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Advanced Emergency Airway Management

Advanced Emergency Airway Management. Core Rounds July 22, 2004 Rob Hall MD, PGY5 FRCPC Emergency Medicine Arun Abbi MD, FRCPC. Outline. Some basics and motherhood statements An approach to emergency airway management Minimal literature review Procedures are not the focus Case examples

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Advanced Emergency Airway Management

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  1. Advanced Emergency Airway Management Core Rounds July 22, 2004 Rob Hall MD, PGY5 FRCPC Emergency Medicine Arun Abbi MD, FRCPC

  2. Outline • Some basics and motherhood statements • An approach to emergency airway management • Minimal literature review • Procedures are not the focus • Case examples • Approach • Focus on difficult airways • Selected Controversies • Pediatric airway mx

  3. picture Case MVC vs Trailer, two reds, one needs intubation How do you prepare?

  4. Intubation = flight:preflight, flight, post-flight Pilot picture

  5. APPROACH TO THE AIRWAY

  6. Part of being prepared is knowing your equipment

  7. Know your equipment

  8. Pre-oxgenation is an important step in preparation for intubation • Desat curve

  9. APPROACH TO THE AIRWAY

  10. Cases • 2yo drowning, PEA arrest • What type of airway? • Any drugs? • 77yo female, MVC, as you are assessing, GCS drops, BP 60 palp, HR 40, teeth a bit clenched • What type of airway? • Any drugs?

  11. THE CRASH AIRWAY

  12. Case: Motorbike vs Car • 45yo male, Motorbike vs car • Hemodynamically stable: BP 175/50, HR 70, face ok • GCS 6 (E1V1M4) • Bilateral decorticate posturing • Anatomy looks normal • What type of airway? • What drugs would you use?

  13. THE “EASY” AIRWAY

  14. Pretreatment Lidocaine Fentanyl ? Defasiculator Induction Etomodate or Pentothal Paralytic Succ How does lidocaine work? What is the evidence for lidocaine? When should we use lidocaine? Why use fentanyl here? Is there any role for defasiculation? Case: Motorbike vs Car

  15. Lidocaine Pretreatment Blocks the direct reflex which increases ICP • How does it work? • Laryngoscopy ------------ increased ICP via direct reflex from laryngoscopy stimulation • Laryngoscopy ------------- sympathetic release which increases MAP and ICP • May also decrease brain’s oxygen utilization “Local” anesthetic Effect which decreases The response to laryngoscopy

  16. Lidocaine Pretreatment • How does it work? • Laryngoscopy ------------ stimulation of “airway reflexes” which increases bronchoconstriction +/- secretions “Local” anesthetic effect which decreases the airway response to laryngoscopy

  17. Lidocaine pretreatment: what is the evidence? • Evidence for “tight heads” • Vallancourt C. CJEM. Mar 2002. 4(2). • Systematic review of lidocaine and ICP • 348 studies, 25 RCTs included • Only one paper regarding intubation • 3 papers regarding tracheal suctioning • 24 papers looking at MAP changes with lidocaine

  18. Lidocaine Pretreatment • Vallancourt C. CJEM. Mar 2002. 4(2) • Bedford 1980 looked at intubations • N=20, elective brain tumor surgery • Lidocaine 1.5 mg/kg decreased ICP rise with intubation by 12 mmHg vs placebo • 3 Suctioning papers: decr ICP by 5 mmHg • 24 MAP papers: decrease MAP by average of 7 mmHg with lidocaine 1-3 mg/kg

  19. Lidocaine Pretreatment • Summary • CPP = MAP – ICP • Lidocaine decrease MAP and ICP • What happens to CPP is unknown • Neurologic outcomes not studied • Take home points • We really don’t know if lidocaine is effective • Most people currently are using lidocaine for head injuries and some are using in asthma/copd • Don’t waste time with lidocaine if the patient needs rapid airway control

  20. Case: Motorbike vs car; head trauma, normotensive • Why fentanyl pretreatment? • Is there any role for defasciculation? • What is the induction agent of choice for hypotensive, head injured patients?

