Emergency Airway Management 2014: Mark P. Brady PA-C
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Transcript of Emergency Airway Management 2014: Mark P. Brady PA-C
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2013
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Agenda:
• Airway Anatomy Adult vs. Pediatric • Review of basic equipment • Approach to the Difficult Airway • RSI • Post-Intubation Management • Ventilator Settings • The Crashing Asthmatic
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Important take home points
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The search for the epiglottis
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Are kids just small adults?
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vs Airway Anatomy
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Airways
not Difficult
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• Externally
– Larger head/occiput – Head flexes forward and can obstruct
• Internally – Intra-oral tongue – Large, floppy epiglottis
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• Further differences – “Pinker” vocal cords worsen visualization
– Different location of narrowest point • Peds cuffed tubes?
– Smaller cricothyroid membrane • No surgical crics in children
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Other Considerations
• More gastric insufflation with BVM • Quicker desats during intubation Different
• 10 kg will drop to 90% in <4 minutes (vs. 8 for adult)
• Vagal response (not significant) • Consider Pre-treatment with Atropine (though not literature supported and not the standard of care)
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Cardiorespiratory Arrests
10% 10%
80%
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Hypoxia and Hypercarbia
Bradycardia
Cardiorespiratory Arrests
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Self Confident If he can, you can
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Avoid the “cookie-cutter” approach to every airway you encounter.
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Be familiar with your equipment…
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What tools do I have ?
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Airway Equipment
• Oxygen and Suction • BVM / OPA / NPA • ETT / Bougie / LMA / King LT • Stylet • Magill forceps • End-tidal CO2 monitoring and securing
devices • Surgical Airway Devices
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Airway Equipment
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Airway Equipment
C-E technique is WRONG
E
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Airway Equipment
Use the Two Thumbs Down technique
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Airway Equipment
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Airway Equipment OPA NPA
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King LT
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Airway Equipment
Endotracheal tube
stylet
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Airway Equipment Eschmann Stylet, a.k.a “Gum elastic bougie”
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Airway Equipment
MAGILL FORCEPS
LMA
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Airway Equipment LMA – Laryngeal Mask Airway
Are extraglottic airways harmful in cardiac arrest ?
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Airway Equipment “Yellow” = YES
“Purple” = Pathologic
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Airway Equipment:
• What equipment do we have in our departments?
• Where is it located?
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Broselow Tape The
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• Can’t Protect Airway • Can’t Maintain Ventilation / Oxygenation • Expected Decline in Clinical Status
3 Emergent Indications for Intubation
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Gag reflex is absent in up to 37% of population, and is a poor predictor of airway protection
• Can they talk? • Can they swallow and manage secretions?
Can’t Protect Airway
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• SaO2 <90% on High Flow O2 or PaO2<60 on FiO2>40%
• PaCO2 >55 if baseline is normal, or >10 increase from baseline
• Respiratory Rate
Can’t Maintain Ventilation or Oxygenation
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• Deterioration/Impending Compromise Transport • Airway protection during procedures (ie. endoscopy)
Expected Decline in Clinical Status
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DEFINITIONS
Rapid Sequence Intubation (RSI)
INDUCTION AGENT
PARALYTIC
UNCONSCIOUSNESS MOTOR PARALYSIS
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DEFINITIONS
Delayed Sequence Intubation (DSI) DSI consists of the administration of specific sedative agents, which
do not blunt spontaneous ventilations or airway reflexes;
followed by a period of preoxygenation before the
administration of a paralytic agent.
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CONTRAINDICATIONS
INDICATION RISK
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RSI RATIONALE
Increased success
Decreased aspiration
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Better C-spine control
RATIONALE - Secondary
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Blunting ↑ in ICP / IOP
RATIONALE - Secondary
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Avoid airway trauma
RATIONALE - Secondary
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Avoid airway trauma
RATIONALE - Secondary
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↓ Pain ↓ Discomfort ↓ Recall
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Adverse Drug Events
HAZARDS
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May force crash airway scenario
HAZARDS
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The 7 “P’s”of RSI PREPARATION
PREOXYGENATION
PRETREATMENT
PARALYSIS WITH INDUCTION
PROTECTION AND POSITIONING
PLACEMENT AND PROOF
POST-INTUBATION MANAGEMENT
TIME ZERO
t – 10 minutes
t + 90 seconds
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PREPARATION t – 10 minutes
1. EQUIPMENT PRESENT AND WORKING
INCLUDING EQUIPMENT FOR PLAN “B”
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PREPARATION t – 10 minutes
2. Ask yourself: CAN I…
BAG THE PATIENT TUBE THE PATIENT CRIC THE PATIENT
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“Evaluate for signs of a difficult intubation”
-Obesity -
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Look at the general anatomy Evaluate the 3-3-2 rule Mallampati score Obstruction Neck mobility Saturation Reserve
CAN I TUBE THIS PATIENT?
