1

The Difficult Airway

Presented by John Mohler, RN

John Mohler, RN, BSN, CFRN, CCRN

Care Flight, Reno – Critical Care Services

The Difficult Airway

1

2

3

2

10 Commandments of AirwayManagement

Extrapolated from an article in JEMS 7/05and authored by Corey M. Slovis, MD

Kevin High, RN

Oxygenation & Ventilation are thetop Priorities

“Patient’s do not die or suffer braindamage because you cannot, or do not,intubate them;

they die or suffer brain damage becauseyou cannot, or do not, oxygenate andventilate them”

Airway management does notmean Intubation

4

5

6

3

Be An Expert At BVM Ventilation

Proper techniques

Kids vs adults

Proper masks and how to size

Appropriate pressures and insufflationtimes

Know your Equipment

Know At Least One RescueVentilation Technique

2 person BVM

Use of a blind insertion device

LMA, Combitube, King LT-D airway

7

8

9

4

Develop a personal airwayalgorithm

Don’t let your ego get in the way

If you’re unsuccessful, give anotherprovider a chance

Use an end tidal CO2 detectorand/or esophageal detectordevice to confirm and/or monitorevery intubation

10

11

12

5

When seconds count, don’t counton seconds

Leave nothing to chance

Anticipatory readiness

Invest time in learning airwayskills

www.combitube.org

www.theairwaysite.com/home.htmt (thedifficult airway course)

www.airwayeducation.com (SLAM)

OR time

Simulation mannequins

The Difficult Airway

Difficulty inachievingendotrachealintubation is usuallyattributed to poorvisualization

13

14

15

6

An Algorithmic Approach

If you can’t Intubate –

Bag If you can’t Bag –

Alternative Airway

And if you can’t oxygenate or Ventilate ----

Cut the throat

If You Fail at Intubation…..

Difficult mask ventilation

Beard

Obesity

Edentulous

Large tongue

Elderly

What are you going to do?

16

17

18

7

Campbell, International Trauma Life Support, 6th Ed.© 2008 Pearson Education, Inc., Upper Saddle River, NJ

Airway -

B Beards

O Obesity

O Older patients

T Toothlessness

S Snores or stridor

19Airway -

Difficult BVM Ventilation

M ask seal

O bese

A aged

N o teeth

S tiff (non compliantchest, COPD, Asthma

The 9 FAILURES of PrehospitalAirway Management

1. Failure to RECOGNIZE the need for airway

support

2. Failure to PREOXYGENATE (Breathing

Patients)

3. Failure to PREPARE equipment (Suction!!)

The 9 FAILURES of PrehospitalAirway Management

4. Failure to RECOGNIZE Difficult Airways

5. Failure to ABORT (prolonged effort)

6. Failure to CONFIRM placement

19

21

22

8

The 9 FAILURES of PrehospitalAirway Management

7. Failure to RECOGNIZE a misplaced

endotracheal tube

8. Failure to RECOGNIZE a dislodged

endotracheal tube

9. Failure to have a BACKUP PLAN

Dispelling Myths

1. BLS Airways are INADEQUATE

2. Hyperextending the neck promotes airway

visualization

3. “Visualizing” the tube thru the cords is a type

of airway confirmation

You Need to Become an Expertat BVM

23

24

25

9

1. Death by Hyperventilation: Study concluded that professional rescuersconsistently hyperventilated patients with average ventilation rate of 30 bpm,three times the AHA recommended rate. Excessive ventilation rates inhibitvenous blood return to the right heart and are associated with decreasedsurvival rates.Clearly demonstrates that average delivered breaths per minute amongtrained EMS personnel were at a mean rate of 37 bpm with a meaninspiratory pressure of 50cm/H2O. Even after re-training the mean breathrate was 22 bpm at a mean inspiratory pressure of 44.5cm/H2O. Still wellabove the AHA guidelines of 10 breaths per minute inspiratory pressureswell in excess of the Lower Esophageal Opening Pressure of 20cm/H2O.

Excessive ventilation rates = increased inspiratory pressures = decreasedcoronary perfusion pressures = decreased survival rates.

A manometer enables the caregiver to monitor inspiratory pressures. Wheninspiratory pressures are kept below the LESOP at 20cm/H2O breath ratesare automatically reduced and gastric insufflations are avoided or minimized.

