airway management 3

Airway ManagementAirway Management

Emergency Medicine Emergency Medicine

Seminar SeriesSeminar Series

Michael HaMichael HaSection of Emergency Medicine

4th year Resident

John SokalJohn SokalHealth Sciences Centre

12 years

Bob SweetlandBob SweetlandHealth Sciences Centre

15 years

CHURCHILL

ASHERN

PINE FALLS

April 25, 2002

April 26, 2002

STEINBACH

BOUNDARY TRAILS

May 2, 2002

BRANDON

KILLARNEY

PORTAGE

RUSSELL

DAUPHIN

SWAN RIVER

May 3, 2002

FLIN FLON

LYNN LAKE

THE PAS

May 14, 2002

eMEDiUMeMEDiUM

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CAEP CAEP ACEP ACEP

CME ObjectivesCME Objectives

To discuss:

• the indications for intubation

• the approach to RSI

• capnometry

• bougies

Intubate?

RSI vs. Awake

Preparing for patient

Difficult BVM

Difficult Intubation

Capnography

Laryngoscopy Tips

Bougies

Lightwand - LMA

Preoxygenation

Pretreatment

O2 Delivery

Thiopental

Ketamine

Propofol

Succinylcholine

Rocuronium

Finish

Master

Intubation Indications

Is there a failure of

airway maintenance or protection?


ventilation or oxygenation?

What is the

anticipated clinical course?

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45 female

alcoholic beverages empty pill bottles

HR 125

BP 98/40

RR 20 GCS 8

O2Sats 100% (PRB)

no injuries

Questions?

Indication?

Awake vs RSI?

LOAD?

Induction agent?

Paralytic agent?

cases

Cases60 VF

44 MVA

25 asthma

15 fall

28 bull

16pencil

40fire

22 TCA

54CRF

67HTN

51melena

45 overdose

AMI VF - defibrillated 3x

60 male IHD

HR 110

BP 68 / 40

RR 10

O2Sats 90% (BVM)

Questions?

Indication?

Awake vs RSI?

LOAD?

Induction agent?

Paralytic agent?

cases

MVA MVA 100 kph kph

44 female

HR 130

BP 100 / 70

RR 28

O2Sats 99% (BVM)

GCS 6

Questions?

Indication?

Awake vs RSI?

LOAD?

Induction agent?

Paralytic agent?

cases

SOB 2 days severe distress

HR 145

BP 98 / 42

RR 30

O2Sats 80% (PRB)

Questions?

Indication?

Awake vs RSI?

LOAD?

Induction agent?

Paralytic agent?

25 female asthma

cases

fell from treefell from tree

HR 110

BP 100 / 50

RR 20

O2Sats 99% (BVM)

GCS 8

Questions?

Indication?

Awake vs RSI?

LOAD?

Induction agent?

Paralytic agent?

15 15 female

cases

playing with bull blunt trauma

HR 130

BP 80 / 60

RR 28

O2Sats 99% (PRB)

abdomen rigid

pelvic fracture

Questions?

Indication?

Awake vs RSI?

LOAD?

Induction agent?

Paralytic agent?

cases

28 male

pencil oropharynx 'buddy' pulled it out

HR 80

BP 115 / 60

RR 16

O2Sats 99% (room)

voice change

hematoma visible

Questions?

Indication?

Awake vs RSI?

LOAD?

Induction agent?

Paralytic agent?

cases

16 male

house fire prolonged exposure

HR 115

BP 130 / 60

RR 28

O2Sats 96% (PRB)

singed facial hair

soot in mouth

Questions?

Indication?

Awake vs RSI?

LOAD?

Induction agent?

Paralytic agent?

cases

40 female

ingestion amitryptyline quantity unknown

HR 145

BP 100 / 42

RR 14

O2Sats 99% (PRB)

GCS 8

Questions?

Indication?

Awake vs RSI?

LOAD?

Induction agent?

Paralytic agent?

cases

22 22 female

on dialysis holiday respiratory distress

HR 115

BP 200 / 120

RR 36

O2Sats 88% (NRB)

peaked T's

Questions?

Indication?

Awake vs RSI?

LOAD?

Induction agent?

