Advanced Airway Management

SEDATION – ASSISTED INTUBATION:

A Case Presentation

Scott Henley

NRP, FP-C, CCEMTP

Deputy Chief – Clinical Coordinator

Central Bucks EMS

Outline

• Intubation in general

• Research

• Etomidate (Amidate)

• EMS: PA DOH Protocol

• “The Airway”

• Mature Clinical Decision Making

• Case Presentation

What is Intubation ?

A medical procedure involving the placement of a breathing tube into a patient’s trachea to assist them with their breathing. Medication-Assisted - RSI (Rapid Sequence Induction/Intubation) Use of sedation and paralytics PA ground 911 ALS units are not permitted to carry paralytics per PA DOH. - Sedation Only For credentialed agencies only; this consists of Etomidate only. - PREFERRED Non Medication-Assisted

Intubation In General

• Under attack around the country

- Worse outcomes

- Esophageal intubations (and sometimes unrecognized)

- Limited value

- Other alternatives (King LT, Combitube, CPAP, BVM)

- Low experience/numbers

- De-emphasized in cardiac arrest

• However, When it is needed. . .

- IT IS NEEDED

- Experience is difficult to obtain and maintain

- We need to decrease adverse outcomes, select the right patients, use the right tools as available at the right times.

- Etomidate is one of those tools

Etomidate “Amidate” - Unique sedative / hypnotic

- Associated with stable hemodynamic profile

- 5 to 15 seconds onset of action, often longer

- 5 to 15 minute duration

- If the only agent used for intubation, most patients need post intubation sedation.

- Dose: 0.3mg/kg, maximum of 30mg IVP / IO (PA DOH Protocol)

Etomidate “Amidate”

• Cerebroprotective

- Does not increase ICP (Intracranial Pressure)

- Sedation itself may actually lower ICP

• May cause:

- Myoclonic movements (a quick, involuntary muscle contraction)

- Nausea and vomiting post administration

Etomidate “Amidate”

• Inhibits an enzyme that catalyzes cholesterol to cortisol

- Adrenal suppression

• Worse in septic patients – contraindicated

- Infection

- Fever

- Hypotension

Research

• Prehospital Emergency Care Journal (PEC) 2006 Jan-Mar; 10(1) 8-13

- Airmedical service

- Six months of Etomidate-only intubations (EOI) – 0.3 mg/kg

- Six months of Etomidate + succinylcholine (paralytic)

- 90% trauma

- 49 Patients:

• 63% of EOI (15/24) required additional medications to intubate.

• 4% of succinylcholine (1/25) required additional medications to intubate.

Research • Larynoscopy good or acceptable

- 79% of RSI

- 13% of EOI

• Success

- 92% of RSI

- 25% EOI

• So?

- We know RSI would be better (PROVEN! DATA & LITERATURE ALL POINT TO THIS)

- But this is what we have

- Do not expect perfect intubating conditions with EOI

Research: Closer to Home • Blinded study: - 7mg of Versed (Midazolam) or 20mg of Etomidate - 110 patients: 55 in each category - 75% intubation success with Versed - 76% intubation success with Etomidate But wait ! What about weight-based dosing?

That Was Then. . .

This Is Now. . . Protocol # 4002: Sedation-Assisted Intubation (Etomidate)

₋ Two Etomidate-credentialed ALS providers MUST be present at the time of administration.

₋ Only one of the credentialed providers needs to transport the patient.

₋ Single dose: 0.3mg/kg to a max of 30mg

₋ If the patient needs post intubation sedation, medical command is needed.

₋ Age range to be determined by service medical director.

₋ Complete all regional/service reporting forms post administration.

₋ Service medical director expresses interest, in writing, to the regional Medical Advisory Committee (MAC).

₋ MAC Committee discusses and assigns any extra work to be completed by the service prior to obtaining the medication.

₋ Service completes any assigned tasks by the MAC, completes in-house training, and reports back to the MAC.

₋ Regional MAC takes the final vote to allow the service to begin to carry and perform medication-assisted intubation.