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Look at the general anatomy
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Evaluate the 3-3-2 rule
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Mallampati score
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Obstruction
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Neck mobility
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Saturation Reserve
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Saturation Reserve At 92% the patient’s oxygen saturation
falls off a cliff….
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CAN I BAG THIS PATIENT?
Maybe. Maybe Not.
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Approximate normal ventilation rates: • 10 bpm Adult • 20 bpm Child • 25 bpm Infant
VENTILATE (BLS)
Squeeze.....Release - Release
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Keep Dentures in when using a BVM
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CAN I CRIC THIS PATIENT?
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Indications • Obstruction
• Facial Trauma
• Intubation or other alternatives impossible
• Trismus (clenching)
• > 8 years old
(for open procedures)
SURGICAL AIRWAYS
LAST RESORT!
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DEFense Readiness CONdition
Maximum readiness
Armed Forces ready to deploy and engage in less than 6 hours
Air Force ready to mobilize in 15 minutes
Above normal readiness
Normal readiness
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Discuss / Feel / See Kit
Mark / Kit Bedside
Inject / Prep / Open & Set Kit Scalpel in Hand
Make Skin Cut & Find Membrane
Perform Cric
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Open Cricothyrotomy
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1. Vertical Incision over membrane 2. Pierce membrane in horizontal plane 3. Open and spread to insert 4.0 or 5.0 tube 4. Secure tube in place and ventilate
Open Cricothyrotomy
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PREOXYGENATION t – 5 minutes
1. “First, do not bag!”
2. Avoid “Sellick’s” maneuver (cricoid pressure)
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PREOXYGENATION t – 5 minutes
1. Well-fitting mask
2. 8 vital capacity breaths
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PREOXYGENATION t – 5 minutes
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PREOXYGENATION t – 5 minutes
NIV CPAP for Pre-Oxygenation
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Summary of LOAD PRETREATMENT
L idocaine à optional
O piates à optional
A tropine à for infants consider for kids < 8
D efasciculating à optional dose
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DEFASCICULATING DOSE 1/10 th the RSI dose
Traditional Indications
1. Blunt rise in ICP 2. Decrease risk of aspiration
3. Prevent muscular pain
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PRETREATMENT t – 3 minutes
If you’re going to give these drugs:
…at least give them some time to circulate (3 minutes)
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PARALYSIS WITH INDUCTION
Time “0” INDUCTION AGENTS
Etomidate
Ketamine
Propafol
Midazolam
PARALYTIC AGENTS DEPOLARIZING
Succinylcholine NON-DEPOLARIZING
Vecuronium Rocuronium
+
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PARALYSIS WITH INDUCTION
Time “0”
Sedation then Paralysis
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PARALYSIS WITH INDUCTION
Time “0”
Use of Apneic oxygenation
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Etomidate
– Rapid onset/offset
– Minimal hemodynamic and respiratory effects
– Pediatrics – not approved for patients under 10
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Succinylcholine
• When: Immediately after Etomidate • Onset: Rapid, usually 30-90 secs
• Duration: Short acting, 3-5 mins
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When Sux Really “Sucks” CONTRAINDICATIONS
1. HYPERKALEMIA
RENAL FAILURE RHABDOMYOLYSIS
2. RECEPTOR UPREGULATION SUBACUTE BURNS (>1 day) SUBACUTE DENERVATING DISORDER HISTORY OF MALIGNANT HYPERTHERMIA
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SUX IS STILL KING
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SUX versus ROC
45 seconds ONSET 1 minute 9 minutes DURATION 45 minutes
1 mg/kg 1-1.5 mg/kg
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PROTECTION AND POSITIONING t + 20 seconds
May NOT be helpful
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Positioning: Medical vs. Trauma
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C Spine Precautions
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C Spine Precautions
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Positioning Adult vs Pedi
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Cormack & Lehane Grading
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Sweep Left
and
Look
Orotracheal Intubation Procedure
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Adult vs Pedi
Normal Trachea
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PLACEMENT AND PROOF t + 45 seconds
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POST-INTUBATION MANAGEMENT t + 90 seconds
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More to come next month……….
