Airway Management

Emergency Medicine Seminar Series

John Sokal
Health Sciences Centre 12 years

Michael Ha
Section of Emergency Medicine 4th year Resident

Bob Sweetland
Health Sciences Centre 15 years

ASHERN CHURCHILL PINE FALLS

April 25, 2002

BOUNDARY TRAILS STEINBACH

April 26, 2002

BRANDON KILLARNEY PORTAGE

May 2, 2002

DAUPHIN RUSSELL SWAN RIVER

May 3, 2002

FLIN FLON LYNN LAKE THE PAS

May 14, 2002

eMEDiUM
Emergency Medicine in the U of M

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CAEP

ACEP

CME Objectives
To discuss:

the indications for intubation the approach to RSI capnometry bougies

Intubate? RSI vs. Awake Preparing for patient Difficult BVM Difficult Intubation Capnography Laryngoscopy Tips Bougies Lightwand - LMA

Preoxygenation Pretreatment O2 Delivery Thiopental Ketamine Propofol Succinylcholine Rocuronium

Finish

Intubation Indications

Is there a failure of airway maintenance or protection? Is there a failure of ventilation or oxygenation? What is the anticipated clinical course?
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45 female alcoholic beverages empty pill bottles HR 125 Questions? Indication? BP 98/40 Awake vs RSI? RR 20 GCS 8 O2Sats 100% (PRB) LOAD? Induction agent? no injuries Paralytic agent?
cases

Cases
60 VF 44 MVA 25 asthma 15 fall 28 bull 16pencil 40fire 22 TCA 54CRF 67HTN 51melena 45 overdose

60 male IHD AMI VF - defibrillated 3x HR 110 Questions? Indication? BP 68 / 40 Awake vs RSI? RR 10 O2Sats 90% (BVM) LOAD? Induction agent? Paralytic agent?
cases

44 female MVA 100 kph HR 130 Questions? Indication? BP 100 / 70 Awake vs RSI? RR 28 LOAD? O2Sats 99% (BVM) Induction agent? GCS 6 Paralytic agent?
cases

25 female asthma SOB 2 days severe distress HR 145 Questions? Indication? BP 98 / 42 Awake vs RSI? RR 30 LOAD? O2Sats 80% (PRB) Induction agent? Paralytic agent?
cases

15 female fell from tree HR 110 Questions? Indication? BP 100 / 50 Awake vs RSI? RR 20 LOAD? O2Sats 99% (BVM) Induction agent? GCS 8 Paralytic agent?
cases

28 male playing with bull blunt trauma HR 130 Questions? Indication? BP 80 / 60 Awake vs RSI? RR 28 LOAD? O2Sats 99% (PRB) Induction agent? abdomen rigid Paralytic agent? pelvic fracture
cases

16 male pencil oropharynx 'buddy' pulled it out HR 80 Questions? Indication? BP 115 / 60 Awake vs RSI? RR 16 O2Sats 99% (room) LOAD? Induction agent? voice change hematoma visible Paralytic agent?
cases

40 female house fire prolonged exposure HR 115 Questions? Indication? BP 130 / 60 Awake vs RSI? RR 28 LOAD? O2Sats 96% (PRB) singed facial hair Induction agent? Paralytic agent? soot in mouth
cases

22 female ingestion amitryptyline quantity unknown HR 145 Questions? Indication? BP 100 / 42 Awake vs RSI? RR 14 LOAD? O2Sats 99% (PRB) Induction agent? GCS 8 Paralytic agent?
cases

54 male CRF DM on dialysis holiday respiratory distress HR 115 Questions? Indication? BP 200 / 120 Awake vs RSI? RR 36 LOAD? O2Sats 88% (NRB) Induction agent? peaked T's Paralytic agent?
cases

67 female HTN on ACE inhibitor oral angioedema HR 85 Questions? Indication? BP 150 / 80 Awake vs RSI? RR 20 O2Sats 99% (room) LOAD? Induction agent? slight stridor Paralytic agent?
cases

51 male cirrhosis melena 2 days hematemesis HR 165 Questions? BP 50 palpation Indication? Awake vs RSI? RR 28 LOAD? O2Sats 92% (NRB) vomiting red blood Induction agent? Paralytic agent?
cases

68 male CHF SOB over 3 days worsened overnight HR 125 Questions? Indication? BP 180 / 100 Awake vs RSI? RR 32 LOAD? O2Sats 86% (NRB) Induction agent? Paralytic agent?
cases

Custom Shows

Intubate?