Vent Lab Airflow Bag

5. Lower Esophaheal Sphincter PressureDuring Cardiac Arrest: As LESP pressuresare overcome, the stomach becomes inflatedwhich increases intragastric pressures, elevatesthe diaphragm, restricts lung movement, and inturn reduces respiratory system compliance andlung ventilation which may cause severecomplications such as aspiration, pneumonia,and possibly death. LESP pressures droprapidly from 20cm/H2O to around 5cm/H2Oduring cardiac arrest.

26

27

28

10

How About BVM for the CHF Pt.?

BVM by itself doesn’t cut it, …. But…..

Add a PEEP valve with an effective sealand you have created CPAP!!

Adjuncts for Intubation

Alternatives to Intubation

BVM

BIADs (supraglottic airways)

Orotracheal Intubation With or without sedation

With or without RSI

Digital intubation

Fiberoptic Intubation

Nasotracheal Intubation blind

assisted with a laryngoscope or Fiberoptics

34

35

36

11

Intubation Adjuncts Bullard laryngoscope Articulating laryngoscope (Corazelli-London-McCoy) Optical laryngoscopes Wu, Upsher rigid fiberoptic laryngoscopes Flexible fiberoptic scopes: length 26-60 cm, varying diameters, features

Fiberoptic stylets (Shikani, Visualized endotracheal tube, "Shuttle") Lighted stylets (Trachlight, Vital light, Levitan FPS, etc.) Intubating LMA Gum elastic bougie, plastic reproduction

Standard blades (Macintosh, Miller) Non-standard blades (Phillips, Guedel, Wisconsin, Mac IV, reduced flange)

Blind orotracheal devices: Augustine Guide, Parker Intubating Guide

Retrograde kit Surgical devices

Comparisonarticle

Rescuing an Intubation

Or Simple Techniques to EnsureFirst Pass Success

A Practical Approach toAdvanced Airway Management

Master DL--positioning, progressive visualization,ELM, head elevated laryngoscopy position,

Embrace simple devices that fit with what youalready do--

gum elastic bougie, rescue straight blade, nasal

Rescue ventilation for rare cannotintubate/ventilate--LMA, Combitube

Surgical: cricothyrotomy (4 step), retrograde kit

37

44

45

12

External Laryngeal Manipulation (ELM)(aka bimanual laryngoscopy)

Is not the same as Sellick’s manuever

Is not the same as BURP

Back,up,right (pt’s right),pressure

It is bimanual laryngoscopy withmanipulation of the larynx

Probably the single mostuseful tool in your box

Head Elevation Laryngoscopy Position(HELP)

Rescue (paraglosal) StraightBlade Laryngoscopy

Special blades

46

47

48

13

In a recent review of more than 6000intubations

Almost all were accomplished with alaryngoscope

Rare need for blind nasal intubation orcricothyroidotomy

Only 7 intubations required use of a difficultairway device

Annals of Emergency Medicine. 36(4): Part 2, A196, 2000

Incidence of the Difficult Airways

1-18% in OR depending upon criteria

Failed laryngoscopy rate in OR: 5-35 in 10,000

Cannot intubate, cannot ventilate rate: 2 in10,000

Difficult mask ventilation 5%, inability to maskventilate 1/1500

In ED’s, DL successful 99-99+% overall & >90%of “difficult airways”

Incidence of the Difficult Airways:ED case series…

Nasal 0.2 - 1.3% RSI used > 80% cases In ED’s, 3 or more attempts: 3-5.3% Failed laryngoscopy < 1.0% Cric rates 0.5% - 1.2% Sackles JC. Ann Emerg Med, 1998;31:325-32 Calderon Y. Acad Emerg Med, 1995;2:411-2 Riggs RW. Acad Emerg Med, 1996;3:528 Vissers RJ. Acad Emerg Med, 1998;5:481

49

50

51

14

The bottom line: HUP as anexample

500 airways per year (half trauma) 25 attendings, 36 residents Failed laryngoscopy rate: <1%,

approximately 1 surgical per year 1 failed airway in 5 years per

attendingMost residents will neither see nor do

a surgical airway (cadaver only)

A Practical Approach toAdvanced Airway Management

Master Direct Laryngoscopy

Positioning

ELM

Head elevated laryngoscopy position

Progressive visualization

Recognition of the Posterior Elements

The epiglottis is at the top of the laryngealinlet, and the aryepiglottic folds comedown on each side and join to form theinterarytenoid notch

