8 cc/kg• Rate 12-16• PEEP 5• FiO2 100% then titrate down

Standard Ventilator Settings

POST-INTUBATION MANAGEMENTPOST-INTUBATION MANAGEMENT

Continuous waveform ETCO2

NG / OG tubeEmpty the stomach to reduce the chances of aspiration and to improve lung mechanics

POST-INTUBATION MANAGEMENTPOST-INTUBATION MANAGEMENT

Nebulizers/MDIIf they were intubated for reactive airway disease, then they need frequent nebs

Acute Deterioration Acute Deterioration after Intubationafter IntubationAcute Deterioration Acute Deterioration after Intubationafter Intubation

D.O.P.E.SD.O.P.E.S: :

DDisplacementisplacement

OObstructionbstruction

PPneumothoraxneumothorax

EEquipment failurequipment failure

SStacked Breathstacked Breaths

Basics of Ventilator Management

Lung Injury Obstructive Lung Disease

Use as Default

Basics of Ventilator Management

Lung Injury

Lung Protective Management

1. Mode: use A/C (assist control)

Basics of Ventilator Management

Vt IFR

FiO2

PEEP

RR

Basics of Ventilator Management

VtTidal Volume

6-8 cc/kg IBW

Basics of Ventilator Management

IFRInspiratory Flow Rate

= how quickly the breath is delivered

60-80 LPM

Basics of Ventilator Management

RRRespiratory Rate

16-18 BPM

RR = Ventilation

Basics of Ventilator Management

FiO2

PEEP

1. Start @ 100%2. Wait 5 min3. Get ABG4. Drop to 40%

FiO2

Goal: Saturation of 88-95%

Basics of Ventilator Management

FiO2

PEEPStart with 5

Positive End-Expiratory Pressure - PEEP

Basics of Ventilator Management

FiO2

PEEP

FiO2 + PEEP =Oxygenation

Inspiratory Plateau Pressure_________________________________________________

PeakPlateauPlateau Pressure

< 30 cmH2O

Must find and hold Inspiratory Hold buttonVentilator will then display Plateau Pressure

Basics of Ventilator Management

Vt IFR

FiO2

PEEP

RR

Basics of Ventilator Management

Analgesia 1stSedation 2nd

The Crashing AsthmaticThe Crashing Asthmatic

Crashing Asthmatic

SweatyCan’t TalkTachypneicTripoding

Maximal O2 (NRB)Inhaled AlbuterolInhaled AtroventIV SteroidsIV MagnesiumSC TerbutalineEpinephrine drip

Crashing Asthmatic

THE KITCHEN SINK – Maximal Rx

Crashing Asthmatic

BiPAPCPAP

NON-INVASIVE VENTILATION

Too EarlyToo EarlyToo LateToo Late

Crashing Asthmatic

WHEN TO INTUBATE

Crashing Asthmatic

EtomidateSuccinylcholine

GO FAST!GO FAST!

EtomidateSuccinylcholine

GO FAST!GO FAST!

LidocaineKetamineLidocaineKetamine

KEEP IT SIMPLE! OPTIONS...

HOW TO INTUBATEHOW TO INTUBATE

Crashing Asthmatic

Use a Big ETT AGGRESSIVE TOILET

Reason #1 Reason #1 Mucous PlugsMucous Plugs

Crashing AsthmaticCrashing Asthmatic

Reason #2 Reason #2 DehydrationDehydration

IV FLUID BOLUS

Reason #3 Reason #3 Breath StackingBreath Stacking

Crashing AsthmaticCrashing Asthmatic

Squeeze ChestSqueeze Chest Low Vent SettingsLow Vent Settings

Crashing AsthmaticCrashing Asthmatic

Chest TubesChest Tubes

Reason #4Reason #4BarotraumaBarotrauma

Cardiac Arrest Post-IntubationCardiac Arrest Post-Intubation

11 Disconnect ventilatorDisconnect ventilator 22 Squeeze chest Squeeze chest 33 Bilateral chest tubes Bilateral chest tubes 44 Fluid bolus Fluid bolus

11 Disconnect ventilatorDisconnect ventilator 22 Squeeze chest Squeeze chest 33 Bilateral chest tubes Bilateral chest tubes 44 Fluid bolus Fluid bolus

SummarySummary

Crashing AsthmaticCrashing Asthmatic Last Chance………Last Chance………

Anesthetic Gases

ECMO

Extracorporeal Membrane Oxygenation (ECMO)

Pearls

• Can’t see the cords -

…try BURP

• Another attempt needed – …change something

Call for Call for helphelp ! !

Have a backup plan– “Prior planning prevents poor performance”

Have a backup plan– “Prior planning prevents poor performance”

Don’t panic!Don’t panic!

Thank you!Thank you!

Mark P. Brady PA-CDept.of Emergency MedicineCambridge Health AllianceCambridge, MA