Emergency Airway Management 2014 Mark P. Brady PA-C

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2013

Agenda::

Agenda : Airway Anatomy Adult vs. Pedia tri c Review of basic equipment Approach to the Difficult Airway RSI Post-Intubation Management Ventilator Settings The Crashing Asthmatic

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Important take home points

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The search for the epiglottis

Are kids just small adults?:

Are kids just small adults?

Pediatric vs Adult Airway Anatomy:

Pediatric vs Adult Airway Anatomy

Pediatric Airway Shape:

Pediatric Airway Shape

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Pediatric Adult

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Pediatric airways Use care with cricoid pressure Very compressible

Pediatric Airways are Different not Difficult:

Pediatric Airways are Different not Difficult

Pediatric Airways :

Pediatric Airways Externally Larger head/occiput Head flexes forward and can obstruct Internally Intra-oral tongue Large, floppy epiglottis

Pediatric Intubation Approach:

Pediatric Intubation Approach Further differences “ Pinker ” vocal cords worsen visualization Different location of narrowest point Peds cuffed tubes? Smaller cricothyroid membrane No surgical crics in children

Other Considerations:

Other Considerations More gastric insufflation with BVM Quicker desats during intubation Different 10 kg will drop to 90% in <4 minutes (vs. 8 for adult) Vagal response (not significant) Consider Pre-treatment with Atropine (though not literature supported and not the standard of care)

Pediatric Cardiorespiratory Arrests:

Pediatric Cardiorespiratory Arrests 10% 10% 80%

Pediatric Cardiorespiratory Arrests:

Hypoxia and Hypercarbia Bradycardia CARDIOPULMONARY ARREST Pediatric Cardiorespiratory Arrests

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Self Confident If he can, you can

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Avoid the “ cookie-cutter ” approach to every airway you encounter.

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Be familiar with your equipment…

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What tools do I have ?

Airway Equipment:

Airway Equipment Oxygen and Suction BVM / OPA / NPA ETT / Bougie / LMA / King LT Stylet Magill forceps End-tidal CO2 monitoring and securing devices Surgical Airway Devices

Airway Equipment:

Airway Equipment

Airway Equipment:

Airway Equipment C-E technique is WRONG C E

Airway Equipment:

Airway Equipment Use the Two Thumbs Down technique

Airway Equipment:

Airway Equipment

Airway Equipment:

Airway Equipment OPA NPA

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King LT

Airway Equipment:

Airway Equipment Endotracheal tube stylet

Airway Equipment:

Airway Equipment Eschmann Stylet, a.k.a “ Gum elastic bougie ”

Airway Equipment:

Airway Equipment MAGILL FORCEPS LMA

Airway Equipment:

Airway Equipment LMA – Laryngeal Mask Airway Are extraglottic airways harmful in cardiac arrest ?

Airway Equipment:

Airway Equipment “ Yellow ” = YES “ Purple ” = Pathologic

Airway Equipment::

Airway Equipment: What equipment do we have in our departments? Where is it located?

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Broselow Tape The

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Can ’ t Protect Airway Can ’ t Maintain Ventilation / Oxygenation Expected Decline in Clinical Status 3 Emergent Indications for Intubation

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Gag reflex is absent in up to 37% of population, and is a poor predictor of airway protection Can they talk? Can they swallow and manage secretions? Can ’ t Protect Airway

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SaO2 <90% on High Flow O2 or PaO2<60 on FiO2>40% PaCO2 >55 if baseline is normal, or >10 increase from baseline Respiratory Rate Can ’ t Maintain Ventilation or Oxygenation

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Deterioration/Impending Compromise Transport Airway protection during procedures ( ie . endoscopy) Expected Decline in Clinical Status

DEFINITIONS :

DEFINITIONS Rapid Sequence Intubation (RSI) INDUCTION AGENT PARALYTIC UNCONSCIOUSNESS MOTOR PARALYSIS

DEFINITIONS :

DEFINITIONS Delayed Sequence Intubation (DSI) DSI consists of the administration of specific sedative agents, which do not blunt spontaneous ventilations or airway reflexes; followed by a period of preoxygenation before the administration of a paralytic agent.

CONTRAINDICATIONS:

CONTRAINDICATIONS INDICATION RISK

RSI RATIONALE:

RSI RATIONALE Increased success Decreased aspiration

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Better C-spine control RATIONALE - Secondary

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Blunting ↑ in ICP / IOP RATIONALE - Secondary

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Avoid airway trauma RATIONALE - Secondary

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Avoid airway trauma RATIONALE - Secondary

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↓ Pain ↓ Discomfort ↓ Recall

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Adverse Drug Events HAZARDS

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May force crash airway scenario HAZARDS

The 7 “P’s”of RSI:

The 7 “ P ’ s ” of RSI P REPARATION P REOXYGENATION P RETREATMENT P ARALYSIS WITH INDUCTION P ROTECTION AND POSITIONING P LACEMENT AND PROOF P OST-INTUBATION MANAGEMENT TIME ZERO t – 10 minutes t + 90 seconds

PREPARATION t – 10 minutes:

PREPARATION t – 10 minutes EQUIPMENT PRESENT AND WORKING INCLUDING EQUIPMENT FOR PLAN “ B ”

PREPARATION t – 10 minutes:

PREPARATION t – 10 minutes 2. Ask yourself: CAN I… BAG THE PATIENT TUBE THE PATIENT CRIC THE PATIENT

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“ Evaluate for signs of a difficult intubation ” -Obesity -

Look at the general anatomy Evaluate the 3-3-2 rule Mallampati score Obstruction Neck mobility Saturation Reserve:

L ook at the general anatomy E valuate the 3-3-2 rule M allampati score O bstruction N eck mobility S aturation Reserve CAN I TUBE THIS PATIENT?

