airway management philip ukrainetz, md, pgy5 gord mcneil, md, frcps core rounds, july 18, 2002

Airway ManagementAirway Management

Philip Ukrainetz, MD, PGY5Philip Ukrainetz, MD, PGY5

Gord McNeil, MD, FRCPSGord McNeil, MD, FRCPS

Core Rounds, July 18, 2002Core Rounds, July 18, 2002

CaseCase

6 year old girl, MVA victim. She is 6 year old girl, MVA victim. She is stuporous, has a suspected head injury stuporous, has a suspected head injury and is hypotensive. You have an IV and and is hypotensive. You have an IV and are giving a 20cc/kg NS bolus. What do are giving a 20cc/kg NS bolus. What do you want to do? you want to do?

Three indications to Three indications to intubateintubate

Failure to protect airwayFailure to protect airway Failure to oxygenate or ventilateFailure to oxygenate or ventilate Anticipated courseAnticipated course

AnatomyAnatomy

Pediatric Airway DifferencesPediatric Airway Differences– Larger tongueLarger tongue– Large occiputLarge occiput– Anterior larynxAnterior larynx– Larger epiglottis/floppierLarger epiglottis/floppier– Subglottic area narrowestSubglottic area narrowest– Less musculatureLess musculature– Shorter tracheaShorter trachea– Narrower airway Narrower airway

Pediatric PointersPediatric Pointers

Broselow tapeBroselow tape Avoid 2Avoid 2ndnd dose of sux dose of sux

– infants/children exquisitely sensitive infants/children exquisitely sensitive intractable brady/arrestintractable brady/arrest

Pierre Robin and Treacher Collins’ Pierre Robin and Treacher Collins’ syndromesyndrome– Small mandibles and posteriorly fixed tonguesSmall mandibles and posteriorly fixed tongues

Down syndrome - large tongueDown syndrome - large tongue

Four Types of AirwaysFour Types of Airways

BVMBVM Crash - intubateCrash - intubate RSI – the “8 P’s”RSI – the “8 P’s” Difficult – no paralytic, have a backupDifficult – no paralytic, have a backup

8 Steps to a Successful RSI8 Steps to a Successful RSI

RSI 8 p’s: RSI 8 p’s: – PreparationPreparation– PerusePeruse– Preoxygenate Preoxygenate – PretreatmentPretreatment– ParalysisParalysis– ProtectionProtection– PlacementPlacement– Post intubation managementPost intubation management

Basic Airway Management - 8 Basic Airway Management - 8 P’sP’s

“Prepare” – SIGMA D“Prepare” – SIGMA D What do you need for intubation?What do you need for intubation? SIGMA DSIGMA D

– S = SuctionS = Suction– I = IntravenousI = Intravenous– G= GasG= Gas– M = Mask/BagM = Mask/Bag– A =airway equipment (oral airway, A =airway equipment (oral airway,

laryngoscope, tubes, alternative)laryngoscope, tubes, alternative)– D= DrugsD= Drugs

““Peruse” - LEMON LAWPeruse” - LEMON LAW

L = Look: face, neck, chestL = Look: face, neck, chest E = Examine: mouth, thyromental, floor E = Examine: mouth, thyromental, floor

of mouth to thyroidof mouth to thyroid M = Mallampatti: huge tongue?, back of M = Mallampatti: huge tongue?, back of

throat?throat? O = Obstruction: tumor, epiglottitisO = Obstruction: tumor, epiglottitis N = Neck mobility: OA, RA, syndromicN = Neck mobility: OA, RA, syndromic

LLEMON - LookEMON - Look

LookLook– Evaluate the pt.Evaluate the pt.

ObesityObesity MicrognathiaMicrognathia High arched palateHigh arched palate Narrow faceNarrow face Short or thick neckShort or thick neck Neck traumaNeck trauma Large tongueLarge tongue Presence of facial hairPresence of facial hair DenturesDentures Large teethLarge teeth

LLEEMON –Evaluate 3-3-2MON –Evaluate 3-3-2

Evaluate 3-3-2Evaluate 3-3-2– Evaluate the anatomyEvaluate the anatomy

3 fingerbreadths of mouth opening3 fingerbreadths of mouth opening 3 fingerbreadths between front of chin 3 fingerbreadths between front of chin

and hyoidand hyoid 2 fingerbreadths from mandible to 2 fingerbreadths from mandible to

thyroid cartilagethyroid cartilage CAN I DISPLACE TISSUE SUB-MENTALLY?CAN I DISPLACE TISSUE SUB-MENTALLY?

LELEMMON – Mallampati scoreON – Mallampati score Mallampati scoreMallampati score

– Grade 1Grade 1: entire post. : entire post. Pharynx, visualized to Pharynx, visualized to tonsillar pillarstonsillar pillars

No difficultyNo difficulty– Grade 2Grade 2: hard palate, soft : hard palate, soft

palate and top of uvula palate and top of uvula onlyonly

No difficultyNo difficulty– Grade 3Grade 3: hard and soft : hard and soft

palate onlypalate only Moderate difficultyModerate difficulty

– Grade 4:Grade 4: no visualization no visualization post pharynx or uvula post pharynx or uvula (hard palate only(hard palate only

Severe difficultySevere difficulty

LEMLEMOON -ObstructionN -Obstruction

ObstructionObstruction– Look for upper and lower airway Look for upper and lower airway

obstruction obstruction foreign body aspirationforeign body aspiration EpiglottitisEpiglottitis croup croup AbscessesAbscesses others: surgery,tumors, radiationothers: surgery,tumors, radiation

LEMOLEMONN –Neck Mobility –Neck Mobility

Neck MobilityNeck Mobility– Collar, RA, degenerative arthritis, Collar, RA, degenerative arthritis,

history of surgeryhistory of surgery

– Note: get significant movement Note: get significant movement with BVM ventilation also!!with BVM ventilation also!!

