1. Emergency Airway Management Pat Melanson, MD
- the most essential skill in EM
- establishing or protecting on airway is frequently the essential maneuver for saving a person’s life
- conversely, failure to do so is the fastest way to assure a patient’s demise
- assessment and management of the airway have been appropriately assigned the A in the well known ABC’s of resuscitation for scientific reasons as well as alphabetic
Emergency Airway Management Pat Melanson, MD

2. Safe airway management
airway evaluation
identification of the difficult airway
assessment of other clinical factors
selection of the likely most successful plan of action
reasonable alternative plan

3. Algorithmic Approach to Airway Management
Have a precompiled plan of airway management ready for implementation as clinical airway difficulties are encountered
develop a plan and a back-up plan
Practice guidelines for management of the difficult airway
ASA taskforce
Anesthesiology 78 : , 1993

4. Emergency Airway full stomach altered level of consciousness
deteriorating cardiorespiratory physiology
abnormal or distorted upper airway anatomy
no time for pre-assessment or plan

5. Airway Assessment
compromise or threats
potentially difficult airway

6. The Three Pillars of Airway Management
Patency ( airflow integrity )
Protection against aspiration
Assurance of oxygenation and ventilation

7. Indications for Active Airway Intervention
Patency - relief of obstruction
Protection from aspiration
Hypoxic/ hypercapnic respiratory failure
Airway access for pulmonary toilet, drug delivery,therapeutic hyperventilation
Shock

8. Clinical Signs of Airway Compromise : Patency
Inspiratory stridor
Snoring ( pharyngeal obstruction )
Gurgling ( foreign matter/ secretions )
Drooling ( epiglottitis )
Hoarseness ( laryngeal edema/ vc paralysis)
Paradoxical chest wall movement
Tracheal tug

9. Clinical Signs of Airway Compromise : Protection
Blood in upper airway
Pus in upper airway
persistant vomiting
Loss of protective airway reflexes

10. Clinical Signs of Airway Compromise: Oxygenation and Ventilation
Central cyanosis
Obtundation and diaphoresis
rapid shallow respirations
Accessory muscle use
Retractions
Abdominal paradox

11. The Difficult Airway Difficult laryngoscopy
Difficult bag-mask ventilation
Lower airway difficulty

12. Techniques for the Compromised Airway
Bag-Valve-Mask Ventilation
Endotracheal Intubation
Rapid Sequence Intubation
Alternate techniques for the difficult airway

13. Golden Rules of Bagging
“ Anybody ( almost ) can be oxygenated and ventilated with a bag and a mask “
The art of bagging should be mastered before the art of intubation
Manual ventilation skill with proper equipment is a fundamental premise of advanced airway management

14. Frequent Errors with BVM
failure to recognize its importance
forget to bag ( focussed on ETT )
give up on bagging too early
bag but don’t assess efficacy
failure to assign one person to airway management only

15. Difficult Airway : BVM Upper airway obstruction Lack of dentures Beard
Midfacial smash
facial burns, dressings, scarring
poor lung mechanics

16. Difficult Airway : BVM degree of difficulty from zero to infinite
zero = no external effort/internal device
one person jaw thrust/ face seal
oropharyngeal or nasopharyngeal AW
two person jaw thrust / face seal
both internal airway devices
infinite -no patency despite maximal external effort and full use of OP/NP

17. Difficult Airway : BVM Remove FB - Magill forceps
Triple maneuver if c-spine clear
Head tilt, jaw lift, mouth opening
Nasopharyngeal or oropharyngeal airway
two-person, four-hand technique

18. Prediction of the difficult airway (Intubation)
1200 prospectively studied patients
of 84 patients predicted to have problem, only 22 (25%) actually had a problem
of 43 actual difficult intubations incurred, only 22 (51%) were predicted
Latto IP. and Rosen M

19. Prediction of the difficult airway
history of past airway problems
Careful physical assessment
knowledge and experience to overcome the "unpredicted difficult airway".
learning practical airway management skills in an environment that is not urgent, stressful or life threatening

22. Difficult Airway : Laryngoscopy
Short thick neck
Receding mandible
Buck teeth
Poor mandibular mobility/ limited jaw opening
Limited head and neck movement
( including trauma )
C. Direct laryngoscopy will be made difficult by:
•decreased mobility cervical spines •tempero-mandibular jt •larynx •decreased visualization oral structures •mandibular structures •laryngeal tilt •dentition •secretions •airway obstruction pharyngeal •laryngeal •tracheal

23. Difficult Airway : Laryngoscopy
Tumor, abscess or hematoma
Burns
Angioneurotic edema
Blunt or penetrating trauma
Rheumatoid arthritis, ankylosing spondylitis
Congenital syndromes
Neck surgery or radiation

24. Difficult Airway : Laryngoscopy
3 fingerbreadths mentum to hyoid
3 fb chin to thyroid notch
3 fb upper to lower incisors
Head extension and neck flexion
Mallimpadi classification
Previous history of difficult intubation

25. Mallimpadi Classification ( Tongue to Pharyngeal Size )
I - soft palate, uvula, tonsillar pillars
99 % have grade I laryngoscopic view
II - soft palate, uvula
III - soft palate, base of uvula
IV - soft palate not visible
100% grade III or grade IV views

