Improving the safety of emergency airway management

Elliot Long BSc BMBS FRACP PGCertCU

Disclosures

Cases• 5yo morbidly obese septic

encephalopathy

• 13 month old TOF/OA aspiration pneumonia hypoxic respiratory failure

Management strategy 10ya?

• RSI

7 p’s of RSI• Preparation• Pre-oxygenation• Pre-treatment• Paralysis (with induction of

anaesthesia)• Protection• Placement• Post-intubation management

Actual management:• 5yo morbidly obese septic

encephalopathy

• 13 month old TOF/OA aspiration pneumonia hypoxic respiratory failure

KEY POINTS

• Prioritise avoidance of hypoxia / hypotension

• Plan for failure

• Avoid fixation

What should we call this approach?• How To Not Completely Roger Your

Patient During Airway Management in Emergencies?

Avoiding hypoxia:• Position• Pre-oxygenation• Apnoeic oxygenation• SpO2 stop point for intubation

attempts• First pass success*

Avoiding hypotension• Fluid resuscitation• Inopressor infusion• Don’t sympatectomise your patient

with induction (drug + dose)• Rescue (push) dose inopressor

Where is the money?

• Operator skill?

• Safe system for airway management?

NAP4 • ED / ICU intubations highest risk,

most likely to lead to permanent disability / death

• Failure to use capnography contributed to 74% of deaths or permanent neurological disability

• AVOIDABLE DEATHS DUE TO AIRWAY COMPLICATIONS OCCUR IN ED AND ICU

Summary• Governance• Algorithm• Standardised / simplified

equipment• Checklist• ETCO2• Training• Regular audit

Audit• 71 intubations over 1 year• First pass success 78%, without

hypoxia / hypotension 49%• Difficult airway: 2 (C&L grade 3)• 44% CVS compromise, 87% resp

compromise, 70% GCS<9 prior to intubation

Equipment

Team training

Skills

Simulation

Goals of team training 1. Appreciate what a “difficult airway”

means (anatomical / physiological / situational)

2. Resuscitate prior to intubation3. Exposure to airway equipment / Mx4. Non-technical skills are as important as

technical skills5. Understand fixation error6. Orientation to RCH procedures 7. Improve individual & group practice

Barriers• Historical jurisdiction• Relationships• Culture change• Logistics• Evidence• Cost

Is zero iatrogenic harm possible during emergency airway management?

• I think so! (ongoing QI project)