““Pre-oxygenate” - no Pre-oxygenate” - no baggingbagging

Preoxygenate (nitrogen washout)Preoxygenate (nitrogen washout)– Saturate O2 reservoir, tissues and Saturate O2 reservoir, tissues and

bloodblood– 100% NRB (70%)100% NRB (70%)

5 min healthy adult5 min healthy adult 2.5 min children2.5 min children 8 VC breaths8 VC breaths

How much time do I have?How much time do I have?

70kg adult maintains O2 sat >90% 70kg adult maintains O2 sat >90% for 8 minfor 8 min– From 90% - 0% = < 120 secondsFrom 90% - 0% = < 120 seconds

Obese adult (>120kg) desaturate Obese adult (>120kg) desaturate to 0% in less than 3 minto 0% in less than 3 min

10kg child desaturate <90 in 4 min10kg child desaturate <90 in 4 min– From 90% to 0% in 45 secondsFrom 90% to 0% in 45 seconds

Walls graphWalls graph

““Pre- medicate” - LOADPre- medicate” - LOAD

Lidocaine: tight heads, tight lungsLidocaine: tight heads, tight lungs Opioid: for blunting sympathetic Opioid: for blunting sympathetic

response (ICP, IOP, aortic dissection, response (ICP, IOP, aortic dissection, aneurysm, IHD)aneurysm, IHD)

Atropine: children <= 10Atropine: children <= 10 Defasiculate: for increased ICPDefasiculate: for increased ICP

Lidocaine ?Lidocaine ?

PremisePremise– Laryngoscopy and IntubationLaryngoscopy and Intubation

afferent stim. in post pharynx/ larynxafferent stim. in post pharynx/ larynx increased central stimincreased central stim increased ICPincreased ICP stim of autonomic system stim of autonomic system

– increased HR / BPincreased HR / BP– upper and lower resp. tract leading to upper and lower resp. tract leading to

increased airway resistanceincreased airway resistance

Lidocaine ?Lidocaine ?

Literature (supports)Literature (supports)– suppresses cough reflex suppresses cough reflex – attenuates increase in airway attenuates increase in airway

resistance (from ET tube irritation)resistance (from ET tube irritation)– prevents increased ICPprevents increased ICP– prevents increased IOPprevents increased IOP– decreases dysrhythmias by 30-40%decreases dysrhythmias by 30-40%

Lidocaine ?Lidocaine ?

Literature (?doesn’t support)Literature (?doesn’t support)– use to attenuate use to attenuate sympatheticsympathetic

response to laryngoscopyresponse to laryngoscopy

Use: tight lungs / tight brainsUse: tight lungs / tight brains– 1.5mg/kg 3 min prior 1.5mg/kg 3 min prior

Topical 4% lidocaine and ICP ????Topical 4% lidocaine and ICP ????

Drugs to Decrease Drugs to Decrease Sympathetic Response to Sympathetic Response to

IntubationIntubation (L (LOOAD)AD)

FentanylFentanyl– high dose 5-10 ug/kg (will unequivocally high dose 5-10 ug/kg (will unequivocally

block sympathetic response - block sympathetic response - hypotension, apnea , chest wall rigidity)hypotension, apnea , chest wall rigidity)

– 1.5-3ug/kg (2 min prior) blocks increase 1.5-3ug/kg (2 min prior) blocks increase BP but no effect on HRBP but no effect on HR

Beta-blockersBeta-blockers– will decrease sympathetic responsewill decrease sympathetic response– prob: neg ionotrope, bronchoconstrictionprob: neg ionotrope, bronchoconstriction

Drugs to Decrease Drugs to Decrease Sympathetic Response to Sympathetic Response to

IntubationIntubation

Helfman et alHelfman et al– compared 200 lido, 200 fentanyl, 150 compared 200 lido, 200 fentanyl, 150

esmololesmolol– esmolol only reliably agent in esmolol only reliably agent in

preventing rise in HR and BPpreventing rise in HR and BP Chung et alChung et al

– combination esmolol and fentanyl combination esmolol and fentanyl (2ug/kg and 2mg/kg) best combo with (2ug/kg and 2mg/kg) best combo with limited side-effectslimited side-effects

LOLOAAD - AtropineD - Atropine

Use with SUX in children under the Use with SUX in children under the age of 8 and when giving repeat age of 8 and when giving repeat doses doses – Sinus brady, junctional, sinus arrest Sinus brady, junctional, sinus arrest

usually after a second doseusually after a second dose– Reason: Sch mimicks action of Ach at Reason: Sch mimicks action of Ach at

the cardic muscarinic receptorsthe cardic muscarinic receptors– Dose 0.02mg/kg (no less than 0.1mg), Dose 0.02mg/kg (no less than 0.1mg),

3 min prior to induction3 min prior to induction

LOLOAAD - AtropineD - Atropine

LiteratureLiterature– Prevents brady in childrenPrevents brady in children– Reduces BUT doesn’t eliminate them in Reduces BUT doesn’t eliminate them in

infantsinfants– No effect on older childrenNo effect on older children– Anesthesia literature: volatile anesthetics in Anesthesia literature: volatile anesthetics in

combination with atropine - increased risk combination with atropine - increased risk of arrhythmiasof arrhythmias

– Bottomline: Use atropine on children in the Bottomline: Use atropine on children in the EDED

DefasiculationDefasiculation

Decrease the rise in ICP from Sch Decrease the rise in ICP from Sch induced fasciculation (animal data, induced fasciculation (animal data, limited human)limited human)

Does not attenuate the sympathetic Does not attenuate the sympathetic response to intubation response to intubation

Does not attenuate the increase in Does not attenuate the increase in airway resistance with intubationairway resistance with intubation

1/10 intubating dose1/10 intubating dose

RSI in Adults With Elevated RSI in Adults With Elevated Intracranial Pressure: A Survey of Intracranial Pressure: A Survey of

