When I started. 10/27/2009. Gerald Wydro, MD Clinical Associate Professor Emergency Medicine Temple University School of Medicine

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1 When I started. Gerald Wydro, MD Clinical Associate Professor Emergency Medicine Temple University School of Medicine When I started. When I started. When I started. When I started. How To Make A Fertile Polyploid Hybrid 1

2 When I started. In the beginning.ems & Airway Management.. In the beginning.ems & Airway Management.. In the beginning.ems & Airway Management.. In the beginning.ems & Airway Management.. 2

3 In the beginning.ems & Airway Management.. In the beginning.ems & Airway Management.. So what have we really learned? Look at us now. A lot of advancement New Equipment. New Medications But??? The goal has not changed in a century, Has EMS evolved?? Objectives Brief Anatomy / Physiology Review Intubation Indications and Techniques Preintubation Airway Assessment Alternative Airways Confirmation of placement 3

4 Anatomy Mediastinal Structures Upper airway Larynx Trachea Cartilage rings Carina Mainstem bronchi Left and right Bronchioloes Alveoli Tracheal Rings Alveolar Sacs Physiology Prepare the air Warm Humidify Clean Physiology Prepare the air Warm Humidify Clean Exchange Capillary exchange CO2 O2. 4

5 Failure to maintain / protect the airway Value of intact gag Never really studied May induce vomiting Indications for Intubation More realistic handle secretions swallowing mechanism Remember reversible causes Hypoglycemia Opiate intoxication Failure of Ventilation or Oxygenation Clinical assessment Not reversible Increased oxygen CPAP / BiPAP D50 / Narcan Overall status VS Mental status Be careful not to manage the numbers Clinical Situation Mandates They are only getting sicker Potential for badness Status epilepticus Penetrating torso / neck trauma Closed head injury SDH SAH Serious Overdoses TCA s Endotracheal Intubation These are NOT Indications Because I can Because they are unresponsive Because the ED staff will expect it Endotracheal Intubation Complications Soft tissue trauma/bleeding Dental injury Laryngeal edema Laryngospasm Vocal cord injury Barotrauma Hypoxia Aspiration Esophageal intubation Mainstem bronchus intubation 5

6 Pre Intubation Technique Position, ventilate patient Monitor patient / Safety Net Cardiac monitor Pulse oximeter Preintubation Airway Assessment Assemble, check equipment (suction) Hyperventilate patient ( sec) It seems easy enough Sobering statistics Intubation success rate Intubation Success??? Author Misplaced / total Misplaced % Jenkins Bozeman Stewart Sayre Pointer 2/39 1/100 3/779 3/103 5/ % 1.0% 0.4% 2.9% 1.3% verification of tube placement was performed in the field. Does it make a difference?? Frequency of Prehospital Intubation in PA How would minimum experience standards affect the distribution of out-of-hospital endotracheal intubations? Wang HE - Ann Emerg Med - 01-SEP-2007; 50(3): Out-of-hospital endotracheal intubation: where are we? Wang HE - Ann Emerg Med - 01-JUN-2006; 47(6):

7 Sobering Statistics Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Katz SH Ann Emerg Med 01 Jan 2001; 37(1): 32 7 Intubation success rate Undetected esophageal intubations Purpose: The purpose of our study was to determine the incidence of unrecognized misplaced ETTs that had been inserted in the field, in an emergency medical services (EMS) community in which ETCO 2 monitoring was not consistently used. Sobering Statistics Results: 108 intubated patients who were brought by paramedics to the ED during the 8 month study period.. The overall rate of improperly placed ETTs was 25% Intubation success rate Undetected esophageal intubations Frequency of performing the skill Effect of out of hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial JAMA 2000 Feb 9; 283(6): OBJECTIVE: To compare the survival and neurological outcomes of pediatric patients treated with bag valve mask ventilation (BVM) with those of patients treated with BVM followed by ETI. CONCLUSION: These results indicate that the addition of out ofhospital ETI to a paramedic scope of practice that already includes BVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system. 7

8 So maybe it is time to change our thought process! Can we ever consider an Alternative Airway Algorithm as our initial Intervention? Would you get this patient? Multitude of reasons to consider alternative airway from the initial assessment Must be confident in your skill level and more importantly know the limitations of laryngoscopy! No teeth No problem?? What challenges might this patient provide? Mask Seal Landmarks BLS Airways Securing the tube Open the Mouth Don t be surprised! External characteristics are key 8

9 LEMON Rule L=Look externally (facial trauma, large incisors, beard or moustache, and large tongue) E=Evaluate the rule (incisor distance <3 fingerbreadths, hyoid/mental distance <3 fingerbreadths, thyroid to mouth distance <2 fingerbreadths) Pre Intubation Airway Assessment Jaw opening 3 fingers M=Mallampati Score O=Obstruction (presence of any condition that could cause an obstructed airway) N=Neck mobility (limited neck mobility). Pre Intubation Airway Assessment Jaw opening 3 fingers Hyoid Mental distance 3 fingers Pre Intubation Airway Assessment Jaw opening 3 fingers Hyoid Mental distance 3 fingers Thyro Mental distance 2 fingers Pre Intubation Airway Assessment Airway Assessment Jaw opening 3 fingers Hyoid Mental distance 3 fingers Thyro Mental distance 2 fingers Prominent Upper Incisors Cormack / Lehane Grade Mallampati s classification 9

