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Emergency Airway Management ________________________________ Mark L. Freedman MD, FRCP. Objectives. To review the indications for intubation To briefly discuss RSI To review the airway assessment To discuss difficult airways To review difficult airway algorithms

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Presentation Transcript
slide1

Emergency

Airway Management

________________________________

Mark L. Freedman MD, FRCP

objectives
Objectives
  • To review the indications for intubation
  • To briefly discuss RSI
  • To review the airway assessment
  • To discuss difficult airways
  • To review difficult airway algorithms
  • To discuss an approach to difficult airways
  • Case discussions
slide3
Case
  • 13 yr/o M mountain biking
  • Neck vs. handlebars
  • Sitting-up on bike path
  • Anterior neck swelling
  • VSS
  • Mild stridor
  • What will you do?
the 4 questions
The 4 Questions
  • Does this patient need intubation now?
  • Is this a crash situation?
  • Is this a difficult airway?

4. Can I use RSI?

outline
Outline
  • Indications for intubation
  • Basic airway algorithm
  • Difficult airways
  • Difficult airway algorithm
  • Securing the difficult airway
  • Cases
outline1
Outline
  • Indications for intubation
  • Basic airway algorithm
  • Difficult airways
  • Difficult airway algorithm
  • Securing the difficult airway
  • Cases
indications for intubation
Indications for Intubation
  • Failure of oxygenation
  • Failure of ventilation
  • Failure to protect
  • Impending obstruction
  • Expected management
failure of oxygenation
Failure of Oxygenation
  • Low FiO2
  • Failure of ventilation
  • V/Q mismatch
  • Diffusion abnormalities
  • Anemia
  • Low C.O.
  • Increased tissue O2 consumption
failure of ventilation
Failure of Ventilation

Brain; CHI

Stroke

Raised ICP

Stem; Stroke

Narcotics

Injury

Cord; SCI

Degenerative diseases

Nerve; Peripheral Neuropathy

NMJ; Myasthenia gravis

Guillon-Barre

NMJBs

Muscle; Myopathy

Thorax; Burn eschar

Rib fractures

Lungs; Restrictive disease

Contusions

Abdomen; Tense ascities

Compartment Syndrome

failure to protect
Failure to Protect
  • Low or dropping GCS
  • “GCS less than 8, intubate”
  • Aspiration risk
impending obstruction
Impending Obstruction
  • Expanding hematoma
  • Deep space infection
  • Epiglotitis/Bacterial tracheitis
  • Angioedema/Allergic reaction
  • Inhalation injury
  • Eschar
  • Foreign body
  • Tumour
  • Others….
outline2
Outline
  • Indications for intubation
  • Basic airway algorithm
  • Difficult airways
  • Difficult airway algorithm
  • Securing the difficult airway
  • Cases
basic airway algorithm
Basic airway algorithm

Yes

Fails

Crashing ?

Crash Airway

No

Yes

Fails

Difficult Airway ?

Difficult Airway

Failed Airway

No

Fails

RSI ?

the 8 p s of rsi
The 8 “P”s of RSI
  • 0 - 10min Preparation
  • 0 - 5 min Preoxygenation
  • 0 – 3 min Premedication
  • 0 Pharmacological Induction
  • 0 Pressure
  • 0 Paralysis
  • 0 + 45 sec Place tube
  • 0 + 1 min Post Intubation Care
outline3
Outline
  • Indications for intubation
  • Basic airway algorithm
  • Difficult airways
  • Difficult airway algorithm
  • Securing the difficult airway
  • Cases
difficult airways
Difficult Airways
  • Difficult mask ventilation
  • Difficult laryngoscopy
  • Difficult tracheal intubation
  • Combinations of above
difficult airway
Difficult Airway
  • EMS Incidence;
    • Not known
  • ED Incidence;
    • Not known
    • Cricothyrotomy reported as high as 1%
    • Definitely inflated
    • Reflects an aggressive approach without employing alternate intubation techniques
difficult airways1
Difficult Airways
  • Difficult mask ventilation;
    • Predicting the difficulty (BOOTS);
      • Bearded
      • Older (> 55 years)
      • Obese (BMI > 26 kg/m2)
      • Toothless
      • Snores
difficult airways2
Difficult Airways
  • Difficult laryngoscopy/intubation;
    • Predicting the difficulty (LEMON);
      • Look
      • Evaluate; 3,3,2
      • Mallampati score
      • Obstruction
      • Neck mobility
difficult airways3
Difficult Airways
  • The airway assessment;
      • Look (BOOTS, others)
      • Evaluate; 3,3,2
      • Mallampati score
      • Obstruction
      • Neck mobility
difficult airways4
Difficult Airways
  • Specific situations;
    • Trauma
    • Obesity
    • Pregnancy
    • Pediatrics
difficult airways5
Difficult Airways
  • Not a catastrophe if you can’t see well
  • Not even if you can’t intubate
  • But, if you ALSO can’t ventilate…….
outline4
Outline
  • Indications for intubation
  • Basic airway algorithm
  • Difficult airways
  • Difficult airway algorithm
  • Securing the difficult airway
  • Cases
slide38

Difficult Airway

Anticipated

Unanticipated

Fail to Intubate

Cooperative

Time

Uncooperative

No time

+ Ventilation

Sats Maintained

- Ventilation

Sats Dropping

OR?