EmergencyEmergencyMedicine Residency ProgramsMedicine Residency Programs

Am J Emerg MedAm J Emerg Med :1995 :1995– 100 programs surveyed100 programs surveyed– 67 responses, 65 used RSI in their 67 responses, 65 used RSI in their

programs!!!programs!!!– Top NMB agents – Sux and vecuroniumTop NMB agents – Sux and vecuronium– Top induction agents - midazolam and Top induction agents - midazolam and

thiopentalthiopental– Lidocaine - was routine Lidocaine - was routine – Fentanyl - other pretreatment agentFentanyl - other pretreatment agent– Defasciculating dose used by most programsDefasciculating dose used by most programs

““Paralysis with induction”Paralysis with induction”

Rapid sequence - “intubation before Rapid sequence - “intubation before aspiration” aspiration”

Do not titrateDo not titrate Midazolam, ketamine or thiopentalMidazolam, ketamine or thiopental SuccinylcholineSuccinylcholine

CaseCase

A 6 year old has been seizing for 30 A 6 year old has been seizing for 30 minutes and you have a vial of minutes and you have a vial of etomidate in your hand - should you use etomidate in your hand - should you use it?it?

EtomidateEtomidate

Ultrashort acting non-barbiturate Ultrashort acting non-barbiturate hypnotic agent (no analgesic effects)hypnotic agent (no analgesic effects)

Adv: Adv: – rapid onset and rapid recoveryrapid onset and rapid recovery– hemodynamic stabilityhemodynamic stability– minimal resp depressionminimal resp depression– cerebral protectioncerebral protection

Induction Dose: 0.3 mg/kgInduction Dose: 0.3 mg/kg

EtomidateEtomidate

Onset : one arm-brain circulation (within Onset : one arm-brain circulation (within 1 min)1 min)

Duration : 3-5 minDuration : 3-5 min CerebralCerebral

– decreases CBF by 35% - decr ICPdecreases CBF by 35% - decr ICP– no change MAPno change MAP– CPP increases (increased cerebral CPP increases (increased cerebral

oxygen/demand ratio) - decr ICPoxygen/demand ratio) - decr ICP

EtomidateEtomidate

RespResp– minimal effectsminimal effects– doesn’t release histaminedoesn’t release histamine

CVCV– no change in HR/ MAP/ CI/ PAWPno change in HR/ MAP/ CI/ PAWP

EndocrineEndocrine– concern re: steroid depressionconcern re: steroid depression

EtomidateEtomidate

Dose dependant reversible inhibition of Dose dependant reversible inhibition of 11-beta- hydroxylase (converts 11-11-beta- hydroxylase (converts 11-deoxycortisol to cortisol)deoxycortisol to cortisol)

Studies:Studies:– transient drop in cortisol levels with transient drop in cortisol levels with

induction of anesthesia (6hrs), back induction of anesthesia (6hrs), back to normal in 20 hrsto normal in 20 hrs

– no reported adverse outcomesno reported adverse outcomes

EtomidateEtomidate

CI: CI: < 10, known seizure disorder, < 10, known seizure disorder, pregnantpregnant

Adverse effectsAdverse effects– nausea and vomiting (30-40%)nausea and vomiting (30-40%)– pain on injection (similar to propofol)pain on injection (similar to propofol)– myoclonic movementmyoclonic movement

Pregnancy category CPregnancy category C– embryocidal in ratsembryocidal in rats

CaseCase

A brittle asthmatic comes in A brittle asthmatic comes in obtunded and has a silent chest - obtunded and has a silent chest - you needed to intubate him you needed to intubate him yesterday?yesterday?

What inductionagent shall you What inductionagent shall you use?use?

KetamineKetamine Phencyclidine derivative (similar to Angel Phencyclidine derivative (similar to Angel

Dust)Dust) Dissociative anesthetic (dissociation Dissociative anesthetic (dissociation

between the thalmus and limbic system)between the thalmus and limbic system) Sympathomimetic (increased HR and BP)Sympathomimetic (increased HR and BP) Increases cerebral blood flow by 60% Increases cerebral blood flow by 60%

potentially elevating ICP!potentially elevating ICP! Reduces airway resistanceReduces airway resistance Dose 1-2mg/kg IV, 4-5mg/kg IMDose 1-2mg/kg IV, 4-5mg/kg IM Onset: within 60sOnset: within 60s

CaseCase

Head injured, hemodynamically Head injured, hemodynamically stable 34 year old. Needs to be stable 34 year old. Needs to be intubated what will you pre-intubated what will you pre-medicate with and what is medicate with and what is currently your induction agent of currently your induction agent of choice?choice?

ThiopentalThiopental

Barbituate, potentiates GABABarbituate, potentiates GABA CerebroprotectiveCerebroprotective Dose related potent venodilator and Dose related potent venodilator and

myocardial and resp depressantmyocardial and resp depressant Adult 1-4 mg/kg, child 1- 6 mg/kgAdult 1-4 mg/kg, child 1- 6 mg/kg Onset 15 - 30 secs, duration 3- 5 minOnset 15 - 30 secs, duration 3- 5 min Do not use in hypotensionDo not use in hypotension

CaseCase

One hour ago a zoo keeper was welding One hour ago a zoo keeper was welding in the elephant cage when the elephant in the elephant cage when the elephant panicked, sat on him, and they were panicked, sat on him, and they were both burnt severely. The patient has both burnt severely. The patient has been crushed, paralyzed, head injured, been crushed, paralyzed, head injured, has an open globe injury, but manages has an open globe injury, but manages to squeak out that he had a stroke 4 to squeak out that he had a stroke 4 days ago. You cannot get an IV - can days ago. You cannot get an IV - can you use succinylcholine?you use succinylcholine?