AIRWAY - Learn it ! - Know the anatomy! - Know how to navigate it! - Practice! - RESPECT IT ! ETOMIDATE (and other medications) - Have respect for the sedation-assisted process! - Know the medication! When to use it vs. when not to use it ! - Be prepared for what may or may not happen! - There is nothing “rapid” about the process. - RESPECT the medication!

Bensalem EMS

Central Bucks EMS

Plymouth Ambulance

Trappe Fire Co. EMS

4 Services

- LOOK at the patient before ever attempting to control their airway, what do you see?

- Recognize patients with potentially difficult airways.

- Develop skills to assess & control these airways.

- Know when to attempt and NOT attempt an intubation.

- Know when to abort an intubation and move to a rescue airway.

Any healthcare provider that may be at a patient’s bedside should learn to assess airways and speak up if you see anything abnormal:

Physicians

Nurses

Respiratory Therapists

Patient Care Technicians

X-Ray Technicians

Paramedics

EMTs

What happens when we do this right away?

Mallampati Score

Grade I Grade II Grade III Grade IV

Cormack – Lehane Airway Grading

Grade 1 Grade 2 Grade 3 Grade 4 Visualization of vocal chords Partial view of the vocal chords. View of the epiglottis only Inability to see the epiglottis

- Level of consciousness. - Ability to protect their own airway. (Gag vs. the ability to swallow and control their

own secretions.) - Good positioning and lighting. - Good Technique. - Good knowledge of the anatomy. - Be Confident - Practice, Practice, Practice !

Digital End Tidal Co2 and Waveform Capnography is the GOLD standard of care for endotracheal tube placement confirmation.

“Misplacing an endotracheal tube is not career-ending. Failing to recognize it, is!”

Make Your FIRST Attempt, Your

BEST Attempt !

Not all patients need to be intubated

- BVM

- CPAP (Continuous Positive Airway Pressure)

- Oral / Nasal Airway

- Oxygen

Not all patients need sedation

- Do NOT sedate someone if you anticipate difficult airway indicators and may have difficulty intubating them.

- Knowledge and skill level

Patient Selection

- Oxygen or CPAP alone are not maintaining oxygenation

- BVM required to maintain oxygenation

- Movement causes de-saturation; difficulty moving and maintaining stability.

- BVM’ing a patient to the hospital is NOT a failure

- Pre-oxygenate (Nasal cannula before and during intubation)- “No Desat”

- Three attempts total, per the state. (follow your agency’s protocols)

- Direct Laryngoscopy vs. Video Laryngoscopy

- Move to rescue airway if needed

Set yourself up for success:

- Suction

- Adequate lighting

- Positioning

- Good technique

- Equipment

- Backup Plans

Golden Rule:

DO NOT TAKE SOMETHING AWAY FROM SOMEONE

THAT YOU CAN’T REPLACE !

• ALS Unit, police, and fire department dispatched for a small airplane crash.

• Supplemental report: small aircraft went down into high tension wires, exploded, and then crashed to the ground.

• Thick, black, smoke visible while units were still responding. “Header”

• Power lines within miles of the scene were down; power out in the

immediate area.

• 11:45 am on a Saturday: Hot, clear, sunny day

• Patient had been completely engulfed in flames from the collision in the high tension lines; plane landed in trees, pt. then fell 15-20 ft. to the ground.

• Bystanders used a dry chemical fire extinguisher on the patient.

• A large crowd of bystanders, police, and other responders present.

Scene pictures were taken from the internet

Scene pictures were taken from the internet

• 69 year old male - laying supine on the hot, asphalt surface.

• Estimated by EMS to be approximately 210 lbs. or 95 kg

• Semi-conscious with periods of unresponsiveness.

• Appears greater than 90% burnt circumferentially with second and third

degree burns.

• Mild lacerations and abrasions on his arms and legs, minimal bleeding.

• Obvious deformity of the (L) humerus.

