Airway Management for

CPR and trauma

Jerry Nolan Royal United Hospital Bath, UK

8th International Spark of Life 8-9th April 2011

Australian Resuscitation

Council

Airway management for CPR and trauma

Objectives of airway management during CPR and trauma

Tracheal intubation – pros and cons

Supraglottic airways

Controversies in rapid sequence induction and intubation (RSII) for trauma

Objectives of airway management during CPR

Enable ventilation despite potentially poor lung compliance (especially if continuous chest compressions)

Protect against aspiration

Minimise ‘no flow’ time

Minimise complications

Improve long-term survival

Regurgitation and aspiration: out-of-hospital cardiac arrest

Regurgitation occurs in 20-30% of out-of-hospital cardiac arrests but in 2/3 it occurs before EMS arrival

Regurgitation associated with odds ratio of survival of 0.5 (0.28 – 0.89)

Half of those regurgitating have radiological evidence of aspiration

Simons RW. Resuscitation 2007;74:4267-31 Virkkunen I. Acta Anaesthesiol Scand 2007;51:202-5

Emergency intubation for acutely ill and injured patients

Randomised controlled trials of tracheal intubation versus alternative

Full texts of 452 studies reviewed

2 RCTs of TT versus Combitube OHCA Rabitsch W. Resuscitation 2003;57:27–32.

Goldenberg IF. Chest 1986;90:90–6.

1 RCT of TT versus BVM in children Gausche M. JAMA 2000;9:783–90.

Lecky F et al. Cochrane Collaboration 2009 Issue 1

Tracheal intubation during CPR: advantages

Enables uninterrupted chest compressions

Enables most effective ventilation?

Least likely airway to be dislodged?

Minimises gastric inflation

Protects against aspiration

Quality of resuscitation before and after tracheal intubation

N = 119 Before intubation

After intubation

Difference (mean %, 95% CI)

Chest compressions (% of time)

39 20% 59 18% 20 (16-24)

Compressions per min

47 25 71 23 24 (19-29)

Ventilations per min

5.6 3.7 14 5.0 8.7 (7.6-9.8)

Kramer-Johansen J. Resuscitation 2006;48:61-9

Ontario Prehospital Advanced Life Support (OPALS) Phase III

P<0.001

P=0.83

Stiell IG. N Engl J Med 2004;351:647-56

Intubation success = 93.7%

Operator dependent++

Interrupts chest compressions

Excessive ventilation once intubated?

Does not ‘fail-safe’ Unrecognised oesophageal intubation

Bronchial intubation

Training and skill retention problematic

Tracheal intubation during CPR: disadvantages

Intubation success: cardiac arrest

Study N Intubator Success (%)

Bradley, 1998 57 EMT 49

Sayre, 1998 103 EMT 51

Rumball, 2004 250 EMT 70

Rabitsch, 2003 83 Physician 94

Stiell, 2004 3848 Paramedic 93.7

Deakin, 2010 368 Paramedic 83.8

Lyon, 2010 628 Paramedic 91.2

Hubble, 2010 +++ All 91.2

Hubble MW. Prehosp Emerg Care 2010;14:377–401

The intubation learning curve

11 first-year anaesthesia residents Konrad C. Anesth Analg 1998;86:635-9

Intubations by paramedics, Hampshire, UK 2007

439 tracheal intubation attempts documented by 269 paramedics.

368 (83.8%) documented successful.

Intubations 0 1 2 3 4 5 6 7 8 9 10 11

Paramedics 128 76 28 22 7 1 2 1 0 1 2 1

Deakin C. EMJ 2009;26:888-91

Interruptions in CPR from paramedic tracheal intubation

100 cardiac arrests with real-time data collection including audio

1st tracheal intubation–associated CPR interruption = 46.5 s (IQR 23.5 – 73 s; range 7 to 221 s).

One third exceeded 1 minute.

Wang HE. Ann Emerg Med. 2009;54:645-652

Unrecognised oesophageal intubations: cardiac arrest

Study Number (%)

Lyon RM, 2010 15/628 (2.4)

Sayre MR, 1998 3/103 (2.9)

Rumball C, 2004 7/208 (3.0)

Pellucio M, 1997 10/168 (6.0)

Jones JH, 2004 10/160 (6.3)

Katz SH, 2001 18/108 (16.7)

n Bronchus Oesophageal

Total 149 16 (10.7%) 10 (6.7%)

Trauma 84 11 6

CPR 21 1 1

Other medical 44 4 3

Timmermann A. Anesth Analg 2007;104:619-23

Complications of out-of-hospital intubation by emergency physicians

Confirmation of tracheal tube placement

Technique Cardiac arrest

studies (N)

Sensitivity (%) (tracheal intubation correctly identified)

Specificity (%) (oesophageal

intubation correctly identified)

Clinical assessment 5 74 – 100 66 – 100 Oesophageal detector – syringe

5 73 – 100 50 – 100

Oesophageal detector – bulb

3 71 – 75 89 – 100

Colormetric ETCO2 8 62 – 100 86 – 100 Digital ETCO2 5 70 – 100 100 Waveform ETCO2 2 (3) 100 (64) 100 (100)

( ) = Intubation after very prolonged arrest

Meta-analysis of prehospital airways – supraglottic airways

SAD Insertion Success (%)

95% CI

Combitube 87.4 77.9 – 93.2

LMA 86.3 60.7 – 96.3

LT 96.0 41.7 – 99.9

Hubble MW. Prehosp Emerg Care 2010;14:515-30

Laryngeal tube (LT-D or LTS-D) for out-of-hospital cardiac arrest

Nurses (LT): 30 (80%) Kette F. Resuscitation 2005;66:21-5

Paramedics: 92 (100% success within 2 attempts) Wiese CHR. Resuscitation 2009;80:194-8

