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4/5/2019
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Airway Management in STEMI, Stroke, and Trauma Patients:
Interventions, Timing, and Outcomes
Joshua Stilley, MD FACEP FAAEM
Assistant Professor of Clinical Emergency Medicine
Chief, Division of EMS
Medical Director, Prehospital Services
University of Missouri
Conflicts of Interest & Disclosures
• None
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Objectives
If
Why
When
How
• STEMI
• Stroke
• Trauma
• Cardiac Arrest
• Sepsis
• Opioid Overdose
• Pediatrics
• Vascular catastrophe
• Gonadal torsion
• Ocular emergency
TCD +
TCD+
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http://c1.thejournal.ie/media/2013/06/passed-out-752x501.jpg
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"Controlled Airway"
Intubation Complications
• Inability to intubate
• Multiple attempts
• Mainstem
• Hypoxia
• Dental Trauma
• Damage to airway
• Aspiration
• Bronchospasm
• De-recruitment
https://litfl.com/adverse-effects-of-endotracheal-intubation/
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Physiologic effect of Intubation/PPV
• Pulmonary Changes– Decreased surfactant production– Unequal alveoli inflation– Stress and shear forces
• Decreased Cardiac Output– Decreased venous return– Reduced right ventricular output– Reduced left ventricular output
• Neuro Effects– Decreased venous return -> Increases Intracranial Pressure– Hippocampal Apoptosis
• Induced inflammation• Disordered sleep
N. Soni, P. Williams, Positive pressure ventilation: what is the real cost?, BJA: British Journal of Anaesthesia, Volume 101, Issue 4, October 2008, Pages 446–457, https://doi.org/10.1093/bja/aen240
https://www.uptodate.com/contents/physiologic-and-pathophysiologic-consequences-of-mechanical-ventilation
Clinical Outcomes - TBI
• Worse outcomes if:– Hypoxemia during intubation
– Hypotension during intubation
– Hypocapnia after intubation
• Post-injury apnea requiring ventilation support does not necessarily predict poor outcome.
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Predictors of Peri-Intubation Arrest
• SBP < 90 mm Hg prior to intubation
• Hypoxemia prior to intubation
• Absence of Preoxygenation
• BMI > 25 kg/m2
• Age > 75
De Jong et al. Cardiac Arrest and Mortality Related to Intubation Procedure in Critically Ill Adult Patients: A Multicenter Cohort Study. Critical Care Medicine. Issue: Volume 46(4), April 2018, p 532-539.
Predictors of Peri-Intubation Arrest
De Jong et al. Cardiac Arrest and Mortality Related to Intubation Procedure in Critically Ill Adult Patients: A Multicenter Cohort Study. Critical Care Medicine. Issue: Volume 46(4), April 2018, p 532-539.
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Trauma – Post-Intubation Hypotension
• Post-Intubation Hypotension Prevalence = 36.3%
• ED Mortality AOR 3.45
• In-hospital Mortality AOR, 1.83
Green, Robert S. MD; Butler, Michael B. MD; Erdogan, Mete PhD. Increased mortality in trauma patients who develop postintubation hypotension Journal of Trauma and Acute Care Surgery. October 2017 - Volume 83 - Issue 4 - p 569–574.
https://journals.lww.com/jtrauma/fulltext/2017/10000/Increased_mortality_in_trauma_patients_who_develop.1.aspx
Hyperoxia
• Supratherapeutic levels = >Increased mortality– Stroke, TBI, Cardiac Arrest
Elisa Damiani, Erica Adrario, Massimo Girardis, Rocco Romano, Paolo Pelaia, Mervyn Singer and Abele Donati. Arterial hyperoxia and mortality in critically ill patients: a systematic review and meta-analysis. Critical Care. 2014. 18:711. Elmer J, Scutella M, Pullalarevu R, et al. The association between hyperoxia and patient outcomes after cardiac arrest: analysis of a high-resolution database. Intensive Care Med. 2014;41(1):49-57.
