Emergency MedicineAnd the Difficult Airway

Jordan Barnett, MD FACEP FAAEM

Disclaimer

This presentation is free of

commercial bias

Dichotomy • Anesthesiologists usually have

time to prepare

• Anesthesiologists often can defer care

• Anesthesiologists can obtain information and history from patient

• Anesthesiologists have non chaotic environment

What Does the ED Contend with?

Initial Assessment

• Be comfortable calling for help

• Surgical airway endpoint of all algorithms

• BVM to buy time. Not always imperative to intubate immediately

• Have a difficult airway cart and be familiar with it!

Intubation Plan

• In crash situation, may intubate without paralytics

• Difficult airway cart to bedside

• What is your skill set, tools available?

Predictors of a Difficult AirwayLEMON RULE

• Look at the Anatomy

• Evaluate using 3-3-2 rule

• Mallampati

• Obstructions

• Neck Mobility

LOOK for predictors of Difficult Airway

• Abnormal,jagged, or protruding teeth

• Receding chin

• Facial hair

• Full stomach

• Obesity

Other Items to LOOK for include

• No Teeth

• Elderly

• Snoring

• Large Tongue

• False Teeth

• Narrow Face

Evaluate THE AIRWAY

Evaluate with the 3-3-2 Rule

• Can you get 3 fingers in mouth? If So there is room for insertion of tube and laryngoscope

• Can you fit three fingers between the angle of the jaw and mentum? If so, you can probably lift the tongue forward

• Can you fit two fingersers between the top of the thyroid cartilage and bottom of jaw? If not, high anterior cord probably present

Mallampati Classification

• Grades I and II high success rate at intubation

• Grade III can only see arytenoid cartilage

• Grade IV cannot visualize anything

How to Mallampati Score

• Have Patient seated, extend neck, open mouth and stick out tongue

• Visualize Mouth, tongue, faucial pillars, uvula, and pharynx

No obstruction

Complete obstruction

OBSTRUCTIONS

Types of Obstructions

Neck Mobility?

Fracutre?Arthritis?

Surgical hardware?

Can’t Align Axises For Visualization!

Always

• Try not to utilize medications too quickly. Evaluate airway first. Gives time to call for help

All the predictors are fine theoretically but .......

Difficult Airway Cart• Recommended items include

drawer for medications and basic equipment

• Intubating stylet or bougie

• Intubating laryngeal mask airway

• Light Wand

• Fiberoptics

• surgical airway kit - essential

Intubation equipment

• Options to avoid intubation include CPAP

• Consider intubation in OR

• For blind intubations consider LMA or Bougie

• Digital intubation?

The Bougie

How to use the Bougie

• Bougie acts as guide wire

• Gets Passed Blindly

• Feel for tracheal rings

Lighted Intubation Stylet

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VIDEO

Laryngeal Mask Airway

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Note: This video provided to demonstrate LMA use. No financial interest with the

Solus Brand

Airway Alternatives

• Supraglottic: Combitube; blind nasotracheal intubation still has role

• Infraglottic; Cannot BVM or intubate if access required below cords; Prepare for Cricothyrotomy In peds, consider transtracheal jet ventilation

