10VissersHighRiskAirwaySlides (1)

7/24/2019 10VissersHighRiskAirwaySlides (1)

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The High-Risk AirwayThe High-Risk Airway

Robert J. Vissers, MDRobert J. Vissers, MDRobert J. Vissers, MD


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Difficult Airway AlgorithmsDifficult Airway Algorithms

Common principles

Assessment of ventilation difficulty

Assessment of intubation difficulty

Awake vs. induction and paralysis

Calling for help

Surgical airway is a potential endpoint

Common principlesCommon principles

Assessment of ventilation difficultyAssessment of ventilation difficulty

Assessment of intubation difficultyAssessment of intubation difficulty

Awake vs. induction and paralysisAwake vs. induction and paralysis

Calling for helpCalling for help

Surgical airway is a potential endpointSurgical airway is a potential endpoint


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Difficult Airway AlgorithmsDifficult Airway Algorithms

Important principles

Make a Plan

Use a Checklist

Share with the Team

Important principlesImportant principles

Make a PlanMake a Plan

Use a ChecklistUse a Checklist

Share with the TeamShare with the Team


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Decision to

intubate

Near death?

Unresponsive?

Difficult

Airway?

Rapid

Sequence

Intubation

FailedAirwayDifficult

Airway

Techniques

CrashAirway

Adapted from: Walls RM, Ed. The Manual of Emergency Airway Management Philadelphia, Lippincott, 2000.

Approach to the

Emergency Airway


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Decision toDecision tointubateintubate

Crash Airway?Crash Airway?

Cricothyrotomy?Cricothyrotomy?

DifficultDifficult

Airway?Airway?

RSIRSI

Adapted from: Walls RM, Ed.Adapted from: Walls RM, Ed. TheThe

Manual of Emergency AirwayManual of Emergency Airway

ManagementManagement Philadelphia,Philadelphia,

Lippincott, 2000.Lippincott, 2000.

Approach to theApproach to the

High Risk AirwayHigh Risk Airway

AIRWAYAIRWAY

TIMETIME

ANATOMYANATOMY

PHYSIOLOGYPHYSIOLOGY


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The Difficult AirwayThe Difficult Airway

DIFFICULT BAG

AND MASK VENTILATION

DIFFICULT LARYNGOSCOPY

AND INTUBATION

DIFFICULTDIFFICULT

CRICOTHYROTOMYCRICOTHYROTOMY

The 4 Elements of Difficulty

DIFFICULT RESCUE

MOANS

RODS SHORT

LEMON

* The Difficult Airway Course: Emergency* The Difficult Airway Course: Emergency

Walls RM, Murphy MF, editors. Manual of emergency airway managemWalls RM, Murphy MF, editors. Manual of emergency airway management,ent,

3rd edition. Philadelphia: Lippincott Williams & Wilkins; 2008.3rd edition. Philadelphia: Lippincott Williams & Wilkins; 2008.


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DIFFICULT BAG



AND INTUBATION

DIFFICULTDIFFICULT



DIFFICULT RESCUE

MOANS*





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Assessment of Difficult BVM:

MOANS


MOANSM ask seal

O besity/obstruction

A ge > 55

N o teeth

S tiff lungs

MM ask sealask seal

OO besity/obstructionbesity/obstruction

AA ge > 55ge > 55

NN o teetho teeth

SS tiff lungstiff lungs* The Difficult Airway Course: Emergency* The Difficult Airway Course: Emergency




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DIFFICULT BAG



AND INTUBATION

DIFFICULTDIFFICULT



DIFFICULT RESCUE

LEMON





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LEMON Law LEMON Law

L ook externally

E xamine (3-3-2)

M allampati grade

O bstructionN eck mobility

LL ook externallyook externally

EE xamine (3xamine (3--33--2)2)

MM allampati gradeallampati grade

OO bstructionbstructionNN eck mobilityeck mobility

Cognitive forcing strategies in clinical decisionmaking. P Croskerry. Ann Emerg Med Jan, 2003.

Adapted from: Walls RM, Ed. The Manual of Emergency Airway Management

Philadelphia, Lippincott, 2000.


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LEMON: LookLEMON: Look

Simple visual inspection often reveals

obvious potential difficultiesSimple visual inspection often revealsSimple visual inspection often reveals

obvious potential difficultiesobvious potential difficulties


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LEMON: Examine 3-3-2LEMON: Examine 3-3-2

Assess oral opening - 3 fingers

Measure the mandible - 3 fingers

Position of larynx - 2 fingers

Assess oral openingAssess oral opening -- 3 fingers3 fingers

Measure the mandibleMeasure the mandible -- 3 fingers3 fingers

Position of larynxPosition of larynx -- 2 fingers2 fingers


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Assess oral

opening

should be able

to

accommodate3 fingers

Assess oralAssess oral

openingopening

should be ableshould be able

toto

accommodateaccommodate3 fingers3 fingers


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Measure the

mandible - should

be able to fit 3

fingers between

the mentum andthe hyoid bone

Measure theMeasure the

mandiblemandible -- shouldshould

be able to fit 3be able to fit 3

fingers betweenfingers between

the mentum andthe mentum andthe hyoid bonethe hyoid bone


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Assess position of

larynx should

get 2 fingers

between the

thyroid cartilageand the mandible

Assess position ofAssess position of

larynxlarynxshouldshould

get 2 fingersget 2 fingers

between thebetween the

thyroid cartilagethyroid cartilageand the mandibleand the mandible


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Class I

Class IV

Class II

Class III

LEMON: MallampatiLEMON: Mallampati


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LEMON: Obstruction?LEMON: Obstruction?