• Chief Complaint: None Voiced • GCS: 9 • Perceived 10/10 pain from burns • B/P- 134/90 Pulse- 122 and weak Respirations: 22 and labored Lungs: Decreased in all fields Skin: Hot, burnt, sloughing • Pulse Ox: 86% room air with a good pleth • Obvious airway burns & injury : Thick, black soot from mouth: (+) carbonaceous sputum (burnt saliva)

AIRWAY

BURNS: 90+ body surface area burns

PAIN

TRAUMA: from the 15-20 ft. fall

CONTAMINATION: from the dry chemical extinguisher mixed with the burns

(dry vs. irrigation vs. infection vs. death)

WHERE DO WE START ?!?!

Manual C-Spine stabilization maintained

Oxygen Therapy: 15 lpm NRB mask

Slight Decontamination: Small amount of sterile water dabbed on towels and dabbed throughout the pt’s body.

Pt. wrapped in burn sheets

Placed on long spine board and secured with straps and CIDs.

Interosseous placement: (due to the severity of burns in all extremities)

40mg Lidocaine administered IO push for local anesthetic

Normal Saline run wide open with b/p cuff acting as a “pressure bag”

100mcg Fentanyl administered IO push for pain.

Move the patient to the ambulance, covered with blankets for heat preservation.

Monitor applied: Sinus Tach @ 120-130 (-) ectopy

. . .and now. . . Intubation or no intubation ?!?!

A brief discussion between three ALS providers, we decided, YES !

- Decreased GSC

- Obvious airway injury and burns

- Spo2 is low

- Lung sounds decreased (also keeping an eye on a potential pneumothorax)

- If it doesn’t get done now, will later be too late?

A second line was able to be established: 14ga right forearm – wide open

Preparation for Advanced Airway Management (Intubation):

External assessment: Appears to have normal build/neck, anticipate a Grade 1

External assessment: burns to the face, in the airway upon looking

Prediction: Going to be burnt, discolored, and possibly bloody on direct laryngoscopy.

Reality: We all knew it, however, nobody really wanted to say it. . .

WE GET ONE SHOT AT THIS, AND ONE SHOT ONLY !

Airway equipment was readied and backup plans in place:

Bougie

QuickTrach (in case of emergent cricothyrotomy)

Suction

Second ALS provider

King LT

Pre-Oxygenation initiated:

Nasal Cannula @ 15 lpm

NRB Mask @ 25 lpm (yes, the pt. tolerated it)

30mg Etomidate slow IO push over 50 seconds (pt. became sedated and flaccid)

“The Intubation”

-The most experienced ALS provider performed.

-C-collar loosened, frontal C-spine stabilization maintained

-Direct Laryngoscopy via Mac 3 blade

-Immediately encountered blood and black airway burns

-Intubator provided self bimanual laryngeal manipulation

-Grade 3 View: Cormack-Lehane

-Intubated with a 7.5 ETT, immediately confirmed with digital Etco2 of 36mm/Hg and waveform capnography

-Spo2 remained 96-98% throughout the intubation process

-(+) bilateral breath sounds, (-) epigastric sounds

-Secured at 24cm with commercial tube holder

-Ventilated and oxygenated at 16 breaths/minute

Additional 100mcg Fentanyl administered IVP for pain

Reassessment of vitals:

GCS: Sedated

B/P: 150/100

Pulse: Sinus Tach @ 118 (-) ectopy

Pulse Ox: 99% with good pleth Etco2: 34-41 mm/Hg

10mg Versed administered IVP for continued sedation (two administrations of 5mg)

1400 mL NSS infused

Transport: flown to Temple University Hospital burn center

Day of the Incident

Level 1 trauma on arrival

Found to have 100% TBSA burns: 60% second degree, 40% third degree

Ribs 4 and 5 fractured

Left humerus fracture

Day 2

13:15 Escharotomies of the chest, abdomen, and legs

14:24 Made a DNR, comfort measures only, extubated

15:19 Patient expired

-Learn the airway and keep practicing (even though, we all think we know it) -Be knowledgeable of the ever-so-changing protocols, latest science, and data. -Respect ALL medications, ALL the time! -Respect the sedation-assisted (and RSI) processes. -Continually push yourself to be a stronger and more knowledgeable provider. -Be Confident, and not lazy. -Make strong, sound, mature clinical decisions and always do what’s best for your patients.

Henley@cbems.org