kenneth w. stuebing program manager a-emca, critical care flight paramedic

Kenneth W. StuebingProgram ManagerA-EMCA, Critical Care Flight Paramedic

DIFFICULTDIFFICULTAIRWAYAIRWAYReviewReview

Kenneth W. Stuebing EMCA, CCP(F)

ObjectivesObjectives During this presentation we will discuss:

– A systematic approach to airway assessment– Common terminology (talk the same language)– Pediatric airway concerns– Difficult airway assessment– Introduce facilitated intubation– Introduce Rapid Sequence Induction CONCEPTS– Introduce alternate airway adjuncts– Introduce an AIRWAY algorithm– Practice airway procedures


STRESSED ?STRESSED ? Let me paint the picture for you!

– WHEN: 16:00 hrs. on Friday– WHERE: MAIN & JAMES– WHAT: 8 year old female patient who was hit by a speeding car

(approximately 90 kph)– She is unconscious, responds with groans to pain, does not open

eyes and withdraws from pain. She has a pulse of 50 and is breathing but you notice her skin is pale and lips are blue. She is bradycardic, hypotensive and tachypnic. You note multiple fractures and copious amounts of blood loss with paradoxical (seesaw) breathing. Her air entry is markedly diminished on the left side and crackles on the right (aspiration?). She has a blown left pupil and lateralizing signs.


First Things FirstFirst Things First Indications for intubation

LOC– Obtain / Maintain / Protect Airway– Oxygenation– Positive Pressure Ventilation or control ventilation– Drugs (NAVEL) Fatigue– Access Tracheal Toilet (suction)


WhyWhy PAIN PAINFUL STIMULUS?FUL STIMULUS?

MEDICAL TRAUMA

PROTECT C-SPINE


RESPIRATORY PROCESSRESPIRATORY PROCESS

NATURAL: ALVEOLAR PRESSURE < ATMOSPHERIC

MECHANICAL: ATMOSPHERIC PRESSURE> ALVEOLAR PRESSURE


SELLICK MANEUVERSELLICK MANEUVERoror

CRICOID PRESSURECRICOID PRESSURE FINGER PRESSURE ON

CRICOID CARTILAGE WHICH AIDS IN INTUBATION AND PREVENTS GASTIC DISTENTION & ASPIRATION


Airway AssessmentAirway AssessmentOnce the decision to intubate has been made a deliberate

assessment process needs to be started. Is it a CRASH intubation?

– Death or near death (like “NIKE” “just do it”)– Suction, stylette, lubed ETT, stethoscope, laryngoscope

Is it a DIFFICULT intubation?– LEMON

(DO YOU NEED TO LOAD YOUR PATIENT ?)

Rapid Sequence Induction / Intubation (RSI) future?– Sedation, analgesia, neuromuscular blocking agent


CRASHCRASH AIRWAY AIRWAY VSA Pending VSA Respiratory Arrest GCS < 5 Airway compromise (blood / vomit unable to clear)

Note: positioning is the number 1 airway procedure to prevent aspiration.


DIFFICULTDIFFICULT AIRWAY AIRWAY LEMON assessment scale.

– Prior to taking TOTAL control of airway– May choose to facilitate intubation (versed)– May need to LOAD patient

Lidocaine Opiate Atropine Depolarizing neuromuscular blocking agent (defasiculating)


LEMONLEMON L - Look 1 point E - Evaluate 2 points M - Mallampati (1 - 4) 2 points O - Obstruction 2 points N - Neck 1 point

2 or more equals difficult


LEMONLEMON

L - Look (visual assessment) 1 point (each)– Under / over bite– Big teeth– Facial hair– No neck– Barrel chest

Gut feeling tough tube!!!


LEMONLEMON E - Evaluate 2 points

– Ability to open mouth 3 fingers– Anterior Larynx 3 fingers– Superior Larynx 2 fingers

Children and Asians have anterior and superior larynx.


LEMONLEMON M - Mallampati (1 - 4) = 0 or 2 points

– 1 = can see all of uvula– 2 = can see most of uvula– 3 = can see a part of uvula– 4 = can see none of uvula - all hard palate

Paramedics should lean to a 1 or 4 interpretation.


