advanced airway management for the emergency physician
TRANSCRIPT
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advanced airway managementfor the emergency physician
reuben j. strayermount sinai school of medicine
june 9, 2010
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Discuss the common cognitive mistakes made in airway management
Discuss the elements of first pass success in laryngoscopy
Discuss key decisions in airway management
Discuss problems that arise during airway management (and strategies to solve them)
Discuss controversies in emergency airway management
objectives
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you cannot accurately predict the difficult airway
guiding principles
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you cannot accurately predict the difficult airway
guiding principles
American Journal of Emergency Medicine (2009) 27, 905-9104
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you cannot accurately predict the difficult airway
guiding principles
need to intubate
RSI + hope for the best
difficult airway?
RSI + hope for the best
“difficult airway box” to bedside RSI + hope for the best
get someone else to do it
nah
yes
oh god
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you cannot accurately predict the difficult airway
guiding principles
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you cannot accurately predict the difficult airway
guiding principles
need to intubate
RSI + hope for the best
difficult airway?
RSI + hope for the best
“difficult airway box” to bedside RSI + hope for the best
get someone else to do it
nah
yes
oh god
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operator catecholamine management
guiding principles
patient HR
95% 90%92% 85% 75% 65% 50%
laryngoscopy attempt #1
laryngoscopy attempt #2
laryngoscopy attempt #3
BVM Cricothyrotomy
30%
LMA
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
operator HR
Aspiration ACLS
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airway course algorithms
universal emergency airway algorithmfrom Walls et. al via emcrit.org10
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airway course algorithms
main emergency airway algorithmfrom Walls et. al via emcrit.org11
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airway course algorithms
crash airway algorithmfrom Walls et. al via emcrit.org12
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airway course algorithms
failed airway algorithmfrom Walls et. al via emcrit.org13
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airway course algorithms
difficult airway algorithmfrom Walls et. al via emcrit.org14
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airway course algorithms
from Walls et. al via emcrit.org15
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strayer airway algorithm
vs. Walls algorithms
focus on planning but not on specific techniques
focus on early, effective ventilation after unsuccessful
airway attempt
permission to initiate cricothyrotomy on patients
who are not dead
RSI vs. Awake
Airway attemptPost-intubation management
BVM (perfect technique) or
LMA
Prepare for cricothyrotomy
Supraglottic device
Unsuccessful
Successful
Change something
Unsuccessful
Successful
Successful
Unsuccessful
Next patient
Prepare for failure of intubation and
failure of BVM
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the decision to intubateintubate, and intubate early
especially in dynamic airways
neck traumabulletsanaphylaxis / angioedemabitesthermal and caustic airway injuriesburns
Airway mouth and neck infections, tumors, foreign bodies, bleedsexam: stridor, phonation, swallowing, secretions, dyspnea
Breathing failure of oxygenation or ventilationoften amenable to medical and non-invasive therapies – think NIV
Circulation supporting tissue oxygen delivery by unloading the muscles of respirationsepsis
Expected course anticipated decline, transfer to radiology or another institution
Feral need for prompt, aggressive sedation to protect patient/othersespecially with potential or undiagnosed medical instability
Disability CNS catastrophes and CNS depression, ongoing seizures, weaknessexam: avoid gag – assess ability to swallow and handle secretions (pooling, drooling, gurgling) for neuromuscular weakness: FVC < 12 ml/kg and NIF < 20 cm H20vomiting in the obtunded patient is a particular concern
ACLS17
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RSI vs. awakevs. call for helpvs. immediate cricothyrotomy / ED double setup
you can always paralyze but cannot un-paralyze (yet)
RSI Awake
urgencyperi-arrestdynamic airway already deteriorating
stable GI bleed requiring endoscopyslowly progressive neuromuscular
weakness requiring transfer
difficult airway features known easy airwaynormal anatomy
fixed flexion deformity of the neckcannot open mouth
vomiting riskupper GI bleedbowel obstructionvomiting in ED
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sympatholysis risk, apnea riskall else being equal, paralyzed patients are considerably easier to intubate
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Awake Technique
Favored in patients who require intubation less urgently, have more difficult airway features, and are not high risk for vomiting
! Glycopyrolate 0.2 mg or Atropine .01 mg/kg glyco preferred, ideally given 15 min prior to next step! Suction then pad dry mouth with gauze! Nebulized Lidocaine without epi @ 5 lpm ideally 4 cc of 4% lidocaine but can also use 8 cc of 2% lidocaine! Atomized Lidocaine sprayed to oropharynx especially if unable to give full dose of nebulized lidocaine! Viscous Lidocaine lollipop 2% viscous lido on tongue depressor! Preoxygenate ! Position ! Restrain prn ! Switch to nasal cannula! Lightly sedate with Versed 2-4 mg or Ketamine 20 mg aliquots q 2 min! Intubate awake or place bougie, then paralyze, then pass tube
ketamineketamineketamine
versedfentanyl
dexmedetomidine
timecooperation
IV sedationlocal anesthesia
drynebulizeatomizetopicalize
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laryngoscopy
ear to sternal notch
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laryngoscopy
ear to sternal notch
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laryngoscopy
ear to sternal notch
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laryngoscopy
equipment is ready: suction under right shoulder
assistant pulls right mouth corner
ear to sternal notch
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laryngoscopyassistant pulls right mouth corner
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laryngoscopy
equipment is ready: suction under right shoulder
assistant pulls right mouth corner
find the epiglottis: gentle advance from right, looking for epiglottisvs.