Succinylcholine CISuccinylcholine CI

History of MHHistory of MH Burns > 24 hrs old until healedBurns > 24 hrs old until healed Muscle damage (crush) > 7 days - completely Muscle damage (crush) > 7 days - completely

healedhealed Spinal cord injury, stroke (denervation UMN, Spinal cord injury, stroke (denervation UMN,

LMN) > 7 days - 6 monthsLMN) > 7 days - 6 months Neuromuscular disease, myopathies: Neuromuscular disease, myopathies:

indefinately as long as disease is activeindefinately as long as disease is active Intra-abdominal sepsis > 7 days - resolution Intra-abdominal sepsis > 7 days - resolution

of infectionof infection

SuccinylcholineSuccinylcholine

Depolarizing NM agentDepolarizing NM agent– Onset: Onset: 30-45s30-45s– Duration:Duration: 5-10 min5-10 min

Dosage (IV):Dosage (IV):– 1-1.5mg/kg adult1-1.5mg/kg adult– 2mg/kg child2mg/kg child– 3mg/kg neonate3mg/kg neonate

Can give IM at twice the doseCan give IM at twice the dose

SuccinylcholineSuccinylcholine

Side-effects?Side-effects?– Incr IOP, ICPIncr IOP, ICP– BradycardiaBradycardia– Trismus-masseter muscle spasmTrismus-masseter muscle spasm– FasciculationsFasciculations– Malignant HyperthermiaMalignant Hyperthermia– HyperkalemiaHyperkalemia– Prolonged blockadeProlonged blockade

Sux - HyperkalemiaSux - Hyperkalemia LiteratureLiterature

– Case reports since 1960’sCase reports since 1960’s– No case reports of hyperkalemia in the ED No case reports of hyperkalemia in the ED

(multiple trauma, burns, neurological disease)(multiple trauma, burns, neurological disease)– Literature poor with chronic renal failureLiterature poor with chronic renal failure

Zink et alZink et al– 100 pts (no risk factors)100 pts (no risk factors)– Max increase 1.0 meq/L (K increased in 46pts, Max increase 1.0 meq/L (K increased in 46pts,

dropped in 46 pts and unchanged in 8)dropped in 46 pts and unchanged in 8)– 1 pt found to be in a wheelchair!, K dropped from 1 pt found to be in a wheelchair!, K dropped from

4.6 to 4.14.6 to 4.1

Sux - HyperkalemiaSux - Hyperkalemia Mechanism: ? Increased receptor density Mechanism: ? Increased receptor density

(extra-junctional), more sensitive, (extra-junctional), more sensitive, depolarize for long periods, release of Kdepolarize for long periods, release of K

? Increased K of approx 0.5 meq/L? Increased K of approx 0.5 meq/L Risk factors/guidelines : Risk factors/guidelines :

– Burn victims >24hrs to 1-2 yrs post healing?Burn victims >24hrs to 1-2 yrs post healing?– Crush injuries >7 days post lasting up to 60-90 Crush injuries >7 days post lasting up to 60-90

daysdays– Spinal cord injury/ stroke (denervation injury) >7 Spinal cord injury/ stroke (denervation injury) >7

days to 6 monthsdays to 6 months– Neuromuscular disorders (MS, ALS) indefinitely Neuromuscular disorders (MS, ALS) indefinitely

Sux - HyperkalemiaSux - Hyperkalemia

ConclusionConclusion– Non high risk ptsNon high risk pts

No problems with administrationNo problems with administration

– High risk ptsHigh risk pts CRF probably okayCRF probably okay Others : literature is not great but we have Others : literature is not great but we have

good NDNM blockers, therefore no point to good NDNM blockers, therefore no point to take risktake risk

Sux – Raised IOPSux – Raised IOP Thought to be a contraindication to an open globe Thought to be a contraindication to an open globe

injury!injury! Pressure elevations do occur, are transient, Pressure elevations do occur, are transient,

maximal for 2-4 min post administrationmaximal for 2-4 min post administration– Pressure elevations of 3-8mmHg (never been shown to Pressure elevations of 3-8mmHg (never been shown to

worsen globe injuryworsen globe injury– Comparison: normal blink – increases IOP by 10-Comparison: normal blink – increases IOP by 10-

15mmHg, forceful closure of the eyelid >70 mmHg15mmHg, forceful closure of the eyelid >70 mmHg– Anesthesia continues to use Sux in OR with globe Anesthesia continues to use Sux in OR with globe

injuriesinjuries– Chiu et al:Chiu et al:

if you want to prevent increase in IOP, can give if you want to prevent increase in IOP, can give defasciculating dose of a NDNM blocker (rocuronium 2 min pre defasciculating dose of a NDNM blocker (rocuronium 2 min pre RSI)RSI)

CaseCase

During the G8 summit a cocaine During the G8 summit a cocaine addict comes in SLUDGING. Is it addict comes in SLUDGING. Is it safe to use succinylcholine?safe to use succinylcholine?

Sux – Prolonged blockadeSux – Prolonged blockade Pseudocholinesterase DeficiencyPseudocholinesterase Deficiency

– Congenital Congenital Heterozygous : up to 25 min, homozygous up to 5 hrs Heterozygous : up to 25 min, homozygous up to 5 hrs

after a single doseafter a single dose Homozygous : 1 in 3000 ptsHomozygous : 1 in 3000 pts

– Acquired Acquired Organophosphate poisoningOrganophosphate poisoning Cocaine useCocaine use CRF, severe liver disease, hypothyroidism,malnutrition, CRF, severe liver disease, hypothyroidism,malnutrition,

pregnancy, cytotoxic drugs, metoclopramide, pregnancy, cytotoxic drugs, metoclopramide, bambuturol(long acting beta 2 anonist)bambuturol(long acting beta 2 anonist)

– Note: above none have prolonged blockade over 20-25 Note: above none have prolonged blockade over 20-25 minmin

