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HKCEM College Tutorial. Airway Management in a Comatose patient. AUTHOR DR. LAM PUI KIN, REX OCT 2013. Objectives. Recognise indications for intubation Anticipate difficult airway Preparation for RSI Procedure of RSI How to handle if you fail to intubate. Triage. M/34

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Airway management in a comatose patient

HKCEM College Tutorial

Airway Management in a Comatose patient



OCT 2013


  • Recognise indications for intubation

  • Anticipate difficult airway

  • Preparation for RSI

  • Procedure of RSI

  • How to handle if you fail to intubate


  • M/34

  • presented to ED 2 hours post-ingestion of 20 tablets of psychiatric drug

  • GCS 8

  • BP 149/91 P146

  • RR 20/min

  • Temp 37.3°C

Triage Category I

How would you manage him
How would you manage him?

How would you manage his airway?

Start with ABC

Indications for intubation

Protection of airway

GCS only 8

Lavage may be needed

Prevent aspiration

Other common indications

Airway obstruction

Respiratory Failure

Adjuncts to therapy

Provide hyperventilation

Reduce work of breathing (e.g. decompensated shock)

Situational need

Indications for intubation

Other general indications for

intubating a patient

Why rapid sequence intubation rsi
Why rapid sequence intubation (RSI) ?

  • Rapidly create controlled clinical environment for ETI

  • Reduce stimulation of potentially harmful autonomic reflexes associated with ETI

  • Reduce risk of aspiration

Any absolute contraindication?

No … However

Relative contraindications to rsi
Relative contraindications to RSI

  • Operator concern that both intubation and mask ventilation may not be successful

  • Major laryngeal trauma

  • Upper airway obstruction

  • Distorted facial or airway anatomy

predict difficult airway before initiation of paralytic agent to prevent the situation of cannot ventilate and cannot intubate (CVCI)

Clinical assessment before rsi
Clinical Assessment before RSI

  • AMPLEhistory:



    Past history

    Last meal

    Event- trauma, increased ICP, asthma

  • Neurological assessment before RSI

Lemon law

  • Look externally

  • Evaluate the 3-3-2 rule

  • Mallampati score

  • Obstruction

  • Neck mobility

Moans mnemonic for difficult bvm
MOANS – mnemonic for difficult BVM

  • Mask seal beards, facial trauma

  • Obesity/obstruction BMI > 26, airway obstruction, obstetric patients

  • Age > 55 yrs

  • No teeth

  • Stiffness Increase airway resistance (asthma, COPD), stiff lungs (pulmonary edema)

Rsi is decided for this patient
RSI is decided for this patient

How do you prepare for RSI?





  • A team effort

  • Junior doctor should be covered by a senior who is well versed in RSI

  • Help from an on-call anesthetist should be available when needed

Equipment last sob
Equipment – LAST SOB

Not to forget!

Full PPE in

high risk cases

  • L Laryngoscope

  • A Airway

  • S Suction

  • T Tracheal tube

  • S Stylet, syringe

  • O Oxygen, Oximeter

  • B Bag, eosphageal bulb, bougie

Do you know where is the

difficult airway kit in

your ED ?

Do you know what is



  • Premedications

    • prevent bradycardia

    • prevent raised ICP

    • prevent bronchospasm

  • Induction agent

  • Muscle relaxant

  • Consider sedation and long acting muscle relaxant after RSI

Now, take us through the steps of RSI.

The seven ps of rsi
The Seven Ps of RSI

  • Preparation zero minus 10 min

  • Pre-oxygenation zero minus 5 min

  • Premedication zero minus 3 min

  • Paralysis with induction zero

  • Protection and position 20 to 30 seconds (after succinylcholine)

  • Placement with proof 45 seconds (after succinylcholine)

  • Post-intubation management 1 min

How do you pre oxygenate
How do you pre-oxygenate?

  • IPPV?

  • Any problems?

IPPV will blow up stomach and increase risk of aspiration. If time allows, spontaneous respiration is better.