gentle advance into esophagus, then withdraw, looking for epiglottis
optimize the head: put your right hand under the patient’s head and do sniff and head tilt
forget cricoid pressure
ear to sternal notch
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laryngoscopyoptimize the head: put your right hand under the patient’s head and do sniff and head tilt
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laryngoscopy
equipment is ready: suction under right shoulder
assistant pulls right mouth corner
find the epiglottis: gentle advance from right, looking for epiglottisvs.
gentle advance into esophagus, then withdraw, looking for epiglottis
optimize the head: put your right hand under the patient’s head and do sniff and head tilt
optimize the larynx: use your right hand to maneuver the thyroid cartilage into optimal position
forget cricoid pressure
ear to sternal notch
seat the blade: either in the vallecula, or on the epiglottis itself, then gently lift
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laryngoscopy
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optimize the larynx: use your right hand to maneuver the thyroid cartilage into optimal position
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laryngoscopyoptimize the larynx: use your right hand to maneuver the thyroid cartilage into optimal position
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laryngoscopy
equipment is ready: suction under right shoulder
assistant pulls right mouth corner
find the epiglottis: gentle advance from right, looking for epiglottisvs.
gentle advance into esophagus, then withdraw, looking for epiglottis
optimize the head: put your right hand under the patient’s head and do sniff and head tilt
optimize the larynx: use your right hand to maneuver the thyroid cartilage into optimal position
that’s the best view you’re going to get on this attempt. if it’s not good enough, ventilate
for the love of god, use a bougie
forget cricoid pressure
ear to sternal notch
seat the blade: either in the vallecula, or on the epiglottis itself, then gently lift
before your next attempt change something patient positionblademodalityoperator
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the bougie
essential
strategically designed deflection at the tip
self-confirming
can intubate epiglottis-only views
leave the laryngoscope in
lubricate the tube, pull back and rotate if you get stuck
black stripe is 25 cm - at lips, mid trachea in an adult male
the bougie is your friend
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small tube for small hole
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laryngoscopy
advance the ETT or bougie from the right side and twist, do not lever
suction under right shoulder
assistant pulls right mouth corner
find the epiglottis: gentle advance from right, looking for epiglottisvs.
gentle advance into esophagus, then withdraw, looking for epiglottis
optimize the head: put your right hand under the patient’s head and do sniff and head tilt
optimize the larynx: use your right hand to maneuver the thyroid cartilage into optimal position
that’s the best view you’re going to get on this attempt. if it’s not good enough, ventilate
for the love of god, use a bougie
forget cricoid pressure
ear to sternal notch
seat the blade: either in the vallecula, or on the epiglottis itself, then gently lift
before your next attempt change something
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laryngoscopyadvance the ETT or bougie from the right side and twist, do not lever
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nobadwrong
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laryngoscopyadvance the ETT or bougie from the right side and twist, do not lever
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yesgoodright
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BVMa misunderstood skill
three airways
detach the mask from the bag
two hands down
jaw thrust open the mouth, make an underbite
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BVMjaw thrust open the mouth, make an underbite
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BVMjaw thrust open the mouth, make an underbite
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BVM
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BVMa misunderstood skill
three airways
detach the mask from the bag
two hands down
jaw thrust open the mouth, make an underbite
remove cricoid pressure
reposition with head tilt, sniffing posture
lubricate beard, replace dentures
change mask size - usually larger
add or remove air from the mask cuff
bag slowly and gently squeeze, release, releaseuse the vent to bag
don’t wait for the pulse oxchest rise, appropriate resistance, no
leak, ETC02
consider oxygenation deficit
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BVM LMA Ventilation
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drugs
etomidate adrenal suppressionsafe choice in most situationslowers seizure threshold
ketamine
pretreatments lidocaineatropine
fentanyllidocainedefasciculating agentatropinefentanyl
then now
avoid if hypertension/tachycardia undesirableIM RSI
hypotension / sepsis
reactive airways
contraindication in high ICP is slowly dissolving