Intubate?
45 female alcoholic beverages empty pill bottles HR 125 BP 98/40 RR 20 GCS 8 O2Sats 100% (PRB) no injuries

Indication?

Intubation Indications

Is there a failure of airway maintenance or protection?

Intubate?
50 yo male SOB over 2 days worsened overnight HR 135 BP 150/90 RR 10 O2Sats 86% (NRB) 'tight' wheezes bilaterally

Indication?

Intubation Indications

Is there a failure of ventilation or oxygenation?

Intubate?
34 yo male MVA ejected from car HR 100 BP 105/60 RR 20 GCS 10 O2Sats 100% (PRB) multiple injuries transfering to HSC

Indication?

Intubation Indications

What is the anticipated clinical course?

Intubation Indications

Is there a failure of airway maintenance or protection? Is there a failure of ventilation or oxygenation? What is the anticipated clinical course?
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Custom Shows

RSI vs Awake?

Rapid Sequence Intubation

a potent induction agent followed immediately by a rapidly-acting NMB to induce unconsciousness and motor paralysis for intubation.

the patient has not fasted

at risk of aspiration

Rapid Sequence Intubation

be prepared take nothing that you cannot return or replace approach every airway as a potential difficult airway

The 7 Ps
1. 2. 3. 4. 5. 6. 7.

Preparation Preoxygenation Pretreatment Paralysis with induction Positioning with protection Placement with proof Postintubation management

Awake Intubations
Awake means that patient can:

follow simple instructions provide feedback can respond to events

sedation versed, fentanyl topical lidocaine oral, nasotracheal, fiberoptic

Choices paralyze?
Paralysis contraindications

prediction of difficulty

difficult BVM difficult intubation

lack of equipment unnecessary inexperience

Custom Shows

Preparation Difficult Airways

Preparation
STOP IC BARS S T O P
staff, suction tube oxygen pharmacology (meds)

Preparation
STOP IC BARS I C B A R S
intravenous lines connect to monitors blades, bougies alternate (lightwand) rescue (LMA, combitube) surgical (cricothyroidotomy)
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Difficult Mask Ventilation

B eard

Difficult Mask Ventilation

O bese

Difficult Mask Ventilation

O lder T oothless

Difficult Mask Ventilation

S nores

Preparation
Assessment for Difficult Mask Ventilation

BOOTS
B O O T S
beard obese older toothless snores
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Difficult Mask Ventilation

reposition OP / NP airway 2 person change mask ? obstruction

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Repositioning
Oral Pharyngeal - Laryngeal Axes

Repositioning
Head extended on neck

Repositioning
Sniffing position

Repositioning
Sniffing with extension

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Preparation
Assessment for a difficult intubation

Lemon Law
L E M O N look evaluate (3-3-1 rule) Mallampati obstruction neck mobility
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3-3-1 Rule
3 fingers
mouth opening

3 fingers
hyomental distance (room for tongue)

3 1 3

1 finger
anterior jaw subluxation
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Mallampati

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Preparation Preoxygenation Pretreatment

Preoxygenation
is the establishment of an oxygen reservoir.

no bagging principle of RSI apnea time concept

100% O2 for 5 minutes

effect of body size & metabolic demands

Apnea Time

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Pretreatment
is the administration of drugs to mitigate the adverse effects associated with intubation. L idocaine O piodes A tropine D efasciculation
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Induction Agents

Paralysis after induction

thiopental ketamine propofol etomidate versed succinylcholine rocuronium
skip drug section

INDUCTION

Thiopental

cerebroprotective potent vasodilator myocardial depressant Contraindication: porphyria

INDUCTION

Thiopental
15 - 30 seconds 5 - 10 minutes 3 - 5 mg / kg (euvolemic) 1 - 3 mg / kg (hypovolemic)
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Onset: Duration: Dose:

INDUCTION

Ketamine

analgesia - amnesia bronchodilation catecholamine release ICP (significance ?) (cerebroprotective ??) laryngeal reflexes secretions

stimulating effects:

hypovolemic - hypotensive
agent of choice

INDUCTION

Ketamine
15 - 30 seconds 15 - 30 minutes 1 - 2 mg / kg

Onset: Duration: Dose:

lower dose if profound shock: maximal sympathetic stimulation already ketamine has intrinsic CV depression
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INDUCTION

Propofol
ICP CPP

cerebroprotective

dose-dependant sedation - amnesia no analgesic properties cardiac & respiratory depression related to rate of administration as well as dose potent vasodilator, myocardial depressant (effect may exceed that of thiopental) airway reflexes: dose-dependant depression

