#1 Essential Emergency Airway Care- Airway Preparation Andrew Brainard, MD, MPH, FACEM, FACEM www.thesharpend.org abrainard01@gmail.com

#1 Pre-arrival preparation of Team, Plan, Room, and Equipment Learning Objectives: Prepare TEAM Assign team leader (jacket, roles, plan) Primary airway operator Backup airway operator Airway assistant Drug provider Basic Pre-Arrival PLAN Possible A, B, C, and D Likely Medications Ensure team members understand and are skilled in their roles Prepare ROOM Move bed, Resus tower, and Airway cart Prepare EQUIPMENT Monitor BVM, Adjuncts, Oxygen, Suction Laryngoscopes, ETT, Bougie Backups (SGA/Video/Cric) Drugs R40: 50y/o F found down and unresponsive at home. No signs of trauma, OSA GCS 5, RR 6, SaO2 88%, pulse 100, BP 100/60. Team should prepare for critical patient Team Plan Room Equipment Conduct a Detailed Tour of ED resus area Wear Jacket Bed (Move Bed, Apply Brakes, Head Elevation) Resus Tower (BVM, Suction, Oxygen, SaO2, ET CO2) Airway Cart (Top Through Bottom Drawer) Medications (Cart, Intubation Box, Pyxis) Airway Aids (Posters, Checklist) Video laryngoscope Ventilators, CPAP/BiLevel Store Room Trach, spare ETT, other supplies Paed Dose Calculator on Computer Review all 4 learning objectives ad have every member demonstrate competence in all 4 of the objectives Remind team of RSI checklist

Managing the Airway Team

The Difficult Airway Society Guidelines (http://www. das. uk The Difficult Airway Society Guidelines (http://www.das.uk.com/guidelines/guidelineshome.html) (accessed on 1/01/14) Nicholas Chrimes & Peter Fritz- The Vortex Approach http://www.vortexapproach.com/Vortex_Approach/Vortex.html (accessed on 1/01/14) Murphy MF, Doyle DJ. Airway evaluation. In: Hung OR, Murphy MF, editors. Management of the difficult and failed airway. New York: McGraw-Hill; 2008. p. 1–14. Walls RM. The emergency airway algorithms. In: Manual of Emergency Airway Management, 4th, Walls RM, Murphy MF. (Eds), Lippincott Williams and Wilkins, Philadelphia 2012

Primary Airway Operator Backup Airway Operator Medications Primary Airway Operator Airway Assistant Team Leader Primary Airway Operator Backup Airway Operator Airway Assistant Manual In-line Stabilization Drug Provider Runner/Scribe/Other Intensive Care Backup Airway Operator Drugs Team Leader Intensive Care

Preparing the room and equipment Locate your personnel Resus Nurse(s) ED SMO(s) ED Reg(s) Charge Nurse ICU Anesthetics Prepare the Room Move the bed Move the airway cart Move the resus tower Prepare the Resus Tower Prepare the Monitor Prepare the Airway Cart Drugs Locate your backup stuff Video-laryngoscope etc..

Preparing the Resus Tower and Monitor Suction Tested Under Pt’s R shoulder Oxygen Mask Nasal BVM O2 on Reservoir bag PEEP Monitoring 1st monitor on SaO2 Not on BP arm ETCo2 Tested On BVM 2nd monitor on

Preparing the Airway Cart Cart Location Pt’s right Orientation (able to open drawer) Top Set up as needed Side Bougie, Tube Exchanger 1st Drawer Adjuncts: OPA, NPA, Suction, Mask 2nd & 3rd Drawer Primary: Laryngoscopes, ETCo2, 3rd Drawer ETT, Tie 4th Drawer AirQ SGA (3 sizes) w/ stabilizer 5th Drawer I-LMA, I-LMA ETT, w/ stabilizer Bottom drawer Scalpel Cric Pack pen, scalpel, 6-0 cuffed ETT, disinfectant, gauze, lube, Cook Melker Surgical + Percutaneous Cric Kit Airway Cart Adjuncts Laryngoscope x2 ETT x2 Bougie/Stylet Lube/syringe/tie LMA/Cric Suction

Important Equipment Checks: Resus Tower/Gantry Resus Tower/Gantry Suction Oxygen Mask/BMV/Nasal Medications RSI meds Room Bed Position Height Locked Tower Videoscope Monitoring 1st monitor on SaO2 Not on BP arm ETCo2 Tested On BVM 2nd monitor on Monitor SaO2 ETCo2 BP/ECG Ventilator Oxygen Power Suction Airway Cart Adjuncts Laryngoscope x2 ETT x2 Bougie/Stylet Lube/syringe/tie LMA/Cric Videoscope ETT Stylet On Tower/Gantry Suction Tested Under R shoulder Oxygen Mask BVM Nasal O2 Reservoir bag PEEP Cart Top Adjuncts (OPA/NPA) Laryngoscope Lights tested 2 sizes ETT Lubed Stylet shaped Smaller size ready Syringe/tie Drawers LMA/AirQ sized Cric kit located Circulation IV Fluids A-lines 2nd Monitor

