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Emergency Department Emergency Department Airway ManagementAirway Management

Presented byPresented byNeil Jayasekera MDNeil Jayasekera MD

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ObjectivesObjectives When to IntubateWhen to Intubate Identify the Difficult AirwayIdentify the Difficult Airway Choosing the Appropriate Intubation Choosing the Appropriate Intubation TechniqueTechnique

RSI: Induction AgentsRSI: Induction Agents RSI: Paralytic AgentsRSI: Paralytic Agents RSI Technique – the 6 P’sRSI Technique – the 6 P’s Example of RSI timelineExample of RSI timeline The Failed AirwayThe Failed Airway Laryngeal Mask AirwayLaryngeal Mask Airway

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When to IntubateWhen to Intubate

Failure to maintain or protect Failure to maintain or protect the airwaythe airway

airway is not patent i.e. airway is not patent i.e. obstruction.obstruction.

patient cannot protect his patient cannot protect his airway and is at risk for airway and is at risk for aspirationaspiration

Failure of ventilation or Failure of ventilation or oxygenationoxygenation

COPD, Asthma, Pneumonia, CHF or COPD, Asthma, Pneumonia, CHF or systemic cause such as drug systemic cause such as drug overdose, septic shock, or overdose, septic shock, or neuromuscular disease.neuromuscular disease.

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When a condition is present or When a condition is present or a therapy is required that a therapy is required that mandates intubationmandates intubation

Even in the absence of Even in the absence of airway, ventilatory, or airway, ventilatory, or oxygenation failure. Examples oxygenation failure. Examples include Status Epilepticus, include Status Epilepticus, severe head injury, certain severe head injury, certain overdoses and penetrating neck overdoses and penetrating neck trauma. trauma.

Identifying the Identifying the Difficult Airway:Difficult Airway:

LEMON LawLEMON Law L- look externallyL- look externally E- evaluate 3:3:2 rule (mouth E- evaluate 3:3:2 rule (mouth opening)opening)

M- mallampati scoreM- mallampati score O- obstructionO- obstruction N- neck mobilityN- neck mobility

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LLookook

Short neck, Buck teeth, Receding Short neck, Buck teeth, Receding mandible, Limited jaw opening-mandible, Limited jaw opening- make it more difficult to align make it more difficult to align the oropharynx and larynx during the oropharynx and larynx during laryngoscopy and see the chords.laryngoscopy and see the chords.

Beard-Beard- dentures or any materiel dentures or any materiel on the face make iton the face make it difficult to difficult to get a bag-valve mask seal if get a bag-valve mask seal if intubation is not successful.intubation is not successful.

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LLookook

Children-Children-

Occiput is larger and larynx is Occiput is larger and larynx is higher in the neck so the vocal higher in the neck so the vocal chords are more anterior.chords are more anterior.

Epiglottis is high and very soft Epiglottis is high and very soft and thus easier to obstruct vision and thus easier to obstruct vision of the chords.of the chords.

Airway is very short thus making Airway is very short thus making it easier to intubate the bronchus.it easier to intubate the bronchus.

EExternalxternal

3-3-2 technique-3-3-2 technique- assesses geometric assesses geometric relationships of airway.relationships of airway.

1. ability to open mouth ( 1. ability to open mouth ( 3 3 fingers fingers should fit in patients mouth) should fit in patients mouth)

2.adequacy of chin ( 2.adequacy of chin ( 3 3 fingers fingers should fit between mentum and hyoid should fit between mentum and hyoid bone ) bone )

3. location of larynx ( 3. location of larynx ( 2 2 fingers fingers should fit between thyroid notch and should fit between thyroid notch and floor of mouth). floor of mouth).

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MMallampati Scaleallampati Scale

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

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OObstructionbstruction

Upper airway obstruction-Upper airway obstruction- Such as Such as angioedema, peritonsillar abscess angioedema, peritonsillar abscess with trismus, burns, penetrating with trismus, burns, penetrating neck injury, and epiglottis fit neck injury, and epiglottis fit into this category.into this category.

Facial Trauma and Laryngeal Facial Trauma and Laryngeal trauma-trauma- higher likelihood to need higher likelihood to need a surgical airway.a surgical airway.

