Advanced Emergency Airway Management Core Rounds July 22, 2004 Rob Hall MD, PGY5 FRCPC Emergency Medicine Arun Abbi MD, FRCPC

Advanced Emergency Airway

Management Core Rounds July 22, 2004

Rob Hall MD, PGY5FRCPC Emergency Medicine

Arun Abbi MD, FRCPC

Outline• Some basics and motherhood statements• An approach to emergency airway

management• Minimal literature review• Procedures are not the focus• Case examples

– Approach– Focus on difficult airways– Selected Controversies– Pediatric airway mx

Case

• picture

MVC vs Trailer, two reds, one needs intubationHow do you prepare?

Intubation = flight:preflight, flight, post-flight

Pilot picture

APPROACH TO THE AIRWAY

T h ink o f an in tu ba tion like a p ilo t fly ing a p lan e !

P rep eq u ip m e nt (S O L E S D )P reo xyge na te

T h in k o f 4 b ack u p s! ! !!B a ck up e q u ip m en t ne arby

P R E FL IG H T

T u be 'e m D an no

F L IG H T

C h e ck p la ce m e ntC X R

S ed atio n + /- p a ra lys isT x h ypo ten sio n , hyp ox ia

P O S T -F L IG H T

C on s id e r the fo llow in g a pp roa ch toE D a irw ay m a na g em en t.

Part of being prepared is knowing your equipment

Know your equipment

Pre-oxgenation is an important step in preparation for intubation

• Desat curve

APPROACH TO THE AIRWAY

D oes th e p a tien t n eed to b e in tu b a ted ? A B C D E s

C ard iac a rres tA p n e ic

N ear d ea th

C R A S H A IR W A Y

N ot a c rash a irw ayN o an tic ip a ted d ifficu lty

E A S Y A IR W A Y

D ifficu lt an a tom yD ifficu lt p a th o log y

D IF F IC U L T A IR W A Y

Q u ck ly eva lu a te th e s itu a tion an d th e p a tien t?W h at typ e o f a irw ay?

Cases

• 2yo drowning, PEA arrest– What type of airway?– Any drugs?

• 77yo female, MVC, as you are assessing, GCS drops, BP 60 palp, HR 40, teeth a bit clenched– What type of airway?– Any drugs?

THE CRASH AIRWAY

G o to fa iled a irw ay a lg orith m

R ep eat a ttem p ts (u p to 3 )A d d su cc in ylch o lin e p rn

TIM E(can b ag , sa ts ok )


N O TIM E(can 't b ag , sa ts d rop p in g )

U n su ccess fu l

JU S T D O IT !D irec t la ryn g oscop y w ith n o d ru g s

Case: Motorbike vs Car

• 45yo male, Motorbike vs car• Hemodynamically stable: BP 175/50, HR

70, face ok• GCS 6 (E1V1M4)• Bilateral decorticate posturing• Anatomy looks normal• What type of airway?• What drugs would you use?

THE “EASY” AIRWAY


R ep eat a ttem p ts (u p to 3 )



N O TIM E(can 't b ag , sa ts d rop p in g )

U n su ccess fu l

R A P ID S E Q U E N C E IN TU B A TIO NP rep are , p reoxy, p re trea t, in d u c tion , p a ra lys is ,

p ass th e tu b e , ch eck p lacem en t

Case: Motorbike vs Car

• Pretreatment– Lidocaine– Fentanyl– ? Defasiculator

• Induction– Etomodate or

Pentothal

• Paralytic– Succ

• How does lidocaine work?

• What is the evidence for lidocaine?

• When should we use lidocaine?

• Why use fentanyl here?

• Is there any role for defasiculation?

Lidocaine Pretreatment

• How does it work?

– Laryngoscopy ------------ increased ICP via direct reflex from laryngoscopy stimulation

– Laryngoscopy ------------- sympathetic release which increases MAP and ICP

– May also decrease brain’s oxygen utilization

Blocks the direct reflex which increasesICP

“Local” anesthetic Effect which decreasesThe response to laryngoscopy


• How does it work?

