Airway Management Emergency Medicine  Seminar Series
Michael Ha Section of Emergency Medicine  4th year Resident John Sokal Health Sciences Centre 12 years Bob Sweetland Healt...
April 25, 2002 CHURCHILL ASHERN PINE FALLS
April 26, 2002 STEINBACH BOUNDARY  TRAILS
May 2, 2002 BRANDON KILLARNEY PORTAGE
May 3, 2002 RUSSELL DAUPHIN SWAN RIVER
May 14, 2002 FLIN FLON LYNN LAKE THE PAS
eMEDiUM Emergency Medicine  in the U of M emergency.mb.ca Back
CAEP  ACEP
CME Objectives To discuss: <ul><ul><li>the indications for intubation </li></ul></ul><ul><ul><li>the approach to RSI </li>...
<ul><li>Intubate? </li></ul><ul><li>RSI vs. Awake </li></ul><ul><li>Preparing for patient </li></ul><ul><li>Difficult BVM ...
Intubation Indications <ul><li>Is there a failure of  </li></ul><ul><li>airway maintenance or protection? </li></ul><ul><l...
HR 125  BP 98/40  RR 20  GCS 8  O 2 Sats 100% (PRB) no injuries Questions? Indication? Awake vs RSI? LOAD? Induction agent...
Cases <ul><li>60 	VF </li></ul><ul><li>44 	MVA </li></ul><ul><li>25 	asthma </li></ul><ul><li>15 	fall </li></ul><ul><li>2...
60 male  IHD <ul><li>AMI  </li></ul><ul><li>VF - defibrillated 3x </li></ul>HR  110   BP  68 / 40  RR  10 O 2 Sats 90% (BV...
44 female  <ul><li>MVA  </li></ul><ul><li>100  kph </li></ul>HR  130  BP  100 / 70  RR  28 O 2 Sats 99% (BVM) GCS 6 Questi...
25 female  asthma <ul><li>SOB 2 days </li></ul><ul><li>severe distress </li></ul>HR  145   BP  98 / 42  RR  30 O 2 Sats 80...
15  female   <ul><li>fell from tree </li></ul>HR  110  BP  100 / 50  RR  20 O 2 Sats 99% (BVM) GCS 8 Questions? Indication...
28 male  <ul><li>playing with bull  </li></ul><ul><li>blunt trauma </li></ul>HR 130  BP 80 / 60  RR 28 O 2 Sats 99% (PRB) ...
16 male   <ul><li>pencil oropharynx </li></ul><ul><li>'buddy' pulled it out </li></ul>HR 80  BP 115 / 60  RR 16 O 2 Sats 9...
40 female  <ul><li>house fire </li></ul><ul><li>prolonged exposure </li></ul>HR 115  BP 130 / 60  RR 28 O 2 Sats 96% (PRB)...
22  female   <ul><li>ingestion amitryptyline </li></ul><ul><li>quantity unknown </li></ul>HR 145  BP 100 / 42  RR 14 O 2 S...
54 male  CRF  DM <ul><li>on dialysis holiday </li></ul><ul><li>respiratory distress </li></ul>HR 115  BP 200 / 120  RR 36 ...
67 female  HTN <ul><li>on ACE inhibitor </li></ul><ul><li>oral angioedema </li></ul>HR 85  BP 150 / 80  RR 20 O 2 Sats 99%...
51 male  cirrhosis   <ul><li>melena 2 days </li></ul><ul><li>hematemesis </li></ul>HR  165  BP  50 palpation  RR  28 O 2 S...
68 male  CHF HR 125  BP 180 / 100  RR 32 O 2 Sats 86% (NRB) <ul><li>SOB over 3 days  </li></ul><ul><li>worsened overnight ...
Intubate? Custom Shows
Intubate? HR 125  BP 98/40  RR 20  GCS 8  O 2 Sats 100% (PRB) no injuries Indication? <ul><li>45 female  </li></ul><ul><li...
Intubation Indications <ul><li>Is there a failure of   </li></ul><ul><li>airway maintenance or protection? </li></ul>
Intubate? HR 135  BP 150/90  RR 10 O 2 Sats 86% (NRB)  'tight'  wheezes bilaterally Indication? <ul><li>50 yo male  </li><...