Girardis M, Busani S, Damiani E, et al. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. JAMA. 2016;316(15):1583–1589. doi:10.1001/jama.2016.11993
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Airway Management in OOCHA
PART Airways-2 CAAMSettingComparisonPractitionersSample SizeRandomization
Primary Outcome
BVM-Only RatePrimary FindingImportant SecondaryFinding
Airway Management in OOCHA
PART Airways-2 CAAMSetting USAComparison LT v ETIPractitioners PM and EMTSample Size 3,000Randomization Cluster Randomized
by EMS AgencyPrimary Outcome 72-hour Survival
BVM-Only Rate ~12%Primary Finding LT > ETIImportant SecondaryFinding
LT fasterLow ETI Success Rate
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Airway Management in OOCHA
PART Airways-2 CAAMSetting USA UKComparison LT v ETI i-gel v ETIPractitioners PM and EMT PMSample Size 3,000 9296Randomization Cluster Randomized
by EMS AgencyCluster Randomized by Medic
Primary Outcome 72-hour Survival Hospital Survival with Fav Neuro Status
BVM-Only Rate ~12% ~18%Primary Finding LT > ETI No differenceImportant SecondaryFinding
LT fasterLow ETI Success Rate
i-gel > ETI
Airway Management in OOCHA
PART Airways-2 CAAMSetting USA UK France, BelgiumComparison LT v ETI i-gel v ETI BVM v ETIPractitioners PM and EMT PM PhysiciansSample Size 3,000 9296 2,043Randomization Cluster Randomized
by EMS AgencyCluster Randomized by Medic
Per Patient (Envelope)
Primary Outcome 72-hour Survival Hospital Survival with Fav Neuro Status
28-day survival with Fav Neuro Status
BVM-Only Rate ~12% ~18% N/APrimary Finding LT > ETI No difference InconclusiveImportant SecondaryFinding
LT fasterLow ETI Success Rate
i-gel > ETI BVM -> Poorer Ventilation,Higher Aspiration
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OOHCA: BVM v SGA v ETI
• BVM v ETI: Equivalent
• BVM v ETI: BVM
• BVM v SGA: BVM
Jabre P, Penaloza A, Pinero D, et al. Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial. JAMA. 2018;319(8):779-787. https://www.ncbi.nlm.nih.gov/pubmed/29486039
Hasegawa K, Hiraide A, Chang Y, Brown DFM. Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest. JAMA.2013;309(3):257–266. doi:10.1001/jama.2012.187612
OOHCA
• BVM v Advanced Airway– 649,359 patients
• 57% BVM
• 6% ETI
• 37% SGA
• Favors Intubation
Hasegawa K, Hiraide A, Chang Y, Brown DFM. Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest. JAMA. 2013;309(3):257–266. doi:10.1001/jama.2012.187612
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OOHCA
• BVM v Advanced Airway– 649,359 patients
• 57% BVM
• 6% ETI
• 37% SGA
– Multivariable logistic regression, • AAM OR 0.38 (95% CI, 0.37-0.40)
– Adjusting for age, sex, etiology of arrest, first documented rhythm, witnessed status, type of bystander cardiopulmonary resuscitation, use of public access automated external defibrillator, epinephrine administration, and time intervals.
• Favors Advanced Airway
Hasegawa K, Hiraide A, Chang Y, Brown DFM. Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest. JAMA. 2013;309(3):257–266. doi:10.1001/jama.2012.187612
OOHCA
• ETI v SGA (Meta-Analysis)– Favors ETI
– ROSC, survive to hospital admission, and survive neurologically intact
Justin L. Benoit, Ryan B. Gerecht, Michael T. Steuerwald, Jason T. McMullan. Endotracheal intubation versus supraglottic airway placement in out-of-hospital cardiac arrest: A meta-analysis. Resuscitation. Volume 93. 2015. Pages 20-26. https://www.ncbi.nlm.nih.gov/pubmed/26006743
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OOHCA
• SGA v ETI: Favors SGA
Wang HE, Schmicker RH, Daya MR, et al. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018;320(8):769–778. doi:10.1001/jama.2018.7044 https://www.ncbi.nlm.nih.gov/pubmed/30167699
OOHCA
• ETI v LMA RCT
Wang HE, Schmicker RH, Daya MR, et al. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018;320(8):769–778. doi:10.1001/jama.2018.7044 https://www.ncbi.nlm.nih.gov/pubmed/30167699
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OOHCA
• ETI v LMA RCT
Wang HE, Schmicker RH, Daya MR, et al. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018;320(8):769–778. doi:10.1001/jama.2018.7044 https://www.ncbi.nlm.nih.gov/pubmed/30167699
IHCA
• Intubation within 8.8 minutes favorable
Wang, Chih-Hung et al. The association between timing of tracheal intubation and outcomes of adult in-hospital cardiac arrest: A retrospective cohort study. Resuscitation. Volume 105:59-65 https://www.resuscitationjournal.com/article/S0300-9572(16)30075-2/abstract
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IHCA
• Intubation within 15 minutes associated with decreased survival.
Andersen LW, Granfeldt A, Callaway CW, et al. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA.2017;317(5):494–506. doi:10.1001/jama.2016.20165 https://jamanetwork.com/journals/jama/fullarticle/2598717
Goal => Airway/Ventilation/Oxygenation
http://clccharter.org/mk/MKMedSchool/medschool/systems/system%20research/respiratory/respfacts.htm
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Alternatives
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Robert Matthew Bramante, M.D., and Masha Rand, M.D.
