SEDATION ASSISTED INTUBATION: A Case Presentation · SEDATION – ASSISTED INTUBATION: A Case...
Transcript of SEDATION ASSISTED INTUBATION: A Case Presentation · SEDATION – ASSISTED INTUBATION: A Case...
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Advanced Airway Management
SEDATION – ASSISTED INTUBATION:
A Case Presentation
Scott Henley
NRP, FP-C, CCEMTP
Deputy Chief – Clinical Coordinator
Central Bucks EMS
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Outline
• Intubation in general
• Research
• Etomidate (Amidate)
• EMS: PA DOH Protocol
• “The Airway”
• Mature Clinical Decision Making
• Case Presentation
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What is Intubation ?
A medical procedure involving the placement of a breathing tube into a patient’s trachea to assist them with their breathing. Medication-Assisted - RSI (Rapid Sequence Induction/Intubation) Use of sedation and paralytics PA ground 911 ALS units are not permitted to carry paralytics per PA DOH. - Sedation Only For credentialed agencies only; this consists of Etomidate only. - PREFERRED Non Medication-Assisted
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Intubation In General
• Under attack around the country
- Worse outcomes
- Esophageal intubations (and sometimes unrecognized)
- Limited value
- Other alternatives (King LT, Combitube, CPAP, BVM)
- Low experience/numbers
- De-emphasized in cardiac arrest
• However, When it is needed. . .
- IT IS NEEDED
- Experience is difficult to obtain and maintain
- We need to decrease adverse outcomes, select the right patients, use the right tools as available at the right times.
- Etomidate is one of those tools
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Etomidate “Amidate” - Unique sedative / hypnotic
- Associated with stable hemodynamic profile
- 5 to 15 seconds onset of action, often longer
- 5 to 15 minute duration
- If the only agent used for intubation, most patients need post intubation sedation.
- Dose: 0.3mg/kg, maximum of 30mg IVP / IO (PA DOH Protocol)
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Etomidate “Amidate”
• Cerebroprotective
- Does not increase ICP (Intracranial Pressure)
- Sedation itself may actually lower ICP
• May cause:
- Myoclonic movements (a quick, involuntary muscle contraction)
- Nausea and vomiting post administration
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Etomidate “Amidate”
• Inhibits an enzyme that catalyzes cholesterol to cortisol
- Adrenal suppression
• Worse in septic patients – contraindicated
- Infection
- Fever
- Hypotension
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Research
• Prehospital Emergency Care Journal (PEC) 2006 Jan-Mar; 10(1) 8-13
- Airmedical service
- Six months of Etomidate-only intubations (EOI) – 0.3 mg/kg
- Six months of Etomidate + succinylcholine (paralytic)
- 90% trauma
- 49 Patients:
• 63% of EOI (15/24) required additional medications to intubate.
• 4% of succinylcholine (1/25) required additional medications to intubate.
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Research • Larynoscopy good or acceptable
- 79% of RSI
- 13% of EOI
• Success
- 92% of RSI
- 25% EOI
• So?
- We know RSI would be better (PROVEN! DATA & LITERATURE ALL POINT TO THIS)
- But this is what we have
- Do not expect perfect intubating conditions with EOI
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Research: Closer to Home • Blinded study: - 7mg of Versed (Midazolam) or 20mg of Etomidate - 110 patients: 55 in each category - 75% intubation success with Versed - 76% intubation success with Etomidate But wait ! What about weight-based dosing?
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That Was Then. . .
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This Is Now. . . Protocol # 4002: Sedation-Assisted Intubation (Etomidate)
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₋ Two Etomidate-credentialed ALS providers MUST be present at the time of administration.
₋ Only one of the credentialed providers needs to transport the patient.
₋ Single dose: 0.3mg/kg to a max of 30mg
₋ If the patient needs post intubation sedation, medical command is needed.
₋ Age range to be determined by service medical director.
₋ Complete all regional/service reporting forms post administration.
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₋ Service medical director expresses interest, in writing, to the regional Medical Advisory Committee (MAC).
₋ MAC Committee discusses and assigns any extra work to be completed by the service prior to obtaining the medication.
₋ Service completes any assigned tasks by the MAC, completes in-house training, and reports back to the MAC.