52

53

56

15

Cormack and LehanesClassification of Laryngeal Views

Grade Structures visible

1 Entire glottis, including anteriorand posterior commissure

2 Posterior glottis

3 Epiglottis only, (glottis notexposed)

4 Tongue & palate only seen

Only2-8% ofthe time

The 4 Ds of a difficult intubation

Disproportion:

Large tongue, small thyromental displacement space

Distortion:

tumor, edema, hematoma, goiter, fat, trauma, vomitus,hemorrhage, etc

Decreased mobility of joints:

limited atlanto-occipital extension, TMJ

Dentition:

buck teeth

“Impossible” Laryngoscopy Patients

Those with recent mandible fracture and awired jaw

Those with massive angioedema

Those with severe neck and jaw traumathat precludes conventional attempts atlaryngoscopy

Those with a deep space infection of thefloor of the mouth (Ludwig’s angina)

57

58

59

16

Look externally

Evaluate the 3-3-2 rule

Mallampati scale of visualization

Obstruction

Neck mobility

Difficult Airway

Prepare to bag

Optimize the airway

Airway positioning Sniffing

Head elevated laryngoscopy position (HELP)

ELM before BURP

Bougie in place prior to intubation

Bag the patient and think about an alternativeairway

Failed intubation algorithm

This is where the various styletscome into play

61

62

63

17

Difficulties and Solutions Grade 1 Failure is probably due to too large of a tube

Try again with a smaller tube

Grade 2 ELM-BURP can improve visualization by at least one grade

Try a smaller tube

Try a different blade

Grade 3 Consider different blade, and/or ELM

Bougie

Different airway LMA, intubating LMA, or Combitube

Grade 4 This sucks!

ELM, Try different blade, +/- on the LMA (reported to be no moredifficult in the grade 3 or 4 airway)

Rescuing an Intubation

Simple Techniques to Salvage aFailed Intubation

Rescue Alternatives For A FailedLaryngoscopy

Face mask – BVM ventilation

Cuffed oral pharyngeal airway--COPA Esophageal obturator airway – King LDT Esophageal-Tracheal Combitube LMA Laryngeal Mask Airway (Unique,

Classic, Fastrach, Intubating LMA)

Trans-tracheal jet ventilation

64

74

75

18

OTHER Airway TechniquesOTHER Airway Techniques Non-surgical Techniques

Combination tubes (Combitube)

LMA

Esophageal tubes (King Airway)

Fiberoptics

SurgicalTechniques

Cricothyroidotomy

Needle retrograde intubation

Surgical

RODS

R estricted mouth opening

O bstruction

D isrupted or distorted airway

S tiff lungs or cervical spine

BIADS

77

78

79

19

The Combitube

The Laryngeal Mask Airway

80

81

82

20

Blind nasal tracheal intubation

Endotrol tube with a BAAM whistle

RSI

Nasal Intubations

Video with Maggie

83

84

85

21

Rapid Sequence Intubation

AKA (?erroneously?)

Medication Assisted Intubation

Sometimes Facilitated Intubation

Typically done without a paralytic, sedation only

Different than the Anesthesiologists RSI

Rapid Sequence Induction

Universal Emergency Airway Algorithm

Agonal Arrest

Difficult Airway

RSI

Difficult AirwayAlgorithm

Crash AirwayAlgorithm

Failed AirwayAlgorithm

fails

fails

Yes

Yes

No

No

Video Laryngoscopy

Not Necessarily a Panacea

Visualization is enhanced

PASSING THE TUBE is a different matter

86

87

88

22

Rapid Sequence Intubation (RSI)Depolarizing Agent Non-Depolarizing Agent

Pre-oxygenate, IV, monitor, SpO2, check equipment

Lidocaine 1mg/kg IVAtropine 0.01mg/kg

(0.5 mg adults min adult dose, & 0.1mg min peds dose)

Midazolam 0.1 mg/kg (7mg in adult) or Fentanyl 1-3 ug/kg orEtomidate 0.3-0.5 mg/kg or Thiopental 4 mg/kg orMethohexital 1mg/kg or Ketamine 2-3 mg/kg

Defasiculating dose of Vecuronium 0.01mg/kg

(1 mg Adult dose)

