17SimonDifficultAirway · Delayed Sequence Intubation ... Percutaneous transtracheal intubation...
Transcript of 17SimonDifficultAirway · Delayed Sequence Intubation ... Percutaneous transtracheal intubation...
11/5/2013
1
Topics 2013
The Difficult Airway� Anatomy
• Visualization• Difficult BVM / LMA ventilation
� Physiology• Unable to oxygenate• Unable to ventilate• Severe Acidosis• Hypotension
The Difficult Airway� Deciding which patient to intubate� Timing
• Stable – semi-elective• Crashing• Crashed
Drama BUT ‘REAL’
� May be the single most important topic in Emergency Medicine
Airway management
The area of EM with the greatest immediatebreadth of outcomes within minutes: life and death
11/5/2013
2
Sexy
HEROIC
Dramatic Life Saving
11/5/2013
3
� Forethought� Planning� Attention to detail� Knowledge
Plan Ahead� Equipment� Drugs� Positioning � Check lists…
An intervention to dec complications related to EI in the ICU…..Int Care Med 2010
Severe Mild to Moderate
Death Difficult tube
Cardiac Arrest Esophageal
Severe Hypoxemia Aspiration
Severe Cardiovascular Collapse Arrhythmia requiring RX
Dangerous agitation
� Presence of two operators� Fluid Loading� Pre-oxygenation� RSI drug prep� Sellick� Placement confirmation – capnography� Pressor support� Longer term sedation� Protective low volume vent
11/5/2013
4
Difficult / High Risk� Hypoxic� Hypotensive� Acidotic� Shock� Obstruction� Anatomic difficulty
11/5/2013
5
Oxygenation� Preoxygenation� Positioning� DSI� Apneic Oxygenation
Positioning� Head up 20 degrees /reverse
trendelenberg• Delay time to desat by about 100 seconds
� Jaw thrust
Apneic Oxygenation� Prolong time to desat:
• Normal BMI – by 2-3 minutes• BMI > 30 – by about 100 seconds
11/5/2013
6
Journal of Clinical Anesthesia 2010
Preoxygenation Strategies� NIV
• USE NIV mask or BVM• 5cm of PEEP / 100% O2 / High flow• Sat >95% for >3 min• Leave Mask in place while pushing drugs• Leave NC on at all times
strategies� Ventilator to drive the BVM
• Oral airway• Standard BVM vent• Ventilator on AC at 550ml• Flow at 30 L /min• 12 vent / min + 5-15 PEEP• Attach the vent to the mask
strategies� Ventilator Vs. Bagging� Peep� Atelectasis� Saturation
11/5/2013
7
Delayed Sequence Intubation
• Ketamine 1mg/kg slow push (glycopyrrolate)• NIV / non-rebreather / LMA…….• Sat >95% for >3 min• Paralytic – leave mask while inducing• Leave nasal cannula and intubate
Hydration before induction� Most critically ill are dry� Loss of sympathetic support� Loss of muscle tone� Peep / Pos Pressure vent� Drugs
� Hydration� Phenylephrine
PLAN AHEAD� What drugs do you have available
� What tools do you have
� What are you experienced and comfortable to perform
11/5/2013
8
Can you bag – valve –mask ventilate this patient?Will you be able to see cords?Oral endotracheal intubation fails – what next? This pt develops stridor and sat’s begin to fall??
This asthmatic becomes agitated –her PH is 6.8 PCO2 = 110
Difficult AirwayManagement Steps (7)
1. Always assume the intubation will be difficult! **
2. Familiarize yourself: **Where are your airway tools locatedWhat devices are at your disposal
3. Have backup plans A B & Cdeveloped before the scairway arrives **
** MAJOR TAKE HOME POINTS
11/5/2013
9
Airway Plans A B & COptimize Oral Endotracheal Intubation
conditions
LMA – Combitube – Stylet guided Intubation
Surgical: Needle, Seldinger, or Traditional
A
B
C
More Steps4. Consider the urgency of the case
Airway control is needed:NOW!!Within minutesSemi – elective
5.Can the patient be bag-valve-mask ventilated?
