Emergency ENT Anaesthesia. Richard Semenov
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1 Emergency ENT Anaesthesia Richard Semenov
2 Emergency ENT Anaesthesia Dr Richard Semenov MBBS (Adel) FRCA (UK) FANZCA Dept of Anaesthesia Royal Adelaide Hospital
3 My Experience in Emergency ENT Anaesthesia Dr Richard Semenov MBBS (Adel) FRCA (UK) FANZCA Dept of Anaesthesia Royal Adelaide Hospital
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6 and we ll throw in a Free set of Steak Knives!
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15 Emergency ENT Anaesthesia Dr Richard Semenov Royal National Throat Nose & Ear Hospital
16 Techniques for difficult intubation in ENT Emergencies
17 Techniques for difficult intubation in ENT Emergencies 1. Alternative laryngoscope blades 2. Awake intubation 3. Blind intubation (oral or nasal) 4. Fiberoptic intubation 5. Intubating stylet/tube changer 6. Laryngeal mask airway as an intubating conduit 7. Light wand 8. Retrograde intubation 9. Invasive airway access
18 Techniques for difficult ventilation in ENT Emergencies
19 Techniques for difficult ventilation in ENT Emergencies 1. Two-person mask ventilation 2. Oral and nasopharyngeal airways 3. Laryngeal mask airway 4. Esophageal-tracheal combitube 5. Intratracheal jet stylet 6. Rigid ventilating bronchoscope 7. Invasive airway access 8. Transtracheal jet ventilation
20 Overview Unsuspected difficult airway Acute Epiglottitis Stridor Obstructed Airway Tracheostomy Stridor in recovery Post thyroidectomy bleed Tracheostomy fire Base of tongue tumour Foreign body Bleeding Tonsil Children Neck trauma Mandibular abscess
21 Techniques for difficult intubation & ventilation in ENT Emergencies 1. Two-person mask ventilation 2. Oral and nasopharyngeal airways 3. Laryngeal mask airway 4. Esophageal-tracheal combitube 5. Intratracheal jet stylet 6. Rigid ventilating bronchoscope 7. Invasive airway access 8. Transtracheal jet ventilation 1. Alternative laryngoscope blades 2. Awake intubation 3. Blind intubation (oral or nasal) 4. Fiberoptic intubation 5. Intubating stylet/tube changer 6. Laryngeal mask airway as an intubating c 7. Light wand 8. Retrograde intubation 9. Invasive airway access 10. Videolaryngoscopy
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23 ENT Emergencies Take a breath Go back to basics
24 RAH ENT Report 1 July June 2012
25 RAH ENT Report 1 July June 2012 Total Number of Cases 1051 Emergency Cases 153
26 RAH ENT Report 1 July June Abscess Drainage Ear Infection Grommet Examination of Postnasal space Exploration of Neck wound Extubation in theatre FESS 22
27 RAH ENT Report 1 July June FESS 22 CSF Leak 01 Sinus Infection 04 Epistaxis/ SPA Ligation 12 Epistaxis/ Diathermy Vessels 05
28 RAH ENT Report 1 July June Foreign Body removal Oesophagoscopy Foreign Body removal Bronchoscopy Emergency Intubation Post-op Bleed Tonsillectomy Panendoscopy Tracheostomy 44
29 RAH ENT Report 1 July June Tracheostomy 44 Tube change 09 Awake Trach for tumour 14 Awake Trach for trauma 01 Prolonged Intubation in ICU 14 Failed or inapprop to extubate in Theatre 06