Sellick maneuver

Succinylcholine 1.5 mg/kg adult

2.0 mg/kg < 10 y/o

Vecuronium 0.1-0.15mg/kg(10mg adult)(0.1mg/kg for kids)

Rocuronium 0.6-1.2 mg/kg

Intubation

Assess Tube Placement

Suggested inkids -only

+/-Doesn’t change

outcomes

RSI Notes

Use of BVM during pre-oxygenation increasesrisk of aspiration – Don’t Bag ‘em

Atropine for kids, +/- in adults

DO NOT USE SUCCINYLCHOLINE in patientswith risk of hyperkalemia

DON’T USE KETAMINE with risk of open globeinjury, or increased ICP

Barbiturates can cause hypotension and arevery caustic

Fentanyl can cause chest rigidity

Paralytics produce no sedation or analgesia

Desaturation

• Time to critical desaturation depends uponillness, body habitus, anemia

• Normal healthy adult– Give 100% O2 for 2-3 min

– Saturation 100%

– Stop breathing

– Takes 8-9 minutes to desaturate to 90%

• Pedi patient– Same circumstances

– Takes 2 minutes to desaturate to 90%

91

92

93

23

Preoxygenate

Replaces dead space with 100% O2

100% O2 for 3-4 min with spont breathing

15 LPM N/C plus

15 LPM NRB mask

3-4 deep Pos Press Ventilations with 100% O2

This extends the time foranoxic brain injury from 4minutes to 8-10 minutes

RSI--Timing principle

• Time to critical desaturation depends uponillness, body habitus, anemia Time torecovery from sux – 8-9 minutes– Preoxygenation! Is key

• Give paralytic agent before inductionagent -- limit apneic period– Most important with non-depolarizers, but also

helps with sux

94

95

96

24

Rapid Sequence Intubation

Indications

Decreased LOC

GCS < 8

Refractory hypoxia

Relative indications

Confused, combativepatient with GCS > 8,Who requires sedation

Contraindications Any condition, congenital

or acquired, which wouldmake endotrachealintubation impossible

Relative contraindication Any condition, congenital

or acquired, which wouldmake ETI difficult, orwould make ventilationdifficult in the event of amissed intubation

Procedure

The 7 P’s of RSI Preparation

Pre-oxygenate

Pretreatment or Pre-medicate

Paralysis with induction

Protection and Positioning

Placement with Proof

Post intubation management

RSI PNEUMONICSRSI PNEUMONICS

“PUT OXYGEN RIGHTDOWN INTO THE NOSE” PREPARATION

OXYGEN

REFLEX SYMPATHETICRESPONSE

DEFASCICULATION

INDUCTION AGENT

NEUROMUSCULARBLOCKING AGENT

“SOAP ME” SUCTION

OXYGEN

AIRWAY EQUIPMENT

PHARMACOLOGY

MONITORINGEQUIPMENT

97

98

99

25

Preoxygenate

Replaces dead space with 100% O2

100% O2 for 3-4 min with spont breathing

15LPM N/C plus….

15LPM NRB mask

3-4 deep Pos Press Ventilations with 100% O2

This extends the time foranoxic brain injury from 4minutes to 8-10 minutes

** Passive oxygenation during procedure **

Prepare

Prepare all equipment

Handle works

Assortment of blades

Assortment of tubes

Stylet

BVM and suction

Just in case you miss your intubation

Premedicate There can be an increase in ICP with manipulation

of the upper airway This can be blunted by:

Lidocaine 1.5 mg/kg IVP?? and

Fentanyl 2-5 ug/kg IVP

Children are very responsive to the vagogeniceffects of succinylcholine Atropine 0.02 mg/kg (minimum of 0.1 mg)

Adults with bradycardia or receiving a second doseof succinylcholine should get Atropine 0.3-0.5 mg IVP

Sedation Midazolam 0.1 mg/kg IVP, max. 5 mg

100

102

103

26

Induction Agents

Etomidate Sedative hypnotic

0.2-0.6 mg/kg IVP

Midazolam Sedative hypnotic

0.2-0.4 mg/kg

Amnestic, good for CHI

Thiopental (Pentothal) Barbiturate sedative

2-6 mg/kg

Lowers ICP

Profound resp. depression

Propofol Sedative hypnotic

Tricky to use

Hypotension is common

1-2.5 mg/kg

Ketamine Disassociative hypnotic anesthetic

1-2 mg/kg IVP

4 mg/kg IM

Good bronchodilator

Contraindicated in CHI

Propofol (Diprivan)

• Hypnotic - Anesthetic agent

• Nurses can use it (controversial)

• Nurses can hang and maintain the drip

• Induction – Adult and Peds

– 2 mg/kg IV

• Try not to bag…..