N Engl J Med 2011; 365:e4July 14, 2011DOI: 10.1056/NEJMicm1014034
Mohan S, Varghese G, Kumar S, Subramanian DP. Penetrating facial injury by a wooden log. Natl J Maxillofac Surg [serial online] 2014 [cited 2017 Nov 4];5:228-31. Available from: http://www.njms.in/text.asp?2014/5/2/228/154844
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Mohan S, Varghese G, Kumar S, Subramanian DP. Penetrating facial injury by a wooden log. Natl J Maxillofac Surg [serial online] 2014 [cited 2017 Nov 4];5:228-31. Available from: http://www.njms.in/text.asp?2014/5/2/228/154844
Mohan S, Varghese G, Kumar S, Subramanian DP. Penetrating facial injury by a wooden log. Natl J Maxillofac Surg [serial online] 2014 [cited 2017 Nov 4];5:228-31. Available from: http://www.njms.in/text.asp?2014/5/2/228/154844
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https://prod-images.static.radiopaedia.org/images/46858215/b7ff25d568a49d356be3b47d1beec0_jumbo.jpeg
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Agitated Patient
• Pre-existing or caused by condition
• TBI and Cerebral Hypoxia -> AMS including agitation
• Ketamine to facilitate airway management
George Kovacs MD, MHPE, FRCPC and Nicholas Sowers MD, FRCPC. Airway Management in Trauma. Emergency Medicine Clinics of North America, 2018-02-01, Volume 36, Issue 1, Pages 61-84. https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0733862717300755.
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Old RSI
• GCS < 8 => Intubate
• Stop breathing => Intubate
• Might Vomit => Intubate
• "Look Sick" => Intubate
• Dead-ish => Intubate
New RSI
• Resuscitation Sequence Intubation
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Correct Hypotension
• Access
• Trauma => Blood
• Sepsis => Fluid
• Cardiogenic => Inotrope and/or pump
• All => Pressors
https://litfl.com/intubation-hypotension-and-shock/
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Avoid Hypotension
• Drug dose– ½ Sedative Dose
• Ketamine most stable
– 2 x Paralytic dose• Consider Rocuronium
http://rebelem.com/critical-care-updates-resuscitation-sequence-intubation-hypotension-kills-part-1-of-3/
Avoid Hypotension
• Pressors– Peripheral pressor infusion
– Push dose pressors• Phenylephrine
• Epinephrine
http://rebelem.com/critical-care-updates-resuscitation-sequence-intubation-hypotension-kills-part-1-of-3/
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Avoid Hypoxia
• Positioning– BUHE (Back Up Head Elevated)
• Nasal Cannula– Preoxygenation
– Apneic Oxygenation
• PPV– BVM
– BiPAP
Avoid Hypotension
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Positioning
Positioning
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Positioning
Positioning
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Positioning
Positioning
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Preoxygenation
• NRB @15 + NC @ 15
• BVM @ 15 + PEEP @ 5 + NC @ 15
• NRB @ 40
• BiPAP + NC @ 15
http://rebelem.com/critical-care-updates-resuscitation-sequence-intubation-hypoxemia-kills-part-2-of-3/
BVM During Apneic Period
Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. N Engl J Med 2019; 380:811-821DOI: 10.1056/NEJMoa1812405 https://www.nejm.org/doi/full/10.1056/NEJMoa1812405?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed
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• https://twitter.com/i/status/1113140745613926402
BVM Technique
• Higher Tidal Volume with 2 handed technique
Aaron M. Joffe, D.O.; Scott Hetzel, M.S.; Elaine C. Liew, M.D. A Two-handed Jaw-thrust Technique Is Superior to the One-handed “EC-clamp” Technique for Mask Ventilation in the Apneic Unconscious Person. Anesthesiology 10 2010, Vol.113, 873-879. doi:10.1097/ALN.0b013e3181ec6414
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1933275
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Alternative Preoxygenation/Preventilation
http://rebelem.com/critical-care-updates-resuscitation-sequence-intubation-ph-kills-part-3-of-3/
Suction
https://i.ytimg.com/vi/IPJFshx0i5I/maxresdefault.jpg
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End-Tidal CO2 Waveform Capnography
Bougie First
• Bougie = Higher 1st Pass Success (96% vs 82%) – Patients with difficult airway
Driver BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018;319(21):2179–2189. doi:10.1001/jama.2018.6496
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Video Laryngoscopy
McGrath
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Preparation improves outcomes
• Preoxygenation with noninvasive positive pressure ventilation
• Fluid loading and/or pressors
• Presence of two operators
• Rapid sequence induction
• Capnography
• Protective ventilation
• Preparation and early administration of sedation
• Vasopressor use if needed
Jaber et al. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Medicine. 2010. 36:2:248-255. https://link.springer.com/article/10.1007%2Fs00134-009-1717-8
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Summary
• Airway management = more than intubation
• Prevent and avoid expected complications
• Optimize technique
Thank You
[email protected] @joshuastilley
Credit Dan Berry