Intubation Indications <ul><li>Is there a failure of   </li></ul><ul><li>ventilation or oxygenation ? </li></ul>
Intubate? HR 100  BP 105/60  RR 20  GCS 10 O 2 Sats 100% (PRB)  multiple injuries transfering to HSC  Indication? <ul><li>...
Intubation Indications <ul><li>What is the   </li></ul><ul><ul><li>anticipated clinical course ? </li></ul></ul>
Intubation Indications <ul><li>Is there a failure of  </li></ul><ul><li>airway maintenance or protection? </li></ul><ul><l...
RSI vs Awake? Custom Shows
Rapid Sequence Intubation a potent  induction agent   followed immediately by   <ul><ul><li>the patient has not fasted </l...
Rapid Sequence Intubation <ul><li>take nothing that  </li></ul><ul><li>you cannot return or replace </li></ul><ul><li>appr...
The  7  P’s <ul><li>P reparation </li></ul><ul><li>P reoxygenation </li></ul><ul><li>P retreatment </li></ul><ul><li>P ara...
Awake Intubations <ul><li>“ Awake” means that patient can: </li></ul><ul><ul><ul><li>follow simple instructions </li></ul>...
Choices… paralyze? Paralysis contraindications <ul><li>prediction of difficulty   </li></ul><ul><ul><ul><li>difficult BVM ...
Preparation Difficult   Airways Custom Shows
Preparation STOP IC BARS S staff, suction T tube O oxygen P pharmacology  (meds)
Preparation I intravenous lines C connect to monitors B blades, bougies A alternate  (lightwand)  R rescue  (LMA, combitub...
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 beard O obese O older T toothless S snores Back
Difficult Mask Ventilation reposition OP / NP airway 2 person  change mask ? obstruction Back
Repositioning Oral – Pharyngeal -  Laryngeal Axes
Repositioning Head extended on neck
Repositioning “ Sniffing” position
Repositioning “ Sniffing” with extension Back
Preparation Assessment for a difficult intubation Lemon Law   L look  E evaluate (3-3-1 rule) M Mallampati O obstruction N...
3-3-1 Rule Back 3 3 fingers mouth opening 1 finger anterior jaw  subluxation 3 1 3 fingers hyomental distance (room for to...
Mallampati Back
Preparation Preoxygenation Pretreatment
Preoxygenation is the establishment of an  oxygen reservoir. <ul><ul><li>“ no bagging ”  principle of RSI </li></ul></ul><...
Apnea Time Back
Pretreatment is the administration of drugs  to mitigate the adverse effects  associated with intubation. L  idocaine O  p...
Induction Agents
Paralysis after induction thiopental ketamine propofol etomidate versed succinylcholine rocuronium skip drug section
Thiopental <ul><li>cerebroprotective </li></ul><ul><li>potent vasodilator  </li></ul><ul><li>myocardial depressant </li></...
Thiopental Back INDUCTION Onset: 15 - 30   seconds Dose: 3 -  5   mg / kg (euvolemic) 1 -  3   mg / kg  (hypovolemic) Dura...
Ketamine <ul><li>analgesia  -  amnesia  </li></ul><ul><li>bronchodilation </li></ul><ul><li>catecholamine release </li></u...
Ketamine lower dose if profound shock: maximal sympathetic stimulation already - ketamine has intrinsic CV depression Back...
Propofol <ul><li>dose-dependant sedation - amnesia </li></ul><ul><li>no analgesic properties </li></ul><ul><li>airway refl...
Propofol Onset: 30 - 40   seconds   1 -  3   mg / kg  (induction) Dose: Duration: 5 - 10   minutes Combo:  ketamine  50 mg...
Etomidate <ul><li>most hemodynamically stable </li></ul><ul><li>minimal cardiac & respiratory depression </li></ul><ul><li...
Etomidate Back Onset: 20 - 30   seconds Dose: 0.2 - 0.3   mg / kg INDUCTION Duration: 5 - 15   minutes
NMB
Choices… paralyze? Paralysis contraindications <ul><li>prediction of difficulty   </li></ul><ul><ul><ul><li>difficult BVM ...