Look at the general anatomy:

L ook at the general anatomy

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E valuate the 3-3-2 rule

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M allampati score

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O bstruction

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N eck mobility

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S aturation Reserve

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S aturation Reserve At 92% the patient ’ s oxygen saturation falls off a cliff….

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CAN I BAG THIS PATIENT? Maybe. Maybe Not.

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Approximate normal ventilation rates: 10 bpm Adult 20 bpm Child 25 bpm Infant VENTILATE (BLS) Squeeze ..... Release - Release

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Keep Dentures in when using a BVM

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CAN I CRIC THIS PATIENT?

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Indications Obstruction Facial Trauma Intubation or other alternatives impossible Trismus (clenching) > 8 years old (for open procedures) SURGICAL AIRWAYS LAST RESORT!

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DEFCON DEF ense Readiness CON dition Maximum readiness Armed Forces ready to deploy and engage in less than 6 hours Air Force ready to mobilize in 15 minutes Above normal readiness Normal readiness

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Cric-CON Discuss / Feel / See Kit Mark / Kit Bedside Inject / Prep / Open & Set Kit Scalpel in Hand Make Skin Cut & Find Membrane Perform Cric

Open Cricothyrotomy:

Open Cricothyrotomy

Open Cricothyrotomy:

Vertical Incision over membrane Pierce membrane in horizontal plane Open and spread to insert 4.0 or 5.0 tube Secure tube in place and ventilate Open Cricothyrotomy

PREOXYGENATION t – 5 minutes:

PREOXYGENATION t – 5 minutes 1. “ First, do not bag! ” Avoid “ Sellick ’ s ” maneuver (cricoid pressure)

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Every time you use cricoid pressure… God kills a kitten.

PREOXYGENATION t – 5 minutes:

PREOXYGENATION t – 5 minutes 1. Well-fitting mask 8 vital capacity breaths

PREOXYGENATION t – 5 minutes:

PREOXYGENATION t – 5 minutes

PREOXYGENATION t – 5 minutes:

PREOXYGENATION t – 5 minutes NIV CPAP for Pre-Oxygenation

Summary of LOAD PRETREATMENT:

Summary of LOAD PRETREATMENT L idocaine  optional O piates  optional A tropine  for infants consider for kids < 8 D efasciculating  optional dose

DEFASCICULATING DOSE 1/10 th the RSI dose:

DEFASCICULATING DOSE 1/10 th the RSI dose Traditional Indications Blunt rise in ICP 2. Decrease risk of aspiration Prevent muscular pain

PRETREATMENT t – 3 minutes:

PRETREATMENT t – 3 minutes If you ’ re going to give these drugs: …at least give them some time to circulate (3 minutes)

PARALYSIS WITH INDUCTION Time “0” :

PARALYSIS WITH INDUCTION Time “ 0 ” INDUCTION AGENTS Etomidate Ketamine Propafol Midazolam PARALYTIC AGENTS DEPOLARIZING Succinylcholine NON-DEPOLARIZING Vecuronium Rocuronium +

PARALYSIS WITH INDUCTION Time “0” :

PARALYSIS WITH INDUCTION Time “ 0 ” Sedation then Paralysis

PARALYSIS WITH INDUCTION Time “0” :

PARALYSIS WITH INDUCTION Time “ 0 ” Use of Apneic oxygenation

Etomidate:

Etomidate Rapid onset/offset Minimal hemodynamic and respiratory effects Pediatrics – not approved for patients under 10

Succinylcholine:

Succinylcholine When: Immediately after Etomidate Onset: Rapid, usually 30-90 secs Duration: Short acting, 3-5 mins

When Sux Really “Sucks” CONTRAINDICATIONS:

When Sux Really “ Sucks ” CONTRAINDICATIONS 1. HYPERKALEMIA RENAL FAILURE RHABDOMYOLYSIS 2. RECEPTOR UPREGULATION SUBACUTE BURNS (>1 day) SUBACUTE DENERVATING DISORDER HISTORY OF MALIGNANT HYPERTHERMIA

SUX IS STILL KING:

SUX IS STILL KING

SUX versus ROC:

SUX versus ROC 45 seconds ONSET 1 minute 9 minutes DURATION 45 minutes 1 mg/kg 1-1.5 mg/kg

PROTECTION AND POSITIONING t + 20 seconds:

PROTECTION AND POSITIONING t + 20 seconds May NOT be helpful

Positioning: Medical vs. Trauma:

Positioning: Medical vs. Trauma

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C Spine Precautions

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C Spine Precautions

Positioning Adult vs Pedi:

Positioning Adult vs Pedi

Cormack & Lehane Grading:

Cormack & Lehane Grading

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Sweep Left and Look Orotracheal Intubation Procedure

Adult vs Pedi:

Adult vs Pedi Normal Trachea

PLACEMENT AND PROOF t + 45 seconds:

PLACEMENT AND PROOF t + 45 seconds

POST-INTUBATION MANAGEMENT t + 90 seconds :

POST-INTUBATION MANAGEMENT t + 90 seconds

More to come next month……….:

More to come next month……….

