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14th Annual North State Pre-hospital Conference 2018 May 19, 2018 Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 1 Airway Management and The Difficult Airway Gary McCalla, MD, FACEP Medical Director REACH Air Medical Services

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Page 1: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 1

Airway Management and

The Difficult Airway

Gary McCalla, MD, FACEPMedical DirectorREACH Air Medical Services

Page 2: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 2

“It is not enough to do your best, unless you have prepared to be

the best”.

-John McDonald

Page 3: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 3

Introduction

The primary objective of emergency airway management is to oxygenate and ventilatethe patient

You must be prepared to assure optimal oxygenation and ventilation through proper airway management.Brain death occurs in 6-10 minutes

Page 4: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 4

Objectives

Recognize normal airway anatomy. Identify clinical conditions that require airway

management Use indicators to predict a difficult airway. Discuss options and techniques used to

establish and maintain airway patency.

Page 5: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 5

Glotticopening

Arytenoidcartilage

Tongue

Epiglottis

Vallecula

Vocalcord

Airway Anatomy

Page 6: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 6

Airway ManagementClinical Indications Airway failure or impending airway failure Inability to protect airway (observe for

spontaneous swallow) Do not check a “gag” Inadequate ventilation / oxygenation Presence of clinical conditions that require

active management of the patient and/or the patient’s airway, now or in the future

Always ask do they need intubation right now

Page 7: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 7

Difficult Airway Assessment

LEMONLook externallyEvaluate 3-3-2Mallampati ScoreObstructionNeck Mobility

Page 8: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 8

Difficult Airway Assessment

LEMON Look externally

Page 9: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 9

Difficult Airway Assessment

LEMONEvaluate 3-3-2

Page 10: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 10

Difficult Airway Assessment

LEMONMallampati Score

Page 11: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 11

Difficult Airway Assessment

LEMON Obstruction

Page 12: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 12

Difficult Airway Assessment

LEMON Neck Mobility

Page 13: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 13

Difficult Airway Assessment

Three Quick Questions1. Can the patient open his mouth wide?2. Does the patient have a chin?3. Can the patient move his neck?

Page 14: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 14

HEAVEN Criteria

Another tool being looked at Shown to predict difficult airway Hypoxemia Extremes of size Anatomic challenges Vomit/blood/fluid Exsanguination/anemia Neck Mobility

Page 15: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 15

Airway Management

What is the right airway? If you have an effective BLS airway, you have

to consider Does the benefit of placing an advanced airway

outweigh the potential adverse effects of that attempt?

Time

Page 16: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 16

Apnea time and Airway Management As part of RSI there will be a period of patient

apnea that we will need to deal with Pre oxygenation adds time for safe apnea Ability to BVM is key (MOANS) Can I use a Supra Glottic Airway (RODS) Can I do surgical airway (SHORT) These help us decide how we can manage the

airway during the apnea time

Page 17: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 17

Can I BVM them?

MOANS

Mask seal? Worse with facial hair, trauma, burns

Obstruction/Obese Both make BVM difficult Age over 55 more redundant loose tissue No teeth Leave teeth in for BVM out for ETI Stiff Lungs, need more pressure Asthma,

inhalation etc.

Page 18: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 18

Will a Supra Glottic Airway work?

RODS

Restricted mouth opening Obstruction Distorted anatomy Stiff lungs.

Page 19: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 19

SHORT

Surgery (distorted anatomy) Hematoma ( Blood includes infection) Obstruction/Obesity Radiation (Fresh or old) Tumor

This is a mnemonic for possible difficulties with cricothyrotomy.

Page 20: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 20

Obstruction is not your Friend

Note that Obstruction is in every pneumonic Airway obstruction and inability to manage the

airway with our tools leads you quickly to a surgical crich.