More Steps
4. Consider the urgency of the case5. Can the patient be bag-valve-mask ventilated?
6. Assess airway anatomy7. How great is the risk of aspiration?
1ST ATTEMPT HAS FAILED
� Start with back up plan A
11/5/2013
10
Preparing for the second attempt� Positioning can make a huge difference
• Raise the bed • Top of patients head at very end of gurney• Flex neck 30o - extend head / ramp up
� Change blades – or use the Mac like a Miller� BURP maneuver
• Back – UP - Right - Pressure
Things to Do in Every Airway
Alternative Airway Approaches / Devices� Nasal intubation� Fiberoptic intubation� Gum elastic bougie� Lighted Stylet� Laryngeal Mask Airway (LMA)� Combitube / King
Alternative Airway Approaches / Devices� Tactile digital intubation� Retrograde intubation� Percutaneous transtracheal intubation� Cricothyrotomy – traditional� Cricothyrotomy – needle guided� Video laryngoscopes
11/5/2013
11
Personal recommendations
Bougie
11/5/2013
12
Bougie 60 cm long – 15 French
� Use a laryngoscope� Advance with the concavity facing anterior� As the tip of the bougie enters the glottic opening
feel for ‘clicks’ as it passes over the tracheal rings� Rotate the ETT counter-clockwise
Percutaneous Transtracheal Ventilation (PTV)�Ventilation via a catheter placed through
the cricoid membrane• High frequency jet ventilation (small volumes
of oxygen at rates of 100-200/min)• High pressure standard ventilation (large
volumes at 50psi at a rate of 12-20.min)• Traditional bag valve ventilation (intermediate
volumes, low pressure std rate)
Percutaneous Transtracheal Ventilation� Indications:
• Rescue airway – especially in children
� Contraindications:• *Complete airway obstruction• Unable to identify landmarks
� Complications:• Barotrauma• Esophageal perforation• Hypercapnea
Percutaneous Transtracheal Ventilation
Google search Manual Jet Ventilator
11/5/2013
13
Percutaneous Transtracheal Ventilation
(The MacGuyver Approach)Ketamine
Ketamine� Can be used IM� Doesn’t require refrigeration� Wide safety index� No apnea� Rapid onset
Dexmedetomidine� Alpha 2 agonist� Dissociative state� Preserves airway reflexes� Hypotension, bradycardia, nausea
11/5/2013
14
Midazolam� No refrigeration� IM� Reversible� Rapid onset
Vomiting blood� 45 yr old male with hematemesis� + past hx of ETOH and GI bleed
� 92/64 134 26 94%� Actively vomiting blood� Awake but confused
Hematemesis� What are the immediate issues / questions
that need to be answered?
Can the pt be bag mask ventilated?
Is aspiration a real threat?
How difficult is traditional oral trachealintubation likely to be?
How much time do we have?
Hematemesis� BVM vent likely to be very difficult� A secure airway is needed NOW!!!� Aspiration is a major threat� Too crashed for nasal (+probable
coagulopathy)� +- one attempt at traditional oral
intubation ….
11/5/2013
15
Hematemesis� I recommend trying to pass a bougie if
you can see some anatomy but have the ILMA and a needle cric kit ready
� KETAMINE!
Needle Cricothyrotomy
I suggest using a # 10 blade to produce a larger skin ‘nick’
Needle Cricothyrotomy Needle Cricothyrotomy
11/5/2013
16
Airway Pearls� DSI and NIV as a preoxygenation tool
-Apneic Oxygenation should be standard
-The BVM – bag – holds about 2 L of air – one only needs to administer about 1/4 of the bag to ventilate
-Ketamine is invaluable
Summary� Expect the worst and be prepared� Consider the urgency� Don’t forget BVM ventilation� Balance the needs for ventilation & oxygenation vs.
the risk of aspiration� Become familiar with
• LMA or Combitube• Lightwand or Bougie• Traditional or Seldinger cric• PTV