Airway management in ED - Basics and advanced
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Transcript of Airway management in ED - Basics and advanced
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Airway management in ER settings “Basic & Advanced”
Updated with recent advances
Dr.Venugopalan. P.P DA,DNB,MNAMS,MEM-GWU Director , Emergency Medicine
Aster DM Healthcare
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Why airway management in Emergency Room ?
» Airway management is the cornerstone of resuscitation
» A defining skill for the specialty of emergency medicine
» The emergency physician has primary responsibility for management of the airway
» All airway management techniques lie within the domain of emergency medicine
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
When to intubate ?
» 1.Failure to maintain or protect the airway » 2.Failure of ventilation or oxygenation » 3.Anticipated clinical course and likelihood
of deterioration.
Clinical Decision
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
How do you know airway is patent?
» 1.Level of consciousness » 2.Ability to phonate in response to voice
command or query (Integrity of the upper airway and the level of consciousness)
» 3. Ability to manage his or her own secretions ( pooling of secretions in the oropharynx, absence of swallowing spontaneously or on command)
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Intubation?
A patient who requires a maneuver to establish a patent airway or who easily tolerates an oral airway
probably requires intubation for protection of that airway, unless temporary or readily reversible
condition, such as opioid overdose, is present.
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Ventilatory failure or Oxygenation failure?
» Clinical assessment » Pulse oximetry with or without
capnography » Observation of improvement or
deterioration in the patient’s clinical condition
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
The decision to intubate
intubate, and intubate early
especially in dynamic airways
Bullets - neck traumaBites- anaphylaxis / angioedema thermal and Burns -caustic airway injuries
• 3 Bs Bullets Bites Burns
#
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
ABCDEF
Airway - mouth and neck infections, tumors, foreign bodies, bleeds ]exam: stridor, phonation, swallowing, secretions, dyspnea
Breathing failure of oxygenation or ventilation often amenable to medical and non-invasive therapies – think NIV
Circulation supporting tissue oxygen delivery by unloading the muscles of respiration sepsis
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
ABCDEFDisability : CNS catastrophes and CNS depression, ongoing seizures, weakness exam: avoid gag – assess ability to swallow and handle secretions (pooling, drooling, gurgling) for neuromuscular weakness: FVC < 12 ml/kg and NIF < 20 cm H20
vomiting in the obtunded patient is a particular concern
Expected course :anticipated decline, transfer to radiology or another institution
» Feral -need for prompt, aggressive sedation to protect patient/others
especially with potential or undiagnosed medical instability
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Arterial blood gases (ABGs) generally are not required to determine the patient’s need for intubation
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Anticipated clinical deterioration
» Certain overdoses » Significant multiple trauma, with or without head
injury » Multiple trauma with hypotension, an open femur
fracture, and diffuse abdominal tenderness » Aggressive resuscitation, pain control,invasive
procedures and imaging outside of the emergency department ,inevitable operative management
» Evidence of vascular or direct airway injury in the neck
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Obstructed airway ?
• Tongue and Epiglottis • Any Foreign materials ?
Clear it
Noisy breathing ?
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Tongue obstructing Airway
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Head tilt &Chin lift
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Jaw thrust
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Trauma ?
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Airway
Not – Maintainable ?
Adjuncts
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
• Airway Reflexes ? …..No !
Choice –OPA !
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
O P A
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Sizing - oropharyngeal airway
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Oropharyngeal airway Insertion
OPA InsertionBest method
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
• OPA is not tolerating ? • Airway reflexes retained ? • Inability to open mouth ?
N P A
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
N P A
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Airway
Still not – Maintainable ?
Advanced Airway
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
No Breathing ?
• Give Breaths • Cricoid Pressure ?
E – C Clamp
Place and hold mask properly
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Non-maintainable Airway
Conscious patient? Semiconscious with retained reflexes?
R S I
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
RSI Defined
“Virtually simultaneous administration of a potent sedative agent and a neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation”
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
What are The Problems Inherent to Intubation?
• Laryngoscopy and Intubation – Increased bronchospasm – Increased ICP – Increased catecholamine release
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Beneficial Effects of RSI• “Tight Heads”
– Intracranial pathology • “Tight Hearts” or “Tight Vessels”
– Cardiovascular disease • “Tight Lungs”
– Reactive airway disease
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Conventional With LMA
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
RSI: TimelineT – 10 minutes Prepare T – 5 minutes Preoxygenate T – 3 minutes Pretreat T = 0 Paralysis with
induction T + 30 seconds Protection T + 45 seconds Placement T + 90 seconds Post-Intubation
management
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Airway Evaluation
Problem Airway
epiglottis Vocal cords
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Difficult airway ?
» Difficult intubation, » Difficult BMV, » Difficult ventilation with an extra glottic
device » Difficult circo thyrotomy.
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Double set up » Neuromuscular paralysis
generally should be avoided in patients for whom a high degree of intubation difficulty is predicted, unless the administration of the neuromuscular blocking agent (NMBA) is part of a planned approach to the difficult airway
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Look Externally
» Severely bruised » Bloodied face of a combative trauma patient » Immobilized in a cervical collar on a spine
board » Anatomical deformities » Subjective clinical judgment can be highly
specific (90%) but insensitive and so should be augmented by other evaluations.
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Evaluate 3-3-2.