1) Location?

2) Fixed or mobile?

3) Speed of progression?

1) Location?1) Location?

2) Fixed or mobile?2) Fixed or mobile?

3) Speed of progression?3) Speed of progression?


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LEMON: Neck MobilityLEMON: Neck Mobility

Can the patient flex and extend the

neck?

Actively assess in the non-trauma

obtunded patient.

Cervical spine immobilization - removeanterior collar while c-spine is

immobilized.

Can the patient flex and extend theCan the patient flex and extend the

neck?neck?

Actively assess in the nonActively assess in the non--traumatrauma

obtunded patient.obtunded patient.

Cervical spine immobilizationCervical spine immobilization -- removeremoveanterior collar while canterior collar while c--spine isspine is

immobilized.immobilized.


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LEMON Law LEMON Law

L ook externally

E xamine (3-3-2)

M allampati grade

O bstructionN eck mobility

LL ook externallyook externally

EE xamine (3xamine (3--33--2)2)

MM allampati gradeallampati grade

OO bstructionbstructionNN eck mobilityeck mobility


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LEMON: Predictive?LEMON: Predictive?

156 ED patients requiring intubation

Scored using LEMON

Simple point system used (0 to 10)

Compared to laryngoscopic view (CormackLehane)

Felt to be predictive, P


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LEMON: Predictive?LEMON: Predictive?

Reed MJ et al. Can an airway assessment score predictdifficulty at intubation in the emergency department? EmergMed J 2005 Feb; 22:99-102.

Reed MJ et al. Can an airway assessment score predictReed MJ et al. Can an airway assessment score predictdifficulty at intubation in the emergency department?difficulty at intubation in the emergency department? EmergEmergMed JMed J 2005 Feb; 22:992005 Feb; 22:99--102.102.


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DIFFICULT BAG



AND INTUBATION

DIFFICULTDIFFICULT



DIFFICULT RESCUE

RODS





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Airway

alternatives

Airway

alternativesBVMIntubating LMA

Lightwand

Videolaryngoscope

Fiberoptics

Bougie

CombitubeKing-LT

TTJVCricothyrotomy

Supraglottic:

Infraglottic:

Nasal

BNTI

Fiberoptics


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RODS


RODSR estricted oral opening

O bstruction

D isrupted or distorted

S tiff lungs

RR estricted oral openingestricted oral opening

OO bstructionbstruction

DD isrupted or distortedisrupted or distorted

SS tiff lungstiff lungs





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Rescue DevicesRescue Devices

Most require oral access

Most are designed to deal with highanterior cords

I-LMA, King-LT, Combitube

Intubating stylet (bougie, frova, etc.)

Video glidescope, C-mac, etc

Most require oral accessMost require oral access

Most are designed to deal with highMost are designed to deal with highanterior cordsanterior cords

II--LMA, KingLMA, King--LT, CombitubeLT, Combitube

Intubating stylet (bougie, frova, etc.)Intubating stylet (bougie, frova, etc.)

VideoVideo glidescope, Cglidescope, C--mac, etcmac, etc


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Agitated Burn CaseAgitated Burn Case

42-year-old woman set herself on fire in

her car.

Uncooperative, yelling let me die.

70-80% burns, mostly 3, to face, trunk,

anterior arms and thighs.Unable to get a BP or O2 sat.

4242--yearyear--old woman set herself on fire inold woman set herself on fire in

her car.her car.

Uncooperative, yellingUncooperative, yelling let me dielet me die..

7070--80% burns, mostly 380% burns, mostly 3, to face, trunk,, to face, trunk,

anterior arms and thighs.anterior arms and thighs.Unable to get a BP or O2 sat.Unable to get a BP or O2 sat.


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Intubating Stylet/BougieIntubating Stylet/Bougie


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Decision MakingDecision Making

Question #1:

Is Oxygenation Adequate Or Inadequate?

[Are O2 saturations above or below 90%?]

Question #2:Is The Airway Normal Or Disrupted?

Question #1Question #1::

Is OxygenationIs OxygenationAdequateAdequateOrOrInadequate?Inadequate?

[Are O[Are O22 saturationssaturations aboveabove oror belowbelow 90%?90%?]]

Question #2Question #2::Is The AirwayIs The AirwayNormalNormalOrOrDisrupted?Disrupted?