30 No perfect solution ENT Anaesthesia
31 Emergency ENT Anaesthesia No perfect solution
32 ENT Anaesthesia No perfect solution
33 ENT Anaesthesia No perfect solution 1. Inhalational
34 ENT Anaesthesia No perfect solution 1. Inhalational 2. Awake FOB 3. 4.
35 ENT Anaesthesia No perfect solution 1. Inhalational 2. Awake FOB 3. Rapid Sequence 4.
36 ENT Anaesthesia No perfect solution 1. Inhalational 2. Awake FOB 3. Rapid Sequence 4. Trache under Local
37 ENT Anaesthesia No perfect solution 1. Inhalational 2. Awake FOB 3. Rapid Sequence 4. Trache under Local Child
38 ENT Anaesthesia No perfect solution 1. Inhalational Child Rapid Sequence 4.
39 ENT Anaesthesia No perfect solution 1. Inhalational Rapid Sequence 4.
40 ENT Anaesthesia No perfect solution 1. Inhalational 2. Awake FOB 3. Rapid Sequence 4. Trache under Local
41 ENT Anaesthesia No perfect solution Trauma 1. Inhalational 2. Awake FOB 3. Rapid Sequence 4. Trache under Local
42 ENT Anaesthesia No perfect solution 1. Trauma Rapid Sequence 4. Trache LA
43 ENT Anaesthesia No perfect solution Rapid Sequence 4. Trache LA
44 ENT Anaesthesia No perfect solution Rapid Sequence 4. Trache LA
45 Emergency ENT Anaesthesia 1 Plan each case 2 Keep to known basics
46 Bleeding Tonsil
47 Bleeding Tonsil Issues Frightened child & anxious parents Hypovolaemia Full stomach Residual effects of anaesthetic Difficult intubation
48 Post Tonsillectomy haemorrhage 3.3% in a series of Krishna et al, % in a series of Bhattacharyya, % in a series of Collison et al, % in a series of Ranjit et al, 1999
49 Post Tonsillectomy haemorrhage Risk factors proposed : Patient profile - age, medical conditions Time of the year of surgery Use of local vasoconstrictors and dissection method Immediate post operative state
50 Bleeding Tonsil Prevention Resuscitation Procedure in theatre
51 ENT Anaesthesia Bleeding Tonsil 1. Inhalational 2. Awake FOB 3. Rapid Sequence 4. Trache under Local
52 ENT Anaesthesia Bleeding Tonsil 1. Inhalational Rapid Sequence 4.
53 Bleeding Tonsil Inhalational Lateral Position
54 Bleeding Tonsil Supine Rapid Sequence Previous laryngoscopy LMA
55 Another Call to A & E
56 Another Call to A & E 4 year old girl with inspiratory stridor
57 Another Call to A & E 4 year old girl with inspiratory stridor Unwell for the last 6 hours
58 Another Call to A & E 4 year old girl with inspiratory stridor Unwell for the last 6 hours With a temp of 39 and is now drooling.
59 Acute Epiglottitis Infection Haemophilus Influenza type b Children 2-5 year olds Typical clinical features
60 Acute Epiglottitis Febrile Tachypnoea Sitting forward Drooling
61 Acute Epiglottitis Calm environment No intervention Inhalational Induction
62 Prepared for difficult intubation Tube 1 size smaller than normal Urgent tracheostomy?change to nasal Acute Epiglottitis
63 Prepared for difficult intubation Tube 1 size smaller than normal Urgent tracheostomy?change to nasal Acute Epiglottitis
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67 Acute Epiglottitis Sevoflurane vs Halothane Myocardial dysrhythmias Apnoea in deep planes Airway obstruction
68 Acute Epiglottitis Changing incidence Hib vaccine Introduced Oct , 3 & 4 months
69 Acute Epiglottitis Changing incidence Hib vaccine Introduced Oct , 3 & 4 months
70 Changing Incidence Acute Epiglottitis Incidence in Sheffield Midwinter et al, 1999
71 Acute Epiglottitis Garpenholt et al 1999 Vaccination program in Sweden
72 Acute Epiglottitis >15 year olds
73 Acute Epiglottitis In adults incidence has remained stable Missed vaccination Homeopathy Increased awareness
74 Emergency Bell Rings!
75 Emergency Bell Rings! Patient left in recovery after a long procedure last night. Neck is swelling
76 Postop Thyroid Bleeding
77 Head & Neck Bleed Plan A Prevention Plan B Prevention Plan C Prevention
78 ENT Anaesthesia 1.Inhalational 2.Awake FOB 3.Rapid Sequence 4.Trache under Local
79 ENT Anaesthesia 1.Inhalational 2. 3.Rapid Sequence 4.Trache under Local
80 ENT Anaesthesia PHONE A FRIEND 1.Inhalational 2. 3.Rapid Sequence 4.Trache under Local
81 Head & Neck Bleed Plan A Prevention Plan B Prevention Plan C Prevention Plan Y Remove clips, inhalational induction, remove clot Plan Z Surgical airway
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84 Trache under Local
85 **Emergency Tracheostomy**
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91 Mr Krishnan s ENT list tomorrow, the first patient is a 76 year old man for Panedoscopy and Biopsy.