Page 21: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 21

Airway Management

“Performing an intubation is generally easier than deciding which intubation technique to use, which in turn is generally easier than deciding who to intubate, which in turn is generally easier than deciding precisely whento intubate…”

-Ron Walls, MD

Page 22: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 22

Five questions

Do we need the airway now? Or time for other planning

Will they be easy to BVM? Will they be an easy intubation? Will a supraglottic airway work? Will they be easy to crich?

Page 23: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 23

Airway Management

The Ten(+1) Commandments Remain Calm Have a organized game plan (have enough players) BLS before, during and after ALS Pre-oxygenate (gives you time to not rush the intubation) Keep track of time (with a watch, do not guess) Don’t fail to bail, go back to BVM If you can’t ventilate - Intubate If your first attempt is unsuccessful – Do something different If you can’t Intubate - Ventilate If you can’t Ventilate or Intubate - Rescue Practice, Practice, Practice

Page 24: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 24

Airway Management

Use the proper tube size Pre-oxygenate the patient

prior to an attempt Premedicate with

appropriate medications

Have enough personnel available

Attempt only 3 times total if that fails rescue

Practice, Practice, Practice

Tricks-of-the-Trade

Page 25: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 25

Airway Management

Visualization In the perfect world

BA

CC

A

B

TracheaPharynx

Mouth

Page 26: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 26

Airway Management

Visualization External Laryngeal Manipulation

Cricoid Pressure

Page 27: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 27

Airway Management

Vizualization

Line the ears up with the sternum

Something behind the occiput

Page 28: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 28

Airway ManagementVizualization Morbidly obese patients

Airway Cam Photo

Page 29: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 29

Airway Management

Visualization POC - POM ELM

Page 30: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 30

Airway Management

Alternate Techniques Endotracheal Tube

Introducer A great second attempt

device

Page 31: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 31

LMA Supreme

Better than the old one Good for EMS Firm tip so no flop over Built in bite block Other types also

Page 32: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 32

King Airway

Rescue airway Not blind for us Most of the time

Page 33: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 33

Airway Management

Combitube

G

H

C

B

E

D

A

F

I

Rescue Airways

Combitube

Page 34: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 34

Video larygoscopes

CMAC Glide Scope Others

Page 35: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 35

Airway Management

Rescue Airways Needle Cricothyrotomy

Page 36: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 36

Advanced Airway Management

Rescue Airways Needle Cricothyrotomy

Transtracheal jet insufflator

Page 37: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 37

Airway Management

Rescue Airways Surgical Cricothyrotomy Cricothyrotomy

Page 38: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 38

Airway Management

Lessons Learned Multiple attempts (limit 3 less than 1% success after

that) Failure to be prepared Failing to anticipate a difficult airway Rushing the intubation Equipment failure (Suction) Not changing anything in between intubation attempts Intubating patients instead of treating the underlying

cause When in doubt pull it out

Page 39: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 39

Rapid Sequence Induction

Gary McCalla, MD, FACEPMedical DirectorREACH Air Medical Services

Page 40: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 40

Goals for Today

List indications for rapid sequence induction (RSI). Identify equipment and supplies needed to perform

RSI. Discuss the various types of pharmacological agents

utilized in RSI. Discuss risks/pitfalls of RSI.

Page 41: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 41

What?

Use of chemicals to paralyze and sedate patients to facilitate endotracheal intubation

Page 42: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 42

Who?

Patients with decreased respiratory effort A presumed clinical course that will need it Patients at risk of airway compromise

Decreased O2

Increased CO2

Aspiration Closed Head Injured (CHI) patients

Control ventilation

Page 43: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 43

RSI Considerations

Respiratory failure

Loss of protective airway reflexes (not gag) (Look for spontaneous swallowing)

Glasgow coma score of 8 or less Severe head trauma

Asthma or respiratory illness

Spinal cord injuries

Burns to the face or airway

Combative patients Status epilepticus

Page 44: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 44

Why?

Protect airway (aspiration) Provide oxygenation and ventilation Control ventilation Protect and/or treat ICP Increase success rate

Page 45: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 45

When?