– Laryngoscopy ------------ stimulation of “airway reflexes” which increases bronchoconstriction +/- secretions

“Local” anesthetic effect which decreasesthe airway response to laryngoscopy

Lidocaine pretreatment: what is the evidence?

• Evidence for “tight heads”– Vallancourt C. CJEM. Mar 2002. 4(2).– Systematic review of lidocaine and ICP– 348 studies, 25 RCTs included– Only one paper regarding intubation – 3 papers regarding tracheal suctioning– 24 papers looking at MAP changes with

lidocaine


• Vallancourt C. CJEM. Mar 2002. 4(2)– Bedford 1980 looked at intubations

• N=20, elective brain tumor surgery• Lidocaine 1.5 mg/kg decreased ICP rise with

intubation by 12 mmHg vs placebo

– 3 Suctioning papers: decr ICP by 5 mmHg– 24 MAP papers: decrease MAP by average

of 7 mmHg with lidocaine 1-3 mg/kg

Lidocaine Pretreatment• Summary

– CPP = MAP – ICP– Lidocaine decrease MAP and ICP– What happens to CPP is unknown– Neurologic outcomes not studied

• Take home points– We really don’t know if lidocaine is effective– Most people currently are using lidocaine for

head injuries and some are using in asthma/copd– Don’t waste time with lidocaine if the patient

needs rapid airway control

Case: Motorbike vs car; head trauma, normotensive

• Why fentanyl pretreatment?• Is there any role for

defasciculation?• What is the induction agent of

choice for hypotensive, head injured patients?

Fentanyl Pretreatment

• When is it indicated?– Elevated ICP– Anyone where you don’t want and increase

in HR and BP (cerebral aneurysm or AVM, aortic dissection, active ischemic heart dz, penetrating vascular injury)

• What is the evidence?– Many studies documenting the blunting of

sympathetic response to laryngoscopy and intubation but no outcome studies

Pretreatment: defasiculation

• What? 1/10 the intubation dose of rocuronium, vecuronium, pancuronium

• Why?– Prevents fasciculations from increasing your

ICP and intraocular pressure

• Is this necessary?– Debatable: no evidence for– Reasons why NOT to do this

• Adds another step, another drug• May cause apnea, paralysis at wrong time

Pretreatment Medications Summary

MED INDICATIONS

L Lidocaine Tight headsTight lungs

O Opiate Tight headsAnyone where you don’t want incr HR/BP (Ao dissection, MI, SAH, etc)

A Atropine Kids < 10 yo (some say 6yo)Second dose of succinylcholine

F Fluids HypotensionAnyone where you expect decr BP

D Defasiculator

Tight heads (controversial)Tight eyes (controversial)

Induction agents in hypotensive + head injured• Midazolam: NO• Propofol: NO• Ketamine

– Debatable: likely will increase MAP and ICP– Most think ketamine is contraindicated with high

ICP (limited evidence)

• Pentothal: generally NO, could use at ½ the dose (1-2 mg/kg vs 3-5 mg/kg)

• Etomodate– Drug of choice – Decrease the dose from 0.3 to 0.15 mg/kg

Case: Addy is sick

• 40 yo female• Known Addison’s• Abdo pain +

hypovolemic + septic + ARDS

• BP 85/50, HR 130• Anatomy easy

• What type of airway?

• What drugs?• ? Etomidate for

induction• You give

etomidate and she has a seizure, why?

Etomidate: will become the drug of choice for RSI!• Hemodynamically stable

– Average decrease in SBP is 10%– Average decrease in SBP is 20% if already

hypotensive– CAN DROP YOUR BP!!: decrease dose from

0.3 mg/kg to 0.15 mg/kg if concerned re hypotension

• Decreases ICP• Very rapid onset (20-30sec): some give

after succ

Etomidate

• Side-effects– N/V at emergence in 30%– Adrenal suppression: decreases serum

cortisol, only reported with ICU infusions, never reported after single ED dose

– Myoclonus• ? Brain stem disinhibition• Commonly mistaken for seizure• 30% incidence quoted (? Reporting bias)• Treat with benzo if prolonged/severe

Etomidate

• Contraindications– P Pregnant– P Pediatrics < 10 yo– P Prior seizures– P Poor adrenal function

Case: globe rupture

• 30yo female• Facial smash• Suspect globe

rupture• Is

succinylcholine contraindicated?

