1. Carrie de Moor, MD Associate Medical Director/ED Trauma Director JPS Health Network 4/21/2012

2.  Recognize potential difficult airways  Review Techniques for Advanced Airway Management  Understand options for sedation in RSI during a national shortage of Etomidate  Become familiar with new advanced airway management tools

3.  Poor oxygenation or ventilation  Inability to protect the aiway (Decreased LOC/GCS, secretions, swelling, severe facial trauma)  Potential for rapid deterioration  Patient/Staff safety ( The acutely agitated patient)

4.  Positioning  Assistance at bedside (nursing/RT)  Time to prepare and plan  Fasting patient  Ability to abort the procedure  Anesthesia/surgical back up available

5.  Intact, clear airway  Wide open mouth  Pre-Oxygenated  Intact respiratory drive  Normal dentition  Normal and Easily identifiable anatomy  Good Neck Mobility

6.  This ideally should occur before you attempt!  Review Past Medical History  Physical Exam  Mallampati Classification  Thyromental Distance  Obvious deformities/Trauma  Signs of obstruction  Neck Mobility

7.  Previous Difficult Intubations  Previous Surgical Airway  Congenital Conditions- Pierre Robin Syndrome  Arthritis- Rheumatoid, Ankylosing Spondylitis  Prior C-spine/Neck Surgeries  Head and Neck tumors

12.  Limited Neck Mobility  Facial Instability  Burns  Obesity or very small.  Short Muscular neck  Receding Jaw  Signs of Anaphylaxis  Stridor/FBAO  Scars from Previous Surgeries

13.  Is there blood in the airway?  Is the patient actively vomiting?  Are there teeth missing?  Is there clinical suspicion for Epiglottitis, RPA, or Ludwig’s Angina?  Is the patient immobilized?

18.  Consider Alternatives for Airway Support  CPAP/BiPAP  Call Backup/Intubation in controlled OR setting  Prepare for need to change equipment  Different blades  Different tube sizes  Bougie  LMA/Combitube  Advanced Airway Equipment- Glidescope, Fiberoptics etc  Prepare for Surgical Airway

19.  Sellick’s Maneuver/Cricoid Pressure ( +/-)  BURP maneuver  Good Positioning- Sniff position  Always have a bougie in your pocket  Cricothyrotomy

20. Application of pressure to a patient’s cricoid cartilage during endotracheal intubation to prevent aspiration Pitfalls: Potential for Airway obstruction Evidence that it actually prevents aspiration is lacking A 2007 study published in Annals of Emergency Medicine recommended that “the removal of cricoid pressure be an immediate consideration if there is any difficulty either in intubating or ventilating the ED patient.” (Ellis)

21.  BURP : “backward-upward-rightward pressure” of the larynx  Displaces the thyroid cartilage dorsally so that the larynx is pressed against cervical vertebrae’s body  Ideally two centimeters in cephalic direction, until resistance is felt  Next it should be displaced 0.5 cm -2.0 cm rightward  When used with Sellick’s may actually worsen view

22.  Sniffing Position  First Described in 1936 by Bannister and MacBeth- to align oral, pharyngeal, laryngeal axes to provide optimal exposure of the glottis  Pitfalls: Inadequate for the morbidly obese patient, not an option with suspected cervical spine injury

24.  Ear-to-sternal notch positioning improves the mechanics of ventilation, both with spontaneous breathing, and with mask ventilation.  In the obese patient: shoulders are elevated, the head and neck are extended, and the external auditory meatus is in line with the sternal notch

25. Figure 1. Elevated head-up position. Zvara D A et al. Anesth Analg 2006;102:1592-1592 ©2006 by Lippincott Williams & Wilkins

26. Figure 2. Whelan-Calicott position. Zvara D A et al. Anesth Analg 2006;102:1592-1592 ©2006 by Lippincott Williams & Wilkins

27.  Atlanto-occipital extension is necessary to bring the vocal cords within line-of-sight of the mouth, manual axial in-line stabilization reduces this movement by 60%.

29. Bougie for Intubation

30.  Video

31. “Hey Doc.. We’re out of Etomidate”

32.  There are a number of options for RSI- choose wisely  Succinylcholine vs. Rocuronium/Vecuronium  Consider potential for awake intubation/sedated but not paralyzed intubation  Know your drugs and your doses

33.  Dosage: 2-3 mg/kg IV Push  Onset of action: < 1 minute  Duration 3-10minutes  Benefits: Rapid onset, brief duration, amnestic  Caution: Causes cardiovascular depression and hypotension

34.  Dosage: 1-2mg/kg slow IVP  Onset: 30 seconds to 1 minute  Duration: 5-10 minutes  Benefits: Potent Bronchodilator, leaves protective airway reflexes intact, maintains cardiovascular stability  Caution: Old Dogma regarding elevated ICP with use, increases sympathetic tone, emergence delirium common

35.  Often underutilized due to old dogma regarding ICP  Ketamine is a non-competitive NMDA receptor antagonist and has neuroprotective effects  Studies claiming ketamine should be avoided in head injury are based on 3 studies from the 1970’s, recent studies have shown no convincing evidence that these claims are valid  Acute agitation and emergence reactions may be of concern for conscious sedation. However, in the RSI population where continued sedation with benzodiazepines is possible, this is of less concern.

36.  Dosage needs vary from patient to patient  Onset of action can be unpredictable  Poor choice for true Rapid Sequence Intubation

39.  Cost: $11,000 for the Cobalt  Benefits: Easy to use, easy to observe student/resident procedures, minimal need to manipulate the neck  Features- Pediatric and Adult Sizes, unique 60 degree blade, disposable and reusable options  3 options: Cobalt, Ranger, GVL  Pitfalls: Expensive, limited visibility with significant secretions or blood

41.  Cost: $700-800  Benefits: Easily portable, affordable, no need for special stylette  Pitfalls: Lower resolution than glidescope, less useful in teaching scenarios due to size of screen

43.  Cost: $60,000  Benefits: Maintains the same curvature are the basic MAC blade, may be used for conventional direct laryngoscopy or with video assistance, benefits for teaching scenarios  Pitfalls: Price, mobility

45.  Abrams K.J., Grande C.M. " Airway Management of the trauma patient with cervical spine injury ", Current Opinion in Anesthesiology 1994;7:184-190  The BURP Maneuver. Images in Anesthesiology. Vol. 31. No. 1 January-March 2008 pp 63-6  Cattano, D. Cavallone, L. Airway Management and Airway Positioning: A Clinical Perspective. Anesthesiology News. 2010:35-40.  Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: A risk-benefit analysis. Annals of Emergency Medicine. 2007;50:653-665  EmCrit. “Use of the Bougie for Intubation” http://youtu.be/E7Lo1JD2Brkhttp://youtu.be/E7Lo1JD2Brk  Hastings R.H., Marks J.D. " Airway Management for Trauma Patients with Potential Cervical Injuries ", Anesth Analg 1991;73:471-82.  Zvara D A et al. Positioning for Intubation in Morbidly Obese Patients Anesth Analg 2006;102:1592-1592