INDUCTION

Propofol
30 - 40 seconds 5 - 10 minutes 1 - 3 mg / kg (induction) ketamine 50 mg propofol 50 mg
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Onset: Duration: Dose:

Contraindication: egg, soybean allergies

Combo:

INDUCTION

Etomidate
ICP

cerebroprotective

most hemodynamically stable minimal cardiac & respiratory depression does not block BP response to intubation 30% - 40% nausea / vomiting myoclonus / hiccups cortisol suppression (no ED cases)

INDUCTION

Etomidate
20 - 30 seconds 5 - 15 minutes 0.2 - 0.3 mg / kg

Onset: Duration: Dose:

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NMB

Choices paralyze?
Paralysis contraindications

prediction of difficulty

difficult BVM difficult intubation

lack of equipment unnecessary inexperience

Choices SUX or ROC?

SUX contraindications

difficult BVM or intubation neuromuscular disorders hyperkalemia 24 hours post-burns 7 days post-crush 7 days post-denervation malignant hyperthermia

PARALYSIS

Succinylcholine
fasciculations

depolarizing NMB

duration of action is dependant on: rapid hydrolysis - pseudocholinesterase diffusion away from motor end plate (no pseudocholinesterase at end plate) only a fraction of dose ever reaches end plate give large doses no harm giving too much problem when incompletely paralyzed give extra 20% (2 mg / kg)

PARALYSIS

Succinylcholine
10 - 15 seconds (fasciculations) 45 - 60 seconds (paralysis) 3 - 5 minutes 8 - 10 minutes 1 - 2 mg / kg 2 mg / kg 3 mg / kg
(some resps) (adequate) (adults) (children) (newborns)

Onset:

Duration:

Dose:

PARALYSIS

Succinylcholine

Side- Effects
fasciculations hyperkalemia bradycardia prolonged blockade malignant hyperthermia trismus - masseter muscle spasm
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PARALYSIS

Succinylcholine

Fasciculations
nicotinic receptor stimulation occurs same time as ICP

inhibiting fasciculations - little evidence

side-effects

PARALYSIS

Succinylcholine

SUX-induced Hyperkalemia under normal situations, increase of:

0.5
Preexistent
K+

mEq/L K+

small risk of dysrythmia: CRF

severe acidosis rhabdomyolysis

PARALYSIS

Succinylcholine

Exaggerated release of K+ increased extrajunctional receptors:

5 - 10

mEq/L K+

prolonged depolarization refractory to non-depolarizing NMB, may require large doses

PARALYSIS

Succinylcholine

Exaggerated release of K+ functional denervation of muscle: stroke spinal cord injury extensive burns massive crush injuries neuromuscular disorders
side-effects

PARALYSIS

Succinylcholine

Receptor Recruitment & Sensitization

Burns: Onset: 24 hours 2 years Duration: (% burn does not determine response) Onset: Duration: Onset: Duration:

Crush: Denervation :

7 days 2 - 3 months 7 days 6 months

PARALYSIS

Succinylcholine

Receptor Recruitment & Sensitization Neuromuscular disorders: SUX contraindicated If give SUX: intractable cardiac arrest may occur (even if recognize and treat K+)
side-effects

PARALYSIS

Succinylcholine

Bradycardia
cardiac muscarinic receptor stimulation children have vagal tone succinylmonocholine (a metabolite) sensitizessinus node receptors to repeat doses consider atropine if: age < 10 repeating dose
side-effects

PARALYSIS

Succinylcholine

Prolonged Neuromuscular Blockade

congenital absence of pseudocholinesterase presence of an atypical form may last hours

PARALYSIS

Succinylcholine

Prolonged Neuromuscular Blockade

acquired absence: cocaine metoclopramide (Maxeran) CRF severe liver disease hypothyroidism malnutrition pregnancy cytotoxic drugs organophosphates

PARALYSIS

Succinylcholine

Prolonged Neuromuscular Blockade

acquired absence: even worst of acquired not reported to last > 25 minutes SUX not contraindicated

side-effects

PARALYSIS

Succinylcholine

Malignant Hyperthermia
genetic skeletal muscle abnormality can be triggered by: SUX stress vigorous exercise halothane mortality 60% onset can be acute or delayed for hours

PARALYSIS

Succinylcholine

Malignant Hyperthermia
muscle rigidity autonomic instability hypotension hypoxia severe lactic acidosis myoglobinemia DIC fever - late manifestation
side-effects

PARALYSIS

Succinylcholine

Dantrolene for MH
prevents Ca++ release from sarcoplasmic reticulum of skeletal muscle essential to resuscitation free of serious side-effects give as soon as Dx suspected Dose: 2.5 mg/kg IV q5min until muscle relaxation, or max 4 doses side-effects