• On the exam, maybe!• In real life, NO!

– IOP increases 5-10 mmHg with succ

– IOP increases 10-15 mmHg with blinking

– Think what rough intubation will do!

– Airway control more important– What to do?

• Defasiculation can prevent increase in IOP with succ

• Rocuronium is an option

Contraindications to Succ• Absolute

– Airway skills lacking

– Allergy– Burn > 48hrs– Crush > 48hrs– CNS dz > 48hrs– CRF with

hyperkalemia– Malignant

hyperthermia– Myopathies

• Relative– Pseudocholinesterase

deficiency– Organophosphate

toxic– Foreign body in

airway– Cardiac tamponade– Globe rupture

(debatable)– Abdo sepsis > 1 week

Succ and hyperkalemia• Study of normal patients

– 46% with K+ increase– 46% with K+ decrease– 8% with no change– Max change was 1 mEq/L

• Myopathies are the worst!• Don’t forget about rhabdomyolysis• If in doubt, use rocuronium• Arrest after succ, think hyperkalemia

Case: Aspirator• 75yo female• CVA 3 months ago• Dysphagic• Aspiration, resp

failure, BP 150/70• Anatomy easy• Easy airway

approach• Can’t use

succinylcholine

• What is the timing principle?

Timing Principle

• If you are using rocuronium as the paralytic, it has a longer time to action (1-2 min) than the induction agent– Give rocuronium– Wait 30 – 45 seconds– Give etomidate– Wait 30 seconds– Intubate

Case: I hate myself.

• 25yo female• Benzo, Etoh overdose• GCS 8, BP 120/70, anatomy easy• Type of airway?• Do you need to add an induction

agent to your RSI?

Is an induction agent necessary if you are paralyzing a patient?

• Controversial, no absolute right/wrong• Advantages of adding full induction

– Improved patient comfort and decreased recall

– Blunts rise in ICP, HR, BP, airway resistance– Decreases time to ideal intubation conditions

• Peak effect of succ doesn’t occur until 3 min (despite onset at 45 sec) when given alone

• You don’t want the pt to be apneic for 3 minutes and you don’t want to bag in between unless you have to

• Several studies documenting that IDEAL INTUBATION CONDITIONS are present 45-60 seconds after induction agent + succinylcholine

Case: Pneumonia, oops!

• 80yo female• Resp failure from

pneumonia, Pmhx hypertension and seizures

• HR 110, BP 110/30, easy anatomy


• What drugs?• After intubation

her BP is 80/40, HR 110– What is the ddx?– Why hypotensive?– What is the

treatment?

Post-intubation Hypotension

• Tension pneumo, Myocardial ischemia, Acidosis, high intrathoracic pressures are all on the differential dx

• Volume depletion– Common in anyone with respiratory or critical

illness that necessitates intubation

• Sympathetic tone– Anyone that is critically ill has a maximal

sympathetic output; deep induction takes away the stimulus ----------- end result is that they drop their pressure

– Treat with fluids, pressors (be prepared!)

Case: head to pavement

• 3 yo male• Fall off deck, head

to pavement• GCS 5• Bagged by EMS• RSI by you

• After intubation, patient desaturates and is difficult to bag. AE equal.– Why?– Differential?– Management?

Post intubation Hypoxia• D Dislodged tube (must r/o)• O Obstructed tube• P Pneumothorax• E Equipment failure (wall to

pt)• G Gastric distension

more common in kid, ++ gastric distension leads to compression of the

lungs

Case: I can’t breath

• 16yo female• Hx asthma• Sudden SOB, wheezing, distress• RR30, tired, sats 93%, BP 140,

anatomy easy• Type of airway?• Drugs?