26. Unsuccessful Intubation
Bag the patient
Maximize neck flexion/ head extension
Move tongue out of line of site
Maximize mouth opening
Look for landmarks and adjust blade
BURP maneuver
increasing lifting force
consider Miller blade
- improper positioning is the most common reason for inability to visualize the cords
- second most common cause is haste in the intubation process - slow down and perform each maneuver deliberately and attempt to visualize landmarks along the way
- lateral landmarks ( aryepiglottic folds, tonsillar pillars move towards the midline
( elevate occiput 10 cm )/ 45 degrees neck flexion
- blade too far - - if in esophagus will see no landmarks except general mucosal tissue
- Mac blade on epiglottis- base of epi9glottis will continue to obscure cords
- hockey stick angulation
- look for bubbles
- gum rubber bouge
- fiberoptic, digital, lighted stylet, surgical airway

27. Dilemmas: Awake or Asleep Oral or Nasal
Laryngoscopy or Blind Intubation
To Paralyze or Not

28. Case #1 43 year old female, day 12 post SAH
5 unclipped cerebral aneurysms
vasospasm with left hemiparesis
hydrocephalus with clotted IV drain
rising ICP and BP
decreasing LOC
ate breakfast

29. Techniques DL without pharmacologic aids Awake Direct Laryngoscopy
Awake Blind Nasal
Rapid Sequence Intubation (RSI)
Fiberoptic
Surgical Cricothyroidotomy

30. Anesthesia Airway Maxims
the awake airway is the safest to manage
spontaneous breathing is generally safer than paralysis with PPV by mask
have a low threshold to wake the patient up and cancel the case
call for help early

31. The “Intubation Reflex “
Catecholamine release in response to laryngeal manipulation
Tachycardia, hypertension, raised ICP
Attenuated by beta-blockers, fentanyl
ICP rise possibly attenuated by lidocaine
Midazolam and thiopental have no effect

32. Rapid Sequence Intubation : Definition
The near simultaneous administration of a sedative-hypnotic agent and a neuromuscular blocker in the presence of continuous cricoid pressure to facilitate endotracheal intubation and minimize risk of aspiration
modifications are made depending upon the clinical scenario

33. Rapid Sequence Intubation : Advantages
Optimizes intubating conditions/ facilitates visualization
Increased rate of successful intubation
Decreased time to intubation
Decreased risk of aspiration
Attenuation of hemodynamic and ICP changes

34. Rapid Sequence Intubation : Contraindications
Anticipated difficulty with endotracheal intubation
anatomic distortion
Lack of operator skill or familiarity
inability to preoxygenate

35. Rapid Sequence Intubation : Procedure
Pre-intubation assessment
Pre-oxygenate
Prepare ( for the worst )
Premedicate
Paralyze
Pressure on cricoid
Place the tube
Post intubation assessment

36. Pre-oxygenate ( Time - 5 Minutes)
100 % oxygen for 5 minutes
4 conscious deep breaths of 100 % O2
Fill FRC with reservoir of 100 % O2
Allows 3 to 5 minutes of apnea
Essential to allow avoidance of bagging
If necessary bag with cricoid pressure

37. Preparation ( Time - 5 Minutes )
ETT, stylet, blades, suction, BVM
Cardiac monitor, pulse oximeter, ETCO2
One ( preferably two ) iv lines
Drugs
Difficult airway kit including cric kit
Patient positioning

38. Pre-treatment/ Prime ( Time - 2 Minutes )
Lidocaine 1.5 mg/kg iv
Defasciculating dose of non-depolarizing NMB
Beta-blocker or fentanyl
Induction agent
Thiopental mg/kg
Midazolam mg/kg
Ketamine mg/kg
Fentanyl mcg/kg

39. Paralyze ( Time Zero ) Succinylcholine 1.5 mg/kg iv
Allow seconds for complete muscle relaxation
Alternatives
Vecuromium mg/kg
Rocuronium o mg/kg

40. Pressure Sellick maneuver initiate upon loss of consciousness
continue until ETT balloon inflation
release if active vomiting

41. Place the Tube ( Time Zero + 45 Secs )
Wait for optimal paralysis
Confirm tube placement with ETCO2

42. Post-intubation Hypotension
Loss of sympathetic drive
Myocardial infarction
Tension pneumothorax
Auto-peep

43. Succinylcholine : Contraindications
Hyperkalemia - renal failure
Active neuromuscular disease with functional denervation ( 6 days to 6 months)
Extensive burns or crush injuries
Malignant hyperthermia
Pseudocholinesterase deficiency
Organophosphate poisoning

44. Succinylcholine : Complications
Inability to secure airway
Increased vagal tone ( second dose )
Histamine release ( rare )
Increased ICP/ IOP/ intragastric pressure
Myalgias
Hyperkalemia with burns, NM disease
malignant hyperthermia

45. Difficult Airway Kit Multiple blades and ETTs
ETT guides ( stylets, bougé, light wand)
Emergency nonsurgical ventilation ( LMA, combitube, TTJV )
Emergency surgical airway access ( cricothyroidotomy kit, cricotomes )
ETT placement verification
Fiberoptic and retrograde intubation

46. Emergency Surgical Airway Maxims
they are usually a bloody mess, but ...
a bloody surgical airway is better than an arrested patient with a nice looking neck

47. Case # 2 42 year old female right Pancoast tumor
RUL, RML, RLL collapse
ARDS on left
hypoxemic respiratory failure
cord compression C7 - T4