Etomidate

Pure sedativehypnotic

Dose

0.2 – 0.6 mg/kg

0.3 mg/kg reliable inkids

Duration

5-10 min.

Acts as abronchodilator

Can cause adrenalsuppression

Will affect WBCfunction

104

105

106

27

Ketamine

Dissociative AnestheticAgent

Dissociative Sedatingand Analgesic Agent

Dose

Induction 1-4.5 mg/kg(1-2 mg/kg typical)

IM induction 6.5-13mg/kg (2-4mg/kg IMis typical)

Duration 5-10 min IV, upto 30 min IM

Can act as a bronchioledilator

Can cause and increasein B/P, IOP, ICP

Emergence Reactions(12% incidence)

RSI Notes

The ideal muscle Relaxant

A rapid onset

To minimize the risk of aspiration & hypoxia

A rapid recovery

To facilitate the return of ventilation if intubationproves to be difficult

Minimal hemodynamic effects

Minimal systemic effects

Neuromuscular Blocking Agent

Succinylcholine Depolarizing agent

The only one on our list

Vecuronium (Norcuron)

Rapacuronium (Raplon) ?Recently pulled by FDA

2 mg/kg

Rocuronium (Zemuron) 0.6-1.2 mg/kg IV

1.0-1.8 mg/kg IM

Atracurium

0.3-0.6 mg/kg IV

Cisatracurium (Nimbex)

0.1-0.2 mg/kg IV

Mivacurium (Mivacron)

0.15-0.20 mg/kg IV

107

109

110

28

Succinylcholine

Depolarizing musclerelaxant Binds to postsynaptic

receptor sites causingmuscle depolarization

Dose: 1-2 mg/kg Kids should get the higher

end

Onset: (rapid) 45-60 sec.

Duration: (short) 5-14 min.

The rapid time frame isunique among all of theNMB agents

Unwanted effects:

Increases K+ 0.5 mEq/l

Increases myalgias 20 to the fasiculations

Allergic reactions

Requires refrigerated storage and is only goodfor 14-30 days at room temperature

Succinylcholine Side Effects

Fasciculations Can be overcome by

administering a decreaseddose of a non-depolarizingagent

Skeletal fractures

Vomiting

Extrusion of globe contentsin eye injuries

Elevation of intracranial,intragastric and

intraoccular pressures

Hyperkalemia Not usually of clinical concern

unless your patient has severaldays of

Burns, crush injuries, spinal cordinjuries, or extensive necroticsoft tissue infection

Bradycardia Unpredictable occurrence

> in peds than adults

Kids < 5 y/o give 0.02mg/kg ofatropine

Malignant Hyperthermia

Signs of Malignant Hyperthermia

Tachycardia (usually the first sign)

Hypercarbia (ETCO2)

Hypoxemia (SPO2)

Cardiac dysrhythmias

Hypertension

Skeletal muscle rigidity

Temperature elevation (usually a late sign)

111

112

113

29

Rocuronium

Good alternative toSuccinylcholine

Structurally similar toVecuronium

Dose:

1.2 mg/kg IVP

Onset is dose dependent

Intubating conditions in60 sec.

(45 sec. Forsuccinylcholine)

Paralysis maintained for60-90 min.

(6-8 min. forsuccinylcholine)

Rocuronium

The onset and durationof rocuronium are bothshorter in pediatricpatients than in adults 1.2 mg/kg in kids has an

onset of 30-35 sec., And aduration of about 40 min.

0.8 mg/kg had an onset of46 sec., And a duration ofabout 27 min.

Mild vagolytic

But HRs aren’t significant

Intraocular, gastric andcranial pressures are notsignificantly increased

Serum K+ don’t increase

Doesn’t cause ahistamine release

Like succinylcholine, it requires refrigerated storage and isgood for 60 days at room temperature

Vecuronium (Norcuron)

Defasiculating dose

0.01 mg/kg

Paralytic dose

0.1 mg/kg

RSI dose

0.1 mg/kg for kids

0.1-0.2 mg/kg foradults

Onset 75-180 secdepending on dose

Duration 20-60 min

No cardiovascular effects

Negligible histaminerelease

Requires reconstitution

114

115

116

30

Pass the Tube

Do not bag after giving the paralytic!