PARALYSIS

Succinylcholine

Trismus - Masseter Muscle Spasm

rise in jaw muscle tension is normal should not affect laryngoscopy pretreatment will not prevent if severe, or progresses to other muscles: consider malignant hyperthermia spasm is not pathonomonic for MH if occurs - administer non-depolarizing NMB (Rocuronium) side-effects

PARALYSIS

Rocuronium

Nondepolarizing, does not stimulate receptor no fasciculations minimal hemodynamic effects do not need priming dose

PARALYSIS

Rocuronium
0.6 - 1.2 mg / kg 60 - 90 seconds 30 - 60 minutes

Dose: Onset: Duration:

Defasiculating:

0.05 mg / kg

PARALYSIS

Comparing NMB
SUX ROC
60 - 90 20 - 60
rapid no priming CVS stability sec min

ONSET DURATION advantages

30 - 60 3 - 10
rapid

precautions

K+

PARALYSIS

Comparing NMB
PAN
120 - 180 60 - 90

VEC
sec min

ATRA
120 - 150 20 - 35

150 - 180 25 - 30
no histamine release

histamine release

histamine release

Positioning Proof

Positioning with protection

You are asked to apply: cricoid pressure
(Sellicks maneuver)

BURP
B ackwards U pwards R ightward P ressure

distinct from Sellicks maneuver second assistant first assistants other hand

Maneuvers

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Laryngoscopy

Laryngoscopy

Laryngoscopy

Laryngoscopy

Laryngoscopy

Placement with proof

methods of confirmation chest rise air entry fogging of ETT 60 cc syringe

* capnometer

Colorimetric Capnometry
exhaled CO2 simple color change from

purple

to

yellow

Colorimetric Capnometry
NEGATIVE POSITIVE

Colorimetric Capnometry

ETCO2 < 4 mm Hg ETT not in trachea inadequate perfusion (ineffective CPR)

Colorimetric Capnometry

ETCO2 15 - 38 mm Hg ETT in trachea

Colorimetric Capnometry

ETCO2 4 to < 15 mm Hg retained CO2 in esophagus low perfusion deliver 6 more breaths

Colorimetric Capnometry
Limitations:

decreased cardiac output low metabolic CO2 production ex. hypothermia

Standard of Care
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Bougie Lightwand LMA

Bougie

Epiglottis

Laryngoscopy Grades
Cormack Lehane

Bougie

Lightwand

Lightwand

Source: Laerdal

Lightwand

Source: Laerdal

Laryngeal Mask Airway

skip insertion technique

Source: LMA North America

Laryngeal Mask Airway

deflate the cuff

apply water-soluble lubricant to the posterior surface place index finger at the junction of the cuff
skip insertion technique Source: LMA North America

Laryngeal Mask Airway

press the tip of the cuff upward against the hard

palate and flatten the cuff against it

skip insertion technique Source: LMA North America

Laryngeal Mask Airway

use the index finger to guide the LMA,

press backward toward the other hand, which exerts counter-pressure (do not use force)
skip insertion technique Source: LMA North America

Laryngeal Mask Airway

advance the LMA into the hypopharynx until a

definite resistance is felt. inflate the cuff

skip insertion technique Source: LMA North America

7. Postintubation mgmt
fix tube in place CXR nasogastric / orogastric tube lab etc

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O2 Delivery Systems

O2 Delivery Systems
Nasal cannulae Double rate - add to room air FiO2 ex. 3 L / min + 21 % FiO2 = 27 % Limitations: rates > 3 L / min uncomfortable mouth breathing

O2 Delivery Systems
Simple Face Mask 6 10 L / min flow 35 55 % FiO2 entrainment of room air through exhalation ports

O2 Delivery Systems
Partial Rebreathing Face Mask reservoir bag first ~ 1/3 of exhaled gas

is directed into bag

(that which was in patients upper airway) up to 60 % FiO2

O2 Delivery Systems
Non-Rebreathing Face Mask reservoir bag one-way valves

up to 80 % FiO2 (realistically)

O2 Delivery Systems
Bag Valve Mask (BVM)

up to 100 % FiO2

Summary

Airway Management

eMEDiUM
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HSC ED
Maryann Cromwell
MCromwell@exchange.hsc.mb.ca phone: fax: 787-2934 787-2231

Department of Emergency Medicine Health Sciences Centre GF 201-800 Sherbrook Street Winnipeg, MB R3A 1R9
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CAEP

ACEP