Sux – Trismus/Masseter Sux – Trismus/Masseter muscle Spasmmuscle Spasm

Occasionally can get spasmOccasionally can get spasm Especially in childrenEspecially in children Transient Transient If prolonged, severe and other muscle If prolonged, severe and other muscle

involved should think of MHinvolved should think of MH

Malignant HyperthermiaMalignant Hyperthermia Genetic skeletal muscle membrane Genetic skeletal muscle membrane

abnormality - never been an ED case reportedabnormality - never been an ED case reported Onset acute or delayed - 60% mortalityOnset acute or delayed - 60% mortality ClinicallyClinically

– Muscle rigidityMuscle rigidity– Autonomic instabilityAutonomic instability– HypoxiaHypoxia– HypotensionHypotension– HyperkalemiaHyperkalemia– Lactic acidosisLactic acidosis– Temp. elevation is a late signTemp. elevation is a late sign

CaseCase

You need a paralytic, however the You need a paralytic, however the patient was severely burnt 48 patient was severely burnt 48 hours ago ago. You can see the hours ago ago. You can see the epiglottis but you need just a little epiglottis but you need just a little more relaxation - what would be more relaxation - what would be your paralytic of choice?your paralytic of choice?

RocuroniumRocuronium

Aminosteroid, non-depolarizing Aminosteroid, non-depolarizing neuromuscular blockerneuromuscular blocker

Agent of choice when sux is CIAgent of choice when sux is CI Onset: 1.2-1.8 min (sux 0.8-1.2)Onset: 1.2-1.8 min (sux 0.8-1.2) Dose: 0.6 mg/kgDose: 0.6 mg/kg Duration of action: 30 -45minDuration of action: 30 -45min

RocuroniumRocuronium

Cannot depend on neostigmine in failed Cannot depend on neostigmine in failed intubation - time to recovery will be too longintubation - time to recovery will be too long

Histamine related hypotensionHistamine related hypotension Primary use of non-depolarizing agents is Primary use of non-depolarizing agents is

for defasiculation and paralytic for defasiculation and paralytic maintenance post-intubationmaintenance post-intubation

Rapacuronium1.5 mg/kg, onset 60 sec, Rapacuronium1.5 mg/kg, onset 60 sec, neostigmine could reverse from 24min neostigmine could reverse from 24min duration to 11min looked ideal, however….duration to 11min looked ideal, however….

RapacuroniumRapacuronium

HOLD THE PRESSES!!!HOLD THE PRESSES!!!

March 27, 2001March 27, 2001– ““Injectable Anesthesia Drug Being Injectable Anesthesia Drug Being

Withdrawn From The Market:Withdrawn From The Market: Bronchospasm in 3.4%Bronchospasm in 3.4% 5 case reports of death (? severe 5 case reports of death (? severe

bronchospasm)bronchospasm) Other drugs also givenOther drugs also given Voluntary withdrawal by the company pending Voluntary withdrawal by the company pending

investigationinvestigation

Paralytics (table)Paralytics (table)

Agent Class Dose(mg/kg) Onset Duration

Vecuronium Intem. 0.1 3-5 30-45

Atracurium Intem. 0.5 3-5 30-45

Pancuronium Long 0.1 3-5 60-90

Rocuronium Intem. 0.6 1-2 30-45

Mivacurium Short 0.15 2.5-4 10-20

Rapacuronium Short 1.5 1-2 10-15

CaseCase

You are ready to intubate the RT is You are ready to intubate the RT is screaming in your ear to push all the screaming in your ear to push all the meds and get the !@#$%^&* tube in. meds and get the !@#$%^&* tube in. The RT is bagging the patient and the The RT is bagging the patient and the nurses have drawn up the appropriate nurses have drawn up the appropriate medications for this head injured, medications for this head injured, hemodynamically stable patient - what hemodynamically stable patient - what is your timeline to intubate?is your timeline to intubate?

TimingTiming

10 minutes out: 10 minutes out: – Prepare (SIGMA D) Peruse (LEMON)Prepare (SIGMA D) Peruse (LEMON)

5 minutes out: Pre-oxygenate5 minutes out: Pre-oxygenate 3 minutes out: Pre-treat (LOAD)3 minutes out: Pre-treat (LOAD) Zero: Paralysis with inductionZero: Paralysis with induction Zero +30 sec: Pressure and positionZero +30 sec: Pressure and position Zero +45 sec: Pass tube - jaw flaccidity Zero +45 sec: Pass tube - jaw flaccidity Zero +1 minute: Post-tube mngmtZero +1 minute: Post-tube mngmt

RSI SequenceRSI Sequence

CaseCase

As you go to intubate a child, you get a As you go to intubate a child, you get a beautiful view of the cords and then it beautiful view of the cords and then it disappears. You cannot seem to direct disappears. You cannot seem to direct the RT to give the right amount of BURP the RT to give the right amount of BURP to get the same view. What can you to get the same view. What can you do? do?

““Pressure and position”Pressure and position”

Sellicks maneuver “BURP”Sellicks maneuver “BURP” Sniffing position - cervical extension and Sniffing position - cervical extension and

atlanto-occipital flexionatlanto-occipital flexion

BURPBURP

The Efficacy of the "BURP" The Efficacy of the "BURP" Maneuver During a Difficult Maneuver During a Difficult Laryngoscopy. Takahata O Anesth Laryngoscopy. Takahata O Anesth Analg - 1997 Feb; 84(2): 419-21Analg - 1997 Feb; 84(2): 419-21

[The difficult intubation. The value of BURP and 3 predictive tests of difficult intubation] Ulrich B - Anaesthesist - 1998 Jan; 47(1): 45-50

CaseCase

You have somewhat blindly intubated a You have somewhat blindly intubated a cardiac arrest patient. You are quite cardiac arrest patient. You are quite confident it went in. However, the end confident it went in. However, the end tidal CO2 monitor is not registering tidal CO2 monitor is not registering wave form. By all other measures the wave form. By all other measures the tube appears in - should you yank it?tube appears in - should you yank it?