POST-INTUBATION MANAGEMENT t + 90 seconds :

POST-INTUBATION MANAGEMENT t + 90 seconds CONFIRM PLACEMENT & SECURE TUBE

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Capnography

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Post-intubation CXR

INTUBATION HURTS!:

INTUBATION HURTS! And it keeps on hurting once the tube is in…

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POST-INTUBATION MANAGEMENT Achieve Adequate Analgesia and Sedation

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POST-INTUBATION MANAGEMENT Raise the Head of the Bed to at Least 30°

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Confirm Lung Protective Vent Settings POST-INTUBATION MANAGEMENT Mode AC V T 6-8 cc/kg Rate 12-16 PEEP 5 FiO 2 100% then titrate down Standard Ventilator Settings

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POST-INTUBATION MANAGEMENT Continuous waveform ETCO2 NG / OG tube Empty the stomach to reduce the chances of aspiration and to improve lung mechanics

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POST-INTUBATION MANAGEMENT Nebulizers/MDI If they were intubated for reactive airway disease, then they need frequent nebs

Acute Deterioration after Intubation:

Acute Deterioration after Intubation D.O.P.E.S : D isplacement O bstruction P neumothorax E quipment failure S tacked Breaths

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Basics of Post-Intubation Ventilator Management

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Basics of Ventilator Management Lung Injury Obstructive Lung Disease Use as Default

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Basics of Ventilator Management Lung Injury Lung Protective Management 1. Mode: use A/C (assist control)

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Basics of Ventilator Management Vt IFR FiO 2 PEEP RR

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Basics of Ventilator Management Vt Tidal Volume 6-8 cc/kg IBW Vt = Lung Protection

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Basics of Ventilator Management IFR Inspiratory Flow Rate = how quickly the breath is delivered 60-80 LPM IFR = Comfort

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Basics of Ventilator Management RR Respiratory Rate 16-18 BPM RR = Ventilation

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Basics of Ventilator Management FiO 2 PEEP Start @ 100% Wait 5 min Get ABG Drop to 40% FiO 2 Goal: Saturation of 88-95%

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Basics of Ventilator Management FiO 2 PEEP Start with 5 Positive End-Expiratory Pressure - PEEP

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Basics of Ventilator Management FiO 2 PEEP FiO 2 + PEEP = Oxygenation

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Inspiratory Plateau Pressure _________________________________________________ Peak Plateau Plateau Pressure < 30 cmH 2 O Must find and hold Inspiratory Hold button Ventilator will then display Plateau Pressure

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Basics of Ventilator Management Vt IFR FiO 2 PEEP RR

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Basics of Ventilator Management Analgesia 1st Sedation 2nd

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The Crashing Asthmatic

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Crashing Asthmatic Sweaty Can ’ t Talk Tachypneic Tripoding

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Maximal O2 (NRB) Inhaled Albuterol Inhaled Atrovent IV Steroids IV Magnesium SC Terbutaline Epinephrine drip Crashing Asthmatic THE KITCHEN SINK – Maximal Rx

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Crashing Asthmatic BiPAP CPAP NON-INVASIVE VENTILATION

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Too Early Too Late Crashing Asthmatic WHEN TO INTUBATE

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Crashing Asthmatic Etomidate Succinylcholine GO FAST! Lidocaine Ketamine KEEP IT SIMPLE! OPTIONS... HOW TO INTUBATE

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Crashing Asthmatic Use a Big ETT AGGRESSIVE TOILET Reason #1 Mucous Plugs

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Crashing Asthmatic Reason #2 Dehydration IV FLUID BOLUS

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Reason #3 Breath Stacking Crashing Asthmatic Squeeze Chest Low Vent Settings

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Crashing Asthmatic Chest Tubes Reason #4 Barotrauma

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Cardiac Arrest Post-Intubation 1 Disconnect ventilator 2 Squeeze chest 3 Bilateral chest tubes 4 Fluid bolus Summary

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Crashing Asthmatic Last Chance……… Anesthetic Gases

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ECMO

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Extracorporeal Membrane Oxygenation (ECMO)

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Pearls

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Can ’ t see the cords - …try BURP Another attempt needed – … change something

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Call for help !

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Have a backup plan “ Prior planning prevents poor performance ”

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Don ’ t panic!

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Thank you! Mark P. Brady PA-C Dept.of Emergency Medicine Cambridge Health Alliance Cambridge, MA

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