Video Laryngoscopy in Cardiac Arrest Colby J. Rowe MS, NRP, FP-C Stony Brook Medicine Stony Brook, New York

Introductions Colby Rowe, MS, NRP, FP-C Clinical Instructor of Emergency Medicine Clinical Simulation Coordinator, SOM BLS, ACLS, PALS TC Faculty The Difficult Airway Course: EMS™ Northeast Regional Director Italy, South Korea, Canada

Presenter Disclosure Information Video Laryngoscopy in Cardiac Arrest Colby Rowe FINANCIAL DISCLOSURE: none UNLABELED/UNAPPROVED USES DISCLOSURE:

Objectives Discuss the evolution of advanced airway management techniques. Discuss how the 2015 AHA Guidelines for CPR & ECC apply to advanced airway management. Understand importance of First Pass Success in advanced airway management. Learn techniques of video laryngoscopy to achieve First Pass Success!

Today Two Days Ago in History December 7, 1963 Army-Navy football game  It was early in the fourth quarter of the 64th Army-Navy football game. Army quarterback Rollie Stichweh broke a tackle from 1 yard out and ran in for a touchdown. A few seconds later, television viewers watched it again -- the first instant replay.      "This is not live!" CBS announcer Lindsey Nelson said. "Ladies and gentleman, Army did not score again!"

Airway, Beating…and Circulation?

History of Cardiac Arrest Airway Management Egyptians & Romans Tracheotomies? William Macewaen (Scotland, 1880) ETI for obstruction Joseph O’Dwyer (USA) Blind passage In 1880, in Scotland, William Macewen described how to relieve airway obstruction by passing an oral tube into the trachea. He practiced blind, digital intubation using cadaver models and eventually was able to use this technique clinically. One important problem with the O’Dwyer intubation system and its variants was that they had to be placed blindly. The next important development in clinical airway management was thus the development of direct laryngoscopy, which allowed visualization of the glottic structures.

History of Cardiac Arrest Airway Management Benjamin Guy Babbington Glottiscope Philipp von Bozinni & Garignard de la Tour “Mouth Mirrors” Manual Garcia (1854) Vocal teacher used sunlight and mirrors First direct visualization of human glottic opening

History of Cardiac Arrest Airway Management Chevalier Jackson (1913) “Father of endoscopy” Introduced light source on distal end of blade Henry H. Janeway (1913) Anesthesiologist Introduced battery operated laryngoscope Sir Robert Reynolds Macintosh (1943)

Direct Laryngoscopy Conventional laryngoscope Technique utilized to facilitate direct visualization of the glottic opening when performing endotracheal intubation.

History of Cardiac Arrest Airway Management Pioneers Dr. Peter Safar Dr. James Elam Manual maneuvers Mouth-to-mouth A, B, C’s of Resuscitation The Breath of Life

The Late Dr. John Hinds Modern day resuscitation guidelines. ABC’s as Safar wrote. “Gold Standards” Poor outcomes in OHCA (out of hospital cardiac arrest). Challenges

Challenges Delivery of Oxygen (DO2) in Cardiac Arrest Methods of ventilation Basic v. Advanced strategies Manual maneuvers Devices and adjuncts Early v. Delayed ETI Control Protection Carbon dioxide Less invasive techniques Experienced clinician

Challenges Endotracheal Intubation Success rates of 75-90% TTI (time-to-intubation) Interruptions in CPR Difficult intubations Unrecognized esophageal or dislodged ETT Adjuncts Fraction of oxygen Ventilation rates & strategies

2015 Guidelines for CPR & ECC BVM or ETI? SGD or ETI? What does the science say? “Low quality evidence” “The type of airway used may depend on the skills and training of the healthcare provider.”

So…Why Are We Here?

John C. Sakles, M.D. University Arizona Medical Center Emergency Department 61 beds 70,000 ED visits July 2007-June 2013 Approximately 3000 intubations Half DL & half VL 100% capture

The Data

The Data

The Sakles Conversation

First Pass Success Sakles et al., International Journal of Emergency Medicine (2013)

First Pass Success

The Sakles Conversation

Evidence Assessed GVL, Pentax AWS, and DL 15-30° lateral left tilt with LUCAS TTI and success rate TTV and TTI

Evidence

Evidence Assessed GVL in simulated CPR GVL v. DL with and without compressions “Extremely high success rates”

Evidence EMJ-Tandon et al (October 2014) 20 EM physicians DL, GVL, and GVL-Bougie TTI with compressions Results DL (27s) GVL (20s) GVL-B (60.1)

Evidence Journal of Emergency Medicine-Sakles et al (December 2014) 460 unsuccessful first attempt adult OTI’s (2009-2014) CMAC v. DL for rescue attempt after failed Results CMAC: 116/141 (82.3%) DL: 58/94 (61.7%)

Evidence Resuscitation- Park et al (December 2014) 305 OHCA (May 2011-April 2013) Compared first pass success 83 intubated by novice emergency physicians in the field Results VL (n=49) 91.8% successful 0 interruptions in compressions 0 esophageal intubations DL (n=34) 55.9% successful Median of CCI was 7 seconds 1 esophageal intubation

Video (Indirect) Laryngoscopy Use of a micro-video camera along a laryngoscope blade transmitting image to an external monitor. Facilitates indirect visualization of the glottic opening when performing endotracheal intubation.

Tips for Success Keep it similar! Look for blade! Go midline. Keep your distance. Compress tongue directly into submandibular space. Go 3:00-12:00 (back in time that is). Alternate practice.

The Devices Outline Video Laryngoscopy Optical Laryngoscopy Glidescope C-MAC McGrath King Vision Optical Laryngoscopy AirTraq Technique different than with DL Requires training and practice Visualization vs. tube delivery Cost can be much greater than with DL Cost coming down May be inferior when lots of secretions

Optical Laryngoscopy Placed midline Lift in the vertical plane Align vocal cords center Slowly advance ETT through cords Disengage ETT and remove device

Wrap-Up We need to minimize hands off time VL can minimize interruptions in chest compressions and increases compression fraction VL improves First Pass Success! “Practice doesn’t make perfect; perfect practice makes perfect”

Thank You!