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Emergency Airway Management ________________________________ Mark L. Freedman MD, FRCP PowerPoint PPT Presentation


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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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Emergency Airway Management ________________________________ Mark L. Freedman MD, FRCP

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Emergency airway management mark l freedman md frcp

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


Emergency airway management mark l freedman md frcp

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 - 10minPreparation

  • 0 - 5 minPreoxygenation

  • 0 – 3 minPremedication

  • 0Pharmacological Induction

  • 0Pressure

  • 0Paralysis

  • 0 + 45 secPlace tube

  • 0 + 1 minPost 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


Evaluate 3 3 2

Evaluate 3:3:2


M allampati score

Mallampati score


Neck mobility

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


Emergency airway management mark l freedman md frcp

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


Emergency airway management mark l freedman md frcp

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


Emergency airway management mark l freedman md frcp

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….

  • 40220/11016100%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


Emergency airway management mark l freedman md frcp

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


Emergency airway management mark l freedman md frcp

Questions?


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