1. 10/4/2015 1 Emergency Department Airway Management Presented by Neil Jayasekera MD

2. 10/4/2015 2 Objectives When to Intubate When to Intubate Identify the Difficult Airway Identify the Difficult Airway Choosing the Appropriate Intubation Technique Choosing the Appropriate Intubation Technique RSI: Induction Agents RSI: Induction Agents RSI: Paralytic Agents RSI: Paralytic Agents RSI Technique – the 6 P’s RSI Technique – the 6 P’s Example of RSI timeline Example of RSI timeline The Failed Airway The Failed Airway Laryngeal Mask Airway Laryngeal Mask Airway

3. 10/4/2015 3 When to Intubate Failure to maintain or protect the airway Failure to maintain or protect the airway airway is not patent i.e. obstruction. airway is not patent i.e. obstruction. patient cannot protect his airway and is at risk for aspiration patient cannot protect his airway and is at risk for aspiration

4. Failure of ventilation or oxygenation COPD, Asthma, Pneumonia, CHF or systemic cause such as drug overdose, septic shock, or neuromuscular disease. COPD, Asthma, Pneumonia, CHF or systemic cause such as drug overdose, septic shock, or neuromuscular disease. 10/4/2015 4

5. 5 When a condition is present or a therapy is required that mandates intubation When a condition is present or a therapy is required that mandates intubation Even in the absence of airway, ventilatory, or oxygenation failure. Examples include Status Epilepticus, severe head injury, certain overdoses and penetrating neck trauma. Even in the absence of airway, ventilatory, or oxygenation failure. Examples include Status Epilepticus, severe head injury, certain overdoses and penetrating neck trauma.

6. Identifying the Difficult Airway: LEMON Law L- look externally L- look externally E- evaluate 3:3:2 rule (mouth opening) E- evaluate 3:3:2 rule (mouth opening) M- mallampati score M- mallampati score O- obstruction O- obstruction N- neck mobility N- neck mobility 10/4/2015 6

7. 7 Look Short neck, Buck teeth, Receding mandible, Limited jaw opening- make it more difficult to align the oropharynx and larynx during laryngoscopy and see the chords. Short neck, Buck teeth, Receding mandible, Limited jaw opening- make it more difficult to align the oropharynx and larynx during laryngoscopy and see the chords. Beard- dentures or any materiel on the face make it difficult to get a bag-valve mask seal if intubation is not successful. Beard- dentures or any materiel on the face make it difficult to get a bag-valve mask seal if intubation is not successful.

8. 10/4/2015 8 Look Children- Children- Occiput is larger and larynx is higher in the neck so the vocal chords are more anterior. Occiput is larger and larynx is higher in the neck so the vocal chords are more anterior. Epiglottis is high and very soft and thus easier to obstruct vision of the chords. Epiglottis is high and very soft and thus easier to obstruct vision of the chords. Airway is very short thus making it easier to intubate the bronchus. Airway is very short thus making it easier to intubate the bronchus.

9. External 3-3-2 technique- assesses geometric relationships of airway. 3-3-2 technique- assesses geometric relationships of airway. 1. ability to open mouth ( 3 fingers should fit in patients mouth) 2.adequacy of chin ( 3 fingers should fit between mentum and hyoid bone ) 3. location of larynx ( 2 fingers should fit between thyroid notch and floor of mouth). 10/4/2015 9

10. 10 Mallampati Scale Mallampati scale- based on how much you can see when patient sticks out tongue. Class I- soft palate, uvula, and tonsillar pillars (No difficulty). Class II- soft palate, uvula, fauces visible (No difficulty). Class III- soft palate, base of uvula visible (Moderate difficulty). Class IV- hard palate only visible (Severe difficulty). Mallampati scale- based on how much you can see when patient sticks out tongue. Class I- soft palate, uvula, and tonsillar pillars (No difficulty). Class II- soft palate, uvula, fauces visible (No difficulty). Class III- soft palate, base of uvula visible (Moderate difficulty). Class IV- hard palate only visible (Severe difficulty).

11. 10/4/2015 11 Obstruction Upper airway obstruction- Such as angioedema, peritonsillar abscess with trismus, burns, penetrating neck injury, and epiglottis fit into this category. Upper airway obstruction- Such as angioedema, peritonsillar abscess with trismus, burns, penetrating neck injury, and epiglottis fit into this category. Facial Trauma and Laryngeal trauma- higher likelihood to need a surgical airway. Facial Trauma and Laryngeal trauma- higher likelihood to need a surgical airway.

12. Neck Mobility Limited cervical mobility-secondary to DJD, Rheumatoid Arthritis, immobilized trauma patient in c-spine precautions. 10/4/2015 12

13. 10/4/2015 13 Choosing the appropriate intubation technique Easy Airway- paralyze the patient : Easy Airway- paralyze the patient : Rapid Sequence Intubation Rapid Sequence Intubation Difficult Airway- awake technique : Difficult Airway- awake technique : Blind Nasotracheal Intubation or Blind Nasotracheal Intubation or Awake Oral Intubation with Sedation Awake Oral Intubation with Sedation

14. 10/4/2015 14 Awake Oral Intubation with Sedation- use topical anesthetic (nebulized lidocaine or hurricane spray) and conscious sedation doses of Fentanyl and Versed or both. Awake Oral Intubation with Sedation- use topical anesthetic (nebulized lidocaine or hurricane spray) and conscious sedation doses of Fentanyl and Versed or both.