₋ Regional MAC takes the final vote to allow the service to begin to carry and perform medication-assisted intubation.
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AIRWAY - Learn it ! - Know the anatomy! - Know how to navigate it! - Practice! - RESPECT IT ! ETOMIDATE (and other medications) - Have respect for the sedation-assisted process! - Know the medication! When to use it vs. when not to use it ! - Be prepared for what may or may not happen! - There is nothing “rapid” about the process. - RESPECT the medication!
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Bensalem EMS
Central Bucks EMS
Plymouth Ambulance
Trappe Fire Co. EMS
4 Services
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- LOOK at the patient before ever attempting to control their airway, what do you see?
- Recognize patients with potentially difficult airways.
- Develop skills to assess & control these airways.
- Know when to attempt and NOT attempt an intubation.
- Know when to abort an intubation and move to a rescue airway.
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Any healthcare provider that may be at a patient’s bedside should learn to assess airways and speak up if you see anything abnormal:
Physicians
Nurses
Respiratory Therapists
Patient Care Technicians
X-Ray Technicians
Paramedics
EMTs
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What happens when we do this right away?
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Mallampati Score
Grade I Grade II Grade III Grade IV
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Cormack – Lehane Airway Grading
Grade 1 Grade 2 Grade 3 Grade 4 Visualization of vocal chords Partial view of the vocal chords. View of the epiglottis only Inability to see the epiglottis
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- Level of consciousness. - Ability to protect their own airway. (Gag vs. the ability to swallow and control their
own secretions.) - Good positioning and lighting. - Good Technique. - Good knowledge of the anatomy. - Be Confident - Practice, Practice, Practice !
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Digital End Tidal Co2 and Waveform Capnography is the GOLD standard of care for endotracheal tube placement confirmation.
“Misplacing an endotracheal tube is not career-ending. Failing to recognize it, is!”
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Make Your FIRST Attempt, Your
BEST Attempt !
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Not all patients need to be intubated
- BVM
- CPAP (Continuous Positive Airway Pressure)
- Oral / Nasal Airway
- Oxygen
Not all patients need sedation
- Do NOT sedate someone if you anticipate difficult airway indicators and may have difficulty intubating them.
- Knowledge and skill level
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Patient Selection
- Oxygen or CPAP alone are not maintaining oxygenation
- BVM required to maintain oxygenation
- Movement causes de-saturation; difficulty moving and maintaining stability.
- BVM’ing a patient to the hospital is NOT a failure
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- Pre-oxygenate (Nasal cannula before and during intubation)- “No Desat”
- Three attempts total, per the state. (follow your agency’s protocols)
- Direct Laryngoscopy vs. Video Laryngoscopy
- Move to rescue airway if needed
Set yourself up for success:
- Suction
- Adequate lighting
- Positioning
- Good technique
- Equipment
- Backup Plans
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Golden Rule:
DO NOT TAKE SOMETHING AWAY FROM SOMEONE
THAT YOU CAN’T REPLACE !
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• ALS Unit, police, and fire department dispatched for a small airplane crash.
• Supplemental report: small aircraft went down into high tension wires, exploded, and then crashed to the ground.
• Thick, black, smoke visible while units were still responding. “Header”
• Power lines within miles of the scene were down; power out in the
immediate area.
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• 11:45 am on a Saturday: Hot, clear, sunny day
• Patient had been completely engulfed in flames from the collision in the high tension lines; plane landed in trees, pt. then fell 15-20 ft. to the ground.
• Bystanders used a dry chemical fire extinguisher on the patient.
• A large crowd of bystanders, police, and other responders present.
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Scene pictures were taken from the internet
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Scene pictures were taken from the internet
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• 69 year old male - laying supine on the hot, asphalt surface.
• Estimated by EMS to be approximately 210 lbs. or 95 kg
• Semi-conscious with periods of unresponsiveness.
• Appears greater than 90% burnt circumferentially with second and third
degree burns.
• Mild lacerations and abrasions on his arms and legs, minimal bleeding.
• Obvious deformity of the (L) humerus.
