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#1 Essential Emergency Airway Care - Airway Preparation

#1 Essential Emergency Airway Care - Airway Preparation. Andrew Brainard, MD, MPH, FACEM, FACEM www.thesharpend.org abrainard01@gmail.com. #1 P re-arrival preparation of Team, Plan, Room, and Equipment. Learning Objectives: Prepare TEAM Assign team leader (jacket, roles, plan)

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#1 Essential Emergency Airway Care - Airway Preparation

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  1. #1Essential Emergency Airway Care-Airway Preparation Andrew Brainard, MD, MPH, FACEM, FACEM www.thesharpend.org abrainard01@gmail.com

  2. #1 Pre-arrival preparation of Team, Plan,Room,and Equipment • Learning Objectives: • Prepare TEAM • Assign team leader(jacket, roles, plan) • Primary airway operator • Backup airway operator • Airway assistant • Drug provider • Basic Pre-Arrival PLAN • Possible A, B, C, and D • Likely Medications • Ensure team members understand and are skilled in their roles • Prepare ROOM • Move bed, Resus tower, and Airway cart • Prepare EQUIPMENT • Monitor • BVM, Adjuncts, Oxygen, Suction • Laryngoscopes, ETT, Bougie • Backups (SGA/Video/Cric) • Drugs • R40: 50y/o F found down and unresponsive at home. • No signs of trauma, OSA • GCS 5, RR 6, SaO2 88%, pulse 100, BP 100/60. • Team should prepare for critical patient • Team • Plan • Room • Equipment • Conduct a Detailed Tour of ED resus area • Wear Jacket • Bed (Move Bed, Apply Brakes, Head Elevation) • Resus Tower (BVM, Suction, Oxygen, SaO2, ET CO2) • Airway Cart (Top Through Bottom Drawer) • Medications (Cart, Intubation Box, Pyxis) • Airway Aids (Posters, Checklist) • Video laryngoscope • Ventilators, CPAP/BiLevel • Store Room • Trach, spare ETT, other supplies • Paed Dose Calculator on Computer

  3. Managing the Airway Team

  4. Medications Primary Airway Operator Airway Assistant • Team Leader • Primary Airway Operator • Backup Airway Operator • Airway Assistant • Manual In-line Stabilization • Drug Provider • Runner/Scribe/Other • Intensive Care Backup Airway Operator Drugs Team Leader Intensive Care

  5. Preparing the room and equipment • Locate your personnel • Resus Nurse(s) • ED SMO(s) • ED Reg(s) • Charge Nurse • ICU • Anesthetics • Prepare the Room • Move the bed • Move the airway cart • Move the resus tower • Prepare the Resus Tower • Prepare the Monitor • Prepare the Airway Cart • Drugs • Locate your backup stuff • Video-laryngoscope etc..

  6. Preparing the Resus Tower and Monitor Tower Suction Tested Under Pt’sR shoulder Oxygen Mask Nasal BVM BVM O2 on Reservoir bag PEEP Monitoring 1st monitor on SaO2 Not on BP arm ETCo2 Tested On BVM 2nd monitor on

  7. Preparing the Airway Cart • Cart Location • Pt’s right • Orientation (able to open drawer) • Top • Set up as needed • Side • Bougie, Tube Exchanger • 1st Drawer • Adjuncts: OPA, NPA, Suction, Mask • 2nd& 3rd Drawer • Primary: Laryngoscopes, ETCo2, 3rd Drawer • ETT, Tie • 4th Drawer • AirQ SGA (3 sizes) w/ stabilizer • 5th Drawer • I-LMA, I-LMA ETT, w/ stabilizer • Bottom drawer • Scalpel • Cric Pack • pen, scalpel, 6-0 cuffed ETT, disinfectant, gauze, lube, • Cook Melker Surgical + Percutaneous Cric Kit Suction Airway Cart Adjuncts Laryngoscope x2 ETT x2 Bougie/Stylet Lube/syringe/tie LMA/Cric

  8. Important Equipment Checks: Resus Tower/Gantry Resus Tower/Gantry Suction Oxygen Mask/BMV/Nasal Medications RSI meds Room Bed Position Height Locked Tower Position Height Videoscope Monitoring 1st monitor on SaO2 Not on BP arm ETCo2 Tested On BVM 2nd monitor on Monitor SaO2 ETCo2 BP/ECG Ventilator Oxygen Power Suction Airway Cart Adjuncts Laryngoscope x2 ETT x2 Bougie/Stylet Lube/syringe/tie LMA/Cric Tower/Gantry Suction Tested Under R shoulder Oxygen Mask BVM Nasal BVM O2 Reservoir bag PEEP Cart Top Adjuncts (OPA/NPA) Laryngoscope Lights tested 2 sizes ETT Lubed Stylet shaped Smaller size ready Syringe/tie Drawers LMA/AirQ sized Cric kit located Videoscope ETT Stylet On Circulation IV Fluids A-lines 2nd Monitor

  9. Medications Prep RSI meds Prep IV fluid Prep maintenance meds *Primary Airway Operator* Assure oxygenation Formal airway assessment Vocalize plan A, B, C, D Primary airway procedure *Airway Assistant* Prep airway table Suction, Adjuncts, Laryngoscopy, ETT, Bougie, LMA, Cric Kit, Place nasal O2 External laryngeal manipulation Handles tube/bougie Assists with securing tube *Backup Airway Operator* Examine patient Position patient External laryngeal manipulation Backup airway procedures Perform cricothyroidotomy Monitoring Prep Room Monitoring SaO2, ETCo2, BP, ECG *Drugs* IV/IO x2 Administer RSI meds Team Leader Prepare room/staff Leads resuscitation Intensive Care Continuity of Care Transport