92 Stridor Obstructed Airway The worst fear of most Anaesthetists
93 Stridor Obstructed Airway - issues
94 Stridor Obstructed Airway - issues 1. Elderly cachetic patient 2. Shared airway & poor access 3. Abn anatomy difficult intubation 4. Smoking CVS & Resp disease 5. Large intraop blood loss 6. Carotid sinus stimulation 7. Air embolus or pneumothorax
95 CEPOD recommendations Discussion with Surgeons Adequate preop evaluation SpR s receive training Fibreoptic Intubation Tracheostomy under LA
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97 Mild Moderate Severe
98 Nasendoscope Assess airway OPD Do not touch cords Supraglottic CT scan
99 Nasendoscope Assess airway OPD Do not touch cords Supraglottic CT scan
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101 Supraglottic - Moderate stridor
102 Supraglottic - Moderate stridor Plan A
103 Supraglottic - Moderate stridor Plan A Inhalation induction in theatre Maintain spontaneous ventilation
104 Supraglottic - Moderate stridor Plan A Inhalation induction in theatre Maintain spontaneous ventilation Anaesthesia 1999, 54, The obstructed airway in head and neck surgery. Mason, Fielder.
105 Supraglottic - Moderate stridor Plan A Inhalation induction in theatre Maintain spontaneous ventilation or Take over ventilation & give relaxant
106 Supraglottic - Moderate stridor Take over ventilation & give relaxant Reach end point quicker PEEP to splint airway Achieve ideal intubating conditions
107 Supraglottic - Moderate stridor Plan A Inhalation induction in theatre Maintain spontaneous ventilation or Take over ventilation & give relaxant Plan B LMA & trache asleep
108 Supraglottic - Moderate stridor Plan A Inhalation induction in theatre Maintain spontaneous ventilation or Take over ventilation & give relaxant Plan B LMA Plan C Wake up
109 Supraglottic - Moderate stridor Plan A Inhalation induction in theatre Maintain spontaneous ventilation or Take over ventilation & give relaxant Plan B LMA Plan C Wake up Plan D Surgical Airway
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112 Which Tubes Moderate Stridor
113 Tubes Laser tube Jet ventilate MLT Cricothyroid needle Moderate stridor
114 Where issues arise! Extubation
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117 Extubation 1 Leave tube in and send to ICU
118 Extubation 1 Leave tube in and send to ICU
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120 Extubation 1 Leave tube in and send to ICU 2 Extubate Awake
121 Extubation 1 Leave tube in and send to ICU 2 Extubate Awake
122 Extubation 1 Leave tube in and send to ICU 2 Extubate Awake 3 Extubate Deep
123 Extubation 1 Leave tube in and send to ICU 2 Extubate Awake 3 Extubate Deep Who would do this?
124 Extubation 1 Leave tube in and send to ICU 2 Extubate Awake 3 Extubate Deep
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127 Extubation Deep 1 Smooth slow emergence 2 No risk of coughing on the tube 3 Less risk of laryngospasm
128 Extubation Deep 1 Smooth slow emergence 2 No risk of coughing on the tube 3 Less risk of laryngospasm Change to an LMA
129 Ext Guidelines Advanced Technique 1. Was the patient Easy to Intubate 2. Replace Pillow 3. Suction under direct vision 4. Check for Coroner s clot 5. Leave Sevoflurane ON!
130 Supraglottic lesions Severe Stridor Implications of stridor Late presentation Misdiagnosis
131 Supraglottic Severe stridor Arrive as emergency or deteriorated after radiotherapy Avoid sedation Helium Oxygen mixture Nebulised Adrenaline
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134 ENT Anaesthesia No perfect solution 1. Inhalational 2. Awake FOB 3. Rapid Sequence 4. Trache under Local
135 Supraglottic Severe stridor Surgical airway under LA Tracheostomy Cricothyroidotomy cannulae below the lesion
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151 Postop?
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157 Tracheostomy Induction
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166 No perfect solution ENT Anaesthesia
167 ENT Anaesthesia No perfect solution 1. Inhalational 2. Awake FOB 3. Rapid Sequence 4. Trache under Local
168 Emergency ENT Anaesthesia Thank you
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