3 Wang et al. Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation. Annals . 54; 5, P e1, Nov. 2009“Intubation frequently is associated with interruption of compressions for many seconds. Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions.”-2010 AHA Guidelines
8 Burton et al. Endotracheal Intubation in a Rural EMS State: Procedure Utilization and Impact of Skills Maintenance Guidelines. Prehosp. Emer. Care5 year review ( )957,836 total encountersAnnual mean of 1,352 ETI eligible providers556 providers (41%) attempted at least 1 ETI each year.Mean of 27 providers (2%) annually attempted pediatric ETI.
15 Plan for TodayScenariosCritical decision makingDiscuss optionsReview key elements of those options
16 Disclaimers Pushing scope of practice Sometimes there is no absolute right answerNo financial compensation related to devicesNot endorsing any specific devices
17 “Kenny”31 yo maleAsthma580 lbs (263 kg)Altered MSPeriods of apneaHypoxia/Hypercapnea
18 First responders state they have been unsuccessful with PPV
19 Decision Making Respiratory failure? What does he need? Does he need an advanced airway?How to proceed?
20 Options Continue with basic airway/breathing? CPAP? RSI? Intubation without RSI?
21 Decision Making Basic Airway BIAD ETI Simple Low risk May solve problemBariatric challengeGeneral challengeShort termHasn’t workedSimpleLow riskMay solve problemBariatric challengeGeneral challengeShort termProtectiveHigher pressureLong termBariatric challengeGeneral challenge
22 Langeron, O., Masso, E. et al. Prediction of Difficult Mask Ventilation. Anesthesiology. 2000; 92:1229–36
23 Kheterpal, S, Han, R. Incidence and Predictors of Difficult and Impossible Mask Ventilation. Anesthesiology 2006; 105:885–91
24 A combination of poor chest wall compliance, decreased diaphragmatic excursion, increased upper airway resistance, and redundant supraglottic tissues makes mask ventilation more difﬁcult in obese patients.
25 Soft tissue of face and mandible can make traditional methods of face mask seal challenging
26 Joffe, A, Hetzel, S. A Two-handed Jaw-thrust Technique Is Superior to the One-handed “EC-clamp” Technique for Mask Ventilation in the Apneic Unconscious Person. Anesthesiology 2010; 113:873–9
27 Dr R. Levitan . http://www.airwaycam.com/rescue-ventilation.html
29 H.E.L.P.Traditional methods of airway manipulation can be ineffective due to excess soft tissueHigher pharyngeal critical closing pressureExacerbated in supine positionthe applied pressure below which airflow ceases or the airway occludesGold, A. Schwartz, A. The Pharyngeal Critical Pressure The Whys and Hows of Using Nasal Continuous Positive Airway Pressure Diagnostically. Chest 1996; 110:
30 Flexion and ExtensionLevitan, R. et al. Head-Elevated Laryngoscopy Position: Improving Laryngeal Exposure During Laryngoscopy by Increasing Head Elevation ANNALS. 41:3 MARCH 2003
31 Sniffing Position Flexion of cervical spine Extension of atlanto-occipital joint
32 Collins JS, Lemmens HJ, Brodsky JB Collins JS, Lemmens HJ, Brodsky JB. Obesity and difﬁcult intubation: where is the evidence? Anesthesiology. 2006;104: 617.The “snifﬁng” position, which involves 8 to 10 cm of head elevation, results in suboptimal positioning for laryngoscopy in an obese patient, and this may also confound results and falsely worsen graded views.
40 RAMP also improves preoxygenation times in bariatric patients Altermatt, F, Munoz, H. Pre-oxygenation in the obese patient: effects of position on tolerance to apnoea. British Journal of Anaesthesia 95 (5): 706–9 (2005)Levitan, R. et al. Head-Elevated Laryngoscopy Position: Improving Laryngeal Exposure During Laryngoscopy by Increasing Head Elevation ANNALS. 41:3 MARCH 2003
41 Supine position exacerbates breathing challenges
42 Obese abdomens prevent normal diaphragmatic excursion Increased pressure required to ventilateDecreased FRCEsophageal sphincter opens at cm H2O Once opened, lower pressures will cause continued insufflationLawes EG, Campbell I, et al. INFLATION PRESSURE, GAST. INSUFFLATION AND RSI. Br. J. Anaesth. (1987) 59 (3):
44 “We conclude that obesity alone is not predictive of tracheal intubation difficulties.” Larger neck circumference was associated with a higher Mallampati score (P ) and Grade 3 views during laryngoscopy (P )Anesth Analg 2002;94:732–6
45 Jense HG, Dubin SA, Silverstein PI, et al Jense HG, Dubin SA, Silverstein PI, et al. Effect of obesity on safe duration of apnea in anesthetized humans. Anesth Analg. 1991;72:89-93Obese patients may undergo oxygen desaturation to 90% within 3 minutes compared with 6 minutes in normal-weight patients
46 Pre-Intubation:Pre-oxygenate sitting up if possible.CPAP
47 Aligning axis of vision may be more challenging due to excess soft tissue Obesity can also make “lifting up” on the laryngoscope handle harder, as there is more weight to lift.