10 Neck Mobility Align axis to facilitate orotracheal intubation Decreased mobility C Spine immobilization Rheumatoid arthritis Quick Test Put chin on chest then move toward ceiling Assumes no trauma Extend Back Flex Forward Is there an optimal position? Sniffing position the neck must be flexed on the chest by elevating the head with a cushion under the occiput and the head extended at the atlanto occipital joint. Extension position The neck is placed into simple extension What is the problem? Ventilate and Visualize This is the perfect candidate What is the problem? Ventilate and Visualize This is the perfect candidate Ventilate but cannot Visualize Consider alternative methods What is the problem? Ventilate and Visualize This is the perfect candidate Ventilate cannot Visualize Consider alternative methods Cannot Ventilate or Visualize Your worst nightmare What we do now! Pre-hospital Intubation Determine need for Intubation Hypoventilation Secure Airway Potential deterioration Determine Method Oral / Nasal Successful Intubation Subjective Confirmation Secure Tube Unsuccessful Alternative Airway BVM LMA / Combitube Needle / Surgical Cric 10

11 What we do now! Pre-hospital Intubation Determine need for Intubation Hypoventilation Secure Airway Potential deterioration Determine Method Oral / Nasal Successful Intubation Subjective Confirmation Secure Tube Most prehospital intubations are: Dead / Nearly dead There are others Awake Facilitated Rapid Sequence Unsuccessful Alternative Airway BVM LMA / Combitube Needle / Surgical Cric Awake Intubation Used in the awake patient with a full stomach. Topical anesthesia with lidocaine, cetocaine or other agent. Careful oral insertion of tube. Facilitated Intubation Medication Assisted Used for patients who need definitive airway, but require some sedative. Patient not paralyzed. Requires use of sedatives / induction agents. Generally used in the OR. Rapid Sequence Induction Take the patient from a state of conscious and breathing to complete unconsciousness with apnea. Emergency intubation indicated P i h f ll h Patient has a full stomach Predicted to be successful If fail, manual ventilation will be successful 11

12 Sellick Maneuver Cricoid Pressure! Lessens the chance of aspiration?? Direct pressure over cricoid id to compress the esophagus against the anterior vertebral bodies. BURP Maneuver Alternatives Any patient that may require intubation must undergo a Pre intubation Airway Assessment Think of Alternative Airway maneuvers in a parallel fashion. Positive Pressure Ventilation Widely available High flow oxygen Requires precise airway control No protection from aspiration Can be used with other airway adjuncts Supraglottic Laryngeal Mask Airway Tube with a large ring at distal end Low pressure to fill around glottis Allows trachea to be ventilated Limited Aspiration Protection Not approved on PA for EMS use! Supraglottic Combitube Double lumen / Port Place in esophagus or trachea Blind placement Ventilate with BVM Limited Aspiration Protection Combitube 12

13 Supraglottic King LT Single Lumen / Port Distal Esophageal placement Blind Placement Ventilate with BVM Limited Aspiration Protection Bougie Semi rigid stylette like device Advanced into the larynx and through the cords until the tip rubs cartilage rings Thread an ETT over the end of the bougie, into the larynx. Once the ETT is in place, the bougie is removed. Lighted Stylet ETT placed on stylet When in the trachea, the light will shine though the skin. Area of thyroid cartilage adjunct to blind intubation Transtracheal Jet Ventilation Needle inserted through the cricothyroid membrane allows for oxygenation and minimal ventilation of a patient Rescue Technique!!! Cricothyroidotomy Surgical airway!!!!! Utilized when unable to secure airway with other means. Can t ventilate, Can t visualize Opening made in the cricothyroid membrane. Tube placed into opening. Expensive Toys Shikani GlideScope 13

14 Confirmation of Tube Placement Subjective Visualization Breath Sounds Misting in tube Objective ETCO 2 Waveform preferred breath to breath Esophageal devices EDD Confirmation of Tube Placement Document Misting Equal excursion Equal BS Absent Gastric EDD ETCO 2 Continous Pulse ox Confirmation of Tube Placement Need confirmation Initial placement Every patient move. Combine Subjective and Objective ETCO 2 limited value in arrest NAEMSP Use ETCO 2 and EDD for cardiac arrest. Before intubation Is there another means of getting our desired results BEFORE we attempt intubation? (Especially if we RSI) CPAP PPV with BVM or Demand Valve? Nasal ETT? Do we have all the help we need, all Airway equipment with us? (Suction?) Do not forget non invasive ventilation Intrinsic positive end expiratory pressure is the concept that in patients with severe lung disease, the lung does not fully empty due to the obstruction in the airway resulting in a positive pressure in the airways at end expiration. The patient must first overcome this positive airway pressure before generating a negative pressure to inhale more air CPAP Continuous Positive Airway Pressure Support spont. Resp Provide continuous pressure throughout respiratory cycle usually 10 cm H2O Counteract intrinsic PEEP decrease preload and afterload improve lung compliance decrease the work of breathing 14

15 Contraindications Patients unable to tolerate the increased work of breathing Increased ICP Hemodynamic instability Recent facial, oral, or skull surgery or trauma Active epistaxis Recent Esophageal surgery Active hemoptysis Untreated pneumothorax Less Does intubation it help! Down 16%* Decreased Mortality Down 18%* Reduce ICU admit Patient discomfort Cost *Hubble MW, Richards ME and Wilfong DA: "Estimates of cost-effectiveness of prehospital continuous positive airway pressure in the management of acute pulmonary edema." Prehospital Emergency Care. 12(3):277-85, Remember The Pre intubation Airway Assessment is Critical Sometimes Less is More Noninvasive ventilation when possible Confirmation of placement always Waveform capnography is gold standard! 15