Kelowna June 2011 Airway Assessment and Management Dr. Bruce Starke Golden, BC
Not really...
I am unable to identify any potential conflict of interest and I am unable to identify any potential conflict of interest, and have nothing to declare.
Assess the need for airway intervention Develop a game plan Recognize the difficult airway RSI and alternatives backup plan Hands on equipment
O2 Clear airway, suction Head H d position ii remember C spine! Oropharyngeal airway etc Bag and Mask
Respiratory Failure now, or impending Inability to protect airway For stabilization pre transport
GCS<8, or deteriorating LOC Asthma, COPD exacerbations Uncontrolled seizures Facial, neck trauma Airway burns Chest trauma Anaphylaxis, angioedema
1. Remain calm 2. Have a plan 3. Get help early 4. First attempt at intubation unsuccessful, try again but do something different 5. Can t intubate ventilate 6. Can t intubate or ventilate emergency airway options 7. Practise, review your plan frequently
Obesity, short neck Stiff neck Small mouth opening Prominent incisors Short mandible/beard Airway a injury or deformity Foreign bodies or secretions Mallampati p Score 3 3 2 RULE: 3 fingers of mouth opening 3 fingers mentum to hyoid 2 fingers hyoid to thyroid
Potentially difficult airways...
Mll Mallampati tiscore
Mallampati 0?
1. Preparation 2. Pre oxygenation 3. Pre treatment 4. Paralysis and Induction 5. Protection/Positioning 6. Proof of placement 7. Post intubation management
Oxygen, tubing BVM BVM, mask Oral airway 2 laryngoscopes and blades ET tubes Stylet Securing tape Syringes, needles Medications pretreatment, paralysis, induction, maintenance Oximeter, CO2 monitor, BP, ECG
LMAs McGill MGill forceps Glidescope Bougie introducer Lightwand Specialized laryngoscope blades Flexitip Fibre optics Cricothyrotomy kit Needle cricothyrotomy Jet Jt ventilation
100% o2 Adults 3 5min of 100% O2, or 8 vital capacity breaths Children desat. faster
A. Asthma lidocaine 1.5mg/kg B. Brains/babies bb lidocaine ld Fentanyl 1 3mcg/kg atropine 0.02mg/kg dexamethasone 4mg C. Cardiovascular Fentanyl Lidocaine Opiates Atropine Dexamethasone
Succinylcholine depolarizing muscle relaxant acts on the acetyl choline receptors activates the receptor,so get fasciculation rapid onset, short duration (2 5min.) dose 1 2mg/kg contraindic. burns>24hrs denervating injuries>7d neuromuscular disorders malignant hyperthermia etc.
Non depolarizing Neuromuscular Blockers: Rocuronium slightly slower onset than sux, longer Tx dose 1.0mg/kg to intubate (if sux contraindic.) 0.2mg/kg boluses to maintain Pancuronium slower and longer, tachycardia Mivacurium maybe curium New Stuff
Midazolam Etomidate Ketamine Propofol can be used for induction and maintenance, antiseizure hypotension dose 0.2 0.3mg/kg least cardiovascular effect, reduced CNS O2 demand muscular rigidity,? Adrenal suppression dose 03mg/kg 0.3mg/kg increases HR and CO good if hypotensive bronchodilator, quick look emergence issues, esp in adults dose 1 2mg/kg quick, patients feel great! hypotension, stings on injection dose 1530 1.5 3.0 mg/kg
Head injury pretreat xylocaine, Fentanyl, dex. paralysis sux is OK induction etomidate, or midazolam Seizures induction midazolam, or pentothal Asthma induction ketamine Hypotension induction ketamine Quick look pretreat lidocaine spray, ketamine
Preoxygenate, and pretreat if indicated Induce and apply Cricoid pressure( protection and positioning) Paralyze Intubate, remove stylet, inflate cuff d/c cricoid pressure 6. 6 Placement and Proof ECO EtCO2, auscultate, maintain i O2 sat
Anatomy:
Glidescope view:
Okay...we can deal with this...
Sedation midazolam bolus 2 4mg morphine propofol drip 0.05mg/kg/hr 00 bolus 5 10mg drip 0.03 0.1mg/kg/h g bolus 10 50mg (0.5 1mg/kg) drip 1 3mg/kg/hr Paralysis rocuronium bolus 0.2mg/kg q30 minutes pancuronium bolus 0.1mg/kg q1h
Maintain adequate CO2 Chest xray ET tube position PEEP of 5cm H2O VentilatorV Chest tube?
NG or OG tube Foley More IV lines? Continue circulatorysupport... Td, antibiotics Preparations for transport
O H Oxygen Help S System and supplies H Help I Induction, intubation T Transport
Anaphylaxis Angioedema OH SHIT!
Up to Date: Rural Critical Care Manual RSI ipod app Rapid Sequence Intubation in Adult The Decision to Intubate Pretreatment Agents for RSI Sedation or Induction Agents for RSI Neuromuscular Blocking Agents for RSI
Don t forget to practise!