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• Chief Complaint: None Voiced • GCS: 9 • Perceived 10/10 pain from burns • B/P- 134/90 Pulse- 122 and weak Respirations: 22 and labored Lungs: Decreased in all fields Skin: Hot, burnt, sloughing • Pulse Ox: 86% room air with a good pleth • Obvious airway burns & injury : Thick, black soot from mouth: (+) carbonaceous sputum (burnt saliva)
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AIRWAY
BURNS: 90+ body surface area burns
PAIN
TRAUMA: from the 15-20 ft. fall
CONTAMINATION: from the dry chemical extinguisher mixed with the burns
(dry vs. irrigation vs. infection vs. death)
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WHERE DO WE START ?!?!
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Manual C-Spine stabilization maintained
Oxygen Therapy: 15 lpm NRB mask
Slight Decontamination: Small amount of sterile water dabbed on towels and dabbed throughout the pt’s body.
Pt. wrapped in burn sheets
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Placed on long spine board and secured with straps and CIDs.
Interosseous placement: (due to the severity of burns in all extremities)
40mg Lidocaine administered IO push for local anesthetic
Normal Saline run wide open with b/p cuff acting as a “pressure bag”
100mcg Fentanyl administered IO push for pain.
Move the patient to the ambulance, covered with blankets for heat preservation.
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Monitor applied: Sinus Tach @ 120-130 (-) ectopy
. . .and now. . . Intubation or no intubation ?!?!
A brief discussion between three ALS providers, we decided, YES !
- Decreased GSC
- Obvious airway injury and burns
- Spo2 is low
- Lung sounds decreased (also keeping an eye on a potential pneumothorax)
- If it doesn’t get done now, will later be too late?
A second line was able to be established: 14ga right forearm – wide open
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Preparation for Advanced Airway Management (Intubation):
External assessment: Appears to have normal build/neck, anticipate a Grade 1
External assessment: burns to the face, in the airway upon looking
Prediction: Going to be burnt, discolored, and possibly bloody on direct laryngoscopy.
Reality: We all knew it, however, nobody really wanted to say it. . .
WE GET ONE SHOT AT THIS, AND ONE SHOT ONLY !
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Airway equipment was readied and backup plans in place:
Bougie
QuickTrach (in case of emergent cricothyrotomy)
Suction
Second ALS provider
King LT
Pre-Oxygenation initiated:
Nasal Cannula @ 15 lpm
NRB Mask @ 25 lpm (yes, the pt. tolerated it)
30mg Etomidate slow IO push over 50 seconds (pt. became sedated and flaccid)
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“The Intubation”
-The most experienced ALS provider performed.
-C-collar loosened, frontal C-spine stabilization maintained
-Direct Laryngoscopy via Mac 3 blade
-Immediately encountered blood and black airway burns
-Intubator provided self bimanual laryngeal manipulation
-Grade 3 View: Cormack-Lehane
-Intubated with a 7.5 ETT, immediately confirmed with digital Etco2 of 36mm/Hg and waveform capnography
-Spo2 remained 96-98% throughout the intubation process
-(+) bilateral breath sounds, (-) epigastric sounds
-Secured at 24cm with commercial tube holder
-Ventilated and oxygenated at 16 breaths/minute
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Additional 100mcg Fentanyl administered IVP for pain
Reassessment of vitals:
GCS: Sedated
B/P: 150/100
Pulse: Sinus Tach @ 118 (-) ectopy
Pulse Ox: 99% with good pleth Etco2: 34-41 mm/Hg
10mg Versed administered IVP for continued sedation (two administrations of 5mg)
1400 mL NSS infused
Transport: flown to Temple University Hospital burn center
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Day of the Incident
Level 1 trauma on arrival
Found to have 100% TBSA burns: 60% second degree, 40% third degree
Ribs 4 and 5 fractured
Left humerus fracture
Day 2
13:15 Escharotomies of the chest, abdomen, and legs
14:24 Made a DNR, comfort measures only, extubated
15:19 Patient expired
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-Learn the airway and keep practicing (even though, we all think we know it) -Be knowledgeable of the ever-so-changing protocols, latest science, and data. -Respect ALL medications, ALL the time! -Respect the sedation-assisted (and RSI) processes. -Continually push yourself to be a stronger and more knowledgeable provider. -Be Confident, and not lazy. -Make strong, sound, mature clinical decisions and always do what’s best for your patients.