Paramedics + EPs: 110 (97%?) Schalk R. Resuscitation 2010;81:323-6

Paramedics: 39 (85%) Heuer JF. Eur J Emerg Med 2010;17:10-5

Use of I-gel by non-anaesthetists for in-hospital cardiac arrest

45 insertions by nurses or doctors

44/45 (98%) successful insertion

39/45 (87%) on 1st attempt

Chest rise, no leak 25 (57%)

Chest rise with leak 17 (39%)

No chest rise 2/44 (5%)

Larkin CB. Resuscitation 2010;81S:S58

LMA Supreme Verghese C. Br J Anaesth 2008;101:405-10

Objectives of airway management for trauma

Enable oxygenation

Protect against aspiration

Enable controlled ventilation in TBI

Following RSI and intubation:

Enable resuscitation of the combative patient

Enable safe transport

Pre-hospital intubations (PHI) assessed by anesthesiologist

PHI 203

Combitube 28 (14%)

LMA 6 (3%) Cricothyroidotomy

4 (2%)

Oesophageal intubation 25 (12%)

Failed PHI 63 (31%)

Successful PHI 140 (68%)

Cobas MA. Anaesth Analg 2009;109:489-93

Aug 2003 – June 2006

Pre-hospital intubation (PHI)

Air Ground

Number 115 (57%) 88 (43%)

Intubation Success 82% 52%

Cobas MA. Anaesth Analg 2009;109:489-93

ETCO2 used Air crew use Sux Ground paramedics do 1-3 intubations/year

Prehospital drug-assisted intubation

Study Patients Operator N (% success)

Surgical airway

(%)

Helm, 2006 Mixed German Anaesth

342 (100) 0

Fakhry, 2006 TBI U.S. HEMS Paramedics

175 (96.6) 2.3

Mackay, 2001 Trauma London HEMS Anaesth/EP

359 (98.3) 2.2

2004 – 2008

16-hour training program (180 paramedics)

Randomised (envelopes)

Fentanyl 100 mcg, midaz 0.1 mg/kg, Sux, then pancuronium

Control group intubated if no airway

Primary outcome = Glasgow Outcome Score extended (1-8)

Bernard SA. Ann Surg 2010;252:959-65.

RSI n = 160

Control n = 152

P

Airway secure by RSI 153 (95%) 2

Failed RSI 5 1

Tracheal tube no drugs 1 7

Cardiac arrest 10 (failed tube in 3) 2

Survival to Hosp Dis 107 (67%) 97 (64%) P = 0.57

Median GOSe (IQR) 5 (1 – 6) 3 (1 – 6) P = 0.28

Favourable GOSe (5-8) 80/157 (51%) 56/142 (39%) P = 0.046

Bernard SA. Ann Surg 2010;252:959-65.

Daily clinical experience – intubation

Infrequent airway experience – SAD?

Rare clinical experience – basic only?

Anesth Analg 2009;109:303-5

Sise MJ. J Trauma 2009;66:32-40

Cricothyroidotomies = 7 (0.7%)

Pre-oxygenation

IV access & suction

MILS

Remove collar

Induction (drugs)

Cricoid pressure

Manual ventilation

Oral intubation

Plan B

Rapid Sequence Induction & Intubation (RSII)

El-Orbany M. Anesth Analg 2010;110:1318-25

Manual in line stabilisation of the cervical spine

Existing practice based on:

Studies in uninjured volunteers

Cadaveric models

Case series

MILS makes the view at laryngoscopy worse. Nolan JP. Anaesthesia 1993; 48: 630-633

MILS increases force at laryngoscopy Santoni BG. Anesthesiology 2009;110:24-31

Manoach S. Ann Emerg Med 2007;50:236-45

Strategies to reduce cervical spine movement during intubation

Airway Scope (AWS) better than Mac? Takahashi K. J Trauma 2010;68:363-6

AWS plus bougie better than AWS alone Takenaka I. Anesthesiology 2009;110:1335-40

AirTraq less movement than Mac Turkstra TP. Anesthesiology 2009;111:97-101

Glidescope better view, same movement Robitaille A. Anesth Analg 2008;106:935-41

Trimmel H. Crit Care Med 2011;39:489-93

212 prehospital intubations by anesthesiologists or emergency physicians

Cardiac arrest, coma, trauma

Intubation success

Standard 105/106 (99%)

Airtraq 50/106 (47%)

Cricoid pressure and manual ventilation in RSII

Evidence for benefit is very low level Ellis DY. Ann Emerg Med 2007;50:653-65

Laryngeal view improved when cricoid removed in 11/22 Harris T. Resuscitation 2010;81:810-6

No evidence that positive pressure ventilation increases gastric inflation

NAP 4 Cricothyroidotomies

Success/total Needle Surgical

Anaesthesia 7/19 (narrow) 4/7 (wide)

3/3

ICU 2/5 5/7

ED 0/3 10/10

6 unrecognised oesophageal intubations (ED/ITU) leading to 5 deaths; 3 during anaesthesia – 1 death and 1 brain damage

01 Sept 2008 – 31 Aug 2009

Airway management for CPR and trauma: summary

Tracheal intubation ideal but only if experienced operator

Any healthcare personnel undertaking trauma intubations (pre-hospital and in-hospital) must be highly trained in drug-assisted techniques.

SADs if not skilled in intubation

Controversies in RSII: MILS, cricoid pressure

Abandon needle cricothyroidotomy?