Combitube

Combitube Details• Two Lumens

• Filling one blocks the esophagous

• Second Lumen acts like a standard cuffed tube

• Blind insertion

• 90% Esophageal insertion

• 100 cc for proximal balloon inflation

• 10 ml for distal balloon inflation

• Listen as you inflate through each port

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Tracheal position

Esophageal Position

EMS using King LT

• Easier field insertion

• Simpler to change to ETT

• Can Place King without Interupting CPR

• Placement Edema

Additional options

• Wire guided Seldinger technique

• Keep option to use open techinique if wire unsuccessful

Retrograde Endotracheal

Intubation

Technique In Detail

• Needle through Cricothyroid Membrane

• Retreive End of Wire

• Tube Changer over wire

• Slide in ETT

VIDEO

Anterograde Seldinger

Pass wire through hub

Pass Over Wire

Fiberoptics

Two Types Available

• Flexible

• Rigid

Flexible Fiberoptic Intubation

• Used if Neck Extension Not desirable

• Risk of Dental Damage

• Abnormal airway

• Compromised Airway

Advantages of Fiberoptics

• Excellent visualization

• Minimal hemodynamic stress when performed properly

• oral or nasal intubation is possible

• ability to apply topical anesthesia insufflate oxygen during intubation

Disadvantages

• Expensive

• Requires maintenance

• Blood or secretions impairs visualization

• Requires “Practiced Expertise” for use in acute situations

Video

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Rigid Fiberoptics

• Indicated for limited mouth opening

• Indicated for reduced neck movment

Advantages

• Allows for visualization of the larynx with little neck movement and mouth opening

• Can overcome difficult view

• Sturdy and Durable instruments

Disadvantages

• Skill

• External light source for some devices

• Wu Scope requires considerable mouth opening

Levitan Scope

Bullard Scope

Wu Scope

Upsher Scope

New Laryngoscope blades

• Utilize video camera at end of laryngoscope

• Complications including fogging and inability to visualize airway after intubation

GlideScope• Preferred over Laryngoscope

• Gets around Tongue Easily

• Insert with patient in neutral position

• Can see even in presence of blood and vomit

• Will probably replace Laryngoscope in 5 to 10 years

Transtracheal Jet

• If under 8 and no airway, surgical airway of choice

• Temporary /Stabilizing

Cricothyrotomy

• Taught as the “Final Pathway” to all ER physicians as a last resort for failed airway access

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Ready for some Cases?

Difficult Airway Case 1

• 34 year old chronic alcoholic enters the ER “not feeling well.” History of “back pain” for which he has been seen and treated in the past (err....with Motrin?!)

• Suddenly, during evaluation and obtaining history and physical, patient begins to profusely vomit blood and becomes obtunded.

Case 1 continued

• Monitor shows patient become bradycardic.

• Patient is rolled into rescue position and airway cart called for while multiple peripheral large bore IVs are established

Case 1 continued

• Must protect airway!

• Despite attempts at direct visualization with laryngoscope blade and vigorous suctioning, there is just too much blood to see the cords

Options?

• Blind digital intubation?

• Fiberoptics NOT an option

• Reverse Selinger?

• Crich?

• Lighted stylet?

Case 2

• 73 year old female presents with history of hemoptysis.

• Hasn’t seen a doctor for “years” yet has been loosing weight. Has come to the ER now on the behest of family because of coughing up blood

Case 2 continued

• During the episodes of hemoptysis, patient vagals.

• Airway protection paramount

• Best Management?

Case 3• 35 year old male presented after

dental extraction placed on antibiotics

• Patient presented complaining of pain and swelling of the jaw

• Uvula shift to the left and swollen elevated tongue limit visualization. Sonorous respirations

Discussion

• Conventional laryngoscope blade would probably be ineffective

• Fiberoptics ideal

• Crich kit on standby

• Call to anesthesia to ED on standby if situation not of immediate“Crash” type.

Case 4

• 85 year old female presents via Fire Rescue tachypnic, with only 2-3 word sentences

• Medics report “flash pulmonary Edema” while “at your back door”

• “Doc, we only had time to place her on oxygen and get an IV when we pulled up!”

Case 4 continued

• Patient tachypnic with rales 2/3 up

• JVD

• Pedal Edema at 2+

Discussion

• Most ED docs today would trial patient on BiPAP with airway cart on standby

• Preload reduction with nitrates

• Afterload reduction with Captopril

• Intubation Equipment on standby!

Case 5

• 27 year old male leaped from burning 2 story dwelling landing on back

• Arrives collared and back boarded, unconscious with a Glascow Coma Scale of 5

• Singed nasal hairs with carbonatious sputum

Discussion

• Have to assume potential neck fracture

• Carbonateous sputum and singed nasal hairs taught as signs of pending airway edema

• Head injuries (which have to be assumed) preclude nasal intubation

Management

• 2nd helper holds inline stabalization of neck during attempted intubation

• BURP maneuver

• Anesthesia on standby if can respond timely

• Too much edema? Can’t seen cords? Surgical option of crich.

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