15. 10/4/2015 15 Rapid Sequence Intubation  Cornerstone of modern emergency airway management.  Succinylcholine is the preferred paralytic in the ED because of its rapid and consistent onset of action, short clinical duration, and absence of significant side effects.  The technique involves the simultaneous administration of a potent sedative (induction) agent and a neuromuscular blocking agent, such as Succinylcholine, for the purpose of endotracheal intubation.

16. 10/4/2015 16 Induction Agents Etomidate- ED agent of choice for induction. Etomidate has a similar profile of Versed with rapid onset, rapid peak activity, and brief duration, but is remarkably hemodynamically stable. ED agent of choice for induction. Etomidate has a similar profile of Versed with rapid onset, rapid peak activity, and brief duration, but is remarkably hemodynamically stable. Nonbarbituate hypnotic that works at the GABA receptor. Nonbarbituate hypnotic that works at the GABA receptor. Can be used in all scenarios possible exception is septic pts. Can be used in all scenarios possible exception is septic pts.

17. 10/4/2015 17 Ketamine- a dissociative anesthetic agent. Ketamine is for use in the induction of asthma and trauma pts. who are hypotensive without signs of head trauma. a dissociative anesthetic agent. Ketamine is for use in the induction of asthma and trauma pts. who are hypotensive without signs of head trauma. Ketamine is a brochodilator and increases ICP and cerebreal blood flow. Ketamine is a brochodilator and increases ICP and cerebreal blood flow.

18. 10/4/2015 18 Paralytics Depolarizing agents- Succinylcholine (SCH) which is a chemical combination of 2 molecules of acetylcholine. Binds noncompetitively with ACH receptors on the motor end plate and causes sustained depolarization of the myocyte (thus see defasiculations). Depolarizing agents- Succinylcholine (SCH) which is a chemical combination of 2 molecules of acetylcholine. Binds noncompetitively with ACH receptors on the motor end plate and causes sustained depolarization of the myocyte (thus see defasiculations).

19. 10/4/2015 19 Nondepolarizing agents- such as Vecuronium which binds competitively to ACH receptors preventing access to ACH and thus preventing muscular activity. Nondepolarizing agents- such as Vecuronium which binds competitively to ACH receptors preventing access to ACH and thus preventing muscular activity.

20. 10/4/2015 20 Succinylcholine Rapidly active, producing intubation conditions within 60 seconds. The clinical duration of action is 6-10 minutes but initial recovery of spontaneous respirations may be seen in as few as 3 minutes. Rapidly active, producing intubation conditions within 60 seconds. The clinical duration of action is 6-10 minutes but initial recovery of spontaneous respirations may be seen in as few as 3 minutes.

21. 10/4/2015 21 Side Effects of SCH Bradycardia- SCH is a weak negative inotrope and chronotrope. Give atropine to prevent bradycardia in children less than 10. Bradycardia- SCH is a weak negative inotrope and chronotrope. Give atropine to prevent bradycardia in children less than 10. Defasiculations- from depolarizing effect of SCH, which may increase ICP, intragastric pressure and intraocular pressure. Give defasiculation dose of depolarizing agent. Defasiculations- from depolarizing effect of SCH, which may increase ICP, intragastric pressure and intraocular pressure. Give defasiculation dose of depolarizing agent.

22. 10/4/2015 22 Hyperkalemia- Sux has been associated with severe, fatal hyperkalemia when administered in specific clinical situations: Major burns, Major crush injuries, Denervation Injuries and Severe abdominal Sepsis. Hyperkalemia- Sux has been associated with severe, fatal hyperkalemia when administered in specific clinical situations: Major burns, Major crush injuries, Denervation Injuries and Severe abdominal Sepsis. Malignant Hyperthermia- a syndrome of rapid temperature rise and aggressive rhabdomylosis that occurs in the context of certain volatile general anesthetic agents or succinylcholine in genectically predisposed individuals. The condition is extremely rare and has not been reported in the ED use of Sux. Malignant Hyperthermia- a syndrome of rapid temperature rise and aggressive rhabdomylosis that occurs in the context of certain volatile general anesthetic agents or succinylcholine in genectically predisposed individuals. The condition is extremely rare and has not been reported in the ED use of Sux.