When indicated Scene vs. vehicle BLS “OK” if working

Page 46: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 46

How?

BLS is always “OK” if working The seven “P’s”

Preparation Preoxygenate Pretreat

Time out Paralysis Protect Place Post-intubation

Page 47: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 47

Preparation

Assess for the difficult airway (LEMON)(SHORT)(MOANS) (RODS) L = Look externally E = Evaluate the 3-3-2 M = Mallampati O = Obstruction? N = Neck mobility

Plan approach Assemble drugs and equipment Establish access Establish monitoring

Page 48: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 48

Preoxygenation

Pre-oxygenation is critical in airway management 100% oxygen for five minutes (spontaneous

breathing) 8 vital capacity breaths if underventilating

Provides “reservoir” of oxygen for apnea time Can augment this with high flow oxygen via

Nasal cannula at 12-15L/Min leave on during attempts

Page 49: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 49

Pretreatment

Pretreatment = “LOAD” L = Lidocaine O = Opioid A = Atropine D = Defasciculation

Page 50: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 50

TIME OUT

Is the patient ready Am I ready Are the meds and equipment ready What is my next step if this doesn’t work When will I stop and bag them again This is the plan for the “missed airway”

Page 51: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 51

Paralysis with Induction

Neuromuscular blocker IV push Rocuronium Induction agent IV push Etomidate for most Ketamine for sepsis, asthma, hypotensive

Page 52: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 52

Protection

Sellick manuever Position patient (sniffing) No bagging unless SpO2 < 95%

Why?

Page 53: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 53

Placement

The Six ETT Checks Visualize EtCO2 Lung sounds Chest rise/fall Mist in the tube Pulse oximetry

Page 54: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 54

Post-Intubation Management

Secure the tube Administer longer acting sedation

Page 55: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 55

Dangers/Pitfalls

Tube placement can’t be obtained Rare Rescue devices

Medication reactions Must know your medications HypotensionEtomidate and adrenal suppression Decrease in respiratory drive

Page 56: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 56

Questions

Page 57: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 57

Test Review Question 1:

The LEMON rule is way to access for difficult intubation. True False

Page 58: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 58

Test Review Question 1:

The LEMON rule is way to access for difficult intubation. True False

Page 59: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 59

Test Review Question 2:

Which of these is NOT parts of the MOANS acronym for BVM ease? A. Mask seal B. Age C. Male D. Stiff lungs

Page 60: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 60

Test Review Question 2:

Which of these is NOT parts of the MOANS acronym for BVM ease? A. Mask seal B. Age C. Male D. Stiff lungs

Page 61: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 61

Test Review Question 3:

Checking the gag reflex is necessary for good airway assessment True False

Page 62: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 62

Test Review Question 3:

Checking the gag reflex is necessary for good airway assessment True False

Page 63: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 63

Test Review Question 4:

Tube placement can’t be obtained True False

Page 64: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 64

Test Review Question 4:

Tube placement can’t be obtained True False

Page 65: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 65

Test Review Question 5:

Tube placement can’t be obtained True False

Page 66: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 66

Test Review Question 5:

Tube placement can’t be obtained True False

Page 67: Airway Management and The Difficult Airway · 2018. 5. 19. · Airway Management Lessons Learned Multiple attempts (limit 3 less than 1% success after that) Failure to be prepared

14th Annual North State Pre-hospital Conference 2018 May 19, 2018

Presented by Gary McCalla, MD, FACEP, Medical Director for REACH Air Medical Services 67

The REACH Training Institute

1.888.660.9888 [email protected]


in the Trauma Patient - EmergencyPedia · Emergency Airway Management in the Trauma Patient:: NSW ITIM PAGE 1 AIRWAY MANAGEMENT SUMMARY Algorithm 1 :: Airway Management Airway Management

The Emergency Airway Algorithms2 mg/kg IVP no Attempt intubation ≥ 3 attempts by experienced operator? no no Failed airway yes Maintain oxygenation yes Post intubation management

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