““Pass tube with proof”Pass tube with proof”

Thru cordsThru cords MistingMisting ETCO2ETCO2 Chest rising and fallingChest rising and falling Esophageal detectorEsophageal detector

Basic Airway ManagementBasic Airway ManagementPositioningPositioning

Pass tube with proofPass tube with proof

Position of Tube During IntubationPosition of Tube During Intubation

End Tidal CO2End Tidal CO2

QualitativeQualitative– ColorimetricColorimetric

When color change (yellow = yes) virtually 100% When color change (yellow = yes) virtually 100% specificspecific

False negative with cardiac arrestFalse negative with cardiac arrest

QuantitativeQuantitative– CapnographyCapnography

Measures amount of CO2 in the expired air (direct Measures amount of CO2 in the expired air (direct indicator of CO2 elimination by the lungs) indicator of CO2 elimination by the lungs)

Again false negative with cardiac arrestAgain false negative with cardiac arrest

Esophageal Detection Esophageal Detection Devices (EDD)Devices (EDD)

PremisePremise– Esophagus will collapse with suctionEsophagus will collapse with suction– Trachea rigid structure with lots of air Trachea rigid structure with lots of air

(no collapse(no collapse Not as reliable as end tidal CO2 therfore Not as reliable as end tidal CO2 therfore

should be used as a 2should be used as a 2ndnd line device to line device to confirm tube placementconfirm tube placement

Bulb AspirationBulb Aspiration

““Turkey baster”Turkey baster”– Round compressible ballRound compressible ball– Deflate the bulb and attach to end of Deflate the bulb and attach to end of

ETTETT– Esophagus: delayed or sluggish Esophagus: delayed or sluggish

inflationinflation– Trachea: expands rapidly (within 2 Trachea: expands rapidly (within 2

seconds)seconds)

Syringe TechniqueSyringe Technique

Same principleSame principle Use larger volume of airUse larger volume of air Withdraws 30 cc of airWithdraws 30 cc of air Use rapid aspiration os syringeUse rapid aspiration os syringe

CaseCase

You have successfully intubated a You have successfully intubated a Cormack- Lehane grade IV airway while Cormack- Lehane grade IV airway while telling the trauma team about a 67 foot telling the trauma team about a 67 foot putt you drained at McCall Lake. As you putt you drained at McCall Lake. As you are doing your end-zone dance the are doing your end-zone dance the patient grabs for his tube. The nurse patient grabs for his tube. The nurse screams “Dr. Hotshot - what would you screams “Dr. Hotshot - what would you like for maintenance of sedation and like for maintenance of sedation and paralysis?”paralysis?”

““Post-intubation” Post-intubation”

Use a one third therapeutic dose of benzo Use a one third therapeutic dose of benzo and non-depolarizing paralytic when any and non-depolarizing paralytic when any signs of patient awareness detected signs of patient awareness detected

Appropriate vent settings: PEEP, rate, Appropriate vent settings: PEEP, rate, volumevolume

Post-intubation bradycardia is an esophageal Post-intubation bradycardia is an esophageal intubation until absolutely proven otherwise.intubation until absolutely proven otherwise.

CaseCase

You have successfully intubated a child. You have successfully intubated a child. Sixty seconds later the child becomes Sixty seconds later the child becomes hypotensive. What could be the cause?hypotensive. What could be the cause?

Postintubation Postintubation HypotensionHypotension

Tension pneumothorax:Tension pneumothorax:– Incr PIP, difficulty bagging, decr B/S, Incr PIP, difficulty bagging, decr B/S,

poor satspoor sats– Rx: Chest tubeRx: Chest tube

Induction agents:Induction agents:– Exclude other causesExclude other causes– Rx: Fluid bolus, expectantRx: Fluid bolus, expectant

Postintubation Postintubation HypotensionHypotension

Decreased venous return:Decreased venous return:– High PIPS secondary to high intrathoracic High PIPS secondary to high intrathoracic

pressurepressure– Rx: Fluid bolus, bronchodilator, incr exp Rx: Fluid bolus, bronchodilator, incr exp

time, decr tidal volume and ratetime, decr tidal volume and rate Cardiogenic:Cardiogenic:

– Usually in compromised patient; EKG: Usually in compromised patient; EKG: exclude other causesexclude other causes

– Rx: cautious fluid bolus. pressorsRx: cautious fluid bolus. pressors

Post-tube complicationPost-tube complication

A patient becomes hypoxemic 2 A patient becomes hypoxemic 2 minutes after you intubate him. minutes after you intubate him. What is your differential?What is your differential?

Post-intubation HypoxiaPost-intubation Hypoxia

D: DislodgedD: Dislodged O: ObstructionO: Obstruction P: PTXP: PTX E: Equipment failureE: Equipment failure

Mr. Pierre RobinMr. Pierre Robin

Your called to a 2 year old child who is Your called to a 2 year old child who is

“flat”, mom says he has been unwell for “flat”, mom says he has been unwell for a few days. She found him a few days. She found him unresponsive. You note he has a tiny unresponsive. You note he has a tiny mandible and a large tongue. How are mandible and a large tongue. How are you going to prepare for this airway?you going to prepare for this airway?

