Emergency Airway Management 2014: Mark P. Brady PA-C

2013

Agenda:

•  Airway Anatomy Adult vs. Pediatric •  Review of basic equipment •  Approach to the Difficult Airway •  RSI •  Post-Intubation Management •  Ventilator Settings •  The Crashing Asthmatic

Important take home points

The search for the epiglottis

Are kids just small adults?

vs Airway Anatomy

Airways

not Difficult

•  Externally

– Larger head/occiput – Head flexes forward and can obstruct

•  Internally –  Intra-oral tongue – Large, floppy epiglottis

•  Further differences – “Pinker” vocal cords worsen visualization

– Different location of narrowest point • Peds cuffed tubes?

– Smaller cricothyroid membrane • No surgical crics in children

Other Considerations

•  More gastric insufflation with BVM •  Quicker desats during intubation Different

•  10 kg will drop to 90% in <4 minutes (vs. 8 for adult)

•  Vagal response (not significant) •  Consider Pre-treatment with Atropine (though not literature supported and not the standard of care)

Cardiorespiratory Arrests

10% 10%

80%

Hypoxia and Hypercarbia

Bradycardia

Cardiorespiratory Arrests

Self Confident If he can, you can

Avoid the “cookie-cutter” approach to every airway you encounter.

Be familiar with your equipment…

What tools do I have ?

Airway Equipment

•  Oxygen and Suction •  BVM / OPA / NPA •  ETT / Bougie / LMA / King LT •  Stylet •  Magill forceps •  End-tidal CO2 monitoring and securing

devices •  Surgical Airway Devices

Airway Equipment

Airway Equipment

C-E technique is WRONG

E

Airway Equipment

Use the Two Thumbs Down technique

Airway Equipment

Airway Equipment OPA NPA

King LT

Airway Equipment

Endotracheal tube

stylet

Airway Equipment Eschmann Stylet, a.k.a “Gum elastic bougie”

Airway Equipment

MAGILL FORCEPS

LMA

Airway Equipment LMA – Laryngeal Mask Airway

Are extraglottic airways harmful in cardiac arrest ?

Airway Equipment “Yellow” = YES

“Purple” = Pathologic

Airway Equipment:

• What equipment do we have in our departments?

• Where is it located?

Broselow Tape The

•  Can’t Protect Airway •  Can’t Maintain Ventilation / Oxygenation •  Expected Decline in Clinical Status

3 Emergent Indications for Intubation

Gag reflex is absent in up to 37% of population, and is a poor predictor of airway protection

•  Can they talk? •  Can they swallow and manage secretions?

Can’t Protect Airway

•  SaO2 <90% on High Flow O2 or PaO2<60 on FiO2>40%

•  PaCO2 >55 if baseline is normal, or >10 increase from baseline

•  Respiratory Rate

Can’t Maintain Ventilation or Oxygenation

•  Deterioration/Impending Compromise Transport •  Airway protection during procedures (ie. endoscopy)

Expected Decline in Clinical Status

DEFINITIONS

Rapid Sequence Intubation (RSI)

INDUCTION AGENT

PARALYTIC

UNCONSCIOUSNESS MOTOR PARALYSIS

DEFINITIONS

Delayed Sequence Intubation (DSI) DSI consists of the administration of specific sedative agents, which

do not blunt spontaneous ventilations or airway reflexes;

followed by a period of preoxygenation before the

administration of a paralytic agent.

CONTRAINDICATIONS

INDICATION RISK

RSI RATIONALE

Increased success

Decreased aspiration

Better C-spine control

RATIONALE - Secondary

Blunting ↑ in ICP / IOP


Avoid airway trauma


Avoid airway trauma


↓ Pain ↓ Discomfort ↓ Recall

Adverse Drug Events

HAZARDS

May force crash airway scenario

HAZARDS

The 7 “P’s”of RSI PREPARATION

PREOXYGENATION

PRETREATMENT

PARALYSIS WITH INDUCTION

PROTECTION AND POSITIONING

PLACEMENT AND PROOF

POST-INTUBATION MANAGEMENT

TIME ZERO

t – 10 minutes

t + 90 seconds

PREPARATION t – 10 minutes

1.  EQUIPMENT PRESENT AND WORKING

INCLUDING EQUIPMENT FOR PLAN “B”

PREPARATION t – 10 minutes

2. Ask yourself: CAN I…

BAG THE PATIENT TUBE THE PATIENT CRIC THE PATIENT

“Evaluate for signs of a difficult intubation”

-Obesity -

Look at the general anatomy Evaluate the 3-3-2 rule Mallampati score Obstruction Neck mobility Saturation Reserve

CAN I TUBE THIS PATIENT?