Paralytic agent?

cases

54 male CRF DM

on ACE inhibitor oral angioedema

HR 85

BP 150 / 80

RR 20

O2Sats 99% (room)

slight stridor

Questions?

Indication?

Awake vs RSI?

LOAD?

Induction agent?

Paralytic agent?

cases

67 female HTN

melena 2 days hematemesis

HR 165

BP 50 palpation

RR 28

O2Sats 92% (NRB)

vomiting red blood

Questions?

Indication?

Awake vs RSI?

LOAD?

Induction agent?

Paralytic agent?

cases

51 male cirrhosis

HR 125

BP 180 / 100

RR 32

O2Sats 86% (NRB)

SOB over 3 days SOB over 3 days worsened overnightworsened overnight

Questions?

Indication?

Awake vs RSI?

LOAD?

Induction agent?

Paralytic agent?

cases

68 male CHF

Intubate?Intubate?

Custom Shows

45 female

alcoholic beverages empty pill bottles

Intubate?Intubate?

HR 125 BP 98/40

RR 20 GCS 8

O2Sats 100% (PRB)

no injuries

Indication?

50 yo male

SOB over 2 days worsened overnight

HR 135 BP 150/90

RR 10

O2Sats 86% (NRB)

'tight'

wheezes bilaterally

Intubate?Intubate?

Indication?

HR 100 BP 105/60

RR 20 GCS 10

O2Sats 100% (PRB)

multiple injuries

transfering to HSC

Indication?

34 yo male

MVA ejected from car

Intubate?Intubate?


What is the







What is the


Back

RSI vs Awake?RSI vs Awake?

Custom Shows

Rapid Sequence IntubationRapid Sequence Intubationa potent induction agent

followed immediately by

the patient has not fasted• at risk of aspiration

a rapidly-acting NMB

to induce unconsciousness and motor paralysis for intubation.

Rapid Sequence IntubationRapid Sequence Intubation

take nothing that you cannot return or replace

approach every airway as a potential difficult airway

be prepared

The 7 P’sThe 7 P’s1. Preparation

2. Preoxygenation

3. Pretreatment

4. Paralysis with induction

5. Positioning with protection

6. Placement with proof

7. Postintubation management

Awake IntubationsAwake Intubations

“Awake” means that patient can:

• follow simple instructions

• provide feedback

• can respond to events

• sedation – versed, fentanyl• topical lidocaine• oral, nasotracheal, fiberoptic

Paralysis contraindications

Choices… paralyze?Choices… paralyze?

prediction of difficulty

difficult BVM

difficult intubation

lack of equipment

unnecessary

inexperience

PreparationPreparationDifficultDifficult AirwaysAirways

Custom Shows

STOP IC BARS

S staff, suction

T tube

O oxygen

P pharmacology (meds)

PreparationPreparation


I intravenous lines

C connect to monitors

B blades, bougies

A alternate (lightwand)

R rescue (LMA, combitube)

S surgical (cricothyroidotomy)

STOP IC BARS

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Difficult Mask VentilationDifficult Mask Ventilation

B eard


O bese


O lderT oothless


S nores

PreparationPreparationAssessment for Difficult Mask Ventilation

BOOTS

B beard

O obese

O older

T toothless

S snores

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repositionOP / NP airway2 person change mask? obstruction

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RepositioningRepositioningOral – Pharyngeal - Laryngeal Axes

RepositioningRepositioningHead extended on neck

RepositioningRepositioning“Sniffing” position

RepositioningRepositioning“Sniffing” with extension

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Assessment for a difficult intubation

Lemon Law

L look E evaluate (3-3-1 rule)M MallampatiO obstructionN neck mobility

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3-3-1 Rule3-3-1 Rule

3

3 fingersmouth

opening

1 fingeranterior jaw subluxation

31

3 fingershyomentaldistance

(room for tongue)

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MallampatiMallampati

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PreparationPreparationPreoxygenationPreoxygenation

PretreatmentPretreatment

PreoxygenationPreoxygenationis the establishment of an is the establishment of an oxygen reservoir.oxygen reservoir.

• “ “no baggingno bagging” principle of RSI” principle of RSI

• “ “apnea timeapnea time” concept” concept

• 100% O100% O22 for 5 minutes for 5 minutes

• effect of body size & metabolic demandseffect of body size & metabolic demands

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ApneaTime

PretreatmentPretreatmentis the administration of drugs is the administration of drugs to mitigate the adverse effects to mitigate the adverse effects associated with intubation.associated with intubation.