Pre oxygenation monitoring
Pre Oxygenation + Monitoring

  • to wash out nitrogen from lung

  • High conc O2 mask (near 100%) x 5 minutes (SR)

  • Near 100% O2 x 4 max breath over 30 s (IPPV)

  • especially important in patient with  FRC

    • obese

    • distended abd

    • pregnancy

Benumof JL et al. Anesthesiology 1997;87:979

Premedication load
Premedication – “LOAD”

Lignocaine 1 - 1.5mg/kg

  • Mitigate bronchospasm in severe asthma

  • Blunt ICP rise

  • Controversial

    Opioids - Fentanyl 1-2 mcg/kg

  • Blunt sympathetic discharge and ICP rise

  • E.g. raised ICP, aortic dissection, ruptured aortic aneursym, IHD

Premedication load1
Premedication – “LOAD”

Atropine 0.02 mg/kg (min 0.1mg)

  • To prevent bradycardia (sux used in a child)

    Defasciculation (rarely done in ED)

  • Non-depolarising relaxant

  • 1/10 of paralysing dose

What induction agent would you use
What induction agent would you use?

  • Why?

  • Dosage?

  • Adverse effects?

Cricoid pressure
Cricoid pressure

  • Prevent aspiration of stomach content

  • also prevent insufflation of stomach if IPPV is needed

  • Apply till ETT position confirmed

Cricoid pressure1
Cricoid pressure

  • Around 10 pounds of force over cricoid cartilage

  • force enough to

    • stop swallowing

    • indent a ping-pong

    • cause pain over nose bridge

Which muscle relaxant to use
Which muscle relaxant to use?

  • Why?

  • Dosage?

  • Adverse effects?

Side effects of sux
Side effects of sux

  • CVS

    • bradycardia, junctional, sinus arrest

    • tachycardia (gangionic stimulation)

  • Increase in ICP, IOP, IGP

  • Trismus (patient with myoclonus)

  • Myalgia

  • Histamine release

  • Side effects of sux1
    Side effects of sux

    • Hyperkalemia

      • normal increase 0.5 mmol/L

      • massive release in

        • burn (day 3 till to 1 yr after healing)

        • massive trauma (day 3 to 3 months)

        • neuromuscular-disorders: CVA, cord injury, tetanus (day 5 - 6 months)

        • muscular dystrophy

    • Malignant hyperthermia

    Sux phase ii block
    Sux-- Phase II block

    • Prolonged NMB resembling those of non-depolarising agents

    • Occurs with intermittent/infusion of sux

    • Lower pseudocholinesterase level

      • Hepatic dx, uremia, severe malnutrition, pregnancy, congenital

    • Myasthenia gravis

    • partially reversed by anticholinesterase

    Oelm vs burp optimal external laryngeal manipulation backward upward rightward pressure


    E xternal



    Operator manipulates and obtains view of larynx, then asks assistant to hold

    B ackward

    U pward

    Right ward

    P ressure

    Assistant performs BURP for operator

    OELM vs BURP(optimal external laryngeal manipulation)(backward upward rightward pressure)

    Confirming tube position
    Confirming Tube Position

    Esophageal Intubation (EDD)

    • Aspiration test

    • Self-inflating bulb

    • ETCO2

    Monitor patient
    Monitor patient

    • Make sure tube is fixed securely

    • monitor patient

      • pulse oximeter

      • end tidal CO2

      • BP/P

    Look at this cxr
    Look at this CXR

    What is the


    Remember DOPE when anything goes wrong

    Right Main Bronchus Intubation

    Post intubation management
    Post-intubation management

    • Bite block

    • Maintenance of sedation and NMB

      • Midazolam 0.05 – 0.1 mg/kg IV per dose, titrated

      • Recuronium 0.6 mg/kg IV of vecuronium 0.1 mg/kg IV as

      • Beaware of under-sedation with concomitant use of NMB

      • Consider titrating dose of morphine 0.025-0.05 mg/kg

    • Continuous monitoring

    • Reassess tube position after transfer

    What if you fail to intubate
    What if you fail to intubate?

    • Reoxygenate should take priority over repeated DL attempts

    • Ventilate with BVM

    • Evaluate cause of failure

      • Positioning? Equipment? Inadequate muscle relaxation? etc

    • Call for help from seniors +/- anaesthetist

    • Consider alternatives (Plan B & C)

    • Consider needle & surgical cricothyroidotomy

    Supraglottic devices
    Supraglottic devices



    Intubating LMA

    King airway




    We have covered:

    • Indications for intubation

    • How to assess difficult airway

    • How to perform RSI

    • How to handle if you fail to intubate