Own the Oxygen
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Transcript of Own the Oxygen
![Page 1: Own the Oxygen](https://reader035.fdocuments.net/reader035/viewer/2022062319/55890b17d8b42aac218b467c/html5/thumbnails/1.jpg)
Chris Nickson Emergency Registrar
SCGH, November 2011
Preoxygenation and apneic oxygenation during emergency intubation
OWN THE OXYGEN!
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A talk that pays homage tothe brilliant work of
Richard Levitan and Scott Weingart
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http://lifeinthefastlane.com/2011/11/rr-in-the-fastlane-001/
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3 Steps to Own the Oxygen!
①Preoxygenation• Why, how, and for how long?
②Apneic oxygenation• Why and how?• Positioning, ventilations and maneuvers• Paralytic agents
③Putting it into practice• Risk stratification and logistics
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Why preoxygenate before you intubate?
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Preoxygenation extends safe apnea time
during intubation
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From Weingart and Levitan 2011
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Goals of preoxygenation
①SaO2 100%
②Denitrogenate the lungs (big O2 reservoir)
③Oxygenate the blood (less important)
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What is the best source of high FiO2 for preoxygenation?
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Use a face mask with a reservoir and oxygen flow as high as possible
e.g. NRB mask with 15+ L/min
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How long should you preoxygenate for before intubation?
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If adequate respiratory drive:
3 minutesor
8 breaths with maximal inspiration and expiration
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Is there a role for positive pressure in preoxygenation?
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Yes!
Use CPAP or NIV or BVM with PEEP valve in patients with baseline SpO2 95% or less
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How should you position the patient during preoxygenation?
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Whenever possible, elevate the head
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How long will it take a preoxygenated patient to desaturate?
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Somewhere between 8 minutes and immediately!
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From Walls RM, Murphy MF. Manual of Emergency Airway Management (2008), 3rd edition
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What is the role of apneic oxygenation?
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15 L/min via nasal cannulae extends the safe apnea time
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Are ventilations during the apneic period an option?
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Yes… if benefits > risks
consider if SpO2 90-95%
‘essential’ if SpO2 <90%
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How should the patient be positioned,
and what maneuvers should be used,
during the apneic period?
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Ear-to-sternal notch positioning
Consider nasal airway
Jaw thrust when apneic
(Forget cricoid!)
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Position is everything!
Ear hole at the same height as the neck hole!
(aka sternal notch)
Scott Weingart - http://emcrit.org/
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How does choice of paralytic agent affect oxygenation?
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Suxamethonium leads to
shorter safe apnea times than rocuronium
http://lifeinthefastlane.com/2011/05/ruling-the-resus-room-004/
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In Summary…
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Oxygenate according to risk
Know the logistics…
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Preoxygenation period
• Head up positioning• Ear-to-sternal notch position• Place nasal cannula• High flow oxygen: 15 L/min via NRB• Preoxygenate for 3 minutes with tidal breaths, or
8 maximal inspirations/ expirations• If hypoxic, consider:– CPAP (e.g. 5-15 cmH20 to achieve SO2 >98%)– BVM with PEEP valve
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Apneic period
• Push sedative and roc• Commence 15 L/min oxygen via nasal cannula• Remove face mask• Maintain airway with jaw thrust• If hypoxic, consider:– CPAP– BVM (6 breaths/ min) with PEEP valve
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Intubation period
• Leave the nasal cannula on at 15 L/min while you….
OWN THE AIRWAY!
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Low risk
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High risk
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Hypoxic
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http://lifeinthefastlane.com/2011/02/own-the-airway/
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Remember to check out:http://emcrit.org/preoxygenation/
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THE END