emergency airway management ________________________________ mark l. freedman md, frcp
DESCRIPTION
Emergency Airway Management ________________________________ Mark L. Freedman MD, FRCP. Objectives. To review the indications for intubation To briefly discuss RSI To review the airway assessment To discuss difficult airways To review difficult airway algorithms - PowerPoint PPT PresentationTRANSCRIPT
Emergency
Airway Management________________________________
Mark L. Freedman MD, FRCP
Objectives
• To review the indications for intubation
• To briefly discuss RSI
• To review the airway assessment
• To discuss difficult airways
• To review difficult airway algorithms
• To discuss an approach to difficult airways
• Case discussions
Case
• 13 yr/o M mountain biking
• Neck vs. handlebars
• Sitting-up on bike path
• Anterior neck swelling
• VSS
• Mild stridor
• What will you do?
The 4 Questions
1. Does this patient need intubation now?
2. Is this a crash situation?
3. Is this a difficult airway?
4. Can I use RSI?
Outline
• Indications for intubation
• Basic airway algorithm
• Difficult airways
• Difficult airway algorithm
• Securing the difficult airway
• Cases
Outline
• Indications for intubation
• Basic airway algorithm
• Difficult airways
• Difficult airway algorithm
• Securing the difficult airway
• Cases
Indications for Intubation
• Failure of oxygenation
• Failure of ventilation
• Failure to protect
• Impending obstruction
• Expected management
Failure of Oxygenation
• Low FiO2
• Failure of ventilation
• V/Q mismatch
• Diffusion abnormalities
• Anemia
• Low C.O.
• Increased tissue O2 consumption
Failure of VentilationBrain; CHI
StrokeRaised ICP
Stem; StrokeNarcoticsInjury
Cord; SCIDegenerative diseases
Nerve; Peripheral NeuropathyNMJ; Myasthenia gravis
Guillon-BarreNMJBs
Muscle; MyopathyThorax; Burn eschar
Rib fracturesLungs; Restrictive disease
ContusionsAbdomen; Tense ascities
Compartment Syndrome
Failure to Protect
• Low or dropping GCS
• “GCS less than 8, intubate”
• Aspiration risk
Impending Obstruction
• Expanding hematoma• Deep space infection• Epiglotitis/Bacterial tracheitis• Angioedema/Allergic reaction• Inhalation injury• Eschar• Foreign body• Tumour• Others….
Outline
• Indications for intubation
• Basic airway algorithm
• Difficult airways
• Difficult airway algorithm
• Securing the difficult airway
• Cases
Basic airway algorithm
Difficult Airway ?
RSI ?
Crash Airway
Difficult Airway
No
No
Yes
Yes
Crashing ?
Failed Airway
Fails
Fails
Fails
The 8 “P”s of RSI
• 0 - 10min Preparation• 0 - 5 min Preoxygenation• 0 – 3 min Premedication• 0 Pharmacological Induction• 0 Pressure• 0 Paralysis• 0 + 45 sec Place tube• 0 + 1 min Post Intubation Care
Outline
• Indications for intubation
• Basic airway algorithm
• Difficult airways
• Difficult airway algorithm
• Securing the difficult airway
• Cases
Difficult Airways
• Difficult mask ventilation
• Difficult laryngoscopy
• Difficult tracheal intubation
• Combinations of above
Difficult Airway
• EMS Incidence;– Not known
• ED Incidence;– Not known
– Cricothyrotomy reported as high as 1%
– Definitely inflated
– Reflects an aggressive approach without employing alternate intubation techniques
Difficult Airways
• Difficult mask ventilation;– Predicting the difficulty (BOOTS);
• Bearded• Older (> 55 years)• Obese (BMI > 26 kg/m2)• Toothless• Snores
Difficult Airways
• Difficult laryngoscopy/intubation;– Predicting the difficulty (LEMON);
• Look
• Evaluate; 3,3,2
• Mallampati score
• Obstruction
• Neck mobility
Difficult Airways
• The airway assessment;• Look (BOOTS, others)
• Evaluate; 3,3,2
• Mallampati score
• Obstruction
• Neck mobility
Evaluate 3:3:2
Mallampati score
Neck Mobility
Difficult Airways
• Specific situations;– Trauma– Obesity– Pregnancy– Pediatrics
Difficult Airways
• Not a catastrophe if you can’t see well
• Not even if you can’t intubate
• But, if you ALSO can’t ventilate…….
