1. Emergency Airway Management ________________________________ Mark L. Freedman MD, FRCP

2. 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

3. 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?

4. The 4 Questions 1.Does this patient need intubation now? 2.Is this a crash situation? 3.Is this a difficult airway? 4. Can I use RSI?

5. Outline Indications for intubation Basic airway algorithm Difficult airways Difficult airway algorithm Securing the difficult airway Cases

6. Outline Indications for intubation Basic airway algorithm Difficult airways Difficult airway algorithm Securing the difficult airway Cases

7. Indications for Intubation Failure of oxygenation Failure of ventilation Failure to protect Impending obstruction Expected management

8. Failure of Oxygenation Low FiO2 Failure of ventilation V/Q mismatch Diffusion abnormalities Anemia Low C.O. Increased tissue O2 consumption

9. 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

10. Failure to Protect Low or dropping GCS “GCS less than 8, intubate” Aspiration risk

11. Impending Obstruction Expanding hematoma Deep space infection Epiglotitis/Bacterial tracheitis Angioedema/Allergic reaction Inhalation injury Eschar Foreign body Tumour Others….

12. Outline Indications for intubation Basic airway algorithm Difficult airways Difficult airway algorithm Securing the difficult airway Cases

13. Basic airway algorithm Difficult Airway ? RSI ? Crash Airway Difficult Airway No Yes Crashing ? Failed Airway Fails

14. 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

15. Outline Indications for intubation Basic airway algorithm Difficult airways Difficult airway algorithm Securing the difficult airway Cases

16. Difficult Airways Difficult mask ventilation Difficult laryngoscopy Difficult tracheal intubation Combinations of above

17. 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

18. Difficult Airways Difficult mask ventilation; –Predicting the difficulty (BOOTS); Bearded Older (> 55 years) Obese (BMI > 26 kg/m 2 ) Toothless Snores

19. Difficult Airways Difficult laryngoscopy/intubation; –Predicting the difficulty (LEMON); Look Evaluate; 3,3,2 Mallampati score Obstruction Neck mobility

20. Difficult Airways The airway assessment; Look (BOOTS, others) Evaluate; 3,3,2 Mallampati score Obstruction Neck mobility

28. Evaluate 3:3:2

29. Mallampati score

32. Neck Mobility

34. Difficult Airways Specific situations; –Trauma –Obesity –Pregnancy –Pediatrics

35. 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…….

37. Outline Indications for intubation Basic airway algorithm Difficult airways Difficult airway algorithm Securing the difficult airway Cases

38. Difficult Airway AnticipatedUnanticipated Cooperative Time + Ventilation Sats Maintained - Ventilation Sats Dropping Fail to Intubate Better Position BURP Better Blade Better Drugs Bougie Better Person Glidescope Bronch BNTI LMA TTJV Cricothyrotomy Uncooperative No time OR? Topicalize Sedate Awake; Laryngoscope Glidescope Lighted Stylet FOB Help Sedate Topicalize “Brutane” Sedate More RSI+Double set-up * Suction if bleeding * TTJV Cricothyrotomy

39. Outline Indications for intubation Basic airway algorithm Difficult airways Difficult airway algorithm Securing the difficult airway Cases

40. Securing the Difficult Airway Anticipated; –Best to get patient to ED/OR –BVM as bridge –Otherwise intubation –Don’t burn bridges

42. Securing the Difficult Airway Unanticipated; –Can you ventilate?? Yes = time No = trouble

43. Difficult Airway AnticipatedUnanticipated Cooperative Time + Ventilation Sats Maintained - Ventilation Sats Dropping Fail to Intubate Better Position BURP Better Blade Better Drugs Bougie Better Person Glidescope Bronch BNTI LMA TTJV Cricothyrotomy Uncooperative No time Transport Observe Help Sedate Topicalize “Brutane” Sedate More RSI+Double set-up * Suction if bleeding * TTJV Cricothyrotomy

44. 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

50. Difficult Airway AnticipatedUnanticipated Cooperative Time + Ventilation Sats Maintained - Ventilation Sats Dropping Fail to Intubate Better Position BURP Better Blade Better Drugs Bougie Better Person Glidescope Bronch BNTI LMA TTJV Cricothyrotomy Uncooperative No time Transport Observe Help Sedate Topicalize “Brutane” Sedate More RSI+Double set-up * Suction if bleeding * TTJV Cricothyrotomy

53. Outline Indications for intubation Basic airway algorithm Difficult airways Difficult airway algorithm Securing the difficult airway Cases

54. 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?

55. 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?

56. 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?

57. 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?

58. 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?

59. Case 6 30 y/o male Shotgun blast to face Bleeding and gross disruption of anatomy GCS 15 VSS How will you proceed?

60. The 4 Questions 1.Does this patient need intubation now? 2.Is this a crash situation? 3.Is this a difficult airway? 4. Can I use RSI

61. Difficult Airway AnticipatedUnanticipated Cooperative Time + Ventilation Sats Maintained - Ventilation Sats Dropping Fail to Intubate Better Position BURP Better Blade Better Drugs Bougie Better Person Glidescope Bronch BNTI LMA TTJV Cricothyrotomy Uncooperative No time Transport Observe Help Sedate Topicalize “Brutane” Sedate More RSI+Double set-up * Suction if bleeding * TTJV Cricothyrotomy

62. Securing the Difficult Airway Anticipated; –Best to get patient to ED/OR –BVM as bridge –Otherwise intubation –Don’t burn bridges

63. 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

64. Questions?