Emergency-Airway-Management_Mark-Freedman.ppt

Air way management for mo

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
No
Yes
Yes
Crashing ?
Failed Airway
Fails
Fails
Fails

14. The 8 “P”s of RSI
•0 - 10minPreparation
•0 - 5 minPreoxygenation
•0 – 3 minPremedication
•0 Pharmacological Induction
•0 Pressure
•0 Paralysis
•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
Anticipated Unanticipated
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
Anticipated Unanticipated
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

46. QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

50. Difficult Airway
Anticipated Unanticipated
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….
•40 220/11016100% 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
Anticipated Unanticipated
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?