1. So you want to Dominate the Difficult Airway? By Kane Guthrie Clinical Nurse SCGH ED

2. Objectives Introduction to the difficult airway for the ED nurse. Guide to assessing, managing and assisting with the difficult airway! The algorithm and its purpose! Look at what's in the difficult airway trolley! Understanding of different airway devices!

3. “Loss of the airway, with resultant failure of ventilation and oxygenation, is the terminal pathway for many patients”

4. Indication’s for intubation Based on 3 fundamental clinical Ax: 1.Is there a failure of airway maintenance or protection? 2.Is there a failure of ventilation or oxygenation? 3.What is the anticipated clinical course?

5. The Difficult Airway & the ED Nurse Is one of the most challenging encounters the emergency nurse can be tasked with! It’s a team sport! Knowing your equipment and it’s uses is paramount! Human factors can be an issue!

6. The Difficult Airway in the ED It’s not a one-size-fits all procedure! Incidence of DA in ED 3-5.3%. Pt’s not optimised medically. Generally not fasted. We don’t have the opportunity to: 1.Cancel case 2.Awaken patient

7. The Audit Poor ID of @ risk Pt’s. Poor/incomplete planning. Inadequate provision skilled staff/equipment. Delayed recognition of events. Lack or failure of interpreting ETco2. Failing to plan for failure!

8. Causes of the Difficult Airway!

10. The ED nurses role! Anticipates the difficult airway! Provides assistance & support! Has equipment/drugs ready! Has experience to offer!

11. The Game Plan Team Timeout: – Look at is: Pre-oxygenation optimal? Patient position optimal? Patients haemodynamic’s optimal? Does it look like a difficult airway? The approach is……..

12. The Algorithm

13. Being Prepared SOAPME: Suction Oxygen Airway Pharmacology/personnel Monitoring Equipment

14. Assessing for the DA! LEMON Look externallyFacial trauma, large incisors, beard –moustache, large tongue. Evaluate the 3-3-2 ruleIncisor distance <3 fingerbreadths, hyoid/mental distance <3 fingerbreadths, thyroid-to-mouth distance <2 fingerbreadths. Mallampati classificationScore above 3. ObstructionEvidence of any condition that could cause obstruction. Neck mobilityLimited neck mobility!

15. Assessing for the DA!

16. The Trolley

17. What’s in the Trolley? Top Shelf Cricothroidotomy Kit Cricothyroidostomy kit The Side Jet Ventilator + connector Bougie Draw 1 LMA Nasopharyngeal airways Draw 2 Pentax Video-laryngoscope Draw 3 Alternative laryngoscope blades ETT Balloon cuff tester Draw 4 Tracheostomy Tubes Draw 5 Intubating LMA

18. Pre-oxygenation Provides oxygen reservoir within lungs, blood and body tissues. Allows for several minutes of apnea without desaturation. Nitrogen washout. Use NRB, BVM or NIV for 3-5 mins.

19. Time to Desat!

20. Apneic Oxygenation New Concept! Involves maintaining patent upper airway passage & oxygenation during apneic period. Use jaw thrust & adjuncts with Nasal prongs @ 15l 02.

21. The Humble ETT Direct laryngoscopy – most popular technique! Gold standard – definitive airway! Secures ETT into trachea for optimal oxygenation & ventilation.

22. The LMA Supraglottic airway. Ventilates by delivery oxygen above the level of vocal cords. Designed for the DA. Simple, easy, effective! Excellent back up device!

23. Other Supra-glottic devices

24. Bougie ETT Introducer. Used when difficulty seeing vocal cords. Facilitates blind insertion. Always have one @ the bedside!!

25. Pentax Aids in visulisation of airway & anatomical abnormalities. Provides less trauma to airway & C-spine. Utility difficult in the soiled airway!

26. Is it time for Surgery?

27. Jet Ventilation Indicate in CV-CI scenario. High failure rate in adults. Provides little airway protection and gas exchange. Buy’s time!

28. Cricothroidotomy! “Is the establishment of a surgical opening in the airway through the cricothyroid membrane and placement of a cuffed tracheostomy or ETT.”

29. Take Home Points It’s a team sport! Experience counts in the DA! Learn and know the equipment! Avoid failing to plan for failure!

30. Remember “It’s not about plastic in the trachea, it’s about oxygen in the lungs” Richard Levitan

31. References Nemeyh, J. et.al. (2012). Emergency Airway Management: the difficult airway. Emergency Medicine Clinics North America. 30, 401-420.