  21. Fentanyl Pretreatment • When is it indicated? • Elevated ICP • Anyone where you don’t want and increase in HR and BP (cerebral aneurysm or AVM, aortic dissection, active ischemic heart dz, penetrating vascular injury) • What is the evidence? • Many studies documenting the blunting of sympathetic response to laryngoscopy and intubation but no outcome studies

  22. Pretreatment: defasiculation • What? 1/10 the intubation dose of rocuronium, vecuronium, pancuronium • Why? • Prevents fasciculations from increasing your ICP and intraocular pressure • Is this necessary? • Debatable: no evidence for • Reasons why NOT to do this • Adds another step, another drug • May cause apnea, paralysis at wrong time

  23. Pretreatment Medications Summary

  24. Induction agents in hypotensive + head injured • Midazolam: NO • Propofol: NO • Ketamine • Debatable: likely will increase MAP and ICP • Most think ketamine is contraindicated with high ICP (limited evidence) • Pentothal: generally NO, could use at ½ the dose (1-2 mg/kg vs 3-5 mg/kg) • Etomodate • Drug of choice • Decrease the dose from 0.3 to 0.15 mg/kg

  25. 40 yo female Known Addison’s Abdo pain + hypovolemic + septic + ARDS BP 85/50, HR 130 Anatomy easy What type of airway? What drugs? ? Etomidate for induction You give etomidate and she has a seizure, why? Case: Addy is sick

  26. Etomidate: will become the drug of choice for RSI! • Hemodynamically stable • Average decrease in SBP is 10% • Average decrease in SBP is 20% if already hypotensive • CAN DROP YOUR BP!!: decrease dose from 0.3 mg/kg to 0.15 mg/kg if concerned re hypotension • Decreases ICP • Very rapid onset (20-30sec): some give after succ

  27. Etomidate • Side-effects • N/V at emergence in 30% • Adrenal suppression: decreases serum cortisol, only reported with ICU infusions, never reported after single ED dose • Myoclonus • ? Brain stem disinhibition • Commonly mistaken for seizure • 30% incidence quoted (? Reporting bias) • Treat with benzo if prolonged/severe

  28. Etomidate • Contraindications • P Pregnant • P Pediatrics < 10 yo • P Prior seizures • P Poor adrenal function

  29. 30yo female Facial smash Suspect globe rupture Is succinylcholine contraindicated? On the exam, maybe! In real life, NO! IOP increases 5-10 mmHg with succ IOP increases 10-15 mmHg with blinking Think what rough intubation will do! Airway control more important What to do? Defasiculation can prevent increase in IOP with succ Rocuronium is an option Case: globe rupture

  30. Absolute Airway skills lacking Allergy Burn > 48hrs Crush > 48hrs CNS dz > 48hrs CRF with hyperkalemia Malignant hyperthermia Myopathies Relative Pseudocholinesterase deficiency Organophosphate toxic Foreign body in airway Cardiac tamponade Globe rupture (debatable) Abdo sepsis > 1 week Contraindications to Succ

  31. Succ and hyperkalemia • Study of normal patients • 46% with K+ increase • 46% with K+ decrease • 8% with no change • Max change was 1 mEq/L • Myopathies are the worst! • Don’t forget about rhabdomyolysis • If in doubt, use rocuronium • Arrest after succ, think hyperkalemia

  32. 75yo female CVA 3 months ago Dysphagic Aspiration, resp failure, BP 150/70 Anatomy easy Easy airway approach Can’t use succinylcholine What is the timing principle? Case: Aspirator

  33. Timing Principle • If you are using rocuronium as the paralytic, it has a longer time to action (1-2 min) than the induction agent • Give rocuronium • Wait 30 – 45 seconds • Give etomidate • Wait 30 seconds • Intubate

  34. Case: I hate myself. • 25yo female • Benzo, Etoh overdose • GCS 8, BP 120/70, anatomy easy • Type of airway? • Do you need to add an induction agent to your RSI?

