Kelowna June 2011 Airway Assessment and Management. Golden, BC

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1 Kelowna June 2011 Airway Assessment and Management Dr. Bruce Starke Golden, BC

2 Not really...

3 I am unable to identify any potential conflict of interest and I am unable to identify any potential conflict of interest, and have nothing to declare.

4 Assess the need for airway intervention Develop a game plan Recognize the difficult airway RSI and alternatives backup plan Hands on equipment

5 O2 Clear airway, suction Head H d position ii remember C spine! Oropharyngeal airway etc Bag and Mask

6 Respiratory Failure now, or impending Inability to protect airway For stabilization pre transport

7 GCS<8, or deteriorating LOC Asthma, COPD exacerbations Uncontrolled seizures Facial, neck trauma Airway burns Chest trauma Anaphylaxis, angioedema

8 1. Remain calm 2. Have a plan 3. Get help early 4. First attempt at intubation unsuccessful, try again but do something different 5. Can t intubate ventilate 6. Can t intubate or ventilate emergency airway options 7. Practise, review your plan frequently

9 Obesity, short neck Stiff neck Small mouth opening Prominent incisors Short mandible/beard Airway a injury or deformity Foreign bodies or secretions Mallampati p Score RULE: 3 fingers of mouth opening 3 fingers mentum to hyoid 2 fingers hyoid to thyroid

10 Potentially difficult airways...

11 Mll Mallampati tiscore

12 Mallampati 0?

13 1. Preparation 2. Pre oxygenation 3. Pre treatment 4. Paralysis and Induction 5. Protection/Positioning 6. Proof of placement 7. Post intubation management

14 Oxygen, tubing BVM BVM, mask Oral airway 2 laryngoscopes and blades ET tubes Stylet Securing tape Syringes, needles Medications pretreatment, paralysis, induction, maintenance Oximeter, CO2 monitor, BP, ECG

15 LMAs McGill MGill forceps Glidescope Bougie introducer Lightwand Specialized laryngoscope blades Flexitip Fibre optics Cricothyrotomy kit Needle cricothyrotomy Jet Jt ventilation

16 100% o2 Adults 3 5min of 100% O2, or 8 vital capacity breaths Children desat. faster

17 A. Asthma lidocaine 1.5mg/kg B. Brains/babies bb lidocaine ld Fentanyl 1 3mcg/kg atropine 0.02mg/kg dexamethasone 4mg C. Cardiovascular Fentanyl Lidocaine Opiates Atropine Dexamethasone

18 Succinylcholine depolarizing muscle relaxant acts on the acetyl choline receptors activates the receptor,so get fasciculation rapid onset, short duration (2 5min.) dose 1 2mg/kg contraindic. burns>24hrs denervating injuries>7d neuromuscular disorders malignant hyperthermia etc.

19 Non depolarizing Neuromuscular Blockers: Rocuronium slightly slower onset than sux, longer Tx dose 1.0mg/kg to intubate (if sux contraindic.) 0.2mg/kg boluses to maintain Pancuronium slower and longer, tachycardia Mivacurium maybe curium New Stuff

20 Midazolam Etomidate Ketamine Propofol can be used for induction and maintenance, antiseizure hypotension dose mg/kg least cardiovascular effect, reduced CNS O2 demand muscular rigidity,? Adrenal suppression dose 03mg/kg 0.3mg/kg increases HR and CO good if hypotensive bronchodilator, quick look emergence issues, esp in adults dose 1 2mg/kg quick, patients feel great! hypotension, stings on injection dose mg/kg

21 Head injury pretreat xylocaine, Fentanyl, dex. paralysis sux is OK induction etomidate, or midazolam Seizures induction midazolam, or pentothal Asthma induction ketamine Hypotension induction ketamine Quick look pretreat lidocaine spray, ketamine

22 Preoxygenate, and pretreat if indicated Induce and apply Cricoid pressure( protection and positioning) Paralyze Intubate, remove stylet, inflate cuff d/c cricoid pressure 6. 6 Placement and Proof ECO EtCO2, auscultate, maintain i O2 sat

23 Anatomy:

24 Glidescope view:

25 Okay...we can deal with this...

26 Sedation midazolam bolus 2 4mg morphine propofol drip 0.05mg/kg/hr 00 bolus 5 10mg drip mg/kg/h g bolus 10 50mg (0.5 1mg/kg) drip 1 3mg/kg/hr Paralysis rocuronium bolus 0.2mg/kg q30 minutes pancuronium bolus 0.1mg/kg q1h

27 Maintain adequate CO2 Chest xray ET tube position PEEP of 5cm H2O VentilatorV Chest tube?

28 NG or OG tube Foley More IV lines? Continue circulatorysupport... Td, antibiotics Preparations for transport

29 O H Oxygen Help S System and supplies H Help I Induction, intubation T Transport

30 Anaphylaxis Angioedema OH SHIT!

31 Up to Date: Rural Critical Care Manual RSI ipod app Rapid Sequence Intubation in Adult The Decision to Intubate Pretreatment Agents for RSI Sedation or Induction Agents for RSI Neuromuscular Blocking Agents for RSI

32 Don t forget to practise!

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