1. Abdullah Alsakka E.M. Consultant

2. Questions For The Emergency Physician: 1. Can I predict the difficult airway? 2. How often can I expect to be faced with a difficult airway? 3. What tools do I have to manage the difficult airway? 4. What is the best strategy for managing the difficult airway?

3. 1-Can I Predict The Difficult Airway? Airway management is a skill that defines Emergency Medicine. We are expected to manage the most challenging airways in the hospital with little time, little information, and no margin for error, complication, or failure

4. Success will require three unique skill sets: 1. Ability to immediately predict the difficult airway, 2. Sophisticated proficiency with conventional laryngoscopy and a growing number of airway management devices, 3. A well thought-out approach for dealing with the difficult and failed airway.

5. It is important to understand two definitions 1-The “difficult airway” has three components that may or may not co-exist: 1. Difficult bag-valve mask ventilation 2. Difficult laryngoscopy 3. Difficult surgical airway ASA Difficult Airway Task Force. Anesthesiology 2003; 93:1269-1277.

6. 2-A “failed airway” exists when one or both of the following scenarios occur: 1. Inability to ventilate or intubate the paralyzed patients 2. Three intubation attempts by the same operator ASA Difficult Airway Task Force. Anesthesiology 2003; 93:1269-1277

7. In 2003, the ASA Difficult Airway Task force completed an evidence-based review of the available literature and concluded that there was insufficient evidence to definitively recommend any specific predictive tool, although data suggested that some of these markers were “associated” with difficult airways

13. 2-How Often Can I Expect To Be Faced With A Difficult Airway?

17. 3- What Tools Do I Have To Deal With The Difficult Airway? 1) Blind insertion supra-glottic airway devices a) Double-lumen laryngeal devices i) Combitube® ii) King-LT® b) Laryngeal mask airways i) Standard LMA® ii) Intubating LMA [Fastrack®] c) Intubating stylets i) Gum-elastic bougie ii) Lighted stylet [Trachlight®]

18. 2 ) Direct vision supra-glottic airway devices a) Hand-held fiberoptic intubating stylets i) Levitan Scope® ii) Shikani Optical Stylet® iii) RIFL® b) Hand-held fiberoptic laryngoscopes i) McGraf Scope® ii) Glidescope® iii) Storz Videolaryngoscope® iv) Pentax Airway Scope® c) Traditional flexible fiberoscopes d) Prism/mirror assisted scopes [Airtraq®]

19. 3 ) Infra-glottic airway devices a) Retrograde intubation b) Transtracheal jet ventilation c) Surgical cricothyrotomy i) Open ii) Percutaneous

33. 4-What Is The Best Strategy For Managing The Difficult Airway?

34. Case Example 1: Consider a morbidly obese patient who presents to the ED after an overdose. He has stable vital signs, but is obtunded and not protecting his airway. Airway dimensions and anatomy are “normal.” Oxygen saturations are >95% on supplemental oxygen. Following sedation and paralysis the glottis can not be visualized despite three attempts with re-positioning. Oxygenation can be maintained with BVM ventilation

36. Case Example 2: Now consider the same overdose patient who you have paralyzed and sedated. Aspiration is evident after the first attempt at laryngoscopy and you are having difficulty oxygenating the patient even with adequate positioning and an oral airway.

38. Case Example 3: Consider a patient with Ludwig’s Angina in the setting of a severe dental infection. The patient has stable vital signs and oxygen saturations in the high 90’s. On physical exam this is significant trismus and a large submandibular hematoma. Because of progressive swelling you decide to intubate the patient prior to transfer to a tertiary center

40. Case Example 4: Consider a patient with a gunshot wound to the mouth. The mandible is blown apart and blood is pouring into the airway. Oxygen saturations are dropping and the patient is impossible to bag.