L L idocaineidocaineO O piodespiodesA A tropinetropineD D efasciculationefasciculation

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Induction AgentsInduction Agents

Paralysis after inductionParalysis after induction

thiopentalthiopentalketamineketaminepropofolpropofoletomidateetomidateversedversed

succinylcholinesuccinylcholinerocuroniumrocuronium

skip drug section

Contraindication: porphyria

ThiopentalThiopentalINDUCTIONINDUCTION

cerebroprotective

potent vasodilator myocardial depressant

ThiopentalThiopentalINDUCTIONINDUCTION

Onset: 15 - 30 seconds

Dose: 3 - 5 mg / kg (euvolemic)

1 - 3 mg / kg (hypovolemic)

Duration: 5 - 10 minutes

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analgesia - amnesia

KetamineKetamineINDUCTIONINDUCTION

bronchodilation

catecholamine release

hypovolemic - hypotensive agent of choice

ICP (significance ?)(cerebroprotective ??)

stimulating effects: laryngeal reflexessecretions

KetamineKetamineINDUCTIONINDUCTION


Dose: 1 - 2 mg / kg


lower dose if profound shock:maximal sympathetic stimulation already -ketamine has intrinsic CV depression

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PropofolPropofolINDUCTIONINDUCTION

dose-dependant sedation - amnesia

no analgesic properties

airway reflexes: dose-dependant depression

potent vasodilator, myocardial depressant(effect may exceed that of thiopental)

cardiac & respiratory depression related to rate of administration as well as dose

cerebroprotective ICPICP CPP

Contraindication:Contraindication: egg, soybean allergiesegg, soybean allergies

PropofolPropofolINDUCTIONINDUCTION

Onset:Onset: 30 - 4030 - 40 secondsseconds

1 - 31 - 3 mg / kg mg / kg (induction)(induction)Dose:Dose:

Duration:Duration: 5 - 105 - 10 minutesminutes

Combo: Combo: ketamine 50 mgketamine 50 mgpropofol propofol 50 mg50 mg

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EtomidateEtomidateINDUCTIONINDUCTION

most hemodynamically stablemost hemodynamically stable

minimal cardiac & respiratory depressionminimal cardiac & respiratory depression

cortisol suppression (cortisol suppression (nono ED cases) ED cases)

myoclonus / hiccupsmyoclonus / hiccups

cerebroprotectivecerebroprotective ICPICP

30% - 40% nausea / vomiting30% - 40% nausea / vomiting

does not block BP response to intubation does not block BP response to intubation

Onset:Onset: 20 - 3020 - 30 seconds seconds

Dose:Dose: 0.2 - 0.30.2 - 0.3 mg / kg mg / kg

EtomidateEtomidateINDUCTIONINDUCTION

Duration:Duration: 5 - 155 - 15 minutes minutes

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NMBNMB

Paralysis contraindications

Choices… paralyze?Choices… paralyze?

prediction of difficulty

difficult BVM

difficult intubation

lack of equipment

unnecessary

inexperience

SUX contraindications

Choices… SUX or ROC?Choices… SUX or ROC?

difficult BVM or intubation neuromuscular disorders hyperkalemia 24 hours post-burns 7 days post-crush 7 days post-denervation malignant hyperthermia

SuccinylcholineSuccinylcholinePARALYSISPARALYSIS

• duration of action is dependant on:• rapid hydrolysis - pseudocholinesterase• diffusion away from motor end plate (no

pseudocholinesterase at end plate)

• only a fraction of dose ever reaches end plate give large doses no harm giving too much problem when incompletely paralyzed give extra 20% (2 mg / kg)

• depolarizing NMB fasciculations

Onset: 10 - 15 seconds (fasciculations)

45 - 60 seconds (paralysis)

Dose: 1 - 2 mg / kg (adults) 2 mg / kg (children) 3 mg / kg (newborns)

SuccinylcholineSuccinylcholine

Duration: 3 - 5 minutes (some resps)

8 - 10 minutes (adequate)

