APPROACH TO THE EMERGENCY AIRWAY. Scott B. Davidson MD, FACS Trauma Surgery Service Bronson Methodist Hospital

Transcription

1 APPROACH TO THE EMERGENCY AIRWAY Scott B. Davidson MD, FACS Trauma Surgery Service Bronson Methodist Hospital

2 Objectives History Initial recognition Get your act together Surgical options Complications

3 History Acute Airway Management First description 2000 BC, Hindu/Egyptian texts Dr. Trousseau, 19 th century first human series open tracheostomy, diphtheria pandemic Dr. Chevalier Jackson, 1913 direct laryngoscopy

4 History Acute Airway Management Dr. Pasquale Ciagla, 1985 percutaneous tracheostomy Dr. Moti Klein, patients emergency percutaneous tracheostomy

5 Characteristics of the Emergency Airway Urgency and unpredictability LACK OF: Information Preparation Compliance Equipment Standardization

6 Difficult Emergency Airway Conventionally trained ED physician encounters difficulty in bag-valve-mask (BVM), intubation, or both

7 Ideal Conditions for Intubation Ideal lighting, positioning, etc. Plenty of assistance Time to prepare, plan, discuss Option to abort Empty stomach Back up available

8 Ideal Patient for Intubation Intact, clear airway Wide open mouth Pre-oxygenated Intact respiratory drive Normal dentition/good oral hygiene Clearly identifiable and intact neck and face Big open nostrils Good neck mobility Greater than 90 KG, less than 110 kg

9 How Can We Further Identify a Difficult Airway? PMHx Basic Physical Exam Thyromental Distance Dr. Binnions Lemon Law Mallampati Classification

10 Past Medical History Rheumatoid Arthritis Ankylosing Spondylitis Cervical Fixation Devices Klippel-Fiel Syndrome Thyroid or major neck surgeries Pierre Robin Syndrome Acromegaly

11 Basic Physical Exam Anything that would limit movement of the neck Scars that indicate neck surgeries Kyphosis Burns Trauma, especially instability of the facial and neck structures

12 Thyromental Distance Measure from upper edge of thyroid cartilage to chin, head fully extended Short thyromental distance: anterior larynx, more acute angle, less space for laryngoscope blade Greater than 7 cm, usually an easy intubation Less than 6 cm, difficult airway

13 Dr. Binnions Lemon Law: An easy way to remember multiple tests Look externally Evaluate the rule Mallampati Obstruction Neck mobility

14 L: Look Externally Obesity or very small Short muscular neck Large breasts Prominent upper incisors Receding jaw (dentures) Burns Facial trauma S/S of anaphylaxis Stridor Foreign body

15 E: Evaluate the rule Greater than three fingers from jaw to neck Jaw is greater than 3 fingers wide You can open the mouth greater than two fingers

16 Mellampati Classification

17 Cormack & Lehane Grading

18 Anatomy

19 Normal Larynx/Trachea

20 Obstruction Blood Vomitus Teeth Epiglottis Dentures Tumors FB

21 N: Neck Mobility Spinal precautions Impaled objects Lack of access See PMHx for others

22 Reality

23 Reality

24 Failed ETT

25 Difficult Laryngoscopy Unable to see any portion of the vocal cords after several attempts by conventional laryngoscopy Laryngeal view grade III-IV

26 Urgent vs Crash Airway Urgent: Difficulty in BVM, with or without intubation, patient is likely to be in a hypoxic state. Crash: Patient in cardiopulmonary arrest, deep coma, or near death, who can t maintain ventilation and oxygenation. Requires immediate intervention.

27 Flowchart

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31 Rescue Airways LMA Combitube Video devices Surgical Approaches

32 Laryngeal Mask Airway

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34 Combitube

35 Surgical Airways Transtracheal needle ventilation Cricothyroidotomy: open and percutaneous Tracheostomy: open and percutaneous

36 Transtracheal Ventilation

37 Open Cricothyroidotomy

38 Open Cricothyroidotomy

39 Incisions

40 Emergency Percutaneous Tracheostomy Background Endotracheal intubation is preferred for control of a patient s airway Current surgical standard of care for emergent airway control, when endotracheal intubation cannot be performed, is cricothyroidotomy

