1. Delay Intubation? That is the question… Dr Peter Jordan FACEM Northern Hospital Austin Airway Forum May 2014

2. 3 Cases Background – ED Airway Management Preoxygenation Delayed Sequence Intubation NIV Ketamine How to Make it Happen Case Conclusions Questions

3. Case 1 Confused and uncooperative 36YO male arrives via MAS at 0300 Probable alcohol +/- benzodiazepines +/- TCA Noisy resps, SaO2 89% on High Flow NRBM What are you going to do?

4. Case 2 Sunday PM Obese (>120kg) 48 man COPD/ Sleep apnoea/ HT Decreased Mental status and marked hypoxia. Sa02 68%, HR 140 Now what?

5. Case 3 37YO female – Obvious respiratory distress – unrecordable SaO2, ?cyanosed, Silent chest, Uncooperative – Keeps removing Nebuliser mask and stepping off trolley. History of Severe Asthma - Multiple ICU interventions

6. So you wanna have a crack at intubation? STEM.org.au

7. Consider Base Jumping… BASE jumping is the most dangerous of the extreme sports. It is about forty times more dangerous than plain old parachute jumping The mortality from BASE jumping is around 0.04%.

9. But its not me on the end of the blue cigar.. Difficult laryngoscopy occurred in 24% First pass success occurred in 83.4% Difficult intubation occurred in 3.4% Complications occurred in 29.0% Desaturation in 15.7% Periarrest Cardiac arrest occurred in 2.2% (no deaths) Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia Fogg T et al EMA, 2012

10. Any other party poopers? NAP4 (UK) Death rate ED 0.8% ICU 3% “Difficult” approx. 10% Intubation in ED is 20 times more likely to kill you (as a patient) than base jumping…

11. And the Problem is??

12. But these patients are pretty sick right? When ALS succeeds, we convert a dead patient into a live one When RSI goes wrong we convert a live patient into a dead one

13. What goes wrong? Hypotension most common adverse event (up to 45%) But.. “Hypoxia was the most common primary contributor to death” Patient factors 23% Judgement 10% Education/ Training 7% Other – communication/ task failure http://bja.oxfordjournals.org/content/106/5/632.full.pdf+html

14. So….what can I do to avoid this? Prepare your teamAnticipate Difficult PhysiologyAnticipate Difficult Intubation (consider awake intubation)Prepare equipment and drugsOptimise patient before IntubationBecome excellent at Intubating and cricothyrotomy

15. Preoxygenation Process of administering oxygen to a patient prior to intubation, so as to extend ‘the safe apnea time’ Oxygen consumption during apnea is approximately 250 mL/minute (3 mL/kg per minute) in a healthy patient in critically ill patients desaturation may occur immediately despite preoxygenation

16. Preoxygenation Goals Achieve SaO2 = 100% Denitrogenate the lungs Simply breathing 100% oxygen can increase O2 store in lungs from 450ml to 3000ml Oxygenate the blood (less significant) Maximise FRC

17. Optimizing Preoxygenation Position Nasal cannula O2 at 4-15L/min (as high as tolerated) NRBM at max flow if SaO2 >95% Or NIV if SaO2 <95%, hypercapneic or obese Continue >3 minutes once SaO2 >95%

18. DSI = procedural sedation, where the procedure is preoxygenation The patient cannot tolerate preoxygenation (or other pre- intubation procedures) due to delirium and/ or agitation Facilitates correction of hypoxia before paralysis Sedative (Ketamine) preserves airway reflexes and respiratory drive and has minimal effect on haemodynamics Does not always involve NIV

19. Agitated and uncooperative - requires intubation..

20. Integrated approach to intubation Administer induction agent, ideally ketamine 1-1.5 mg/kgPlace non-rebreather mask and nasal cannula at 15 L/min eachif SaO2 95% >3minsAdminister neuromuscular blockerPerform Jaw thrustContinue Oxygenating via nasal prongs (max flow) +/- continued CPAP 45secondsIntubate patient

21. Is there any evidence? Weingart SD. Preoxygenation, reoxygenation, and delayed sequence intubation in the emergency department. J Emerg Med. 2011 Jun;40(6):661-7. Epub 2010 Apr 8. Review. PubMed PMID: 20378297. [Free fulltext]20378297Free fulltext Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012 Mar;59(3):165-75.e1. Epub 2011 Nov 3. Review. PubMed PMID: 22050948. [Free fulltext]22050948Free fulltext

22. Other opportunities? Better preparation Self Team Environment patient NGT insertion IV access Vasopressors/ Inotropes IV Fluids Bronchodilation Observation/ Monitoring Buys Time - ”Double Set-up?”

23. What if the patient improves? Great!! But beware… NNT = 4 (avoiding intubation) Failed NIV worsens outcomes If in doubt – Plan A is best Timing of Noninvasive Ventilation Failure - Causes, Risk Factors, and Potential Remedies. Ezgi Ozyilmaz, Aylin Ozsancak Ugurlu, Stefano Nava BMC Pulm Med. 2014;14(19)

24. What about Ketamine? Analgesic dose (0.1-0.3 mg/kg) – patient safely analgised – generally inadequate for DSI Recreational dose (0.2-0.5 mg/kg) – patient ‘high’ he’s happy but you’re not Partially (intermittently) dissociated dose (0.4-0.8 mg/kg) – patient ‘pear shaped’….he’s unhappy..uncooperative = you’re unhappy Dissociative dose (>0.7 mg/kg) - both happy and patient fully cooperative!!

