a question you always want to know about tracheal intubation:

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A question you always want to know about tracheal intubation: What to do if I can’t intubate a patient?

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A question you always want to know about tracheal intubation:. What to do if I can’t intubate a patient?. Intubation. Outcomes of the difficult intubation in malpractice claims. My own experience. - PowerPoint PPT Presentation

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Page 1: A question you always want to know about tracheal intubation:

A question you always want to know about tracheal intubation:

What to do if I can’t intubate a patient?

Page 2: A question you always want to know about tracheal intubation:
Page 3: A question you always want to know about tracheal intubation:

Outcomes of the difficult intubation in malpractice claims

DifficultAirway Claims

(n=283)

Other claims(n=4176)

Death *131 (46%) 1293 (31%)

Brain damage 31 (11%) 504 (12%)

Airway Injury *97 (34%) 169 (4%)

Aspiration 19 (7%) 139 (3%)

Cost 135000 $ 100000 $

Page 4: A question you always want to know about tracheal intubation:

My own experience

• I couldn’t intubate a patient with respiratory arrest on my first duty in ICU. Retrograde intubation was performed successfully.

• In a patient with severe airway obstruction emergency tracheostomy was made

• Difficult intubation before elective surgical procedure. Blind nasal intubation failed. The patient was intubated by a chief of the department

• A cuff of the tube was ruptured in the middle of an operation. Re-intubation after 3rd attempt

Page 5: A question you always want to know about tracheal intubation:

Is it real in our every day life?

• A call was received by the medical director of the clinic: a worker from a major construction company fell down from the height. They are in 10 min from the clinic, accompanied by a nurse from the company. The nurse is very nervous: the man can’t b breath and she’s trying to ventilate him by mask.

• A patient admitted to our holding room: He’s severely obtunded. T-40C, RR-36’, HR-140’, SO2-72%, improved to 78% on 12 l/min of oxygen. CXR- bilateral pneumonia.

Page 6: A question you always want to know about tracheal intubation:

Continue

• A doctor from the clinic escorts an unconscious patient to the hospital. The patient’s condition deteriorates, SO2 drops despite supplementary oxygen inhalation.

• In the medical unit of SVO2, the staff tried to manage an unconscious patient in apparent respiratory distress who admitted about 5 minutes ago

• Air evacuations: 5 intubations were performed.

Page 7: A question you always want to know about tracheal intubation:

Emergency intubation vs elective one

Emergency Elective

Difficult intubation isusually unpredictable

Predictable in about 60 %of cases

No time for preparation Enough time forpreparation

Experienced staff isunavailable

Experienced staff isavailable

Full stomach Empty stomach

Patient's condition isunstable

Stable

Page 8: A question you always want to know about tracheal intubation:

Reasons for intubation in emergency situation

• Hypoxia• Hypoventilation ( hypercapnia)• Unconscious patient who’s unable to protect

his/her airway• Too labored breathing put patient's condition

in danger• Unstable patient• A patient who can’t be managed without

intubation

Page 9: A question you always want to know about tracheal intubation:
Page 10: A question you always want to know about tracheal intubation:

Make a decision on the base of the whole picture!

• 18 y.o. girl with APL admitted to the ICU. She is very weak and disoriented. VS: RR-28’, HR-120’, BP-120/80, SaO2-40%. PaO2- 32, PaCO2- 32. Breathing is unlabored.

• 46 y. o. man admitted to the ICU due to long-term respiratory failure. VS: RR-24, BP-140/90, SaO2 -40, PaO2-44, PaCO2-55

Page 11: A question you always want to know about tracheal intubation:

Continue

• 10 years old boy with blunt head trauma and mandibular fracture after car accident. He was hospitalized to an ICU, 36 hours before arrival our evacuation team. GCS-7. VS: RR-22’, HR=120’, BP-110/80, SaO2-92% on room air. Breathing spontaneously. There is blood in the oral cavity. Tympanic membrane on the left with hemorrhage.

Page 12: A question you always want to know about tracheal intubation:

Physiology (a little)

• Hypoxia: hyperventilation will be pronounced when the PaO2 falls to 40.2 mm Hg, coma occurs when PaO2 is below 32.7 mm Hg (BMJ: ABC of oxygen transport)

• Hypercapnia: A healthy person will bear PaCO2 75 mm Hg without any damage

• In case of apnoea when airway are open and oxygen is the ambient mask, the patient can theoretically survive 100 minutes (JF Nunn)

Page 13: A question you always want to know about tracheal intubation:

Principal stores of body oxygenWhile breathingair

While breathing100% oxygen

In the lungs(FRS)

450 ml 3000 ml

In the blood 850 ml 950 ml

Dissolved intissue

50 ml 100

Combined withmyoglobin

200 ml 200 ml

Total 1550 ml 4250 ml

Fully preoxygenated patient can survive up to 8 min without becoming hypoxic

Page 14: A question you always want to know about tracheal intubation:

Types of translaryngeal intubation

disadvantag elack of patient's com fort

laryng ospazmdiff icult to perform

advantag epresevation of b reath ing

very low risk of asp ira tion

b lind nasal itub ation

conv entional in tub ation

Aw aken intub ationlocal anesthes ia

consc iouss sedation

disadvantageasp iration

adv erse effects o f m uscle re laxantslong recov ery

adv antag egood re laxation

no laryng osp azmp atient's com fort

intub ation w ith m uscle p ara lys is

d isadvantag ediff icu lt v isualization of vocal cordsrisk of asp ira tion and laryng osp azm

advantagelow risk of asp iration

p reserv ation of b reath ing

Intub ation w ithout m usc le p ara lys is(sp ontaneous b reath ing is p reserved)

Translaryngeal intub ation

Page 15: A question you always want to know about tracheal intubation:

Multiple choice questions:Smart thoughts before the start

• Why I didn’t go to the business school instead of medical university?

• Should I ask for help?• They don’t pay me enough• The clinic is unprepared for this, nurses poorly

trained, medical director… and etc• What should I do before?• Do I have a plan?

Page 16: A question you always want to know about tracheal intubation:

Answers

• Measures before: a) how to improve oxygenation, ventilation and protect airway? b) Do I monitor the patient properly?

• Heeeelp (will not work): who to ask, when and what to ask

• What about a plan?

Page 17: A question you always want to know about tracheal intubation:

If you failed…?

Page 18: A question you always want to know about tracheal intubation:

Every boxer had a plan until he missed first strong punch

Mike Tyson (philosopher)

Better don’t say that I’m wrong

Page 19: A question you always want to know about tracheal intubation:

If you failed

• mask ventilation is possible

• continue ventilation• protect airway• make another attempt• don’t forget about

external maneuvers

• mask ventilation isn’t possible

• Try jaw thrust• oral or nasal airway• clean secretion

Page 20: A question you always want to know about tracheal intubation:

Continue

• Intubation failed, but mask ventilation is possible-consider

• Continue mask ventilation until help is available

• Retrograde intubation• Transtracheal ventilation

with oral airway

• Remember Tyson?• Transtracheal

ventilation• Combi tube• Open cricotomy

Page 21: A question you always want to know about tracheal intubation:

Practice will help