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Obstruction or obesity
» Visualization of the glottis, or intubation itself, mechanically impossible
» Epiglottitis, head and neck cancer, Ludwig’s angina, neck hematoma, or glottic polyps
» Examine the patient for airway obstruction and assess the patient’s voice to satisfy this evaluation step
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Neck mobility
» Neck mobility is desirable for any intubation technique and is essential for positioning the patient for optimal direct laryngoscopy. Neck mobility is assessed with the patient’s flexion and extension of the head and neck through a full range of motion
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Lemon in ER setting
» Unresponsive patient - Mallampatti is not practical - LEON
» Unresponsive plus Trauma - Mallampatti and Neck mobility are not practical - LEO
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Cormack and Lehane[CL]
» The most widely used system for grading laryngoscopic view of the glottis is that of Cormack and Lehane (CL)
» Grades laryngoscopy according to the extent to which laryngeal and glottic structures can be seen.
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
CL grading
» Grade 1 laryngoscopy, all or nearly all of the glottic aperture is seen.
» Grade 2 laryngoscopy visualizes only a portion of the glottis (arytenoid cartilages alone or arytenoid cartilages plus part of the vocal cords).
» Grade 3 laryngoscopy visualizes only the epiglottis.
» Grade 4 laryngoscopy, not even the epiglottis is visible.
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Percentage Of Glottic Opening (POGO) score
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Confirmation of Endotracheal Tube Placement
» Direct visualisation » Chest auscultation » Gastric auscultation » Bag resistance » Exhaled volume » Visualization of condensation within the ETT » Chest radiography » All are prone to failure as means of confirming
tracheal intubation.
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
ETCO2
» End-tidal carbon dioxide (ETCO2) detection device to the ETT and assess it through six manual ventilations
» Disposable, colorimetric ETCO2 detectors are highly reliable, convenient, and easy to interpret, indicating adequate CO2 detection by color change
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
End tidal CO2 detection
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
USG- EDD» When ETCO2 detection is not possible,
tracheal tube position can be confirmed with other techniques.
» One novel approach Bedside ultrasound.
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Esophageal Detector Devices (EDD)
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Recognize Adequacy of Ventilations
Pulse oximeter
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Chest X ray
» Although chest radiography is universally recommended after ETT placement, its primary purpose is to ensure that the tube is well positioned below the cords and above the carina.
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Other methods Gold standard
• Fiberoptic confirmation
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Difficult Airway Assessment• 4 D’s
– Distortion, Disproportion, Dysmobility, Dentition • BONES
– Beard, Obese, No teeth, Elderly, Snores (sleep apnea)
• SHORT – Surgery (head/neck/jaw), Hematoma, Obese,
Radiation, Tumor • LEMON • MALLAMPATI • Always have a “Rescue Airway” technique
ready
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
McI
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Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Rescue Airways
• Gum Elastic Bougie (GEB) • Laryngeal Mask Airway (LMA/ILMA) • Combitube • Surgical Cricothyrotomy
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Advanced airway –Best choice Intubation
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Equipments Needed
❑ Laryngoscope with different types of blade.
❑ ET tube with proper size and type. Average adult male: 8.5 mm Average adult female: 7.5 mm Low pressure cuff tubes above 8 years Uncuffed tubes below 8 years
< 4 Age + 3.5
3
> 4 Age + 4.5
4
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Laryngoscope
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Align the airway axis by proper positions
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
• Align the 3 axes – critical for success • Sellick’s maneuver
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
ET Tube insertion
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Laryngeal Mask Airway
❑A silicone rubber device that combines. Tracheal intubation and the use of a face mask.
❑Used for situations when intubation attempts have failed, bag-valve mask ventilation is unsuccessful, and the patient needs immediate airway management.
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
LMA- SizesSize Description Weight
1 Neonates Upto 5 Kg
1 ½ Pediatric 5 - 10 Kg
2 Infant 10 – 20 Kg
2 ½ Child 20-30 Kg
3 Large child/ Small Adult 30 – 50 Kg
4 Adult 50 – 70 Kg
5 Adult > 70 Kg
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Combitube Insertion
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Surgical Airway
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Blind Nasotracheal Intubation
• BNTI remains a valid method of intubation in the out-of-hospital setting, where it occasionally is used. In the ED, BNTI rarely, if ever, should be used and is reserved for patients in whom the presence of a narrowly defined type of difficult airway makes RSI undesirable or contraindicated and alternatives
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Awake Oral Intubation» Awake oral intubation is a technique in which
sedative and topical anesthetic agents are administered to permit management of a difficult airway without neuromuscular blockade.
» Topical anesthesia may be achieved by spray, nebulization, or local anesthetic nerve block. After the patient is sedated and topical anesthesia has been achieved, gentle direct, video, or flexible endoscopic laryngoscopy is performed to determine whether the glottis is visible and intubation possible
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Awake intubation
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
What is the Disaster in Airway management?
Can’t Intubate !
Can’t Ventilate !!
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
• Rescue Airway
LMA ,Combitube , Bougie assisted intubation
Surgical Airway
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
New Airway Devices
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Video Assisted Laryngoscope
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Airway management made easy
Algorithms
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
Approximate Blood oxygen level !
➢SpO2 100% = PaO2 100mm of Hg ➢SpO2 90%= PaO2 60mm of Hg ➢SpO2 60%= PaO2 30mm of Hg ➢SpO2 50%= PaO2 27mm of Hg
Venugopalan.P.P; EMCME 2009;MIMS.CALICUT.15.03.09
THANK YOU