25. Ketamine sounds is a wonder drug.. Potentially significant Adverse Effects.. Laryngospasm – mostly in children (0.4%) Hypersalivation (~30%) Emesis (~5-15% - but almost always during emergence) Transient respiratory depression (usually in the first 2-3 minutes following a large, rapidly administered IV dose) Transient mild increase in heart rate and blood pressure

26. Contraindications? Absolute <3 months of age Psychosis, (even if currently stable and controlled with medications) Relative Age of 3-12 months History of airway instability, tracheal surgery, or tracheal stenosis Unstable cardiovascular disease, including angina, heart failure, or uncontrolled hypertension Acute Globe Injury and Glaucoma Green SM, Roback MG, Kennedy RM, Krauss B. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Annals of emergency medicine. 2011 – in press. PMID: 21256625

27. Ketamine Alternatives Dexmedetomidine Fentanyl/ Remifenatanyl/ Alfentanyl Droperidol Combinations

28. NIV - Contraindications Pneumothorax Trauma AMI Severe acidosis Pre arrest Resource Issues

29. NIV - What can go wrong? Excessive secretions Mask leaks Pneumothorax Vomiting/ aspiration Patient-ventilator asynchrony

30. What if this happens? physiotherapeutic techniques judicious use of oral/ oro-pharyngeal suction Brief PPV changing ventilator settings – FiO2 (usually up) and pressures (up or down..Max 15cm EPAP) Sedation/ More sedation Proceed to intubation

31. Other ideas? emupdates.com

32. So should I use DSI or not? Yes..in carefully selected situations… Improves Airway assessment and planning includes oxygenation status and predictors of difficult preoxygenation as well as “difficult airway” Shared Mental Model Facilitates use of other adjuncts Communicates expectation of Intubation – preparedness Methodical

33. Challenges/ Pitfalls: Cognitive Barriers Evidence – Local validation Protocols and guidelines Patient selection Ketamine – understand and become familiar (whole team) Training (multidisciplinary) Teamwork Anticipate complications Very Close observation and monitoring

34. Making it Happen Politics – gain approval/ agreement Train with your team Crisis Resource Management Debrief/ Discuss/ Audit/ Report airwayregistry.org.au

35. Case Conclusions 1. Confused 36yo M..Intoxicated Polypharmacy OD + probable aspiration 2. Obese (>120kg) 48 man Decreased Mental status and marked hypoxia. 3. 37YO female Cyanotic agitated asthmatic

36. Thanks………….Questions? Sources: emcrit.org prehospitalmed.com (PHARM) STEM.org.au lifeinthefastlane.com emupdates.com Original Research and Reviews (see following slides)

37. references Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia Fogg T et al EMA, 2012 Ballard C, Fosse et al NIV improves preoxygenation before intubation of hypoxic patients. Am J Resp Care. 2006;174:171-7 Delay J et al, The effectiveness of Non Invasive Positive Pressure Ventilation to enhance oxygenation in morbidly obese patients. An RCT. Anaesth Anal: 2008: 5 Green SM, Roback MG, Kennedy RM, Krauss B. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Annals of emergency medicine. 2011 – in press. PMID: 2125662521256625 Green SM, Cote CJ. Ketamine and neurotoxicity: clinical and implications for emergency medicine. Ann Emerg Med. 2009;54:181-190

38. references Green SM, Li J. Ketamine in adults: what emergency physicians need to know about patient selection and emergence reactions [editorial]. Acad Emerg Med. 2000;7:278-281 Mayberg TS, Lam AM, Matta BF, et al. Ketamine does not increase cerebral blood flow velocity or intracranial pressure during isoflurane/nitrous oxide anesthesia in patients undergoing craniotomy. Anesth Analg. 1995;81:84-89. Bar-Joseph G, Guilburd Y, Tamir A, et al. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. J Neurosurg Pediatr. 2009;4:40-46. Bourgoin A, Albanese J, Wereszczynski N, et al. Safety of sedation with ketamine in severe head injury patients: comparison with sufentanil. Crit Care Med. 2003;31:711-717. 985-1028. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments † T. M. Cook,N. Woodall, J. Harper, J. Benger, Br. J. Anaesth. (2011) 106 (5) T. M. CookN. WoodallJ. HarperJ. Benger

39. references Vardy JM, Dignon N, Mukherjee N, et al. Audit of the safety and effectiveness of ketamine for procedural sedation in the emergency department. Emerg Med J. 2008;25:579-582 Takeshita H, Okuda Y, Sari A. The effects of ketamine on cerebral circulation and metabolism in man. Anesthesiology. 1972;36:69-75 Timing of Noninvasive Ventilation Failure - Causes, Risk Factors, and Potential Remedies. Ezgi Ozyilmaz, Aylin Ozsancak Ugurlu, Stefano Nava BMC Pulm Med. 2014;14(19) Strayer RJ, Nelson LS. Adverse events associated with ketamine for procedural sedation in adults. Am J Emerg Med. 2008;26: Himmelseher S, Durieux ME. Revising a dogma: ketamine for patients with neurological injury? Anesth Analg. 2005;101:524-534.