  35. Is an induction agent necessary if you are paralyzing a patient? • Controversial, no absolute right/wrong • Advantages of adding full induction • Improved patient comfort and decreased recall • Blunts rise in ICP, HR, BP, airway resistance • Decreases time to ideal intubation conditions • Peak effect of succ doesn’t occur until 3 min (despite onset at 45 sec) when given alone • You don’t want the pt to be apneic for 3 minutes and you don’t want to bag in between unless you have to • Several studies documenting that IDEAL INTUBATION CONDITIONS are present 45-60 seconds after induction agent + succinylcholine

  36. 80yo female Resp failure from pneumonia, Pmhx hypertension and seizures HR 110, BP 110/30, easy anatomy What type of airway? What drugs? After intubation her BP is 80/40, HR 110 What is the ddx? Why hypotensive? What is the treatment? Case: Pneumonia, oops!

  37. Post-intubation Hypotension • Tension pneumo, Myocardial ischemia, Acidosis, high intrathoracic pressures are all on the differential dx • Volume depletion • Common in anyone with respiratory or critical illness that necessitates intubation • Sympathetic tone • Anyone that is critically ill has a maximal sympathetic output; deep induction takes away the stimulus ----------- end result is that they drop their pressure • Treat with fluids, pressors (be prepared!)

  38. 3 yo male Fall off deck, head to pavement GCS 5 Bagged by EMS RSI by you After intubation, patient desaturates and is difficult to bag. AE equal. Why? Differential? Management? Case: head to pavement

  39. Post intubation Hypoxia • D Dislodged tube (must r/o) • O Obstructed tube • P Pneumothorax • E Equipment failure (wall to pt) • G Gastric distension more common in kid, ++ gastric distension leads to compression of the lungs

  40. Case: I can’t breath • 16yo female • Hx asthma • Sudden SOB, wheezing, distress • RR30, tired, sats 93%, BP 140, anatomy easy • Type of airway? • Drugs?

  41. Intubation of the Asthmatic • Pretreatment • Lidocaine 1.5 mg/kg decreases bronchospastic response to laryngoscopy • Atropine 0.5 mg adult, 0.02 mg/kg peds to decrease airway secretions • Induction • Ketamine likely induction agent of choice • Pretreat with atropine to decrease secretions • Paralysis • Succinylcholine

  42. Post Intubation Management of the Asthmatic LOW AND SLOW!!!! RR 8-10 bpm, TV 6-8 ml/kg, Fi02 100%, PEEP ????, Inspiratory flow rate 100 L/min (usually 60 L/min) Watch peak inspiratory and plateau pressures

  43. I’m dead-sexy! SOB NYD Resp failure What type of airway? What drugs? What position? What back ups? Case: Fast Food Nation

  44. DIFFICULT AIRWAY ALGORITHM Call for help, Difficult airway cart

  45. Picture 1 Picture 2 Positioning of the Morbidly obese

  46. Intubation of the Morbidly Obese • Be READY for a difficult airway • Starting with RSI is DANGEROUS! • Triple set up probably the best • Lidocaine neb, lidocaine spray, have RSI drugs ready, have all your back ups ready, do laryngoscopy, place the tube if you can • Why else is this a SCARY patient?

  47. Predictors of difficult BVM • B Beards • O Obesity, OSA • N Neck trauma, NO teeth • E Expectant (pregnant) • S Snores Be cautious with your RSI as your back-up of BVM may not be available!

  48. DIFFICULT INTUBATION + DIFFICULT BAG-VALVE-MASK VENTILATION • Facial trauma • Neck trauma • Massive obesity • Congenital or acquired airway anatomy anomalies adam Adam Wear your “Depends”

  49. Difficult Emergency Airway Managment • NEAR data (National Emergency Airway Registry) • Registry of 10,000 ED intubations • 97% of ED intubations are done by EP.s • RSI used in 85% of non-arrested pts • BNTI used in 5% of all intubations • 1-3% are difficult laryngoscopies • Oral ETT after RSI successful in 99.6%

  50. Back to the Fast Food Nation… You do your “awake” laryngoscopy and all you can see is a hint of the epiglottis, what do you do??????

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