Emergency Airway Management ________________________________ Mark L. Freedman MD, FRCP

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 • Does this patient need intubation now? • Is this a crash situation? • 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 Yes Fails Crashing ? Crash Airway No Yes Fails Difficult Airway ? Difficult Airway Failed Airway No Fails RSI ?

14. The 8 “P”s 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

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/m2) • 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 Fail to Intubate Cooperative Time Uncooperative No time + Ventilation Sats Maintained - Ventilation Sats Dropping OR? Topicalize Sedate Awake; Laryngoscope Glidescope Lighted Stylet FOB Help Sedate Topicalize “Brutane” Sedate More RSI+Double set-up Better Position BURP Better Blade Better Drugs Bougie Better Person Glidescope Bronch BNTI LMA TTJV Cricothyrotomy TTJV Cricothyrotomy * Suction if bleeding *

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 Fail to Intubate Cooperative Time Uncooperative No time + Ventilation Sats Maintained - Ventilation Sats Dropping Help Sedate Topicalize “Brutane” Sedate More RSI+Double 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 *

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

50. Difficult Airway Anticipated Unanticipated Fail to Intubate Cooperative Time Uncooperative No time + Ventilation Sats Maintained - Ventilation Sats Dropping Help Sedate Topicalize “Brutane” Sedate More RSI+Double 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 *