Outline
• Indications for intubation
• Basic airway algorithm
• Difficult airways
• Difficult airway algorithm
• Securing the difficult airway
• Cases
Difficult Airway
Anticipated Unanticipated
Cooperative
Time
+ Ventilation
Sats Maintained
- Ventilation
Sats Dropping
Fail to Intubate
Better Position
BURP
Better Blade
Better Drugs
Bougie
Better Person
Glidescope
Bronch
BNTI
LMA
TTJV
Cricothyrotomy
Uncooperative
No time
OR?
Topicalize
Sedate
Awake;Laryngoscope
Glidescope
Lighted Stylet
FOB
Help
Sedate
Topicalize
“Brutane”
Sedate More
RSI+Double set-up
* Suction if bleeding *
TTJV
Cricothyrotomy
Outline
• Indications for intubation
• Basic airway algorithm
• Difficult airways
• Difficult airway algorithm
• Securing the difficult airway
• Cases
Securing the Difficult Airway
• Anticipated;– Best to get patient to ED/OR– BVM as bridge– Otherwise intubation– Don’t burn bridges
Securing the Difficult Airway
• Unanticipated;– Can you ventilate??
• Yes = time
• No = trouble
Difficult Airway
Anticipated Unanticipated
Cooperative
Time
+ Ventilation
Sats Maintained
- Ventilation
Sats Dropping
Fail to Intubate
Better Position
BURP
Better Blade
Better Drugs
Bougie
Better Person
Glidescope
Bronch
BNTI
LMA
TTJV
Cricothyrotomy
Uncooperative
No time
Transport
Observe
Help
Sedate
Topicalize
“Brutane”
Sedate More
RSI+Double set-up
* Suction if bleeding *
TTJV
Cricothyrotomy
Difficult Airways
• Difficult ventilation;1. Head tilt/chin lift2. Exaggerated Jaw thrust3. Oral/nasal airways4. Two handed/two person technique5. Consider mask change6. Ease up on cricoid pressure7. Rule out FB
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Difficult Airway
Anticipated Unanticipated
Cooperative
Time
+ Ventilation
Sats Maintained
- Ventilation
Sats Dropping
Fail to Intubate
Better Position
BURP
Better Blade
Better Drugs
Bougie
Better Person
Glidescope
Bronch
BNTI
LMA
TTJV
Cricothyrotomy
Uncooperative
No time
Transport
Observe
Help
Sedate
Topicalize
“Brutane”
Sedate More
RSI+Double set-up
* Suction if bleeding *
TTJV
Cricothyrotomy
Outline
• Indications for intubation
• Basic airway algorithm
• Difficult airways
• Difficult airway algorithm
• Securing the difficult airway
• Cases
Case 1
• 13 yr/o M mountain biking• Neck vs. handlebars• Sitting-up on bike path• Anterior neck swelling• VSS• Mild stridor • How will you proceed?
Case 2
• 40 yr/o M• Fall from height• Spike through mandible into eye• HD stable, respiratory distress• Gaping mandible and bleeding into airway • GCS 14• How will you proceed?
Case 3
• 67 yr/o F• Sudden collapse • On ship in Southern Ocean (Antarctica)• Decreased LOC, blown pupil, posturing• GCS 6….5….4….• 40 220/110 16 100% 37.0• How will you proceed?
Case 4
• 30 yr/o M• Hanging two feet off ground• Found unconscious• Now agitated • Anterior neck;
– rope mark– Swelling– ++ tender
• How will you proceed?
Case 5
• 40 yr/o F• Extensive full thickness burns;
– Head, face
– Neck, thorax, and arms circumferentially
• VSS• GCS 15• Gross stridor• How will you proceed?
Case 6
• 30 y/o male
• Shotgun blast to face
• Bleeding and gross disruption of anatomy
• GCS 15
• VSS
• How will you proceed?
The 4 Questions
1. Does this patient need intubation now?
2. Is this a crash situation?
3. Is this a difficult airway?
4. Can I use RSI
Difficult Airway
Anticipated Unanticipated
Cooperative
Time
+ Ventilation
Sats Maintained
- Ventilation
Sats Dropping
Fail to Intubate
Better Position
BURP
Better Blade
Better Drugs
Bougie
Better Person
Glidescope
Bronch
BNTI
LMA
TTJV
Cricothyrotomy
Uncooperative
No time
Transport
Observe
Help
Sedate
Topicalize
“Brutane”
Sedate More
RSI+Double set-up
* Suction if bleeding *
TTJV
Cricothyrotomy
Securing the Difficult Airway
• Anticipated;– Best to get patient to ED/OR– BVM as bridge– Otherwise intubation– Don’t burn bridges
Difficult Airways
• Difficult ventilation;1. Head tilt/chin lift2. Exaggerated Jaw thrust3. Oral/nasal airways4. Two handed/Two person technique5. Consider mask change6. Ease up on cricoid pressure7. Rule out FB
Questions?