the emergency airway national review course in emergency medicine kirk magee md, msc, frcpc...
TRANSCRIPT
![Page 1: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/1.jpg)
The Emergency Airway
National Review Course in Emergency Medicine
Kirk Magee MD, MSc, FRCPCAssociate Professor
Dalhousie Department of Emergency Medicine
![Page 2: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/2.jpg)
![Page 3: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/3.jpg)
Outline:
• Recognition: is this an airway question?
• Cases
![Page 4: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/4.jpg)
Case
• A 35 year old female presents to the ED with an altered LOC. She was found surrounded by empty pill bottles
• Vital Signs: HR 130, BP 115/78, sats 98%, GCS 6/15
• Is this an airway question?
![Page 5: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/5.jpg)
Types of Airway questions
• Recognition of the need for an airway• Description of RSI and recognition of
relative contraindications• Recognition and management of a
difficult airway• Post intubation management• Approach to the failed airway
![Page 6: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/6.jpg)
How to drive an examiner nuts…
• “I would perform an RSI with a double set-up”
![Page 7: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/7.jpg)
Exam triggers to the difficult airway:
• Morbidly obese• Trauma to head or neck• Burns• Stridor• Prior unsuccessful attempts• Asthma• Anaphylaxis
![Page 8: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/8.jpg)
Beware…
BMV
Laryngoscopy
![Page 9: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/9.jpg)
Difficult Mask Ventilation
• Beard mask seal issues
• Obese lung/chest wall compliance
• Older head/neck position
• Toothless mask seal
• Snores/Stridor obstruction‘BOOTS’
![Page 10: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/10.jpg)
Predicting Difficult Laryngoscopy and Intubation
MMAP the airway:• Mallampati and Measure
3-3-1
• A-O extension
• Pathologic conditions
‘MMAP’
![Page 11: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/11.jpg)
Lets get ready to rumble!
![Page 12: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/12.jpg)
Cases
![Page 13: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/13.jpg)
Case 1
• 34 yo asthmatic presents with severe respiratory distress
• Normal airway
• VS: 122, 32, 156/90
![Page 14: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/14.jpg)
Special Considerations
• Percipitating causes:– Pneumothorax, mucous plug– Role of epinephrine
• Difficult/impossible to BMV• Permissive hypercapnea• Ketamine• Apneic oxygenation
![Page 15: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/15.jpg)
Apneic Oxygenation
![Page 16: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/16.jpg)
Pre-oxygenation combining high flow nasal canula and a non-rebreather mask• Measured inspired oxygen NRBM @ 15 lpm only
60-70%– Pt’s expired gasses are mixing with applied O2 in
nasopharynx
• High flow nasal O2 flushes the nasopharynx with O2
– When pt inspires, inhale higher percentage of inspired O2
• Small changes in FiO2 create dramatic changes in the availability of O2 at the aveolus
![Page 17: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/17.jpg)
Apneic Oxygenation
• Alveoli will continue to take up O2 even without diaphragmatic movments
• Optimal circumstances: PaO2 can be maintained at > 100 mmHg for up to 100 minutes without a single breathe!
![Page 18: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/18.jpg)
“NO DESAT”
Nasal Oxygen During Efforts Securing A Tube
![Page 19: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/19.jpg)
“If you enter the exam as a resident, that is how
you will leave, but if you enter as a consultant…”
Be decisive!
![Page 20: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/20.jpg)
Case 2
• 4 yo presents with a 3 day hx of fever and “flu-like” symptoms
• Unable to arouse• VS: 139, 6, 60/40
![Page 21: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/21.jpg)
Special Considerations
• Not just “little adults”
![Page 22: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/22.jpg)
The Pediatric Airway
• Smaller airway• Large occiput• Tongue is larger• Larynx is relatively cephalad in position• Epiglottis is more floppy• < 10 yrs, narrowest portion of airway is
below vocal cords• Higher basal metabolic rate• bradycardia
![Page 23: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/23.jpg)
Important pediatric numbers:• ET Tube size:
• ET Tube depth:
Age
4
Age
2
+ 4
+ 4
Breslow Tape
![Page 24: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/24.jpg)
Case 3
• 26 yo Type 1 diabetic
• Florid DKA, not protecting his airway
• VS: 127, 28, 95/66, 95%
![Page 25: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/25.jpg)
![Page 26: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/26.jpg)
Special Considerations
• Hyperkalemia• Post-intubation still need high
respiratory rate– DKA– ASA overdose
![Page 27: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/27.jpg)
Contraindications to Sux
• Hyperkalemia• Burns > 10% BSA• Crush injury• Denervation• Neuromuscular disease
– ALS, MS• Malignant hyperthemia
![Page 28: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/28.jpg)
Case 4
• 50 yo pulled from burning car
• Significant burns to face, stridor
• VS: 112, 28, 132/88, 88%
![Page 29: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/29.jpg)
Special Considerations
• Difficult airway• Toxicology
– CO– CN
![Page 30: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/30.jpg)
MMAP: Pathological Obstructing Conditions…
e.g. Periglottic edema
e.g. Glottic trauma
![Page 31: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/31.jpg)
MMAP: Pathologically Obstructing Conditions…
…with deep sedation may be impossible to BMV or intubate !!