Topicalize

Sedate

Awake;

Laryngoscope

Glidescope

Lighted Stylet

FOB

Help

Sedate

Topicalize

“Brutane”

Sedate More

RSI+Double set-up

Better Position

BURP

Better Blade

Better Drugs

Bougie

Better Person

Glidescope

Bronch

BNTI

LMA

TTJV

Cricothyrotomy

TTJV

Cricothyrotomy

* Suction if bleeding *

outline5
Outline
  • Indications for intubation
  • Basic airway algorithm
  • Difficult airways
  • Difficult airway algorithm
  • Securing the difficult airway
  • Cases
securing the difficult airway
Securing the Difficult Airway
  • Anticipated;
    • Best to get patient to ED/OR
    • BVM as bridge
    • Otherwise intubation
    • Don’t burn bridges
securing the difficult airway1
Securing the Difficult Airway
  • Unanticipated;
    • Can you ventilate??
      • Yes = time
      • No = trouble
slide43

Difficult Airway

Anticipated

Unanticipated

Fail to Intubate

Cooperative

Time

Uncooperative

No time

+ Ventilation

Sats Maintained

- Ventilation

Sats Dropping

Help

Sedate

Topicalize

“Brutane”

Sedate More

RSI+Double set-up

Transport

Observe

Better Position

BURP

Better Blade

Better Drugs

Bougie

Better Person

Glidescope

Bronch

BNTI

LMA

TTJV

Cricothyrotomy

TTJV

Cricothyrotomy

* Suction if bleeding *

difficult airways6
Difficult Airways
  • Difficult ventilation;

1. Head tilt/chin lift

2. Exaggerated Jaw thrust

3. Oral/nasal airways

4. Two handed/two person technique

5. Consider mask change

6. Ease up on cricoid pressure

7. Rule out FB

slide50

Difficult Airway

Anticipated

Unanticipated

Fail to Intubate

Cooperative

Time

Uncooperative

No time

+ Ventilation

Sats Maintained

- Ventilation

Sats Dropping

Help

Sedate

Topicalize

“Brutane”

Sedate More

RSI+Double set-up

Transport

Observe

Better Position

BURP

Better Blade

Better Drugs

Bougie

Better Person

Glidescope

Bronch

BNTI

LMA

TTJV

Cricothyrotomy

TTJV

Cricothyrotomy

* Suction if bleeding *

outline6
Outline
  • Indications for intubation
  • Basic airway algorithm
  • Difficult airways
  • Difficult airway algorithm
  • Securing the difficult airway
  • Cases
case 1
Case 1
  • 13 yr/o M mountain biking
  • Neck vs. handlebars
  • Sitting-up on bike path
  • Anterior neck swelling
  • VSS
  • Mild stridor
  • How will you proceed?
case 2
Case 2
  • 40 yr/o M
  • Fall from height
  • Spike through mandible into eye
  • HD stable, respiratory distress
  • Gaping mandible and bleeding into airway
  • GCS 14
  • How will you proceed?
case 3
Case 3
  • 67 yr/o F
  • Sudden collapse
  • On ship in Southern Ocean (Antarctica)
  • Decreased LOC, blown pupil, posturing
  • GCS 6….5….4….
  • 40 220/110 16 100% 37.0
  • How will you proceed?
case 4
Case 4
  • 30 yr/o M
  • Hanging two feet off ground
  • Found unconscious
  • Now agitated
  • Anterior neck;
    • rope mark
    • Swelling
    • ++ tender
  • How will you proceed?
case 5
Case 5
  • 40 yr/o F
  • Extensive full thickness burns;
    • Head, face
    • Neck, thorax, and arms circumferentially
  • VSS
  • GCS 15
  • Gross stridor
  • How will you proceed?
case 6
Case 6
  • 30 y/o male
  • Shotgun blast to face
  • Bleeding and gross disruption of anatomy
  • GCS 15
  • VSS
  • How will you proceed?
the 4 questions1
The 4 Questions
  • Does this patient need intubation now?
  • Is this a crash situation?
  • Is this a difficult airway?

4. Can I use RSI

slide61

Difficult Airway

Anticipated

Unanticipated

Fail to Intubate

Cooperative

Time

Uncooperative

No time

+ Ventilation

Sats Maintained

- Ventilation

Sats Dropping

Help

Sedate

Topicalize

“Brutane”

Sedate More

RSI+Double set-up

Transport

Observe

Better Position

BURP

Better Blade

Better Drugs

Bougie

Better Person

Glidescope

Bronch

BNTI

LMA

TTJV

Cricothyrotomy

TTJV

Cricothyrotomy

* Suction if bleeding *

securing the difficult airway2
Securing the Difficult Airway
  • Anticipated;
    • Best to get patient to ED/OR
    • BVM as bridge
    • Otherwise intubation
    • Don’t burn bridges
difficult airways7
Difficult Airways
  • Difficult ventilation;

1. Head tilt/chin lift

2. Exaggerated Jaw thrust

3. Oral/nasal airways

4. Two handed/Two person technique

5. Consider mask change

6. Ease up on cricoid pressure

7. Rule out FB

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