Look at the general anatomy

Evaluate the 3-3-2 rule

Mallampati score

Obstruction

Neck mobility

Saturation Reserve

Saturation Reserve At 92% the patient’s oxygen saturation

falls off a cliff….

CAN I BAG THIS PATIENT?

Maybe. Maybe Not.

Approximate normal ventilation rates: •  10 bpm Adult •  20 bpm Child •  25 bpm Infant

VENTILATE (BLS)

Squeeze.....Release - Release

Keep Dentures in when using a BVM

CAN I CRIC THIS PATIENT?

Indications •  Obstruction

•  Facial Trauma

•  Intubation or other alternatives impossible

•  Trismus (clenching)

•  > 8 years old

(for open procedures)

SURGICAL AIRWAYS

LAST RESORT!

DEFense Readiness CONdition

Maximum readiness

Armed Forces ready to deploy and engage in less than 6 hours

Air Force ready to mobilize in 15 minutes

Above normal readiness

Normal readiness

Discuss / Feel / See Kit

Mark / Kit Bedside

Inject / Prep / Open & Set Kit Scalpel in Hand

Make Skin Cut & Find Membrane

Perform Cric

Open Cricothyrotomy

1.  Vertical Incision over membrane 2.  Pierce membrane in horizontal plane 3.  Open and spread to insert 4.0 or 5.0 tube 4.  Secure tube in place and ventilate

Open Cricothyrotomy

PREOXYGENATION t – 5 minutes

1. “First, do not bag!”

2. Avoid “Sellick’s” maneuver (cricoid pressure)


1. Well-fitting mask

2.  8 vital capacity breaths



NIV CPAP for Pre-Oxygenation

Summary of LOAD PRETREATMENT

L idocaine à optional

O piates à optional

A tropine à for infants consider for kids < 8

D efasciculating à optional dose

DEFASCICULATING DOSE 1/10 th the RSI dose

Traditional Indications

1.  Blunt rise in ICP 2. Decrease risk of aspiration

3.  Prevent muscular pain

PRETREATMENT t – 3 minutes

If you’re going to give these drugs:

…at least give them some time to circulate (3 minutes)


Time “0” INDUCTION AGENTS

Etomidate

Ketamine

Propafol

Midazolam

PARALYTIC AGENTS DEPOLARIZING

Succinylcholine NON-DEPOLARIZING

Vecuronium Rocuronium

+


Time “0”

Sedation then Paralysis


Time “0”

Use of Apneic oxygenation

Etomidate

– Rapid onset/offset

– Minimal hemodynamic and respiratory effects

– Pediatrics – not approved for patients under 10

Succinylcholine

•  When: Immediately after Etomidate •  Onset: Rapid, usually 30-90 secs

•  Duration: Short acting, 3-5 mins

When Sux Really “Sucks” CONTRAINDICATIONS

1. HYPERKALEMIA

RENAL FAILURE RHABDOMYOLYSIS

2. RECEPTOR UPREGULATION SUBACUTE BURNS (>1 day) SUBACUTE DENERVATING DISORDER HISTORY OF MALIGNANT HYPERTHERMIA

SUX IS STILL KING

SUX versus ROC

45 seconds ONSET 1 minute 9 minutes DURATION 45 minutes

1 mg/kg 1-1.5 mg/kg

PROTECTION AND POSITIONING t + 20 seconds

May NOT be helpful

Positioning: Medical vs. Trauma

C Spine Precautions

C Spine Precautions

Positioning Adult vs Pedi

Cormack & Lehane Grading

Sweep Left

and

Look

Orotracheal Intubation Procedure

Adult vs Pedi

Normal Trachea

PLACEMENT AND PROOF t + 45 seconds

POST-INTUBATION MANAGEMENT t + 90 seconds

More to come next month……….

