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?