Sellick’s maneuver only!

Wait 45 sec. By the clock and thenperform your intubation

** Passive oxygenation during procedure **

Rapid Sequence Intubation (RSI)Depolarizing Agent Non-Depolarizing Agent

Pre-oxygenate, IV, monitor, SpO2, check equipment

Lidocaine 1mg/kg IVAtropine 0.01mg/kg

(0.5 mg adults min adult dose, & 0.1mg min peds dose)

Midazolam 0.1 mg/kg (7mg in adult) or Fentanyl 1-3 ug/kg orEtomidate 0.3-0.5 mg/kg or Thiopental 4 mg/kg orMethohexital 1mg/kg or Ketamine 2-3 mg/kg

Defasiculating dose of Vecuronium 0.01mg/kg

(1 mg Adult dose)

Sellick maneuver

Succinylcholine 1.5 mg/kg adult

2.0 mg/kg < 10 y/o

Vecuronium 0.1mg/kg (10mgadult)(0.1mg/kg for kids)

Rocuronium 0.6-1.2 mg/kg

Intubation

Assess Tube Placement

Suggested inkids -only

+/-Doesn’t change

outcomes

RSI Notes

Use of BVM during pre-oxygenation increasesrisk of aspiration – Don’t Bag ‘em

Atropine for kids, +/- in adults

DO NOT USE SUCCINYLCHOLINE in patientswith risk of hyperkalemia

DON’T USE KETAMINE with risk of open globeinjury, or increased ICP

Barbiturates can cause hypotension and arevery caustic

Fentanyl can cause chest rigidity

Paralytics produce no sedation or analgesia

117

118

119

31

Generic RSI

100% Oxygen

Etomidate 0.3 mg/kg

Succinylcholine 1.5 mg/kg

Asthma/COPD (70 kg adult)

100 % Oxygen

Lidocaine 70 mg

Ketamine 70 -140 mg

Succinylcholine 105 mg

Etomidate 21 mg

RSI when Succinylcholine isContraindicated (70 kg)

100%

Etomidate 21 mg

Rocuronium 84 mg

Or

Vecuronium 7 mg

120

122

123

32

Generic Peds RSI

100 % Oxygen

Atropine 0.02 mg/kg

Etomidate 0.3 mg/kg

Succinylcholine 2 mg/kg

Or Vecuronium 0.1 mg/kg

Rocuronium 1.2 mg/kg

RSI in Critical Neuro Pt’s (70 kg)(not in shock!)

As ICP increases, the brain fails to autoregulate

Block the Reflex Sympathetic Response

Lidocaine is often suggested, (esmolol is probablybetter given 3 min prior to intubation)

No touch intubation with first pass success Video laryngoscopy by the most skilled clinician

Head up positioning

Control B/P before RSI

Nicardipine

RSI in Critical Neuro Pt’s (70 kg)(not in shock!)

100% Hyperoxygenation (NRB + N/C)

High dose Fentanyl (5mcg/kg suggested)

Give slow or at 100mcg increments

Etomidate 21 mg or Propofol (140mg)

KetaFol

Rocuronium 84 mg

Better than, but

Vecuronium 7 mg

HOB elevated, neutralposition

Either areprobably better

thanSuccinylcholine inthe context of the

Critical NeuroPatient

124

125

126

33

The Post Intubated Critical NeuroPt.

Keep sedated and pain free

Drips like Fentanyl & Propofol

Keep normocapneic or low normal PaCO2

of 35-38 mmHg (Blood Gases)

EtCO2 useful if high, but not accurate if lowand doesn’t mean that the PaCO2 is low

Keep ICP < 20 and CPP > 55 or 60 mmHg

This is animportant

point

RSI for the Shock Patient (70 kg)(including TBI Pt’s)

100% Hyperoxygenation (NRB + N/C)

Fix hypotension with fluids or pressors

Low dose pretreatment and high doseparalytics

Ketamine 0.5 mg/kg

Succinylcholine 2mg/kg or

Rocuronium 1.6mg/kg, but 1.2mg/kg for us

+/- on Fentanylor Etomidate

EmcritPodcast

How About a Patient Who’sAlready Intubated?