POST-INTUBATION MANAGEMENT t + 90 seconds

CONFIRM PLACEMENT

& SECURE

TUBE

Capnography

Post-intubation CXR

INTUBATION HURTS! And it keeps on hurting once the tube is in…

POST-INTUBATION MANAGEMENT Achieve Adequate Analgesia and Sedation


Raise the Head of the Bed to at Least 30°

Confirm Lung Protective Vent Settings


•  Mode AC •  VT 6-8 cc/kg •  Rate 12-16 •  PEEP 5 •  FiO2 100% then titrate down

Standard Ventilator Settings


Continuous waveform ETCO2

NG / OG tube Empty the stomach to reduce the chances of aspiration and to improve lung mechanics


Nebulizers/MDI If they were intubated for reactive airway disease, then they need frequent nebs

Acute Deterioration after Intubation D.O.P.E.S: Displacement Obstruction Pneumothorax Equipment failure Stacked Breaths

Basics of Ventilator Management

Lung Injury Obstructive Lung Disease

Use as Default

Basics of Ventilator Management Lung Injury

Lung Protective Management

1. Mode: use A/C (assist control)


Vt

IFR

FiO2 PEEP

RR


Vt

Tidal Volume 6-8 cc/kg IBW


IFR Inspiratory Flow Rate

= how quickly the breath is delivered

60-80 LPM


RR Respiratory Rate 16-18 BPM

RR = Ventilation


FiO2 PEEP

1.  Start @ 100% 2.  Wait 5 min 3.  Get ABG 4.  Drop to 40%

FiO2

Goal: Saturation of 88-95%


FiO2 PEEP Start with 5

Positive End-Expiratory Pressure - PEEP


FiO2 PEEP

FiO2 + PEEP = Oxygenation

Inspiratory Plateau Pressure _________________________________________________

Peak Plateau Plateau Pressure

< 30 cmH2O

Must find and hold Inspiratory Hold button Ventilator will then display Plateau Pressure


Vt

IFR

FiO2 PEEP

RR


Analgesia 1st Sedation 2nd

The Crashing Asthmatic

Crashing Asthmatic

Sweaty Can’t Talk Tachypneic Tripoding

Maximal O2 (NRB) Inhaled Albuterol Inhaled Atrovent IV Steroids IV Magnesium SC Terbutaline Epinephrine drip

Crashing Asthmatic

THE KITCHEN SINK – Maximal Rx

Crashing Asthmatic

BiPAP CPAP

NON-INVASIVE VENTILATION

Too Early Too Late

Crashing Asthmatic

WHEN TO INTUBATE

Crashing Asthmatic

Etomidate Succinylcholine GO FAST!

Lidocaine Ketamine

KEEP IT SIMPLE! OPTIONS...

HOW TO INTUBATE

Crashing Asthmatic

Use a Big ETT AGGRESSIVE TOILET

Reason #1 Mucous Plugs

Crashing Asthmatic

Reason #2 Dehydration

IV FLUID BOLUS

Reason #3 Breath Stacking

Crashing Asthmatic

Squeeze Chest Low Vent Settings

Crashing Asthmatic

Chest Tubes

Reason #4 Barotrauma

Cardiac Arrest Post-Intubation

1 Disconnect ventilator 2 Squeeze chest 3 Bilateral chest tubes 4 Fluid bolus

Summary

Crashing Asthmatic Last Chance………

Anesthetic Gases

ECMO

Extracorporeal Membrane Oxygenation (ECMO)

Pearls

•  Can’t see the cords - …try BURP

•  Another attempt needed – …change something

Call for help !

Have a backup plan – “Prior planning prevents poor performance”

Don’t panic!

Thank you!

Mark P. Brady PA-C Dept.of Emergency Medicine Cambridge Health Alliance Cambridge, MA

Health & Medicine

Emergency Airway Management 2014: Mark P. Brady PA-C