bcc4: john vassiliadis on the unexpected difficult airway
DESCRIPTION
John Vassiliadis speaks at Bedside Critical Care Conference 4 about The Unexpected DIfficult Airway. He speaks from an ICU perspective about intubation - how and who should do it to help achieve better results.TRANSCRIPT
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The Unexpected Difficult Airway
A/Prof John VassiliadisSenior Staff Specialist Emergency Medicine
Deputy Director Sydney Clinical Skills & Simulation Centre, RNSH
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I am NOT an anaesthetist!!!
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Intubating In ED
• Why it is a danger zone
• Role of Checklists
• Pre-oxygenation and Apnoeic Oxygenation
• Laryngoscopy
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Danger Zone
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ED Patient Airways are Different
• They are emergent
– Usually for airway +/- breathing failure
– Limited history
– Limited opportunity to predict difficult airway or difficult
laryngoscopy
– They are sick… Really sick (ie high metabolic demands)
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Oh S!!!I knew I should have called in sick today!!
I LOVE it when I have a registrar!!
I have a bad feeling about this one!!!
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Our training and Skill Level
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Our Training and Skill Level
Adequate supervision and supportAnaesthetics and ICU experienceE-learning and simulation training to practice drillsCredentialling process and guidelines on who should be allowed to intubate in ED and other critical care environments
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Suggested parameters for predicting the difficult airway
Long upper incisors and/or prominent overbiteInter-incisor distance <3 finger breathsMandibular floor distance < 3 finger breathsThyromental distance < 2 finger breathsMallampati score > 2High arched palateLarge, thick tongueShort, thick neckPatient unable to touch the chin to the chest
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Are they any good?
In 2003 ASA Difficult Airway Task force after a
review of literature found there was
insufficient evidence to recommend any
predictive tool, however some of these
markers were associated with difficult
airways!
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So..What Do We Do?
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Ron Walls and Difficult Airway Team
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The JV Method
Looks Bloody Hard!!Looks Bloody Hard!!
ED Physician GestaltED Physician Gestalt
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Have an Approach and A Plan
ED appropriate assessment, checklist and difficult airway algorithm
Meticulous preparation, pre-oxygeation, positioning, apnoeic
oxygenation
Excellent laryngoscopy
Plan B and C and D....
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Ramping and Positioning
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Preoxygenation
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Weingart & Levitan, Annals of EM Weingart & Levitan, Annals of EM Volume 59, No. 3, March 2012 pp 165-Volume 59, No. 3, March 2012 pp 165-175175
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C-MAC
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C-MAC
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Take Home Messages
ED Intubations are DifficultNeed Experience and TrainingPrepare and PlanPreoxygenate and Apnoeic VentilationC-MAC and bougie
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