23. 10/4/2015 23 RSI Technique- the 6 P’s 1.Preparation- pt. is assessed for difficulty of intubation, all meds drawn up, equipment is assembled and staff is ready for intubation 1.Preparation- pt. is assessed for difficulty of intubation, all meds drawn up, equipment is assembled and staff is ready for intubation

24. 10/4/2015 24 2. Preoxygenation- administration of 100% oxygen by non-rebreather for 5 minutes in a normal adult results in the establishment of an adequate oxygen reservoir to permit 3-5 minutes of apnea before desaturations less than 90% occur (i.e. replacing nitrogen reservoir in lungs with oxygen). 2. Preoxygenation- administration of 100% oxygen by non-rebreather for 5 minutes in a normal adult results in the establishment of an adequate oxygen reservoir to permit 3-5 minutes of apnea before desaturations less than 90% occur (i.e. replacing nitrogen reservoir in lungs with oxygen).

25. 10/4/2015 25 3. Pretreatment- 3. Pretreatment- Lidocaine- attenuates rise in ICP and blunts reactive airway response to laryngoscopy and tube placement. Lidocaine- attenuates rise in ICP and blunts reactive airway response to laryngoscopy and tube placement. Atropine-prevents bradycardia associated with intubation in chldren less then 10. Atropine-prevents bradycardia associated with intubation in chldren less then 10. Defasiculation dose - of a nondepolarizing agent to blunt the fasiculation response of succinylcholine ( may blunt increase ICP with intubation). Defasiculation dose - of a nondepolarizing agent to blunt the fasiculation response of succinylcholine ( may blunt increase ICP with intubation).

26. 4. Paralysis with induction- 4. Paralysis with induction- 1.Induction agent- sedative administered in dose sufficient to produce unconscious state. 2.Paralytic agent-given immediately after induction agent. 10/4/2015 26

27. 10/4/2015 27 5. Placement- placement of the tube through the chords under direct visualization. If you miss the intubation you can BVM the pt. with the Sellick’s maneuver ( to prevent air from getting into the stomach) and then try again. 5. Placement- placement of the tube through the chords under direct visualization. If you miss the intubation you can BVM the pt. with the Sellick’s maneuver ( to prevent air from getting into the stomach) and then try again.

28. 10/4/2015 28 6. Postintubation management- listen to stomach, chest. Get X-ray to confirm tube placement. For definitive evidence of tube placement utilize end-tidal CO2 detector. 6. Postintubation management- listen to stomach, chest. Get X-ray to confirm tube placement. For definitive evidence of tube placement utilize end-tidal CO2 detector.

29. 10/4/2015 29 Example of RSI Timeline 5:00- Preoxygenate and prepare equipment- pulse ox, monitor, draw up meds. 3:00- Lidocaine 1mg/kg attenuates laryngospasm and decreases ICP. Atropine 0.01 mg/kg attenuates bradycardia with Sux, peds <10. Fentanyl 2-3mcg/kg attenuates catecholamine release. Vecuronium 0.01mg/kg attenuates fasiculations of Sux, decreases ICP.

30. 10/4/2015 30 0:00- Induction: Etomidate 0.3mg/kg or Versed 0.1mg/kg, Ketamine 1.0-2.0 mg/kg Etomidate 0.3mg/kg or Versed 0.1mg/kg, Ketamine 1.0-2.0 mg/kg Paralytic: Paralytic: Succyinlcholine 1.0-1.5 mg/kg Succyinlcholine 1.0-1.5 mg/kg onset 30-45 seconds,duration 3-10 minutes onset 30-45 seconds,duration 3-10 minutes +0:45- Intubation: 7.5-8.0 ETT female. 7.5-8.0 ETT female. 8.0-8.5 ETT male. 8.0-8.5 ETT male. Check tube placement, use capnometer. Check tube placement, use capnometer.

31. The Failed Airway Inability to intubate patient after 3 attempts by an experienced provider or inability to BVM ventilate a patient. Inability to intubate patient after 3 attempts by an experienced provider or inability to BVM ventilate a patient. Change method or technique on every attempt to intubate. Change method or technique on every attempt to intubate. 1.muscle tone-can’t intubate awake, consider RSI 2.position of patient- need SNIFF position 3.B.U.R.P- backward, upward, rightward pressure 10/4/2015 31

32. The Failed Airway 4. Change blade length or blade type. 5. Change operator. 6. Consider cricothyroidectomy – invasive 7. Consider LMA or other rescue airway device 10/4/2015 32

33. 10/4/2015 33 Laryngeal Mask Airway A. LMA- consists of a oval shaped, tan colored, silicone mask with an inflatable rim, connected to a tube that allows ventilation. The tube is blindly inserted into the pharynx then inflated, providing a seal that permits ventilation of the trachea with minimal gastric insufflation. A. LMA- consists of a oval shaped, tan colored, silicone mask with an inflatable rim, connected to a tube that allows ventilation. The tube is blindly inserted into the pharynx then inflated, providing a seal that permits ventilation of the trachea with minimal gastric insufflation.

34. 10/4/2015 34 B. Complications- with a ETT there is a cuff that is insufflated to prevent aspiration. A LMA has no cuff and so the patient is at risk of aspiration. A LMA still can be used as a bridging device until a definitive airway can be established. B. Complications- with a ETT there is a cuff that is insufflated to prevent aspiration. A LMA has no cuff and so the patient is at risk of aspiration. A LMA still can be used as a bridging device until a definitive airway can be established.