Airway Management and The Difficult Airway

Transcription

1 Airway Management and The Difficult Airway Gary McCalla, MD, FACEP Medical Director REACH Air Medical Services Services 1

2 It is not enough to do your best, unless you have prepared to be the best. -John McDonald Services 2

3 Introduction The primary objective of emergency airway management is to oxygenate and ventilate the patient You must be prepared to assure optimal oxygenation and ventilation through proper airway management. Brain death occurs in 6-10 minutes Services 3

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. Services 4

5 Airway Anatomy Vallecula Vocal cord Tongue Epiglottis Glottic opening Arytenoid cartilage Services 5

6 Airway Management Clinical 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 Services 6

7 Difficult Airway Assessment LEMON Look externally Evaluate Mallampati Score Obstruction Neck Mobility Services 7

8 Difficult Airway Assessment LEMON Look externally Services 8

9 Difficult Airway Assessment LEMON Evaluate Services 9

10 Difficult Airway Assessment LEMON Mallampati Score Services 10

11 Difficult Airway Assessment LEMON Obstruction Services 11

12 Difficult Airway Assessment LEMON Neck Mobility Services 12

13 Difficult Airway Assessment Three Quick Questions 1. Can the patient open his mouth wide? 2. Does the patient have a chin? 3. Can the patient move his neck? Services 13

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 Services 14

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 Services 15

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 Services 16

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. Services 17

18 Will a Supra Glottic Airway work? RODS Restricted mouth opening Obstruction Distorted anatomy Stiff lungs. Services 18

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. Services 19

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. Services 20

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 when to intubate -Ron Walls, MD Services 21

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? Services 22

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 Services 23

24 Airway Management Tricks-of-the-Trade 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 Services 24

25 Airway Management Visualization In the perfect world A A Mouth B B Pharynx C Trachea C Services 25

26 Airway Management Visualization External Laryngeal Manipulation Cricoid Pressure Services 26

27 Airway Management Vizualization Line the ears up with the sternum Something behind the occiput Services 27

28 Airway Management Vizualization Morbidly obese patients Airway Cam Photo Services 28

29 Airway Management Visualization POC - POM ELM Services 29

30 Airway Management Alternate Techniques Endotracheal Tube Introducer A great second attempt device Services 30

31 LMA Supreme Better than the old one Good for EMS Firm tip so no flop over Built in bite block Other types also Services 31

32 King Airway Rescue airway Not blind for us Most of the time Services 32

33 Airway Management Rescue Airways Combitube B F Combitube H A C G E I D Services 33

34 Video larygoscopes CMAC Glide Scope Others Services 34

35 Airway Management Rescue Airways Needle Cricothyrotomy Services 35

36 Advanced Airway Management Rescue Airways Needle Cricothyrotomy Transtracheal jet insufflator Services 36

37 Airway Management Rescue Airways Surgical Cricothyrotomy Cricothyrotomy Services 37

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 Services 38

39 Rapid Sequence Induction Gary McCalla, MD, FACEP Medical Director REACH Air Medical Services Services 39

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. Services 40

41 What? Use of chemicals to paralyze and sedate patients to facilitate endotracheal intubation Services 41

42 Who? Patients with decreased respiratory effort A presumed clinical course that will need it Patients at risk of airway compromise Decreased O 2 Increased CO 2 Aspiration Closed Head Injured (CHI) patients Control ventilation Services 42

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 Services 43

44 Why? Protect airway (aspiration) Provide oxygenation and ventilation Control ventilation Protect and/or treat ICP Increase success rate Services 44

45 When? When indicated Scene vs. vehicle BLS OK if working Services 45

46 How? BLS is always OK if working The seven P s Preparation Preoxygenate Pretreat Time out Paralysis Protect Place Post-intubation Services 46

47 Preparation Assess for the difficult airway (LEMON)(SHORT)(MOANS) (RODS) L = Look externally E = Evaluate the M = Mallampati O = Obstruction? N = Neck mobility Plan approach Assemble drugs and equipment Establish access Establish monitoring Services 47

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 Services 48

49 Pretreatment Pretreatment = LOAD L = Lidocaine O = Opioid A = Atropine D = Defasciculation Services 49

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 Services 50

51 Paralysis with Induction Neuromuscular blocker IV push Rocuronium Induction agent IV push Etomidate for most Ketamine for sepsis, asthma, hypotensive Services 51

52 Protection Sellick manuever Position patient (sniffing) No bagging unless SpO 2 < 95% Why? Services 52

53 Placement The Six ETT Checks Visualize EtCO2 Lung sounds Chest rise/fall Mist in the tube Pulse oximetry Services 53

54 Post-Intubation Management Secure the tube Administer longer acting sedation Services 54

55 Dangers/Pitfalls Tube placement can t be obtained Rare Rescue devices Medication reactions Must know your medications Hypotension Etomidate and adrenal suppression Decrease in respiratory drive Services 55

56 Questions Services 56

57 Test Review Question 1: The LEMON rule is way to access for difficult intubation. True False Services 57

58 Test Review Question 1: The LEMON rule is way to access for difficult intubation. True False Services 58

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 Services 59

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 Services 60

61 Test Review Question 3: Checking the gag reflex is necessary for good airway assessment True False Services 61

62 Test Review Question 3: Checking the gag reflex is necessary for good airway assessment True False Services 62

63 Test Review Question 4: Tube placement can t be obtained True False Services 63

64 Test Review Question 4: Tube placement can t be obtained True False Services 64

65 Test Review Question 5: Tube placement can t be obtained True False Services 65

66 Test Review Question 5: Tube placement can t be obtained True False Services 66

67 The REACH Training Institute Services 67