56 Decision Making Basic Airway ETI Simple Low risk May not require protectionRapid changes thus farCould go from bad to really badProtection vs. edemaLong termEdema may be thereCan exacerbate short term problemCan exacerbate long term problem
57 Liquid Scald Burns 24% of all burns 2nd highest mortality among causes of burnsHighest percentage <2 yrsIncreases mortality rate among burns by 20%50% if >20% TSAUS CDC 2010 statisticsHuffer, C. The Role of Bronchoscopy in Acute Burns. Indiana University Pulmonary and Critical Care Fellowship Fellows’ Case Archive Case #2
58 Protective keratin layer of skin not present in orotracheal pathway Steam vs. Copper (both heated to 100°C)Transfer heat to body tissueDecreases by 60°C,,Copper transfers only 230 W xsecWater gives up 2530 W xsecProtective keratin layer of skin not present in orotracheal pathway
59 Inhalation Injury Commonly limited to the upper airway Animal experiments have shown that if air at 142°C is inhaled it has cooled to 38°C by the time it reaches carinaSteam, frequently injures lower airwayHathaway, P, Stern, E. Steam Inhalation Causing Delayed Airway Occlusion. AJR 1996;166:322
60 Mlcak, R, Suman O, et al. Respiratory Management of Inhalation Injury Mlcak, R, Suman O, et al. Respiratory Management of Inhalation Injury. Burns. 33(2007) 2-13Acute upper airway obstruction occurs in approximately one-ﬁfth to one-third of hospitalized burn victims with inhalation injury
61 Most common 12-24 hour post insult Can occur w/in 30 minutes
76 Decision Making Do nothing Basic Airway ETI Simple Low risk Pharm might workNot good nowLikely getting worseSimpleLow riskMay buy timeNo protectionLikely doesn’t solve the ongoing problemProtectiveClinical courseLong termEdema may be thereCan exacerbate short term problemCan exacerbate long term problem
78 Epidemiologyestimated 252,338 persons <14 years treated with non-fatal coin-related aspiration/ingestiondeaths each year80% of deaths are pediatricCoins are most common non-food foreign bodyChena, X, Milkovich, S. Pediatric coin ingestion and aspiration. Int J of Ped Otorhinolaryngology (2006) 70, 325—329
79 Chena, X, Milkovich, S. Pediatric coin ingestion and aspiration Chena, X, Milkovich, S. Pediatric coin ingestion and aspiration. Int J of Ped Otorhinolaryngology (2006) 70, 325—329
80 Signs and Symptoms >40% have no symptoms Classic presentation (present in roughly 40%StridorWheezingCoughingDyspneaJim Holliman. Aspirated and Ingested Foreign Bodies. Uniformed Services U. of the Health Sciences. Bethesda, MD
81 Jim Holliman. Aspirated and Ingested Foreign Bodies Jim Holliman. Aspirated and Ingested Foreign Bodies. Uniformed Services U. of the Health Sciences. Bethesda, MD
91 Needle Cricothyroidotomy Prepare equipment.14 ga IV catheter or biggerSyringe (if possible)Transtracheal jet insufflation device (or BVM?)6.0 ET hub
92 Oxygenation without Ventilation Apneac oxygenation4 seconds of 15 LPM O2 = roughly 800 mL of oxygen into the tracheaMay or may not be effective due to shunt physiologyHeard, A, Green, J, Eakins, P. The formulation and introduction of a ‘can’t intubate,can’t ventilate’ algorithm into clinical practice. Anaesthesia, 2009, 64, pages 601–608
98 BIG RAMPPPPB: BUY TIME: Increase FiO2, NIV, Optimise Medical Rx I: INDICATION FOR INTUBATION: do you really need to do it & do it now? G: GET HELP: Anaesthetics, ICU, ENT, Nurses, Orderlies R: RAMP: Build a big ramp! A: APNOEIC OXYGENATION: use nasal prongs to maintain diffusion of O2 M: MINIMAL DRUGS: local anaesthetic spray/neb, ketamine/ketofol +/- sux/roc P: PRE-OXYGENATE WITH NIV P: PARALYSIS – ONLY IF NEEDED P: PLAN FOR FAILURE: Surgical airway kit by the bedside P: POST INTUBATION CARE