Team Leader *Primary Airway Operator* Prepare room/staff Medications Prep RSI meds Prep IV fluid Prep maintenance meds *Primary Airway Operator* Assure oxygenation Formal airway assessment Vocalize plan A, B, C, D Primary airway procedure *Airway Assistant* Prep airway table Suction, Adjuncts, Laryngoscopy, ETT, Bougie, LMA, Cric Kit, Place nasal O2 External laryngeal manipulation Handles tube/bougie Assists with securing tube *Backup Airway Operator* Examine patient Position patient External laryngeal manipulation Backup airway procedures Perform cricothyroidotomy Monitoring Prep Room SaO2, ETCo2, BP, ECG *Drugs* IV/IO x2 Administer RSI meds Team Leader Prepare room/staff Leads resuscitation Intensive Care Continuity of Care Transport

Indications for advanced airway management Goals of Care Non-futile treatment Able to complete continuity of care Unprotected airway Obtunded, GCS <8, Cardiac arrest, Trauma Oxygenation or ventilation Not appropriate for BVM/CPAP/BiLevel Clinical course Agitated patient needing sedation for patient and staff safety Expected future airway difficulty trauma, burns, infection, angioedema Need for pain control in patients during future procedures Theatre, CT, etc. Expected multi-organ failure or severe sepsis

Different urgency of airway control Crash- Extreme time pressure Forced-to-act Difficulty oxygenating and ventilating Emergent- Substantial time pressure Can be oxygenated Allows for some preplanning and preparation Semi-Elective- Minimal time pressure on stable patient Full assessment and planning time

Airway Assessment MOANS (Mask) RODS (SGA/LMA) LEMON (Intubation) M: mask seal O: obstruction / obesity A: age (>55) N: no teeth S: stiff lungs or c-spine RODS (SGA/LMA) R: restricted mouth O: obstruction D: disrupted or distorted S: stiff lungs or c-spine LEMON (Intubation) L: look E: evaluate 3-3-2 M: mallampati O: obstruction / obesity N: neck SHORT (Surgical Airway) S: surgery H: haematoma O: obesity R: radiation T: tumor

Primary Airway Operator Primary Airway Operator Airway Assistant Primary Airway Operator Airway Assistant Primary Airway Operator Team Leader Team Leader Drugs Drugs *Confirm that people understand their roles* Primary Formal Airway Assessment** Plan A, B, C, D Pullout Criteria Primary Formal Airway Assessment** Plan A, B, C, D Pullout Criteria Backup Backup Criteria Cric plan Backup Backup Criteria Cric plan Airway Assistant External Laryngeal Manipulation Bougie/tube procedure Equipment names & sizes Airway Assistant External Laryngeal Manipulation Bougie/tube procedure Equipment names & sizes Drugs Access Dose Drugs Access Dose

The Pre-arrival briefing We have a 40 y/o female who has taken a large poly-overdose with a decreased level of responsiveness. She is reported to have vomited several times and is ventilating poorly. If we think airway management is indicated and our formal airway assessment indicates it is appropriate to proceed, our plan will be to intubate her. The team will be: Me as team leader Fred as primary airway operator Linda as backup airway operator Viola as airway assistant I will also push the drugs Assuming no contraindications, we will RSI with Thio and Sux, with dose to be determined. Our plan will be: A- Direct laryngoscopy with bougie+7.5 tube B- Video laryngoscopy with stylet+7.5 tube C- AirQ size #3.5 D- Cric for Sats <80% and dropping We will use all our “best practice” techniques. Everyone understand their roles? Questions or suggestions? Let’s make sure everything is ready for this patient’s arrival. AirQ 3.5 Direct laryngoscopy bougie+7.5 tube Video laryngoscopy stylet+7.5 tube Airway Assistant External Laryngeal Manipulation Bougie/tube procedure Equipment names & sizes Primary Formal Airway Assessment** Plan A, B, C, D Pullout Criteria Backup Backup Criteria Cric plan Drugs Access Dose *Confirm that people understand their roles*

Tips for managing the team Knowledge Experience Respect Seniority Mannerisms Age Gender Introduce yourself Ask for everyone’s name Assign roles Preplan Practice Volume

Brief Preparation References: George Kovacs and J. Adam Law: Airway Management in Emergencies, 2nd Ed, 2011 Walls RM and Murphy MF. Manual of Emergency Airway Management, 4th Ed, 2012 Chris Nickson: Own the Airway- Life in the Fast Lane (http://lifeinthefastlane.com/own-the-airway/) (accessed on 15/6/2014) Reuben Strayer. Free Emergency Medicine Talks: Contemporary Strategies in Airway Management http://freeemergencytalks.net/wp-content/uploads/2012/07/2012-06-29-D3T3-1430-Contemporary-Strategies-in-Airway-Management.mp3 (Accessed on 1/06/13) Tim Leeuwenburg. SMACCGold: Checklists in Airway Management (http://vimeo.com/89997364) (18min) (accessed on 15/6/2014) The Difficult Airway Society Guidelines (http://www.das.uk.com/guidelines/guidelineshome.html) (accessed on 15/6/2014) Nicholas Chrimes & Peter Fritz- The Vortex Approach http://www.vortexapproach.com/Vortex_Approach/Vortex.html (accessed on 15/6/2014) Javier Benitez, Academic life in emergency medicine. Mnemonics for difficult airway predictors- http://academiclifeinem.com/mnemonics-for-difficult-airway-predictors/ (accessed on 15/6/2014)