Intubation of the Asthmatic• Pretreatment

– Lidocaine 1.5 mg/kg decreases bronchospastic response to laryngoscopy

– Atropine 0.5 mg adult, 0.02 mg/kg peds to decrease airway secretions

• Induction – Ketamine likely induction agent of choice– Pretreat with atropine to decrease secretions

• Paralysis– Succinylcholine

Post Intubation Management of the Asthmatic

LOW AND SLOW!!!!

RR 8-10 bpm, TV 6-8 ml/kg, Fi02 100%, PEEP ????, Inspiratory flow rate 100 L/min (usually 60 L/min)Watch peak inspiratory and plateau pressures

Case: Fast Food Nation

• I’m dead-sexy! • SOB NYD• Resp failure• What type of

airway?• What drugs?• What position?• What back ups?

DIFFICULT AIRWAY ALGORITHM

Is th e p a tien t easy to b ag ? D o a "B V M tria l"

B lin d N TI

P rexoyg en ationL id oca in e n eb /sp rayL ig h t sed a tion p rn

A w ake In tu b a tion o rS ed ation on ly

L id oca in e n eb /sp rayL ig h t sed a tion an d take a look

R S I d ru g s read yC ric k it read y

"Trip le S e t u p ""Q u ick L ook "

U n ab le to m a in ta in sa ts a t 9 0 % ....G o to F a iled A irw ay A lg orith m

Call for help, Difficult airway cart

Positioning of the Morbidly obese

• Picture 1 • Picture 2

Intubation of the Morbidly Obese

• Be READY for a difficult airway• Starting with RSI is DANGEROUS!• Triple set up probably the best

– Lidocaine neb, lidocaine spray, have RSI drugs ready, have all your back ups ready, do laryngoscopy, place the tube if you can

• Why else is this a SCARY patient?

Predictors of difficult BVM

• B Beards• O Obesity, OSA• N Neck trauma, NO teeth• E Expectant (pregnant)• S Snores

Be cautious with your RSI as your back-up of BVM may not be available!

DIFFICULT INTUBATION + DIFFICULT BAG-VALVE-MASK VENTILATION

• Facial trauma• Neck trauma• Massive obesity• Congenital or acquired airway

anatomy anomalies

Wear your “Depends”

adamAdam

Difficult Emergency Airway Managment

• NEAR data (National Emergency Airway Registry)– Registry of 10,000 ED intubations– 97% of ED intubations are done by EP.s– RSI used in 85% of non-arrested pts– BNTI used in 5% of all intubations– 1-3% are difficult laryngoscopies– Oral ETT after RSI successful in 99.6%

Back to the Fast Food Nation…

You do your “awake” laryngoscopy and all you can see is a hint of the epiglottis, what do you do??????

What to do when you can’t see S…

B B.U.R.P.

B Bouigee

B Big hockey stick on stylet

B Blade change

B “Better” physician

B Back ups

Case: Face vs Baseball bat

• 30yo male• Assaulted• Head injured,

facial smash, airway bloody, GCS 10, BP150

• “Underlying anatomy” looks ok


• What type of preparation?

• What drugs?• How do things

change is he is combative?

Intubation with severe facial trauma• Can you bag the patient? • Oral intubation with RSI is usually

successful but is a bit dangerous• Safest approach is likely “Triple Setup”

– Local, draw RSI drugs, prep back ups, perform laryngoscopy, tube if you can or back off and do RSI if it isn’t too bad

• What would your back ups be?– Bouigee, Trach light, LMA– BNTI contraindicated with severe facial

trauma

Case: I can’t breath• CHF, hypertensive,

needs intubation• Drugs?• Several induction

agents can be used– Ketamine (pretreat

with atropine)– Etomidate– Fentanyl/midazolam

• CHF + Cardiogenic shock• Drugs?• Pretreatment

– Fluid bolus– Have pressor ready or

already going

• Induction agents limited– Etomidate (full or ½ dose)– Ketamine– No induction agent