LEMONLEMON

O - Obstruction 2 points

– Tumors– Hematoma– Swelling


LEMONLEMON

N - Neck 1 point – Immobility, unable for flex or extend neck– C -spine precautions– Kyphosis– Osteoporosis– Severe Rheumatoid Arthritis

2 or more equals difficult airway is expected


What if it is difficult?What if it is difficult? Concern for paralytics and heavy use of

analgesics and sedatives. If patient quits breathing and you are unable to ventilate - you have broken fundamental premise of medicine “CAUSE NO HARM”.

Before taking TOTAL control of a patient’s airway an accurate / defendable assessment for due diligence AND a back up must be available.

Blind nasal intubation with slight sedation may be beneficial.


Facilitated IntubationFacilitated Intubation Sedation (decrease LOC)

– Versed (January 2002 with patch) concerns for hypotensive patients helps blunt sympathetic response amnesia

Analgesia (stop pain)– Morphine

concerns for hypotensive patients helps blunt sympathetic response

– Fentanyl (synthetic opiate 100 x stronger than morphine) concerns for hypotensive patients helps blunt sympathetic response


VersedVersedMadazolam HCLMadazolam HCL

Classification: Sedative (anxiolytic and hypnotic)– CNS depressant (benzodiazepines, barbiturates, etc)

Mode of Action:– Inhibitory action of the GABA receptors (ý~aminobutyric acid):

When GABA binds to CNS receptors it increases the chloride that enters the cell. This causes a SMALL hyperpolarization and moves the postsynaptic receptor away from its action potential. (resting potential more negative)

Benzodiazepines bind to specific, high affinity sites on CNS cell membranes beside GABA receptors, resulting in more frequent opening of the chloride channels. This hyperpolarizes the postsynaptic receptor even MORE then GABA alone and further inhibits neuronal firing.

Benzodiazepines also interfere with the release of calcium from the sacroplasmic reticulum in the CNS inhibiting these cells further.


BenzodiazepinesBenzodiazepines BENZODIAZEPINES:

– GABA receptors are only found in the CNS

– have no analgesic or anti psychotic effects

– do not affect the autonomic nervous system (still BP caution)

– all have exhibit varied level of these actions:

Anxiolytic Muscle relaxant Sedative / hypnotic Anticonvulsant



– Anxiolytic at low doses they are

anxiolytics, thought to selectively inhibit neuronal circuits in the brain’s limbic system.

– Muscle Relaxant relax spasticity of

skeletal muscle, by increasing presynaptic inhibition of the spinal cord.



– Sedative / hypnotic All Benzos have these

properties at high doses can cause hypnosis and respiratory depression and hypotension.

– Anticonvulsant Several types are used

to treat epilepsy however some don’t have a long enough half life to be useful.


BenzodiazepinesBenzodiazepines Pharmacology:

– Absorption and distribution: Lipophilic benzodiazepines are rapidly & completely absorbed after PO, IV

& SQ administration & distributed evenly throughout the body.

– Duration of actions: Half lives of this classification of drug are VERY important for their clinical

use. They are divided into 3 categories: Long acting: (Valium / Diazepam) Intermediate acting: (Lorazepam) Short acting: (Triazolam, Versed)

– Metabolism & Excretion: most are metabolised in the liver and therefore caution should be used when

administering to people with hepatic dysfunction eliminated in the urine.


VersedVersedMadazolam HCLMadazolam HCL

Adverse affects:– Drowsiness and confusion – Hypoventilation– Tackycardia / bradycardia– Hypotension

Caution:– It will potentiate effects of alcohol and other CNS depressants

Versed in use by January - February 2002

Dose: > or = 40 kg 0.05mg/kg (0.1 mg/kg)


RSIRSI Induction / Sedation

– Versed & Morphine (?) Neuromuscular blocking agent

– Succinylcholine (depolarizing or fasiculating) Acetylcholine Agonist: causes systemic release of ALL acetylcholine

from motor nerve endings which bind to nicotinic receptors on the neuromuscular endplates of all skeletal muscle. This causes a fasiculation (seizure) while all muscles contract or depolarize at once.

