Physical Exam. T 97.4, HR 76, BP 90/51, Sat 96% Lethargic Lungs clear Heart regular Abdomen soft, epigastric tenderness, distension
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1 Case Report 58yM with non-bilious non-bloody vomiting for one week. Also reported epigastric abdominal pain. PMH: obesity, HTN, HIV, prior CVA with left sided weakness, bipolar disorder PSH: none SH: former smoker, denied drinking or drug use
2 Case Report NKDA Meds: zantac, flexeril, norvir, truvada, raltegravir, plavix, flomax, neurontin, sitagliptin/metformin, novolin, actos, norvasc, losartan, seroquel, lithium
3 Physical Exam T 97.4, HR 76, BP 90/51, Sat 96% Lethargic Lungs clear Heart regular Abdomen soft, epigastric tenderness, distension
4 Labs CBC 9.4/14/45/210 BMP 134/5.1/93/24/82/9.8/122 Alb 4.0/AST 18/ALT 26/AP 99/TB 0.3 PT 13/PTT 26/INR 1.3 Amylase 930, Lipase 1007 Lactate 8.1 ABG 7.10/33/51/76%/BE -17
5 Studies EKG NSR 77bpm CXR prominent interstitial markings CT abdomen without contrast: small pleural effusions and pericardial effusion, pancreas normal, no free air, no obstruction
6 Hospital Course Admitted to MICU with diagnosis of acute pancreatitis and acute renal failure Central line placed Minimal urine output despite 6L NS Persistent hypotension requiring levophed Elected intubation for lethargy, Sat 90s
7 Hospital Course Preoxygenated Etomidate and Lidocaine given Laryngoscopy x2, laryngeal opening not visualized Etomidate and Rocuronium given Glidescope x2, unable to advance ETT Vomited Larygneal mask airway placed, Sat 80s Trauma code called
8 Hospital Course HR 110s, SBP 100s on levophed 30, Sat 80s Obese patient with short neck Urgent tracheostomy performed with 6mm ETT Positive CO2, equal breath sounds Transported directly to OR for revision of tracheostomy and exchange of 6mm endotracheal tube for 8mm tracheostomy tube Transferred back to MICU on pressors
9 Hospital Course Pressor requirement increased Hemodialysis performed Patient made DNR by family Expired HD#1
10 Emergent Airway Management Christopher Turner
11 Overview Evaluation of the airway Indications for definitive airway Key airway decision-making questions Non-invasive techniques Invasive techniques Realities of a surgical airway
12 Evaluation of Airway First step in ATLS primary survey In the awake nonintubated patient, ask their name Stridor or hoarseness may indicate a problem Look, listen and feel Pulse oximetery Airway compromise may manifest as agitation, confusion and combativeness
13 Indications for Definitive Airway Airway obstruction Hypoventilation Persistent hypoxemia despite supplemental O2 GCS 8 Severe hemorrhagic shock Cardiac arrest
14 Key Airway Decision-Making Questions 1. Does the patient need to be intubated 2. How rapidly does the patient need to be intubated 3. Will the intubation be difficult 4. What is the chosen method to control the airway 5. What are the back-up plans
15 Airway Management Non-Invasive Techniques
16 Chin Lift
17 Jaw Thrust
18 Oropharyngeal Airway
19 Nasopharyngeal Airway
20 Bag Valve Mask
21 Bag Valve Mask
22
23 Invasive Techniques Endotracheal Intubation
24 Endotracheal Intubation Equipment Bag valve mask Laryngoscope Endotracheal tube Stylet Functioning suction End tidal CO2 detector Stethoscope
25 Endotracheal Intubation Rapid Sequence Intubation 1. Prepare equipment and supplies 2. Preoxygenate 3. Premedicate (etomidate) 4. Cricoid pressure 5. Paralyze (succinylcholine) 6. Intubate 7. Confirm tube by auscultation and capnography 8. Secure airway 9. Chest XR
26 Endotracheal Intubation Medications Etomidate (anesthetic and amnestic) 0.3mg/kg IV 20mg dose for 70kg patient 2mg/mL 10mL volume Succinylcholine (paralytic) 1.5mg/kg IV 100mg dose for 70kg patient 20mg/mL 5mL volume
27 Endotracheal Intubation Technique Macintosh Miller
28 Surgical Airway
29 Endotracheal Intubation Other Techniques Laryngeal mask airway
30 Endotracheal Intubation Other Techniques Video laryngoscope
31 Endotracheal Intubation Other Techniques Flexible fiberoptic bronchoscopic assisted intubation
32 Invasive Techniques Surgical Airway
33 Surgical Airway Required Equipment Scalpel (#10 blade) Endotracheal tube (6mm) Mask and gloves
34 Surgical Airway Optional Equipment Gown Betadine 1% Lidocaine Curved hemostat clamp Trousseau dilator Tracheal hook 10cc syringe
35 Surgical Airway Anatomy
36 Surgical Airway Technique
37 Surgical Airway Technique
38 Surgical Airway Technique
39 Surgical Airway Technique
40 Surgical Airway Technique
41 Surgical Airway
42 Invasive Techniques Needle Cricothyroidotomy
43 Needle Cricothyroidotomy Equipment 12 or 14G angiocatheter 3mL syringe Y-connector 7mm endotracheal tube Mask and gloves
44 Needle Cricothyroidotomy Technique
45 Needle Cricothyroidotomy Technique
46 Needle Cricothyroidotomy Technique
47 Needle Cricothyroidotomy Technique
48 Realities of a Surgical Airway
49 What I Had: Middle of day, rested Two surgical attendings Two fourth year surgical residents Anesthesia and MICU teams Relatively stable patient Surgical tray and functioning suction ICU conditions
50 What You Will Have: Middle of night, exhausted No surgical attending No surgical resident Hysteric presyncopal medical resident Actively dying obese patient Scalpel No light No suction Surgical gods against you
51 Lessons for Surgeons in the Final Moments of Air France Flight 447 World Journal of Surgery June 2013, Vol 37(6): Method Review of crash reports of Flight 447 which lost speed after formation of ice prevented air from entering flight speed indicators during a storm Following a subsequent stall, the aircraft fell at a rate of 10,000 feet/min until it crashed into the Atlantic killing 228 passengers and crew
52 Lessons for Surgeons in the Final Moments of Air France Flight 447 World Journal of Surgery June 2013, Vol 37(6): Results There were errors in decision making, reasoning, communication, and teamwork A reliance on autopilot meant that the pilots were unfamiliar with high-altitude flying when the autopilot is disengaged The absence of the senior pilot in the critical final minutes slowed error recognition and recovery
53 Lessons for Surgeons in the Final Moments of Air France Flight 447 World Journal of Surgery June 2013, Vol 37(6): Conclusions Both simulation-based and non-simulation-based training should include surprise and startle events beyond the scenarios trainees might expect In the face of increasing reliance on modern technology, surgeons should ensure that they would be able to perform procedures in the absence of such technologies
54 Summary Do not hesitate to establish definitive airway Noninvasive methods Chin lift or jaw thrust Nasal or oral airways Bag valve mask Emergent cricothryoidotomy #10 blade, 6mm ETT, glove and mask Vertical incision
55 Question #1 What number blade is this?
56 Question #2 You are about to perform rapid sequence intubation. You ask the nurse to get what medications at what doses?
57 Question #3 At the oral boards, you are asked to describe the surgical steps of an emergency cricothyroidotomy. What do you say?
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