Emergency Airway Management G. Greenfield, L. Mabon, Sarah McPherson, J. Huffman July 16, 2009

Become an airway ninja: Approach (30min, large group) Airway Pharmacology (30min, small group) Peds/Toys (2x15 min, small group) Difficult/Failed Intubation (30min small group) Goal of session: Make you an airway ninja. One of the main points I want to impress upon you today is that disaster airways are our turf and we need to know their management inside and out. Yes, Anes gets more practice with the laryngoscope than we do, but arguably we spend more time dealing with the gong shows and difficult scenarios; particularly the crashing patient who’s pushing your hand. Of course knowledge is key and you need to have your basis in anatomy and physiology solid to become a 8th degree black belt master, but today we’re going to assume you have the basics down, review the “need to know” items from those categories and work on the integration of those pieces into your clinical skillset. Practice the practical aspects in the short session today, as well as the procedural skills lab, your anesthesia rotation and every single day in the department. This is the only chance we’ll get to discuss these topics this year.

Indications for Intubation: [some signs are obvious, like this stop sign. You know that as soon as you see this, you have to stop your car or you’re going to end up on the wrong side of a trauma stretcher. Others signs aren’t always so clear. One of the most important decisions in airway mgmt is the one when you decide to pull the trigger and intervene. Too soon or in the wrong pt and you could end up causing major difficulties or even death for somebody who was just fine without you and too late and well…we all know what happens then. A great analogy Gavin and I were discussing was that old saying that just because you own a gun, it doesn’t mean you should fire it!

Indications Obtain and Maintain a patent airway Correct deficient gas exchange Protect the Airway Preempt predicted clinical deterioration Goals of airway management are simple: Oxygenation and Ventilation – could be positioning, and could be more aggressive Indications for intubation: Obtain and Maintain a patent airway Correct deficient gas exchange This is a clinical decision, not a biochemical one. Don’t wait for an ABG! Usually oxygenation and ventilation go together, but can anybody think of a situation of just ventilation collapse? [asthma] Oxygenation? [sepsis] Protect the airway (e.g. against aspiration of gastric contents and blood) GCS is okay, but fraught with the difficulties associated with any prospective decision tool. Some authors (including those endorsed by the AIME course) advocate for the ability to handle secretions as one of your decision points. To preempt predicted clinical deterioration to one of the above three situations

Airway Evaluation Laryngoscopy and intubation Bag-mask ventilation Rescue oxygenation techniques Most of the time, when we talk about airway evaluation, we only talk about predictors of difficult laryngoscopy and intubation, but really we should be thinking about those patients who are difficult to bag mask ventilate and difficult to cric as difficult also.

Airway Evaluation Here are a few mnemonics to use…if you’re a mnemonic person. If you’re not. Try to think about these physiologically as we go along. Predictors of difficult bag-mask ventilation: [BOOTS] B – beard O – older (>55) O – obese T – toothless S – Sounds: (snoring, stridor); Stiff lungs (wheeze, chest wall)   Predictors of difficult extraglottic device use: [RODS] R – restricted mouth opening O – obstruction at or below the level of the cords D – displacement, distortion or disruption of the airway S – stuff lungs or chest wall Predictors of difficult laryngoscopy and intubation: [LEMON] L – Look Externally (trauma, collar, burns, small chin, small mouth, etc.) E – Evaluate 3-3-2 rule (minimum 3 fingers mouth opening, 3 of thyromental span and 1cm of jaw protrusion) M – Mallampati Classification (class 3-4  difficulty) O – Obstruction N – Neck Mobility Predictors of difficult cricothyrotomy: [DART] D – Distortion of the overlying anatomy due to blunt trauma, hematoma, or infection A – Access issues due to obesity, or inability to extend the head and neck R – History of neck radiation T – Tumor

3-3-2 Rule 3 – ability to open mouth 3 – ability to displace the tongue AND align axis 2 – Position of larynx in relation to the base of the tongue (<2 = under the base of tongue  anterior, >2 abnormally far away)

Mallampati Classification Should be done sitting up with head slightly forward and mouth open as wide as possible (no vocalization or dramatic tongue protrusion) Class 1 and 2 are associated with low intubation failure rates, 3 and 4 are more likely to predict a difficult intubation (but failure rates are still less than 10%) Bottom line: When uvula disappears, the chance of difficult intubation increases.

Algorithms – from difficult intubation paper Pros: standartdize…let’s you have something to fall back on in an emergency Cons: cookbook.

Anatomy and Presenting Physiology Pt Assessment: Anatomy and Presenting Physiology NO difficulty predicted Cooperative Awake* or RSI Uncooperative RSI Difficult airway predicted Awake* Assess ability to BMV/Oxygenate 1st question….do you predict difficulty? 2nd question…is the patient co-operative?

Assess ability to BMV/Oxygenate BMV and rescue oxygenation predicted successful RSI BMV and/or rescue oxygenation NOT predicted successful Other options* Other options include: Awake! Deferring intubation Calling for additional expertise Pharmacologic restraint (Ketamine) Blind Nasal intubation (complications) Proceed with RSI and a reduced margin of safety Primary surgical airway

Take Home Points Know when to intubate Obtain or maintain a patent airway Correct deficient gas exchange Protect the airway Preempt predicted deterioration For every intubation, come up with a plan based on the predicted difficulty and patients ability to cooperate

Small Group #3 Cases

Failed 1st Attempt! Can you Bag? Yes 2nd Look 3rd/other doc No! EGD Cric

Tips Grade 3 or 4 view? Can’t BMV Bougie Laryngeal manipulation Different blade Lightwand Fiberoptic intubation Stylet Paralysis EGD *iLMA then intubate through that! Can’t BMV Positioning 2 person bagging OPA/NPA Extraglottic Device Rule out obstruction Turn difficult into ninja…

Case 1 45M, healthy until 5d ago Progressive cough/sob Presents to ED septic After 3L fluids, ABx 39.8, 95/64, 138, 30, 88%nrb Mottled VBG 7.28/48/60/18, Lactate 3.2 Amazingly he is still talking to you No predictors of difficult airway Awake or RSI No difficulty predictors (have them take you through LEMON) Co-Operative Can do Awake or RSI

Case 2 60M, Called EMS for crushing CP VF arrest en route  shocked with ROSC In trauma bay, GCS = 5, can’t get a pressure but there is a carotid pulse. No predictors of difficult airway No difficulty, Cooperative (unconscious) “awake” vs RSI 30mg Etomidate and laryngoscopy  asystole Peri-mortem No difficulty Unconscious (awake) AWAKE – do not RSI – inductions agents will kill this man!

Case 3 18F. Found down on a park bench downtown No signs of trauma En Route waking up and becoming increasingly combative with EMS On Arrival in ED, basically she’s an orangutan. 37.8, 118, 24, 128/74 94% No indicators of difficult intubation No difficulty / uncooperative  RSI No difficulty, uncooperative  RSI

This guy…stridorous Difficult/co-operative  Awake!! 52m. Ankalosing spondylitis, RA, severe kyphosis

This guy…unconscious Difficult / not cooperative / BVM should be successful Young guy, in collar

Difficult / not co-operative / BVM not predicted to be successful  other options Delay intubation until the OR EGD Awake nasal fiberoptic

Difficult / not co-operative / BVM not predicted to be successful  other options Delay intubation until the OR EGD Awake nasal fiberoptic