41 Emergency PT Advantages Packaged kit Sternal notch vs cricothyroid membrane Seldinger technique familiar Larger tube

42 PT vs Surg Cric Packaged kit Scalpel and tube Sternal notch vs cric membrane Seldinger technique Faster Less training? Larger tube

43 Ciaglia Blue Rhino

44 Percutaneous Tracheostomy Technique

45 Superficial Anatomy Hyoid Bone Thyroid Cartilage Cricoid Cartilage SCM Sternal Head SCM Sternal Notch

46 CT Anatomy

47 Landmarks

48 PDT Steps

49 PDT Steps

50 PDT Steps

51 PDT (Coffee Time)

52 Emerg PT Bronson Hospital J Trauma Acute Care Surg, 2012 Ten patients had no airway in place Four patients had a King airway in place Two patients had a Combi-tube in place Two patients had cricothyroidotomy

53 Emerg PT Bronson Hospital J Acute Care Surg, 2012 No complications or mortality directly related to the procedure Safely performed in 9 patients BMI > 30 6 of 18 patients had procedure b/w 7p- 7a All procedures performed without bronchoscopy

54 Experience and Complications Technical and Non-Technical

55 Complications of Tracheostomy Early Bleeding Dislodgment, extubation Hypoxia Hypercarbia Bacteremia Airway fire Tube malposition (airway occlusion) Foreign body Pneumothorax Recurrent nerve Late Bleeding Dislodgment, extubation Tracheal stenosis Fistulae Arterial (e.g., brachiocephalic, inferior thyroid) Cutaneous Pleural Pericardial Esophageal Tube malposition and obstruction Foreign body Infection Abscess Cellulitis Nearby wound Necrotizing Granulation tissue Tracheomalacia

56 Avoiding Complications Advanced airway equipment ready Qualified help and teamwork Lidocaine with epinephrine for LA Sedation/Paralysis and vasopressors Sutures Positioning

57 Early Complications of Tracheostomy, Pitfalls Avoiding Them Air leak Displacement Hemorrhage Loss of airway Tear of the posterior membranous trachea Pneumothorax/Subcutaneous emphysema

58 Incorrect Needle Placement Avoid puncture/ dilation of paratracheal structures Digital guidance, stabilize trachea with cricoid pressure Ultrasound Guidance Bronchoscopic confirmation

59 Orientation of Dilator Dilators are curved, trachea slopes posteriorly Dilator should be angled cephalad in order to enter trachea at right angle

60 Cuff Leaks Tracheostomy tube too small for patient s airway Pilot valve leak Severed pilot balloon Tracheostomy cuff leak Malposition of tracheostomy tube

61 Malposition Broad lateral surface of cuff does not properly oppose wall of trachea Smaller area of contact is prone to leaks

62 Insertional Bleeding Generally keep going as dilation and tamponade will stop it Consider suturing Epinephrine Source: Veins Thyroid gland Rare: innominate artery

63 Laceration of Membranous Airway Forceful insertion Friable airway Occurs with injury to membranous (posterior) portion and adjacent anterior esophagus requires surgery

64 Posterior Tracheal Perforation Tracheostomy tube must be loaded onto dilator correctly After entry into trachea, redirected to match curve of tracheostomy tube Follow bronchoscopically

65 Late Complications Tracheo-innominate fistula 1% Chronic erosion of tracheostomy tube (often cuff) anteriorly into adjacent innominate (brachiocephalic) artery

66 Tracheoinominate Fistula Within 48 hours of procedure, not likely Ant jugular, thyroid veins etc Time for erosion to form Bleeding days 3 to 42 - assume TIF till proven otherwise Sentinel bleed occurs in 50% of those who then have massive TIF bleed

67 Options for TIF Rx Inflate/hyper-inflate balloon Remove tracheostomy, put finger in and press anteriorly Intubate orally with bronchoscope to target ETT cuff to below/at site of bleeding, removing tracheostomy at same time 67

68 Options for TIF Rx Remove tracheostomy, intubate with ETT via stoma ± FOB assistance Goal is to stop bleeding or at least prevent bleeding into lung, Then go to OR with thoracic surgeon 68

69 Conclusion Anticipate emergency airway Be familiar with multiple techniques Train as often as possible New techniques/technology evolving

70 70 Thank you! bronsonhealth.com