PARALYSISPARALYSIS


Side- Effects

• fasciculations

• hyperkalemia

• bradycardia

• malignant hyperthermia

• prolonged blockade

• trismus - masseter muscle spasm

PARALYSISPARALYSIS

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Fasciculations

• nicotinic receptor stimulation

• inhibiting fasciculations - little evidence

• occurs same time as ICP

PARALYSISPARALYSIS

side-effects


SUX-induced Hyperkalemia

• under normal situations, increase of:

0.50.5 mEq/L KmEq/L K++

• small risk of dysrythmia: CRF severe acidosis rhabdomyolysis

Preexistent K+

PARALYSISPARALYSIS

• increased extrajunctional receptors:

5 - 105 - 10 mEq/L KmEq/L K+ +

prolonged depolarization

refractory to non-depolarizing NMB, may require large doses


Exaggerated release of KExaggerated release of K++

PARALYSISPARALYSIS


Exaggerated release of K+

• functional denervation of muscle: stroke spinal cord injury

• extensive burns

• massive crush injuries

• neuromuscular disorders

PARALYSISPARALYSIS

side-effects


Receptor Recruitment & Sensitization

Onset: 7 daysDuration: 2 - 3 months

Crush:

Onset: 7 daysDuration: 6 months

Denervation:

Onset: 24 hoursDuration: 2 years

Burns:

(% burn does not determine response)

Neuromuscular disorders:


Receptor Recruitment & Sensitization

SUX contraindicated

If give SUX: intractable cardiac arrest may

occur (even if recognize and treat K+)

side-effects


Bradycardia

• cardiac muscarinic receptor stimulation

• succinylmonocholine (a metabolite) sensitizessinus node receptors to repeat doses

consider atropine if: age < 10repeating dose

• children have vagal tone

PARALYSISPARALYSIS

side-effects


Prolonged Neuromuscular BlockadeProlonged Neuromuscular Blockade

• congenital absence of pseudocholinesterase

• presence of an atypical form

may last hours

PARALYSISPARALYSIS

• acquired absence:• cocaine• metoclopramide (Maxeran)• CRF• severe liver disease• hypothyroidism• malnutrition• pregnancy• cytotoxic drugs• organophosphates


Prolonged Neuromuscular Blockade

PARALYSISPARALYSIS

• acquired absence:

• even worst of acquired not reportedto last > 25 minutes

SUX not contraindicated


Prolonged Neuromuscular Blockade

PARALYSISPARALYSIS

side-effects

• mortality 60%

• onset can be acute or delayed for hours


Malignant Hyperthermia

• genetic skeletal muscle abnormality

• can be triggered by: SUX stress vigorous exercise halothane

PARALYSISPARALYSIS

• muscle rigidity• autonomic instability• hypotension• hypoxia• severe lactic acidosis• myoglobinemia• DIC• fever - late manifestation


Malignant Hyperthermia

PARALYSISPARALYSIS

side-effects

• prevents Ca++ release from sarcoplasmic reticulum of skeletal muscle


Dantrolene for MH

• essential to resuscitation

• give as soon as Dx suspected

• free of serious side-effects

Dose: 2.5 mg/kg IV q5min until muscle relaxation, or max 4

doses

PARALYSISPARALYSIS

side-effects


Trismus - Masseter Muscle Spasm

• rise in jaw muscle tension is normal should not affect laryngoscopy

• pretreatment will not prevent

• if severe, or progresses to other muscles: consider malignant hyperthermia spasm is not pathonomonic for MH

• if occurs - administer non-depolarizing NMB (Rocuronium)

PARALYSISPARALYSIS

side-effects

RocuroniumRocuronium

• Nondepolarizing, does not stimulate receptor

no fasciculations

PARALYSISPARALYSIS

• minimal hemodynamic effects

• do not need priming dose

Dose: 0.6 - 1.2 mg / kg

RocuroniumRocuroniumPARALYSISPARALYSIS



Defasiculating: 0.05 mg / kg

Comparing NMBComparing NMBPARALYSISPARALYSIS

SUX ROCONSET 30 - 60 60 - 90 sec

DURATION 3 - 10 20 - 60 min

rapid rapidno primingCVS stability

advantages

precautions K+

Comparing NMBComparing NMBPARALYSISPARALYSIS

sec

min

VEC

150 - 180

25 - 30

no histaminerelease

PAN

120 - 180

60 - 90

histaminerelease

ATRA

120 - 150

20 - 35

histaminerelease

PositioningPositioningProofProof

Positioning with protectionPositioning with protection

You are asked to apply:

cricoid pressure

(Sellick’s maneuver)