Controversies with Intubation of the CHF patient

• Should you do an “awake” intubation– Advantages: less problems with hypotension

from RSI drugs– Disadvantages: intubation is more difficult

and takes longer; they don’t tolerate hypoxia during prolonged attempts very well

– Recommendations:• RSI if anatomy looks easy• Awake if anatomy looks difficult

Controversies with Intubation of the CHF patient

• Should you leave the patient sitting– Advantages: avoids the large venous return

with lying them down– Disadvantages: most people are less familiar

with intubation in the sitting position and intubation may take longer

– Recommendations:• Leave sitting if you are good at it• Otherwise, leave sitting initially, push RSI drugs,

wait for full paralysis, lie down quickly and place the tube

I can’t breath!

Granny arrests just as you do the laryngoscopy……..

Why?

Bradyasystolic arrests after intubation of the CHF patient• Why?

– Large venous return as you lie them down– Vagal response to laryngoscopy and/or

succinylcholine (patient already has maximal sympathetic tone and adrenals are “dry”)

– Induction agent crashes their pressure– The patient was already dying

• Take home points– Likely a combination of all of the above– Be ready for the patient to crash

• Crash cart attached, fluid bolus, pressor ready, atropine ready

Other difficult airways• Airway Burns• Anaphylaxis• Angioedema• Neck trauma

– Blunt– Penetrating

• Oral infections• Airway foreign

bodies

• Is Immediate transfer to OR available?

• Is fiberoptic intubation in the ED available?

• Key points for ED management– Approach as difficult airways– Call for back up and set up for

surgical airway– Start with an “awake” intubation:

RSI is an option if you look and see that the airway isn’t too bad

Case: Head vs stairs• 30 yo male, fell down

15 stairs, intoxicated, vomited after, GCS 6, failed intubation by medics, LMA inserted

• LMA in place, Sats 88%, AE equal, BP 150/70, prominent incisors, small chin, anterior larynx


• What drugs?• Grade 4

laryngoscopy with blood and vomit in the airway. Management?

Case: Head vs stairs

• Oral intubation attempts fail X 2 despite B.U.R.P. and blade change

• Blind insertion of a gum elastic bouigee failed


• What is the key question now?

• Management?

THE FAILED AIRWAY ALGORITHM

R etrog rad eF ib erop tic

I-L M AB N TI, com b itu b e

B ou ig eeTrach lig h t

L M A


R escu e L M A

S u rg ica l A irw ayA d u lts = c ric o r TTJV

P ed s = TTJV

N O TIM E(can 't b ag , sa ts d rop p in g ,

p a tien t c rash in g )

"C a ll fo r everyth in g "-d ifficu lt A W cart

-an es th es ia , 2 n d E P- c ric k it + /- su rg eon

Th e F A IL E D A IR W A Y =U n ab le to m a in ta in sa ts > 9 0 % w ith B V M

3 fa iled in tu b a tion a ttem p ts

Case

• 2 yo drowning• Full arrest• Is this a difficult airway?

Children are different not difficult (generally)!

Head Large occiput

Oropharynx

Large tongue, large tonsils, large adenoids, large and floppy epiglottis, sharp angle b/w epiglottis and glottis,

Neck Anterior larynx, higher tracheal opening, cricoid ring is the narrowest part of the airway, small cricothyroid membrane, soft and flexible neck tissue, good neck mobility

General More anatomic variation between agesLess anatomic variation between kids of the same ageFewer changes in airway with body habitus

Other Higher metabolic rates, lower FRCs, quicker desaturation, higher tidal volumes

Pediatric PEARLS

• Intubation tricks– Inch down slowly: don’t go deep and

then pull back – Provide your own B.U.R.P.– Beware that cricoid pressure from an

assistant can really move the airway– Place an NG before: decompresses

the stomach, makes it easier to back, may help you place the tube

Pediatric PEARLS

• EDD– Slow expansion is not a reliable

indicator of esophageal intubaion in small kids because the trachea is too collapsible

• Bouigee– The smallest tube it will fit through is

a #5

Proper BVM in pediatrics:C-E position, lift the jaw to the mask, light pressure so you don’t occlude the airway, minor position changes important, properly sized equipment

• WRONG! • RIGHT! C E

What is the dose of midazolam in a 2 week old

neonate?