  10. Indications for advanced airway management • Goals of Care • Non-futile treatment • Able to complete continuity of care • Unprotected airway • Obtunded, GCS <8, Cardiac arrest, Trauma • Oxygenation or ventilation • Not appropriate for BVM/CPAP/BiLevel • Clinical course • Agitated patient needing sedation for patient and staff safety • Expected future airway difficulty • trauma, burns, infection, angioedema • Need for pain control in patients during future procedures • Theatre, CT, etc. • Expected multi-organ failure or severe sepsis

  11. Different urgency of airway control • Crash- • Extreme time pressure • Forced-to-act • Difficulty oxygenating and ventilating • Emergent- • Substantial time pressure • Can be oxygenated • Allows for some preplanning and preparation • Semi-Elective- • Minimal time pressure on stable patient • Full assessment and planning time

  12. Airway Assessment • RODS(SGA/LMA) • R: restricted mouth • O: obstruction • D: disrupted or distorted • S: stiff lungs or c-spine • MOANS(Mask) • M: mask seal • O: obstruction / obesity • A: age (>55) • N: no teeth • S: stiff lungs or c-spine • SHORT(Surgical Airway) • S: surgery • H: haematoma • O: obesity • R: radiation • T: tumor • LEMON(Intubation) • L: look • E: evaluate 3-3-2 • M: mallampati • O: obstruction / obesity • N: neck

  13. Primary Airway Operator Airway Assistant Primary Airway Operator Airway Assistant Team Leader Team Leader Drugs Drugs *Confirm that people understand their roles* • Airway Assistant • External Laryngeal Manipulation • Bougie/tube procedure • Equipment names & sizes • Drugs • Access • Drugs • Dose • Drugs • Access • Drugs • Dose • Airway Assistant • External Laryngeal Manipulation • Bougie/tube procedure • Equipment names & sizes • Backup • Backup Criteria • Cric plan • Backup • Backup Criteria • Cric plan • Primary • Formal Airway Assessment** • Plan A, B, C, D • Pullout Criteria • Primary • Formal Airway Assessment** • Plan A, B, C, D • Pullout Criteria

  14. The Pre-arrival briefing Direct laryngoscopy bougie+7.5 tube • We have a 40 y/o female who has taken a large poly-overdose with a decreased level of responsiveness. She is reported to have vomited several times and is ventilating poorly. • If we think airway management is indicated and our formal airway assessment indicates it is appropriate to proceed, our plan will be to intubate her. • The team will be: • Me as team leader • Fred as primary airway operator • Linda as backup airway operator • Viola as airway assistant • I will also push the drugs • Assuming no contraindications, we will RSI with Thio and Sux, with dose to be determined. • Our plan will be: A- Direct laryngoscopy with bougie+7.5 tube B- Video laryngoscopy with stylet+7.5 tube C- AirQ size #3.5 D- Cric for Sats <80% and dropping • We will use all our “best practice” techniques. • Everyone understand their roles? • Questions or suggestions? • Let’s make sure everything is ready for this patient’s arrival. Video laryngoscopy stylet+7.5 tube AirQ 3.5 *Confirm that people understand their roles* • Primary • Formal Airway Assessment** • Plan A, B, C, D • Pullout Criteria • Backup • Backup Criteria • Cric plan • Airway Assistant • External Laryngeal Manipulation • Bougie/tube procedure • Equipment names & sizes • Drugs • Access • Drugs • Dose

  15. Tips for managing the team • Knowledge • Experience • Respect • Seniority • Mannerisms • Age • Gender • Introduce yourself • Ask for everyone’s name • Assign roles • Preplan • Practice • Volume

  16. Brief Preparation References: • George Kovacs and J. Adam Law: Airway Management in Emergencies, 2nd Ed, 2011 • Walls RMand Murphy MF. Manual of Emergency Airway Management, 4th Ed, 2012 • Chris Nickson: Own the Airway- Life in the Fast Lane (http://lifeinthefastlane.com/own-the-airway/) (accessed on 15/6/2014) • Reuben Strayer. Free Emergency Medicine Talks: Contemporary Strategies in Airway Management http://freeemergencytalks.net/wp-content/uploads/2012/07/2012-06-29-D3T3-1430-Contemporary-Strategies-in-Airway-Management.mp3 (Accessed on 1/06/13) • Tim Leeuwenburg. SMACCGold: Checklists in Airway Management (http://vimeo.com/89997364) (18min) (accessed on 15/6/2014) • The Difficult Airway Society Guidelines (http://www.das.uk.com/guidelines/guidelineshome.html) (accessed on 15/6/2014) • Nicholas Chrimes & Peter Fritz- The Vortex Approach http://www.vortexapproach.com/Vortex_Approach/Vortex.html(accessed on 15/6/2014) • Javier Benitez, Academic life in emergency medicine. Mnemonics for difficult airway predictors- http://academiclifeinem.com/mnemonics-for-difficult-airway-predictors/ (accessed on 15/6/2014)

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