Advanced Emergency Airway Management RSI Techniques for the Difficult or Failed Airway

Dilemmas: Intubate Awake or Asleep Oral or Nasal Laryngoscopy or Blind Intubation To Paralyze or Not

Techniques DL without pharmacologic aids Awake Direct Laryngoscopy Awake Blind Nasal Rapid Sequence Intubation (RSI) Fiberoptic Surgical Cricothyroidotomy

Blind Nasal Intubation success rates % in most series high complication rates –epistaxis –pharyngeal/ esophageal perforations –increased incidence of O2 desaturation Considered second line approach only reserved for when RSI contraindicated

Oral Intubation Without Drugs Reserved for the completely unconscious, unresponsive, and apneic Arrest situations only

Oral Intubation with Sedation proponents argue use of BZ or opioids –improves airway access –decreases patient resistance –avoids risks of neuromuscular blockade Generally obtunds patient to point of loss of protective reflexes and respiratory drive lower success rate, higher complications compared with RSI

Oral Intubation with Sedation “ In general, the technique of administering a potent sedative agent to obtund the patient’s responses and permit intubation in the absence of NMB is hazardous and to be discouraged… is not an appropriate alternative to properly conducted RSI and affords neither the success rate or the minimal complication rate of RSI.” –RM Walls, page 4, Chapter 1, Rosen

Oral Intubation with Sedation:Use for the Anticipated Difficult Airway if time permits –topical anesthesia –careful titrated sedation –avoid obtundation ‘Awake” intubation technique

Emergency Airway Concerns “full” stomach minimal respiratory reserve hemodynamic instability acute myocardial ischemia increased intracranial pressure The “Difficult” Airway –Laryngoscopy –bag-mask difficulty

The “Intubation Reflex “ Catecholamine release in response to laryngeal manipulation Tachycardia, hypertension, raised ICP Attenuated by beta-blockers, fentanyl ICP rise possibly attenuated by lidocaine Midazolam and thiopental have no effect

Rapid Sequence Intubation : Definition The near simultaneous administration of a sedative-hypnotic agent and a neuromuscular blocker in the presence of continuous cricoid pressure to facilitate endotracheal intubation and minimize risk of aspiration modifications are made depending upon the clinical scenario

Rapid Sequence Intubation : Advantages Optimizes intubating conditions/ facilitates visualization Increased rate of successful intubation Decreased time to intubation Decreased risk of aspiration Attenuation of hemodynamic and ICP changes

Rapid Sequence Intubation : Contraindications Anticipated difficulty with endotracheal intubation –anatomic distortion Lack of operator skill or familiarity inability to preoxygenate

Rapid Sequence Intubation: Principles Emergency intubation is indicated The patient has a “full” stomach Intubation is predicted to be successful If intubation fails, ventilation is predicted to be successful

Rapid Sequence Intubation : Procedure Pre-intubation assessment Pre-oxygenate Prepare ( for the worst ) Premedicate Paralyze Pressure on cricoid Place the tube Post intubation assessment

Pre-oxygenate ( Time - 5 Minutes) 100 % oxygen for 5 minutes 4 conscious deep breaths of 100 % O2 Fill FRC with reservoir of 100 % O2 Allows 3 to 5 minutes of apnea Essential to allow avoidance of bagging If necessary bag with cricoid pressure

Preparation ( Time - 5 Minutes ) ETT, stylet, blades, suction, BVM Cardiac monitor, pulse oximeter, ETCO2 One ( preferably two ) iv lines Drugs Difficult airway kit including cric kit Patient positioning

Pre-treatment/ Prime ( Time - 2 Minutes ) Lidocaine 1.5 mg/kg iv Defasciculating dose of non-depolarizing NMB Beta-blocker or fentanyl Induction agent –Thiopental mg/kg –Midazolam mg/kg –Ketamine mg/kg –Fentanyl mcg/kg

Paralyze ( Time Zero ) Succinylcholine 1.5 mg/kg iv Allow seconds for complete muscle relaxation Alternatives –Vecuromium mg/kg –Rocuronium o mg/kg

Pressure Sellick maneuver initiate upon loss of consciousness continue until ETT balloon inflation release if active vomiting

Place the Tube ( Time Zero + 45 Secs ) Wait for optimal paralysis Confirm tube placement with ETCO2

Post-intubation Hypotension Loss of sympathetic drive Myocardial infarction Tension pneumothorax Auto-peep

Succinylcholine : Contraindications Hyperkalemia - renal failure Active neuromuscular disease with functional denervation ( 6 days to 6 months) Extensive burns or crush injuries Malignant hyperthermia Pseudocholinesterase deficiency Organophosphate poisoning

Succinylcholine : Complications Inability to secure airway Increased vagal tone ( second dose ) Histamine release ( rare ) Increased ICP/ IOP/ intragastric pressure Myalgias Hyperkalemia with burns, NM disease malignant hyperthermia

Difficult Airway Kit Multiple blades and ETTs ETT guides ( stylets, bougé, light wand) Emergency nonsurgical ventilation ( LMA, Combitube, TTJV ) Emergency surgical airway access ( cricothyroidotomy kit, cricotomes ) ETT placement verification Fiberoptic and retrograde intubation

Emergency Surgical Airway Maxims they are usually a bloody mess, but... a bloody surgical airway is better than an arrested patient with a nice looking neck