NNeck Mobilityeck Mobility

Limited cervical mobilityLimited cervical mobility--secondary to DJD, Rheumatoid secondary to DJD, Rheumatoid Arthritis, immobilized trauma Arthritis, immobilized trauma patient in c-spine patient in c-spine precautions.precautions.

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Choosing the appropriate Choosing the appropriate intubation techniqueintubation technique

Easy Airway- paralyze the patient :Easy Airway- paralyze the patient : Rapid Sequence Rapid Sequence IntubationIntubation

Difficult Airway- awake technique :Difficult Airway- awake technique : Blind Nasotracheal Blind Nasotracheal Intubation Intubation oror

Awake Oral Intubation Awake Oral Intubation with Sedationwith Sedation

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Awake Oral Intubation with Awake Oral Intubation with Sedation-Sedation- use topical use topical anesthetic (anesthetic (nebulized lidocainenebulized lidocaine or hurricane spray) and or hurricane spray) and conscious sedation doses of conscious sedation doses of FentanylFentanyl and and VersedVersed or both. or both.

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Rapid Sequence IntubationRapid Sequence Intubation Cornerstone of modern emergency airway Cornerstone of modern emergency airway management. management.

Succinylcholine is the preferred Succinylcholine is the preferred paralytic in the ED because of its rapid paralytic in the ED because of its rapid and consistent onset of action, short and consistent onset of action, short clinical duration, and absence of clinical duration, and absence of significant side effects.significant side effects.

The technique involves the simultaneous The technique involves the simultaneous administration of a potent sedative administration of a potent sedative (induction) agent and a neuromuscular (induction) agent and a neuromuscular blocking agent, such as Succinylcholine, blocking agent, such as Succinylcholine, for the purpose of endotracheal for the purpose of endotracheal intubation. intubation.

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Induction AgentsInduction Agents

Etomidate- Etomidate- ED agent of choice for induction. ED agent of choice for induction. Etomidate has a similar profile of Versed Etomidate has a similar profile of Versed with rapid onset, rapid peak activity, and with rapid onset, rapid peak activity, and brief duration, but is remarkably brief duration, but is remarkably hemodynamically stable. hemodynamically stable.

Nonbarbituate hypnotic that works at the Nonbarbituate hypnotic that works at the GABA receptor.GABA receptor.

Can be used in all scenarios possible Can be used in all scenarios possible exception is septic pts.exception is septic pts.

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Ketamine- Ketamine- a dissociative anesthetic a dissociative anesthetic agent. Ketamine is for use in agent. Ketamine is for use in the induction of asthma and the induction of asthma and trauma pts. who are hypotensive trauma pts. who are hypotensive without signs of head trauma. without signs of head trauma.

Ketamine is a brochodilator and Ketamine is a brochodilator and increases ICP and cerebreal increases ICP and cerebreal blood flow.blood flow.

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ParalyticsParalytics

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

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Nondepolarizing agents- Nondepolarizing agents- such as such as Vecuronium which binds Vecuronium which binds competitively to ACH receptors competitively to ACH receptors preventing access to ACH and preventing access to ACH and thus preventing muscular thus preventing muscular activity.activity.

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SuccinylcholineSuccinylcholine

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

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Side Effects of SCHSide Effects of SCH

Bradycardia-Bradycardia- SCH is a weak negative SCH is a weak negative inotrope and chronotrope. Give inotrope and chronotrope. Give atropine to prevent bradycardia in atropine to prevent bradycardia in children less than 10.children less than 10.

Defasiculations-Defasiculations- from depolarizing from depolarizing effect of SCH, which may increase effect of SCH, which may increase ICP, intragastric pressure and ICP, intragastric pressure and intraocular pressure. Give intraocular pressure. Give defasiculation dose of depolarizing defasiculation dose of depolarizing agent.agent.

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Hyperkalemia-Hyperkalemia- Sux has been associated Sux has been associated with severe, fatal hyperkalemia when with severe, fatal hyperkalemia when administered in specific clinical administered in specific clinical situations: Major burns, Major crush situations: Major burns, Major crush injuries, Denervation Injuries and injuries, Denervation Injuries and Severe abdominal Sepsis.Severe abdominal Sepsis.