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CombitubeCombitube


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King-LTKing-LT


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I-LMAI-LMA


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Video LaryngoscopyVideo Laryngoscopy


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GlidescopeGlidescope


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Awake look/scopesAwake look/scopes

Antisyalogogue atropine orglycopyrrolate

Anesthesia lidocaine (2-4%),benzocaine

Decongestant oxymetazoline (afrin) Nebulize, atomize (MADgic), viscous

Sedation ketamine, versed

AntisyalogogueAntisyalogogue atropine oratropine orglycopyrrolateglycopyrrolate

AnesthesiaAnesthesia lidocaine (2lidocaine (2--4%),4%),benzocainebenzocaine

DecongestantDecongestant oxymetazoline (afrin)oxymetazoline (afrin) Nebulize, atomize (MADgicNebulize, atomize (MADgic), viscous), viscous

SedationSedation ketamine, versedketamine, versed


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DIFFICULT BAG



AND INTUBATION

DIFFICULTDIFFICULT



DIFFICULT RESCUE

SHORT





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SHORT


SHORTS urgery or disruption

H ematoma

O besity

R adiation

T umor

SS urgery or disruptionurgery or disruption

HH ematomaematoma

OO besitybesity

RR adiationadiation

TT umorumor


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No landmarks?No landmarks?

The tongue is your friend find it and

follow it to the glottis

Suction, suction, suction

4-finger rule for the cricothyroid

membrane

TheThe tonguetongue is your friendis your friendfind it andfind it and

follow it to the glottisfollow it to the glottis

SuctionSuction, suction, suction, suction, suction

44--finger rulefinger rule for the cricothyroidfor the cricothyroid

membranemembrane


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Cricothyroid membrane

under the 4th

finger

Cricothyroid membrane

under the 4th

finger


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Septic ShockSeptic Shock

24 yo woman

Fever, delerium

Purpuric rash

Hypotensive 94/58

T 41, P 152RR 32, Pulse ox 100%

2424 yoyo womanwoman

Fever,Fever, deleriumdelerium

PurpuricPurpuric rashrash

HypotensiveHypotensive 94/5894/58

T 41T 41, P 152, P 152RR 32, Pulse ox 100%RR 32, Pulse ox 100%


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RSI in Septic shockRSI in Septic shock

Primary goal: avoid exacerbation of

hypoperfusion

Need to differentiate shock state

Consider before intubation:

Assessment of volume statusIVFs as pretreatment before intubation

Vasopressor before intubation

A vs C: hemodynamic compromise vshypoxia

Primary goal: avoid exacerbation ofPrimary goal: avoid exacerbation of

hypoperfusionhypoperfusion

Need to differentiate shock stateNeed to differentiate shock state

Consider before intubation:Consider before intubation:

Assessment of volume statusAssessment of volume status IVFsIVFs as pretreatment before intubationas pretreatment before intubation

VasopressorVasopressorbefore intubationbefore intubation

AA vsvs C: hemodynamic compromiseC: hemodynamic compromise vsvs

hypoxiahypoxia


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My Favorite PretreatmentMy Favorite Pretreatment

Consider volumestatus before

intubation

Avoid post-

intubation

hypotension

Consider volumeConsider volume

status beforestatus before

intubationintubation

Avoid postAvoid post--

intubationintubation

hypotensionhypotension


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RSI in Septic shockRSI in Septic shock

Acidosis associated with compensatory

respiratory alkalosis (tachypnea,

kussmauls)

Post intubation ventilate at high RR,

normal rate may lead to transient

worsening of acidosis

AcidosisAcidosis associated with compensatoryassociated with compensatory

respiratory alkalosis (respiratory alkalosis (tachypneatachypnea,,

kussmaulkussmaulss))

Post intubationPost intubation ventilate at high RR,ventilate at high RR,

normal ratenormal rate may lead to transientmay lead to transient

worsening of acidosisworsening of acidosis


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More airway?More airway?


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PreparationPreparation

Time-out

Run the check-list

Criticalpoints.net - course

TimeTime--outout

Run the checkRun the check--listlist

Criticalpoints.netCriticalpoints.net -- coursecourse


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SummarySummary

Organized, rapid, simple approach

Assess for difficult ventilation

MOANS

Assess for difficult intubation

LEMON

Organized, rapid, simple approachOrganized, rapid, simple approach

Assess for difficult ventilationAssess for difficult ventilation

MOANSMOANS

Assess for difficult intubationAssess for difficult intubation

LEMONLEMON


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SummarySummary

Do I have TIME?

Does the ANATOMY predict rescue?

Anticipate PHYSIOLOGIC problems?

Whats the PLAN?

Do I haveDo I have TIME?TIME?

Does theDoes theANATOMYANATOMY predict rescue?predict rescue?

AnticipateAnticipate PHYSIOLOGICPHYSIOLOGIC problems?problems?

WhatWhats thes the PLAN?PLAN?

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