Braslow is your FRIEND in Exams and in Real life

Pediatric Equipment, etc

• Tube size Braslow (age/4 +4)• Blade size Braslow

– Premie 0– 0-2 1– 2-10 2– >10 3

• Cuffed Braslow (>8yo)• Tube depth Braslow (ETT size X

3)

Cuffed tubes in pediatrics is controversial

• Several recent studies questioning the dogma that cuffed tubes are not used < 8yo

• Cuffed tubes– High ventilation pressures: asthma,

ARDS, post drowning

What is unique about RSI in pediatrics?

• Pretreatment– Atropine < 10yo, < 6 yo ???– Preoxygenation important as they will

desaturate quicker– Defasiculation generally not used

• Paralytic– Remember that succ dose is higher

• Infants/Children 2 mg/kg, neonates 3 mg/kg

– Should rocuronium be used routinely in pediatric RSI?

Succinylcholine versus Rocuronium for pediatric RSI

• Succinylcholine– Faster onset (45

seconds)– Shorter duration

(8 minutes)– Risk of

hyperkalemia (especially with undiagnosed myopathies)

• Rocuronium– Slower onset (1-2)

min– Longer duration

(30-40 min, may decrease to 20 with reversal)

– No hyperkalemia risk

Positioning in pediatrics

Case: “sore throat”, needs amoxil

• 4yo male• Sore throat today• Febrile, no cough• Looks sick,

anxious• Tripod position• Drooling,

stridorous

• Type of airway?• Management now?• Management after

he completely obstructs?

• ? OR management or ER management of the airway

DIFFICULT PEDIATRIC AIRWAY ALGORITHM

Is th e p a tien t easy to b ag ? D o a "B V M tria l"

B lin d N TI

P rexoyg en ationL id oca in e n eb /sp rayL ig h t sed a tion p rn

A w ake In tu b a tion o rS ed ation on ly

L id oca in e n eb /sp rayL ig h t sed a tion an d take a look

R S I d ru g s read yC ric k it read y

"Trip le S e t u p ""Q u ick L ook "

U n ab le to m a in ta in sa ts a t 9 0 % ....G o to F a iled A irw ay A lg orith m

Call for help, Difficult airway cart

Use the same approach to the difficult airway; BNTI is generally considered contraindicated in kids < 10yo

THE FAILED PEDIATRIC AIRWAY ALGORITHM

O th er ad ju n c ts n o tcom m on ly u sed in p ed s

(I-L M A , trach lig h t,fib e rop tics )

B V M an d w a it fo r h e lpL M A

B ou ig ee if E TT > # 5


R escu e L M A

S u rg ica l A irw ay> 1 0 yo = c ric o r TTJV

< 1 0 yo = TTJV

N O TIM E(can 't b ag , sa ts d rop p in g ,

p a tien t c rash in g )

"C a ll fo r everyth in g "-d ifficu lt A W cart

-an es th es ia , 2 n d E P- c ric k it + /- su rg eon

Th e F A IL E D A IR W A Y =U n ab le to m a in ta in sa ts > 9 0 % w ith B V M

3 fa iled in tu b a tion a ttem p ts

Should Paramedics intubate kids?

• Gausche. JAMA Feb 2000; 283(6): 783-90– RCT of BVM vs ETT in pediatrics– N = 830– Trends toward worse survival and

neurological outcome in kids in ETT group– Critique: low rates of intubation, even/odd

day randomization, short transport times– Take home: bag and drive unless long

transport time

TAKE HOME MESSAGES

• Preparation is key• Prepare for the worst• Have a solid approach to the crash,

easy, difficult and especially the FAILED AIRWAY

• Kids are different, not difficult

The End…

Documents

Advanced Emergency Airway Management Core Rounds July 22, 2004 Rob Hall MD, PGY5 FRCPC Emergency Medicine Arun Abbi MD, FRCPC