Since ALL acetylcholine is released it is impossible for muscle contraction to occur until stores have been replenished.

– Note: skilled practitioners can usually intubate ~ 80 - 90% of the population without too much trouble. The remaining 10 - 20 % falls under the difficult to very difficult category.


LOADLOAD Lidocaine

– to blunt ICP for patient with: CVA Head Injuries

Opiate - Analgesia– Fentanyl

concerns for hypotensive patients will also blunt ICP and reduce sympathetic response

Atropine (have ready)– to stop vagal response - particularly pediatrics

Defasiculating neuromuscular blocking agent - ART– used to stop fasiculation caused by Succinycholine


Emergency Cricothyrotomy ProtocolEmergency Cricothyrotomy ProtocolIf a patient cannot be ventilated due to life-threatening suspected upper airway obstruction, the Advanced Care Paramedic may attempt a cricothyrotomy according to the following protocol after receiving orders from the BHP.

Indications:A patient that requires intubation andUnable to intubate and Unable to adequately ventilate

Conditions:Patient 40 kg and 12 years old

Contraindications:Suspected fractured larynxInability to localize the cricothyroid membrane


Emergency Cricothyrotomy ProtocolEmergency Cricothyrotomy ProtocolProcedure: 1. Administer 100% O2.2. Contact the BHP for on-line medical direction to proceed with this protocol.3. If every attempt to contact a BHP has failed, the AC Paramedic may continue with this protocol in a life-threatening situation if all other indications and conditions are met. The AC Paramedic should contact the BHP (and the Base Hospital) as soon as possible after the procedure and document the patch failure and decision to proceed.4. Place patient on his or her back, and then extend the head and neck (provided there are no c-spine injuries).5. Grasp the larynx with your thumb and middle finger. Locate the cricoid cartilage and the cricothyroid membrane with the index finger. Prep the area quickly.

Follow the appropriate procedures following for the specific equipment used. The seldinger cricothyrotomy should be the primary method used but if the equipment is not available, the needle cricothyrotomy procedures should be followed.


Emergency Cricothyrotomy ProtocolEmergency Cricothyrotomy ProtocolSeldinger (Melker) Cricothyrotomy Kit:1. While stabilizing the thyroid cartilage make a vertical incision in the midline of the cricothyroid membrane with a scalpel.2. Use the supplied 18g TFE catheter with the 6cc syringe attached. Insert the catheter into the airway at a 45º caudal angle looking for free air in the syringe.3. Remove the syringe and needle leaving the catheter in place. Always maintain contact with the guidewire, never let go!4. Advance the soft flexible end of the wire guide through the catheter and into the airway several centimeters caudally.5. Remove the catheter leaving the wire guide in place. (STEP # 1)6. Feed the dilator (with airway catheter in place) over the wire. Ensure that the stiff end of the wire protrudes out of the back of the dilator. 7. Advance the dilator into the airway until the flange of the 15mm airway adapter is resting against the patient's neck.8. Remove the dilator and wire guide. Use caution to ensure that the wire guide is not lost into the trachea.9. Secure the flange of the airway adapter to the patient.10.Attach a BVM and attempt to ventilate the patient. Genesis or other ventilators must not be used.11.Initiate rapid transport to the closest appropriate hospital.12.Patch to the Base Hospital if complications arise or further orders are required.


Emergency Cricothyrotomy ProtocolEmergency Cricothyrotomy ProtocolNeedle Cricothyrotomy:7. Attach a 14 gauge over-the-needle catheter to a 10 cc syringe filled with saline. Carefully insert the needle through the skin and cricothyroid membrane into the trachea while aspirating for free air. Direct the needle at a 45 degree angle caudally.8. Aspirate with the syringe. If air is returned easily by way of seeing bubbles in the saline filled syringe, you are in the trachea. If it is difficult to aspirate with the syringe, or if you obtain blood, re-evaluate needle placement. 9. Withdraw the stylette, while gently advancing the catheter downward into position.10.Attach an adapter to the hub of the catheter and begin ventilating with 100% O2 with a BVM. Genesis or other ventilators must not be used.11.Secure the catheter and continue ventilation, allowing time for passive expiration12. Initiate rapid transport to the closest appropriate hospital. 13. Patch to the Base Hospital if complications arise or further orders are required.