![Page 32: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/32.jpg)
Two Possible Scenarios
• Can’t Intubate• Can Ventillate
• Can’t Intubate• Can’t ventillate
![Page 33: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/33.jpg)
What are your options?
• If not contraindicated, RSI may actually improve success rate– Double set-up
• Are you the right person, is the ED the right location?
• Awake intubation
![Page 34: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/34.jpg)
‘Awake’ intubation
Advantages• Airway maintained
• Breathing continues• Stable
hemodynamics
Disadvantages• Can be difficult• Cooperation• Adverse reflexes
(GI/CNS/CVS)
…Intubation with topical airway anesthesia and light sedation.
![Page 35: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/35.jpg)
Rescue device: Glide Scope®
![Page 37: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/37.jpg)
Rescue ventilation devices: I-LMA
![Page 38: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/38.jpg)
Rescue devices: Lighted Stylet
![Page 39: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/39.jpg)
Rescue techniques
• Glide Scope®
• LMA• I-LMA• Lighted Stylet• Esophagotracheal Combitube• Retrograde Intubation• Fiberoptic Intubation
![Page 40: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/40.jpg)
Can’t ventilate, Can’t intubate
![Page 41: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/41.jpg)
Cricothryotomy Contraindications:
• Distorted neck anatomy• Pre-existing infection• Coagulopathy
• +++ difficult in pts < 10 yrs of age
Relative Contraindications!
![Page 42: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/42.jpg)
What equipment do you need?• Scalpel• Tracheal dilator (Trousseau dilator) or
spreader• Tracheal hook• Portex or Shiley tube (No. 5-6 in
adult)
![Page 43: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/43.jpg)
Decribe how you would perform a cricothyrotomy
![Page 44: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/44.jpg)
Case 5
• 72 yo with altered LOC and urosepsis
• Normal airway
• VS: 124, 20, 70/40
![Page 45: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/45.jpg)
Special Considerations
• CBA not ABC!– Maximize BP first
• Relative contraindication for etomidate?
![Page 46: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/46.jpg)
“If only I had been a vet…”
![Page 47: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/47.jpg)
Case 6
• 26 yo mountain biker “clothes-lined” on wire fence at high speed
• Pt is unable to talk; obvious respiratory distress
• Edema and echymosis evident at his neck
• VS: 115, 26, 160/85, 88%
![Page 48: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/48.jpg)
Special Considerations
• The “most difficult” airway!• Patent airway may be lost with deep
sedation/paralysis• How does the scenario change with:
– Time from injury– Community vs Urban ED– “stable” vs. “unstable”
![Page 49: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/49.jpg)
Your 1st attempt should not be in Ottawa at the exam centre!
![Page 50: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/50.jpg)
Putting it all together
• Preparation – predictors of difficult BMV/laryngoscopy
• Preoxygenate – no BMV• Paralysis and induction agent• Placement of tube and confirmation• Post tube management
![Page 51: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/51.jpg)
Putting it all together…Assess predictors of
difficult BMV/laryngoscopy
Pre-oxygenate
Paralytic/Induction Agent
Reposition
BURP
Bougie
Blade/ETT Change
Confirm Tube Placement
Rescue Techniques
Post Intubation Management
Cricothyrotomy
Unsuccessful
Unsuccessful
Unsuccessful
![Page 52: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/52.jpg)
Difficult Laryngoscopy and Intubation: Putting it all together…
QuickTime™ and aCinepak decompressor
are needed to see this picture.
![Page 53: The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine](https://reader035.vdocuments.us/reader035/viewer/2022062516/56649db05503460f94a9e25e/html5/thumbnails/53.jpg)