Emergency

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Emergency Airway Management ____________________
____________ Mark L. Freedman MD, FRCP
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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

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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?

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The 4 Questions

• Does this patient need intubation now?
• Is this a crash situation?
• Is this a difficult airway?
• 4. Can I use RSI?

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Outline

• Indications for intubation
• Basic airway algorithm
• Difficult airways
• Difficult airway algorithm
• Securing the difficult airway
• Cases

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Outline

• Indications for intubation
• Basic airway algorithm
• Difficult airways
• Difficult airway algorithm
• Securing the difficult airway
• Cases

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Indications for Intubation

• Failure of oxygenation
• Failure of ventilation
• Failure to protect
• Impending obstruction
• Expected management

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Failure of Oxygenation

• Low FiO2
• Failure of ventilation
• V/Q mismatch
• Diffusion abnormalities
• Anemia
• Low C.O.
• Increased tissue O2 consumption

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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

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Failure to Protect

• Low or dropping GCS
• GCS less than 8, intubate
• Aspiration risk

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Impending Obstruction

• Expanding hematoma
• Deep space infection
• Epiglotitis/Bacterial tracheitis
• Angioedema/Allergic reaction
• Inhalation injury
• Eschar
• Foreign body
• Tumour
• Others.

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Outline

• Indications for intubation
• Basic airway algorithm
• Difficult airways
• Difficult airway algorithm
• Securing the difficult airway
• Cases

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Basic airway algorithm
Yes
Fails
Crash Airway
Crashing ?
No
Yes
Fails
Difficult Airway ?
Difficult Airway
Failed Airway
No
Fails
RSI ?
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The 8 Ps of RSI

• 0 - 10min Preparation
• 0 - 5 min Preoxygenation
• 0 3 min Premedication
• 0 Pharmacological Induction
• 0 Pressure
• 0 Paralysis
• 0 45 sec Place tube
• 0 1 min Post Intubation Care

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Outline

• Indications for intubation
• Basic airway algorithm
• Difficult airways
• Difficult airway algorithm
• Securing the difficult airway
• Cases

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Difficult Airways

• Difficult mask ventilation
• Difficult laryngoscopy
• Difficult tracheal intubation
• Combinations of above

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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

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Difficult Airways

• Difficult mask ventilation
• Predicting the difficulty (BOOTS)
• Bearded
• Older (gt 55 years)
• Obese (BMI gt 26 kg/m2)
• Toothless
• Snores

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Difficult Airways

• Difficult laryngoscopy/intubation
• Predicting the difficulty (LEMON)
• Look
• Evaluate 3,3,2
• Mallampati score
• Obstruction
• Neck mobility

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Difficult Airways

• The airway assessment
• Look (BOOTS, others)
• Evaluate 3,3,2
• Mallampati score
• Obstruction
• Neck mobility

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Evaluate 332
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Mallampati score
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Neck Mobility
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Difficult Airways

• Specific situations
• Trauma
• Obesity
• Pregnancy
• Pediatrics

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Difficult Airways

• Not a catastrophe if you cant see well
• Not even if you cant intubate
• But, if you ALSO cant ventilate.

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Outline

• Indications for intubation
• Basic airway algorithm
• Difficult airways
• Difficult airway algorithm
• Securing the difficult airway
• Cases

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Difficult Airway
Anticipated
Unanticipated
Fail to Intubate
Cooperative Time
Uncooperative No time
Ventilation Sats Maintained
- Ventilation Sats Dropping
OR? Topicalize Sedate Awake Laryngoscope Glides
cope Lighted Stylet FOB
Help Sedate Topicalize Brutane Sedate
More RSIDouble set-up
Better Position BURP Better Blade Better
Drugs Bougie Better Person Glidescope Bronch BNTI
LMA
TTJV Cricothyrotomy
TTJV Cricothyrotomy
Suction if bleeding
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Outline

• Indications for intubation
• Basic airway algorithm
• Difficult airways
• Difficult airway algorithm
• Securing the difficult airway
• Cases

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Securing the Difficult Airway

• Anticipated
• Best to get patient to ED/OR
• BVM as bridge
• Otherwise intubation
• Dont burn bridges

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Securing the Difficult Airway

• Unanticipated
• Can you ventilate??
• Yes time
• No trouble

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Difficult Airway
Anticipated
Unanticipated
Fail to Intubate
Cooperative Time
Uncooperative No time
Ventilation Sats Maintained
- Ventilation Sats Dropping
Help Sedate Topicalize Brutane Sedate
More RSIDouble set-up
Transport Observe
Better Position BURP Better Blade Better
Drugs Bougie Better Person Glidescope Bronch BNTI
LMA
TTJV Cricothyrotomy
TTJV Cricothyrotomy
Suction if bleeding
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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

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Difficult Airway
Anticipated
Unanticipated
Fail to Intubate
Cooperative Time
Uncooperative No time
Ventilation Sats Maintained
- Ventilation Sats Dropping
Help Sedate Topicalize Brutane Sedate
More RSIDouble set-up
Transport Observe
Better Position BURP Better Blade Better
Drugs Bougie Better Person Glidescope Bronch BNTI
LMA
TTJV Cricothyrotomy
TTJV Cricothyrotomy
Suction if bleeding
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Outline

• Indications for intubation
• Basic airway algorithm
• Difficult airways
• Difficult airway algorithm
• Securing the difficult airway
• Cases

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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?

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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?

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Case 3

• 67 yr/o F
• Sudden collapse
• On ship in Southern Ocean (Antarctica)
• Decreased LOC, blown pupil, posturing
• GCS 6.5.4.
• 40 220/110 16 100 37.0
• How will you proceed?

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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?

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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?

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Case 6

• 30 y/o male
• Shotgun blast to face
• Bleeding and gross disruption of anatomy
• GCS 15
• VSS
• How will you proceed?

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The 4 Questions

• Does this patient need intubation now?
• Is this a crash situation?
• Is this a difficult airway?
• 4. Can I use RSI

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Difficult Airway
Anticipated
Unanticipated
Fail to Intubate
Cooperative Time
Uncooperative No time
Ventilation Sats Maintained
- Ventilation Sats Dropping
Help Sedate Topicalize Brutane Sedate
More RSIDouble set-up
Transport Observe
Better Position BURP Better Blade Better
Drugs Bougie Better Person Glidescope Bronch BNTI
LMA
TTJV Cricothyrotomy
TTJV Cricothyrotomy
Suction if bleeding
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Securing the Difficult Airway

• Anticipated
• Best to get patient to ED/OR
• BVM as bridge
• Otherwise intubation
• Dont burn bridges

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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

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• Questions?