Malignant Hyperthermia-Malignant Hyperthermia- a syndrome of a syndrome of rapid temperature rise and aggressive rapid temperature rise and aggressive rhabdomylosis that occurs in the rhabdomylosis that occurs in the context of certain volatile general context of certain volatile general anesthetic agents or succinylcholine anesthetic agents or succinylcholine in genectically predisposed in genectically predisposed individuals. The condition is individuals. The condition is extremely rare and has not been extremely rare and has not been reported in the ED use of Sux.reported in the ED use of Sux.

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RSI Technique- the 6 RSI Technique- the 6 P’sP’s

1.Preparation-1.Preparation- pt. is assessed pt. is assessed for difficulty of intubation, for difficulty of intubation, all meds drawn up, equipment is all meds drawn up, equipment is assembled and staff is ready assembled and staff is ready for intubationfor intubation

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

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3. Pretreatment-3. Pretreatment- LidocaineLidocaine- attenuates rise in ICP and - attenuates rise in ICP and blunts reactive airway response to blunts reactive airway response to laryngoscopy and tube placement. laryngoscopy and tube placement.

Atropine-Atropine-prevents bradycardia prevents bradycardia associated with intubation in chldren associated with intubation in chldren less then 10.less then 10.

Defasiculation doseDefasiculation dose - of a - of a nondepolarizing agent to blunt the nondepolarizing agent to blunt the fasiculation response of fasiculation response of succinylcholine ( may blunt increase succinylcholine ( may blunt increase ICP with intubation).ICP with intubation).

4. Paralysis with induction4. Paralysis with induction--

1.Induction agent- sedative 1.Induction agent- sedative administered in dose sufficient administered in dose sufficient to produce unconscious state.to produce unconscious state.

2.Paralytic agent-given 2.Paralytic agent-given immediately after induction immediately after induction agent.agent.

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

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

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Example of RSI TimelineExample of RSI Timeline5:00-5:00- Preoxygenate and prepare Preoxygenate and prepare equipment- pulse ox, equipment- pulse ox, monitor, draw up monitor, draw up meds.meds.

3:00- 3:00- Lidocaine 1mg/kg attenuates Lidocaine 1mg/kg attenuates laryngospasm and laryngospasm and decreases ICP.decreases ICP.

Atropine 0.01 mg/kg attenuates Atropine 0.01 mg/kg attenuates bradycardia with bradycardia with Sux, peds <10.Sux, peds <10.

Fentanyl 2-3mcg/kg attenuates Fentanyl 2-3mcg/kg attenuates catecholamine catecholamine release.release.

Vecuronium 0.01mg/kg attenuates Vecuronium 0.01mg/kg attenuates fasiculations of fasiculations of Sux, decreases ICP.Sux, decreases ICP.

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0:00- 0:00- Induction:Induction: Etomidate 0.3mg/kg or Versed Etomidate 0.3mg/kg or Versed

0.1mg/kg, 0.1mg/kg, Ketamine 1.0-2.0 Ketamine 1.0-2.0 mg/kg 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 onset 30-45 seconds ,duration 3-10 minutesminutes

+0:45-+0:45- Intubation: 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 Check tube placement , use capnometer.capnometer.

The Failed AirwayThe Failed Airway

Inability to intubate patient after 3 Inability to intubate patient after 3 attempts by an experienced provider or attempts by an experienced provider or inability to BVM ventilate a patient.inability to BVM ventilate a patient.

Change method or technique on every Change method or technique on every attempt to intubate.attempt to intubate.

1.muscle tone-can’t intubate awake, 1.muscle tone-can’t intubate awake, consider RSIconsider RSI

2.position of patient- need SNIFF 2.position of patient- need SNIFF positionposition

3.B.U.R.P- backward, upward, rightward 3.B.U.R.P- backward, upward, rightward pressurepressure

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The Failed AirwayThe Failed Airway

4. Change blade length or blade 4. Change blade length or blade type.type.

5. Change operator.5. Change operator.

6. Consider cricothyroidectomy – 6. Consider cricothyroidectomy – invasiveinvasive

7. Consider LMA or other 7. Consider LMA or other rescue airway devicerescue airway device

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Laryngeal Mask AirwayLaryngeal Mask Airway

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

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