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

2. 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.

3. 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!

4. 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

5. 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.

6. 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 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

7. 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)

8. 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.

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

10. 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?

11. 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

12. 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

13. Small Group #3 Cases

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

15. 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…

16. 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

17. 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!

18. 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

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

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

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

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