BURPBURP

B ackwards

U pwards

R ightward

P ressure

• distinct from Sellick’s maneuver• second assistant• first assistant’s other hand

ManeuversManeuvers

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LaryngoscopyLaryngoscopy

Placement with proofPlacement with proof

methods of confirmation

chest riseair entryfogging of ETT60 cc syringe

* capnometer

Colorimetric CapnometryColorimetric Capnometry

exhaled CO2

simple color change from

purple to yellow


NEGATIVE POSITIVE


ETCOETCO2 2 < 4 mm Hg< 4 mm Hg

ETT ETT not innot in trachea trachea

inadequate perfusioninadequate perfusion (ineffective CPR)(ineffective CPR)


ETCOETCO2 2 15 - 38 mm Hg15 - 38 mm Hg

ETT ETT inin trachea trachea


ETCOETCO2 2 4 to < 15 mm Hg4 to < 15 mm Hg

retained COretained CO22 in esophagus in esophagus

low perfusionlow perfusion

deliver deliver 66 more breaths more breaths


Standard of CareStandard of Care

Limitations:

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• decreased cardiac output

• low metabolic CO2 productionex. hypothermia

BougieBougieLightwandLightwand

LMALMA

BougieBougie

Epiglottis

Laryngoscopy GradesLaryngoscopy Grades

CormackLehane

Bougie

LightwandLightwand

LightwandLightwand

Source: Laerdal

Laryngeal Mask AirwayLaryngeal Mask Airway

Source: LMA North Americaskip insertion technique


Source: LMA North America

• deflate the cuff deflate the cuff • apply water-soluble lubricant to the apply water-soluble lubricant to the

posterior surfaceposterior surface• place index finger at the junction of the cuffplace index finger at the junction of the cuff

skip insertion technique



• press the tip of the cuff upward against the hard press the tip of the cuff upward against the hard palate and flatten the cuff against itpalate and flatten the cuff against it




• use the index finger to guide the LMA, use the index finger to guide the LMA, press backward toward the other hand, which press backward toward the other hand, which exerts counter-pressure (do not use force)exerts counter-pressure (do not use force)




• advance the LMA into the hypopharynx until a advance the LMA into the hypopharynx until a definite resistance is felt.definite resistance is felt.

• inflate the cuffinflate the cuff


7. Postintubation mgmt7. Postintubation mgmt

fix tube in placefix tube in placeCXRCXRnasogastric / orogastric tube / orogastric tubelab lab

etcetc

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O2 Delivery SystemsO2 Delivery Systems

O2 Delivery Systems

Nasal cannulae

Double rate - add to room air FiO2

ex. 3 L / min + 21 % FiO2

= 27 %

Limitations:rates > 3 L / min uncomfortablemouth breathing

O2 Delivery Systems

Simple Face Mask

6 – 10 L / min flow

35 – 55 % FiO2

• entrainment of room air through exhalation ports

O2 Delivery Systems

PartialRebreathingFace Mask

reservoir bag

• first ~ 1/3 of exhaled gas is directed into bag

(that which was in patient’s upper airway)

• up to 60 % FiO2

O2 Delivery Systems

Non-Rebreathing Face Mask

• reservoir bag• one-way valves

• up to 80 % FiO2

(realistically)

O2 Delivery Systems

Bag Valve Mask

(BVM)

• up to 100 % FiO2

SummarySummary

Airway ManagementAirway Management

?? ??

eMEDiUMeMEDiUM

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HSC ED HSC ED

Maryann Cromwell

[email protected]

phone: 787-2934fax: 787-2231

Department of Emergency MedicineHealth Sciences CentreGF 201-800 Sherbrook StreetWinnipeg, MBR3A 1R9

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CAEP CAEP ACEP ACEP

airway management 3

Health & Medicine

paralytic agent

awake vs rsi

rsi vs

potentinduction agent

prb questions

awake preparing

awake intubations

injuries indication