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POST-INTUBATION MANAGEMENT t + 90 seconds
CONFIRM PLACEMENT
& SECURE
TUBE
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Capnography
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Post-intubation CXR
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INTUBATION HURTS! And it keeps on hurting once the tube is in…
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POST-INTUBATION MANAGEMENT Achieve Adequate Analgesia and Sedation
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POST-INTUBATION MANAGEMENT
Raise the Head of the Bed to at Least 30°
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Confirm Lung Protective Vent Settings
POST-INTUBATION MANAGEMENT
• Mode AC • VT 6-8 cc/kg • Rate 12-16 • PEEP 5 • FiO2 100% then titrate down
Standard Ventilator Settings
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POST-INTUBATION MANAGEMENT
Continuous waveform ETCO2
NG / OG tube Empty the stomach to reduce the chances of aspiration and to improve lung mechanics
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POST-INTUBATION MANAGEMENT
Nebulizers/MDI If they were intubated for reactive airway disease, then they need frequent nebs
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Acute Deterioration after Intubation D.O.P.E.S: Displacement Obstruction Pneumothorax Equipment failure Stacked Breaths
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Basics of Ventilator Management
Lung Injury Obstructive Lung Disease
Use as Default
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Basics of Ventilator Management Lung Injury
Lung Protective Management
1. Mode: use A/C (assist control)
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Basics of Ventilator Management
Vt
IFR
FiO2 PEEP
RR
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Basics of Ventilator Management
Vt
Tidal Volume 6-8 cc/kg IBW
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Basics of Ventilator Management
IFR Inspiratory Flow Rate
= how quickly the breath is delivered
60-80 LPM
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Basics of Ventilator Management
RR Respiratory Rate 16-18 BPM
RR = Ventilation
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Basics of Ventilator Management
FiO2 PEEP
1. Start @ 100% 2. Wait 5 min 3. Get ABG 4. Drop to 40%
FiO2
Goal: Saturation of 88-95%
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Basics of Ventilator Management
FiO2 PEEP Start with 5
Positive End-Expiratory Pressure - PEEP
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Basics of Ventilator Management
FiO2 PEEP
FiO2 + PEEP = Oxygenation
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Inspiratory Plateau Pressure _________________________________________________
Peak Plateau Plateau Pressure
< 30 cmH2O
Must find and hold Inspiratory Hold button Ventilator will then display Plateau Pressure
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Basics of Ventilator Management
Vt
IFR
FiO2 PEEP
RR
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Basics of Ventilator Management
Analgesia 1st Sedation 2nd
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The Crashing Asthmatic
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Crashing Asthmatic
Sweaty Can’t Talk Tachypneic Tripoding
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Maximal O2 (NRB) Inhaled Albuterol Inhaled Atrovent IV Steroids IV Magnesium SC Terbutaline Epinephrine drip
Crashing Asthmatic
THE KITCHEN SINK – Maximal Rx
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Crashing Asthmatic
BiPAP CPAP
NON-INVASIVE VENTILATION
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Too Early Too Late
Crashing Asthmatic
WHEN TO INTUBATE
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Crashing Asthmatic
Etomidate Succinylcholine GO FAST!
Lidocaine Ketamine
KEEP IT SIMPLE! OPTIONS...
HOW TO INTUBATE
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Crashing Asthmatic
Use a Big ETT AGGRESSIVE TOILET
Reason #1 Mucous Plugs
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Crashing Asthmatic
Reason #2 Dehydration
IV FLUID BOLUS
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Reason #3 Breath Stacking
Crashing Asthmatic
Squeeze Chest Low Vent Settings
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Crashing Asthmatic
Chest Tubes
Reason #4 Barotrauma
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Cardiac Arrest Post-Intubation
1 Disconnect ventilator 2 Squeeze chest 3 Bilateral chest tubes 4 Fluid bolus
Summary
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Crashing Asthmatic Last Chance………
Anesthetic Gases
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ECMO
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Extracorporeal Membrane Oxygenation (ECMO)
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Pearls
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• Can’t see the cords - …try BURP
• Another attempt needed – …change something
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Call for help !
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Have a backup plan – “Prior planning prevents poor performance”
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Don’t panic!
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Thank you!
Mark P. Brady PA-C Dept.of Emergency Medicine Cambridge Health Alliance Cambridge, MA