Difficult AirwayDifficult Airway

Emergency PhysiciansEmergency Physicians– National Emergency Airway RegistryNational Emergency Airway Registry– 6294 intubations6294 intubations– 85% successful on first attempt85% successful on first attempt– 99% ultimately successful99% ultimately successful– 1% failed airway requiring rescue 1% failed airway requiring rescue

maneuversmaneuvers

Difficult AirwayDifficult Airway

Sakles Jc et al Sakles Jc et al Ann Emergency MedAnn Emergency Med 19981998

Intubations over 1 yr in their ED Intubations over 1 yr in their ED (N=610)(N=610)– 569 (93%)by staff/residents569 (93%)by staff/residents– 515(84%) used RSI515(84%) used RSI– 98.9% intubated successfully98.9% intubated successfully

Difficult AirwayDifficult Airway

Paralytics and Aeromedical Paralytics and Aeromedical TransportTransport– Program A (RSI) success rate: 93.5%Program A (RSI) success rate: 93.5%– Program B (no RSI) : 66.7%Program B (no RSI) : 66.7%

Same program after institution if RSISame program after institution if RSI Success: 90.5%Success: 90.5%

Difficult Airway – BARFDifficult Airway – BARF

B(5): Best view, Best person, Bougie, B(5): Best view, Best person, Bougie, Blade change, BURP manueuverBlade change, BURP manueuver

Alternative airway: LMA, lighted styletAlternative airway: LMA, lighted stylet Rescue: BMV with BURPRescue: BMV with BURP Failed airway: TTJV if <8 years old, crich Failed airway: TTJV if <8 years old, crich

if >8if >8

Best ViewBest View

Cormack-Lehane Cormack-Lehane laryngoscopy laryngoscopy grading system grading system

Grade 1 & 2 low Grade 1 & 2 low failure ratesfailure rates

Grade 3 & 4 high Grade 3 & 4 high failure ratesfailure rates

Blade ChangeBlade Change

Macintosh (curved)Macintosh (curved)– McCoy – articulating tipMcCoy – articulating tip

Miller (straight)Miller (straight)– Use with children younger than 8y/o, Use with children younger than 8y/o,

and people with anterior larynx (short and people with anterior larynx (short mental- hyoid distance)mental- hyoid distance)

– Wisconsin and Guedel bladesWisconsin and Guedel blades Larger more rounded barrelLarger more rounded barrel

Blade ChangeBlade Change

Laryngoscopy and IntubationLaryngoscopy and Intubation– ““the single greatest obstacle to the single greatest obstacle to

successful intubation is the tongue… successful intubation is the tongue… the tongue is the enemy”the tongue is the enemy”

– Paraglossal techniqueParaglossal technique Step 1 (blind) insert blade blindly into the Step 1 (blind) insert blade blindly into the

esophagusesophagus Step 2 (visual) withdraw blade until you Step 2 (visual) withdraw blade until you

visualize the cords /epiglottisvisualize the cords /epiglottis

Alternative Airway Alternative Airway techniquetechnique

LMALMA Orotracheal or nasotrachealOrotracheal or nasotracheal Lighted styletLighted stylet DigitalDigital RetrogradeRetrograde FibreopticFibreoptic

Alternative Airway - Alternative Airway - Laryngeal MaskLaryngeal Mask

Does not constitute Does not constitute definitive airway definitive airway managementmanagement

Temporizing Temporizing measure in the EDmeasure in the ED

Size : Size : – #3 teenagers and #3 teenagers and

small female adultssmall female adults– #4 average size #4 average size

adultadult– #5 large adults#5 large adults

Alternative Airway-Alternative Airway-Laryngeal MaskLaryngeal Mask

Inflate cuffInflate cuff– #3 – 20cc#3 – 20cc– #4 – 30cc#4 – 30cc– #5 – 40cc#5 – 40cc– Or until no leakOr until no leak

Note: no literature Note: no literature describing the describing the

success rate in the success rate in the ED(OR success ED(OR success >95%)>95%)

Alternative Airway - LMAAlternative Airway - LMA

Zideman D - Zideman D - Ann Emerg MedAnn Emerg Med - 01-Apr-2001; 37(4 Suppl): - 01-Apr-2001; 37(4 Suppl):

S126-36S126-36 Not studied in infant/child resuscitationNot studied in infant/child resuscitation Complications more frequent in pedsComplications more frequent in peds Correct sizeCorrect size

– 1 = smallest; 3-4 = adult female; 4-5 = 1 = smallest; 3-4 = adult female; 4-5 = adult maleadult male

May be dislodged during transport/CPRMay be dislodged during transport/CPR Aspiration – little protectionAspiration – little protection

Alternative Airway - Alternative Airway - CombitubeCombitube

Double lumen, double cuff airwayDouble lumen, double cuff airway Insert in the midlineInsert in the midline Inflate proximal large oropharyngeal balloon Inflate proximal large oropharyngeal balloon

( 100mls of air) – via blue pilot balloon ( 100mls of air) – via blue pilot balloon Inflate white distal balloon with 5-15mls airInflate white distal balloon with 5-15mls air Ventilate first through the long blue port – if Ventilate first through the long blue port – if

air in lungs the tube in the esophagus air in lungs the tube in the esophagus (majority of time in esophagus)(majority of time in esophagus)

If air in stomach then tube in the trachea (rare If air in stomach then tube in the trachea (rare event) then ventilate through the short clear event) then ventilate through the short clear portport

Alternative Airway - Alternative Airway - CombitubeCombitube

Effective airway Effective airway management management devicedevice

Higher success rate Higher success rate than LMA in the than LMA in the prehospital settingprehospital setting

High rate of High rate of success and few success and few complications when complications when used for prehospital used for prehospital cardiac arrestcardiac arrest

Alternative Airway Alternative Airway Nasotracheal IntubationNasotracheal Intubation

AdvantagesAdvantages– Very few over RSIVery few over RSI

Disadvantages:Disadvantages:– Takes a long timeTakes a long time– Higher failure rateHigher failure rate– Higher Higher

complication ratecomplication rate– Use smaller tube Use smaller tube

sizesize

Alternative Airway Alternative Airway Nasotracheal IntubationNasotracheal Intubation IndicationIndication

– A potentially difficult intubation who is A potentially difficult intubation who is spontaneously breathing - epiglottitisspontaneously breathing - epiglottitis

– Pt you do not want to paralyzePt you do not want to paralyze ContraindicatedContraindicated