Already intubated, but agitated andcombative

Patient has received NOTHING to this point

Anything other than Succinylcholine plussedation of choice

127

128

129

34

Case Study 1

25 y/o male involved in a single car MVAinto a pole. +LOC on scene, nowcombative with a GCS=7. No breathsounds on the right. Abdomen distended.Open femur fracture with active bleeding/

HR=125, BP=105/70, RR=6

Questions

What are the issues?

What drugs are you going to use?

130

131

132

35

Case Study #2

35 y/o female presented to the ED withsevere headache. CT scan shows a largesubarachnoid hemorrhage. The patient isnow very somnolent, responding only todeep painful stimuli. Blown pupil on left.Moves all four extremities.

HR=100, BP=190/100, RR=12

Questions

What are the issues?

What drugs do you wish to use?

Case Study #3

40 y/o male with a GSW to the neck. Thepatient is in obvious respiratory distress.Large hematoma to left of trachea isnoted. Active bleeding from the mouth.

HR=120, BP=155/80, RR=25

133

134

135

36

Questions

What are the issues?

What is your strategic plan?

Case Study #4

A 30 y/o female with acute asthmaexacerbation. Combative and cyanotic.Very poor air movement, and unable tospeak.

HR=120, BP=130/90, RR=30, SPO2=75%

Questions

What are the issues?

?Strategies?

Drug selection?

136

137

138

37

Remember!

Keep Him Sedatedand Feeling No Pain

• Morphine or Fentanyl (IVP or drip)

• Midazolam drip (IVP or drip)

Post Intubation Standards

Keep ‘em sedate

Keep ‘em paralyzed

Keep ‘em narcotized

Note depth of insertion

Note Vent settings All intubated patients go on the vent

Keep SpO2 > 94%

Keep EtCO2 35-40 mmHg

139

140

141

38

Cut the Neck

It takes time and cajones, particularly whendone by inexperienced personnel

When started on dead patients Cricothyrotomyhas essentially a zero survival rate

Cricothyrotomy is usually technically difficult witha difficult laryngoscopy

i.e . Laryngoscopy and cricothyrotomy will both bechallenging in the morbidly obese patient

Cut the Neck

It takes time and Cajones, particularly whendone by inexperienced personnel

When started on dead patients Cricothyrotomyhas essentially a zero survival rate

Cricothyrotomy is usually technically difficult witha difficult laryngoscopy

i.e . Laryngoscopy and cricothyrotomy will both bechallenging in the morbidly obese patient

142

143

144

39

SHORT

S urgery or other airway disruption

H ematoma (includes infection or abscess)

O besity

R adiation distortion

T umor

If you can’t Intubate by any means – ventilatewith a BVM

If this is not possible – ventilate with aLMA, or Combitube

If difficulty visualizing was a problem thenan intubating LMA should be utilized

If you can’t ventilate and O2 sats are dropping –then oxygenate with a cricothyroidotomy

And if you can’t oxygenate OR your needle willneed to be in place for longer than 15-30 min

Cut the throat

145

146

147

40

148

149

150

41

The Pertrach

151

152

153

42

154

155

156

43

Surgical Cric

157

158

159

44

Blood, secretions and vomit are common in theemergent airway prevent adequate visualizationthrough a fiberoptic

Fiberoptics are expensive, break easily, requiresterilization and take time to do

LMAs may be acceptable, but won’t protect thepatient from aspiration

Combination tracheal-esophageal or 3rd generationesophageal tubes may be the answer

160

161

162

45

• How about an “awake Cricothyroidotomy”?

Bougie Assisted Cric

The Top Ten Take Home Points

1. Operator directed external laryngeal manipulation - yourright hand

2. Recognition of posterior structures, interarytenoid notch 3. Gum elastic bougie 4. Head elevated laryngoscopy technique 5. Consider early use of a BIAD or supraglottic airway 6. Stainless steel Macintosh blade with fiberoptic light 7. Endotrol tube with BAAM whistle for nasal intubation 8. Lighted stylet 9. Paraglossal straight blade technique with progressive

visualization Rescue blade (Henderson > Phillips > Wisconsin > Miller)

10. Retrograde intubation kit

163

164

165

46

ANY QUESTIONS??

166