Emergency Airway Management. Richard P. Dutton, M.D., M.B.A. Chief Quality Officer US Anesthesia Partners

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2 Emergency Airway Management Richard P. Dutton, M.D., M.B.A. Chief Quality Officer US Anesthesia Partners

3 Disclosures I have studied a lot of airway gizmos over the years. I have no financial interest in any of these companies.

4 Learning Objectives At the conclusion of this lecture, I hope you will have absorbed: The need for an emergency airway algorithm The relative value of different airway approaches The essential components of RSI

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6 Trauma Resuscitation Unit

7 Mr. R. Y. Nightmare The patient is a 65 year old male, the driver of a car which swerved off the road and hit a tree. This was a high energy collision, with substantial damage to the vehicle. There are no skid marks at the scene.

8 Presentation The patient is lethargic, but breathing. He has a GCS of about 12. He is seizing when you arrive, but stops on his own. Judging by the gurgling sound he is making, he may be aspirating. Here he is:

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10 Who needs intubation?

11 Dead Near dead PEA Severe TBI Really drunk Moderate TBI Mostly drunk A little shocky Mild TBI Merely obnoxious Shaken, but not stirred } } } Need intubation Don t need drugs Need intubation Need drugs Don t need intubation

12 Emergency Intubations The patient must wind up with an airway waking them up is not an option Unexpected difficulties are more likely The environment may be unfamiliar Your assistants may be untrained Positioning may be difficult Patient injury can play a role

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14 Compromise of the Airway in Trauma Patients I Direct airway trauma Mandibular fractures Maxillary fractures Penetrating wounds

15 Compromise of the Airway in Trauma Patients II Indirect airway trauma Cervical spine injury Bleeding into soft tissues Subcutaneous emphysema Pneumothorax Burns

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17 Rate of Surgical Airway Access Trained flight nurses / paramedics: 8 16% Emergency Room doctors: 1-2% Anesthesiologists: %

18 Shock Trauma Emergency Airway Experience TOTAL AIRWAYS BETWEEN 1996 AND Orotracheal airways Emergent Cricothyroidotomy Nasotracheal airways Emergent Tracheotomy

19 When do we miss? Difficult Anatomy Injury to Head or Neck Laryngospasm Foreign Body Mass 5

20 Why do we do well? An organized plan Good equipment and preparation New (and old) technology Experience!

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22 The STC Airway Algorithm Premises: If you need an airway, there s no going back Your first try is your best try If it isn t within 3 feet of you, it might as well be on Mars The surgeon is your friend

23 Need for intubation Known or suspected Difficult airway Rapid Sequence Induction Cooperative, stable Uncooperative, unstable Consider alternatives: Awake fiberoptic intubation Tracheotomy under local anesthesia Pre-oxygenation Cricoid pressure In-line cervical stabilization Success *Options following LMA placement include: Induction Muscle relaxation Laryngoscopy #1 Success Confirmation: Further intubation attempts Intubation through the LMA Surgical airway Laryngoscopy #2 +/- Bougie Success Capnometry Auscultation Laryngoscopy #3 by attending anesthesiologist Success Attempt LMA placement Success Failure Consider Options* Surgical Airway Operating room for formal tracheotomy

24 The Algorithm Oxygenation throughout Cricoid Pressure, In-line stabilization Induction Direct laryngoscopy #1 Direct laryngoscopy # 2 (bougie) Supraglottic Airway (SGA) Tricks & Toys Surgical Airway

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26 Words about Video Laryngoscopy An acceptable choice for the first or second look This may be how we intubate in 2020 Short learning curve Stylet tricks Pronounced hockey stick Use theirs! Use a bougie Can also facilitate airway exam and bronchoscopic intubation (elective)

27 Gum Elastic Bougie

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30 Medications Anesthesia is optional, an airway is not Relaxation provides the best conditions, but requires commitment to completing the procedure Sedation is nice, but so is a good BP

31 Induction Medications Shock increases brain sensitivity to anesthetics A little goes a long way Any anesthetic will interfere with Fight or flight Decreased catechols = decreased BP There is no such thing as a safe anesthetic

32 C-Spine Precautions Odds of worsening a C-spine injury during direct laryngoscopy: One in 10,000 Odds of dying if given muscle relaxants and not successfully intubated: One in 1

33 Confirmation of Intubation Good visualization Fog in tube Normal compliance Equal breath sounds No sounds over the stomach Esophageal bulb detector These are nice

34 Confirmation of Intubation CO 2 This is required!

35 Tricks and Toys

36 Dutton s Principles of Airway Gizmos It s not the first 1,000 intubations with the device that show the improvement. The chance of the device helping in an emergency is inversely proportional to the number of moving parts.

37 Awake Nasal Intubation Technique: Topicalize nose and throat Insert tube Follow breath sounds to trachea A slick technique, requiring no systemic drugs Works better in some patients than others Watch out for no-man s land! Has a long learning curve

38 Blades of Glory (Mac, Miller, Heinie, short-handle, flip-tip, wedge connector, etc.) Only worth trying if you ve practiced ahead of time! Will help in about 1% of cases

39 Fiberoptic Intubating Fiberoptic addition to laryngoscope Improve view Less movement Requires experience Laryngoscopes

40 Study Metrics for Airway Success

41 Light Wand Blind passage Pre-loaded ETT Requires dark room Transillumination

42 Transtracheal Jet Ventilation Via Needle g catheter over needle thru cricothyroid membrane Connect to an oxygen source

43 Trans-Tracheal Jet Issues Catheter kinking >>> No ventilation Catheter mal-position into soft tissues Instant pneumothorax Need for an airway Need for a chest tube! Why not just do a surgical airway?

44 Retrograde Wire Intubation Crichothyroid catheter, directed cephalad; pass long wire; fish out of mouth or nose; thread FOB and ETT over wire; follow back to trachea. NOT for emergencies!

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46 Flexible Fiberoptic Intubation Expensive Fragile Time consuming Pt preparation Route Local Sedation Oral Nasal

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48 R. Y. Nightmare: Outcome Preoxygenation (assisted) Cricoid and in-line Induction Failed intubation with bougie x2 Unable to place LMA Crichothyroidotomy Discharge to rehab, hospital day 5

49 Surgical Airway Concepts If you use succinylcholine, you must be willing to place a surgical airway The MOST expensive complication of a surgical airway is the failure to place one in a timely fashion

50 Surgical Airway Vertical skin incision Find and incise cricothyroid membrane Insert endotracheal tube, inflate cuff, pull back out of right mainstem Clean up

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52 One Last Case 22 year old, unpleasantly drunk Found down outside a bar, probably assaulted Airway and vital signs stable Spends flight spitting on Walt, the Flight Paramedic Walt knows I am on call

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54 Contact Me!