propofolmidazolamthiopental
hypertension, seizures, hypersympathetic delirium
propofol disappears before paralytic
half dose paralytic: do notvecuronium only if rocuronium not available
roc vs. sux
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problems with succinylcholine
predisposition to malignant hyperthermiabradycardiafasciculations – increased ICP, myalgias, hastened desaturationmasseter spasm
rhabdomyolysisexisting hyperkalemiamultiple sclerosisALSmuscular dystrophies / inherited myopathiesdenervating injuries > 72 hours old (e.g. stroke, spinal cord injury)burns > 72 hours oldcrush injury > 72 hours oldtetanus, botulism, and other exotoxin infectionssevere infections >72 hours old (esp. intra-abdominal infections)immobilization (including patients found down)
K
roc vs. sux
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contraindications to rocuronium
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onset
Heier et al. Rapid Tracheal Intubation with Large-Dose Rocuronium: A Probability-Based Approach. Anesthesia & Analgesia 2000;90(1):175
black: excellent intubating conditionswhite: good intubating conditionshatched: poor intubating conditions
success: intubation within 30 seconds
intubating conditions at 40 seconds
roc vs. sux
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0.6
1.0
1.2
roc vs. suxonset
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succinylcholine5-10 minutes
rocuronium30-90 minutes
roc vs. suxduration
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can’t intubate, can’t ventilate
roc vs. suxduration
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failure to use awake techniquefailure to use rescue device
failure to perform surgical airway
dangerous decision-making
can’t intubate, can’t ventilate
tummy tuck vs. airway burn
roc vs. suxduration
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can’t intubate, can ventilate
“...the need to support the patient’s ventilations in the event of a failed airway for a minimum of 20–25 min before reversal can be attempted is a daunting prospect. Like many others, I therefore have little enthusiasm
for the concept of using rocuronium for all patients undergoing RSI.”
Ron Walls
sux, round 2 (and 3)
roc rocks
roc vs. suxduration
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post-intubation managementtube confirmation
continuous capnography > colorimetric capnography >>> chest auscultationfalse negatives
esophageal detector device
bougie test
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post-intubation management
post-intubation pharmacology
paralysissedationanalgesia
old school new school
analgesiasedationparalysis
still paralyzeddiagnostic uncertaintytransportpainful procedures
ICU
fentanyl drip to light sedation
vs. stable on the vent phasejust intubated phase
benzodiazepines to deep sedation
add an opiate
avoid re-paralysis: ketamine bolus
if you must re-paralyze: roc or vec
titrate up opiates and titrate down sedatives when stable
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special situations
patients without oxygenation reserve
do not try to fix oxygenation with quick intubation
pre-oxygenate with NIV
immediate oxygenation with LMA
keep airway patent as patient is induced
Weingart S. Preoxygenation, reoxygenation, and delayed sequence intubation in the emergency department. Journal of Emergency Medicine 2010 (in press)
awake technique?
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special situations
patients without ventilation reserve
DKA, severe sepsis, salicylate toxicity, toxic alcohol toxicity
awake technique?
BVM during induction
BVM very early if laryngoscopy unsuccessful - quick look then iLMA
hyperventilation before intubation = hyperventilation after intubationETCO2 vs. PaCO2
also applies to patients who are susceptible to changes in ICP
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special situations
trauma
if you don’t get a good view with manual in-line stabilization mobilize the neck
exception: diagnosed or very likely cervical spine injury
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special situations
hypotension
IVF prior to induction
pressors prior to induction, be ready with pressors post-induction
RSI and positive pressure worsen hypotension
reduce the dose of the induction agent
don’t forget the paralytic
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special situations
high aspiration risk
NGT prior to intubation
intubate in semi-upright position
upper GI bleedingbowel obstruction
pre-induction vomiting
bag early, but slightly less early
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key points
you cannot predict the difficult airway – have a plan for failed intubation and failed ventilation and be ready to carry out that plan
initiate rescue maneuvers such as ventilation and cricothyrotomy early so that the patient has enough reserve to allow for calm and effective execution
replace BVM with LMA ventilation
make the bougie part of your routine
ask the question: should I use an awake technique?
BVM with three airways in, two hands down
rocuronium
use a checklist to keep you focussed on what’s important
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thanksrichard levitan scott weingart ron walls