Needle CricothyroidotomyNeedle Cricothyroidotomy

SECOND LINE PROCEDURE that should be used if Seldinger technique is not possible. (BHP may give orders from 8 - 12 year old patient)Provides temporary oxygenation but no ventilationNote:Exhalation may be difficult through such a small diameter catheter and the paramedic should lengthen the time between breaths to allow for exhalation.The BHP may consider giving orders for a second catheter horizontally next to the first to allow for better exhalation and this should be discussed during the patch.


Cricothyroidotomy Cricothyroidotomy (Melker)(Melker)


Cricothyroidotomy Cricothyroidotomy (Melker)(Melker)

2Maintain landmark with one hand & insert the 6cc syringe with 18 guage TFE catheter and introducer needle. Advance needle on a 45° angle to the frontal plane in the midline in a caudad direction. While inserting needle draw back on syringe to verify when trachea has been found.

Landmark cricothyroidmembrane between the thyroid and cricoid cartilages and prep area.


CricothyroidotomyCricothyroidotomy

Remove the syringe and needle leaving the catheter in place. Advance the soft, flexible end of the guidewire through the TFE catheter and into the airway several centimeters.

3 4While holding on to the guidewire ensuring not to let it move carefully remove theTFE.



While holding the guidewire make a vertical incision with the # 15 short handle scapel blade to allow dilator to be inserted.

5While holding on to the guidewire advance the preassembleddilator and airway catheter with the tapered end first over the guidewire.

6

PLAY EMERGENCY AIRWAY PLAY EMERGENCY AIRWAY VIDEO!VIDEO!


Airway Assessment Algorithm

CRASH INTUABTIONDEATH OR NEAR DEATH

NO

DIFFICULT AIRWAYLEMON

Yes

Can you ventilate the patient?

Consider Adjunct Devices Lighted Stylette LMA

Rapid SequenceInduction / Intubation(future consideration)

VersedFentanylSuccinylcholine

NO

Note 1: Confirmation includes 3 methods with 1 being end tidal CO2 confirmationNote 2: Reassess continually to determine whether the patient’s condition reverts to

“Crash Intubation” or “Facilitated” criteria.

YES

YESINTUBATE:

Lubricated TubeStyletteSuctionStethescopeSyringe

No

SUCCESSFUL?

..

SUCCESSFUL?

NO

NO

SUCCESSFUL?

Continue to ventilatewith adjunct or BVM

ConsiderLidocaine

YESNo

NO

YES: Confirm(see Note 1)

REASSESS (see Note 2)


CONSIDERPATCH FOR

FACILITATEDINTUBATION:

Versed/Morphine

Perform Cricothyrotomy


Airway Assessment Algorithm

CRASH INTUABTIONDEATH OR NEAR DEATH

NO

DIFFICULT AIRWAYLEMON

Yes

Can you ventilate the patient?

Consider Adjunct Devices Lighted Stylette LMA

NO

Perform Cricothyrotomy

Note 1: Confirmation by 3 methods; one must be end-tidal CO2 (when available).Note 2: Reassess continually to determine whether the patient’s condition reverts to

“Crash Intubation” or “Facilitated” criteria.

YES

YESINTUBATE:

Lubricated TubeStyletteSuctionStethescopeSyringe

NoCONSIDERPATCH FOR

FACILITATEDINTUBATION:

Versed/Morphine

SUCCESSFUL?

..

SUCCESSFUL?


NO

NO

Continue to ventilatewith adjunct or BVM

ConsiderLidocaine

REASSESS (see Note 2)


QuestionsQuestions


Reference MaterialReference Material Website @ www.springnet.com/criticalcare PALS / NALS The ICU Book by Paul L. Marino Hemodynamic Monitoring by Darovic Lippicotts Pharmacology Merck Manual Hemodynamic Monitoring by Dana Oakes Handouts - Compiled Information

(Sunnybrook)


Thank you

Kenneth W. StuebingClinical Co-ordinator H.B.H.

CCP(F), AEMCA

kenneth w. stuebing program manager a-emca, critical care flight paramedic

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