– Combative ptsCombative pts– Anatomically deranged airwayAnatomically deranged airway– Neck hematomasNeck hematomas– Raised ICPRaised ICP– Severe facial traumaSevere facial trauma– CoagulopathyCoagulopathy

Alternative Airway Alternative Airway Nasotracheal IntubationNasotracheal Intubation

PearlsPearls– Sniffing positionSniffing position– Pull tongue forward by grasping with Pull tongue forward by grasping with

gauzegauze– Only 60-70% successful on first Only 60-70% successful on first

attempt (10-20% of NTI’s are simply attempt (10-20% of NTI’s are simply not possiblenot possible

Alternative Airway Alternative Airway Lighted StyletLighted Stylet

Use if cannot directly Use if cannot directly visualize the larynx visualize the larynx with laryngoscopywith laryngoscopy

Relies on Relies on transillumination of transillumination of the soft tissues of the the soft tissues of the neckneck

Trachea: well defined Trachea: well defined glowglow

Esophagus: diffuse Esophagus: diffuse light glowlight glow

Alternative Airway Alternative Airway Lighted StyletLighted Stylet

Success rates consistent with or exceed Success rates consistent with or exceed that of conventional laryngoscopythat of conventional laryngoscopy

Alternative Airway Alternative Airway Digital IntubationDigital Intubation

Tactile intubation Tactile intubation techniquetechnique

Use of fingers to direct Use of fingers to direct the tube into the larynxthe tube into the larynx

Not easy to perform (if Not easy to perform (if have small hands)have small hands)

Indications:Indications:– No laryngoscopy No laryngoscopy

equipmentequipment– Visualization of the Visualization of the

larynx is impossible larynx is impossible (blood, secretions)(blood, secretions)

– Best for premature and Best for premature and newborn infantsnewborn infants

Rescue AirwayRescue Airway

BVM with BURPBVM with BURP

BONES - predicts difficult mask ventilationBONES - predicts difficult mask ventilation B: BeardB: Beard O: ObeseO: Obese N: No teethN: No teeth E: Elderly (>55 y/o)E: Elderly (>55 y/o) S: SnoresS: Snores

Failed Airway Failed Airway

Surgical:Surgical: Needle crich & TTJV, cricothyrotomy, Needle crich & TTJV, cricothyrotomy,

retrograde intubationretrograde intubationDifficult crich: SHORTDifficult crich: SHORTS: SurgeryS: SurgeryH: HematomaH: HematomaO: ObeseO: ObeseR: RadiationR: RadiationT: TumorT: Tumor

Failed AirwayFailed Airway Cricothyroidodomy not recomm. age <8Cricothyroidodomy not recomm. age <8

– complication rate 10-40%complication rate 10-40%– Retrograde?Retrograde?

Transtracheal jet ventilationTranstracheal jet ventilation– surgical method of choice in emergencysurgical method of choice in emergency– allows ventilation for 45-60 minsallows ventilation for 45-60 mins– risk – aspiration, subcutaneous risk – aspiration, subcutaneous

emphysema, barotrauma, bleeding, emphysema, barotrauma, bleeding, catheter dislodgment, CO2 retentioncatheter dislodgment, CO2 retention

Failed Airway Failed Airway Retrograde IntubationRetrograde Intubation

Puncture the cricothyroid membrane Puncture the cricothyroid membrane then thread a wire retrograde to the then thread a wire retrograde to the mouth, the tube is then inserted over mouth, the tube is then inserted over the wirethe wire

Use as rescue techniqueUse as rescue technique Do not use if infection at the site of the Do not use if infection at the site of the

needle punctureneedle puncture Note: does take time to doNote: does take time to do

Failed Airway Failed Airway Surgical AirwaySurgical Airway

CricothyrotomyCricothyrotomy– NEAR StudyNEAR Study

Only 1% of 4000 Ed intubations required cric.Only 1% of 4000 Ed intubations required cric. 20% complication rate (mostly minor)20% complication rate (mostly minor)

– 4 step process4 step process– Pediatrics age >8 y/oPediatrics age >8 y/o– #4 Shiley cuffed tube#4 Shiley cuffed tube

Needle cricothyrotomy (age <8)Needle cricothyrotomy (age <8)

Failed Airway Failed Airway Surgical AirwaySurgical Airway

Needle cricothyrotomy/ TTJVNeedle cricothyrotomy/ TTJV– Temporizing measureTemporizing measure– Surgical airway of choice for age <8 Surgical airway of choice for age <8

y/oy/o– Need supraglottic patency Need supraglottic patency

(exhalation)(exhalation)– No airway protectionNo airway protection

Failed Airway Failed Airway Surgical AirwaySurgical Airway

Needle cricothyrotomy/ TTJVNeedle cricothyrotomy/ TTJV– 12-16G needle12-16G needle– <5 y/o ventilation only by bag<5 y/o ventilation only by bag– 5-12 y/o 30 psi5-12 y/o 30 psi– 12 – adult 30-50 psi12 – adult 30-50 psi

CaseCase

A lucid, perfectly well 20 year old A lucid, perfectly well 20 year old has been hit in the throat with a 67 has been hit in the throat with a 67 foot putt. He is stridorous and sats foot putt. He is stridorous and sats are fine. He has a large hematoma are fine. He has a large hematoma externally. He is slowly getting externally. He is slowly getting worse. How would you like to worse. How would you like to intubate him?intubate him?

Awake intubationAwake intubation

Lidocaine spray Lidocaine spray 4% lidocaine on pledgets4% lidocaine on pledgets Titrated dose of midazolam and fentanylTitrated dose of midazolam and fentanyl Take a look - can turn into a formal RSITake a look - can turn into a formal RSI

Thanks Thanks

Idan Khan MD, FRCPSIdan Khan MD, FRCPS

Gord McNeil MD, FRCPSGord McNeil MD, FRCPS