Choices… SUX or ROC? SUX contraindications <ul><li>difficult BVM or intubation </li></ul><ul><li>neuromuscular disorders <...
Succinylcholine <ul><li>duration of action is dependant on: </li></ul><ul><ul><ul><li>rapid hydrolysis - pseudocholinester...
Succinylcholine Onset: 10 - 15   seconds  (fasciculations) 45 - 60  seconds (paralysis) Dose: 1  -  2   mg / kg  (adults) ...
Succinylcholine Side- Effects <ul><li>fasciculations </li></ul><ul><li>hyperkalemia </li></ul><ul><li>bradycardia </li></u...
Succinylcholine Fasciculations <ul><li>nicotinic receptor stimulation </li></ul><ul><li>inhibiting fasciculations - little...
Succinylcholine SUX-induced Hyperkalemia <ul><li>under normal situations, increase of:  0.5   mEq/L  K +   </li></ul><ul><...
Succinylcholine <ul><li>increased extrajunctional receptors: </li></ul><ul><li>5 - 10   mEq/L  K +  </li></ul><ul><ul><li>...
Succinylcholine Exaggerated release of K + <ul><li>functional  denervation  of muscle: </li></ul><ul><ul><ul><li>stroke </...
Succinylcholine PARALYSIS Receptor Recruitment & Sensitization Onset: 7   days Duration: 2 - 3   months Crush: Onset: 7   ...
Succinylcholine Neuromuscular disorders: SUX contraindicated side-effects PARALYSIS Receptor Recruitment & Sensitization <...
Succinylcholine Bradycardia <ul><li>cardiac muscarinic receptor stimulation </li></ul><ul><li>succinylmonocholine (a metab...
Succinylcholine Prolonged Neuromuscular Blockade <ul><li>congenital absence  </li></ul><ul><li>of pseudocholinesterase </l...
Succinylcholine <ul><li>acquired absence: </li></ul><ul><ul><ul><li>cocaine </li></ul></ul></ul><ul><ul><ul><li>metoclopra...
Succinylcholine <ul><li>acquired absence: </li></ul><ul><ul><ul><li>even worst of acquired not reported </li></ul></ul></u...
Succinylcholine <ul><li>mortality 60%  </li></ul><ul><li>onset can be acute or delayed for hours </li></ul>Malignant Hyper...
Succinylcholine <ul><ul><li>muscle rigidity </li></ul></ul><ul><ul><li>autonomic instability </li></ul></ul><ul><ul><li>hy...
Succinylcholine <ul><li>prevents Ca ++  release from sarcoplasmic  reticulum of skeletal muscle  </li></ul>Dantrolene  for...
Succinylcholine Trismus - Masseter Muscle Spasm <ul><li>rise in jaw muscle tension is normal </li></ul><ul><ul><ul><li>sho...
Rocuronium <ul><li>Nondepolarizing,  </li></ul><ul><li>does not stimulate receptor </li></ul><ul><ul><ul><ul><li>no fascic...
Rocuronium Dose: 0.6 - 1.2   mg / kg PARALYSIS Onset: 60 - 90   seconds Duration: 30 - 60   minutes Defasiculating: 0.05  ...
Comparing NMB SUX ROC PARALYSIS ONSET 30 - 60 60 - 90  sec DURATION 3 - 10 20 - 60 min rapid rapid no priming CVS stabilit...
Comparing NMB PARALYSIS sec min VEC 150 - 180 25 -  30 no histamine release PAN 120 - 180 60 -  90 histamine release ATRA ...
Positioning Proof
Positioning with protection You are asked to apply: cricoid pressure (Sellick’s maneuver)
BURP B  ackwards U  pwards R  ightward P  ressure <ul><li>distinct from Sellick’s maneuver </li></ul><ul><ul><li>second as...
Maneuvers Back
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 ETCO 2  < 4  mm Hg ETT  not in  trachea inadequate perfusion (ineffective CPR)
Colorimetric Capnometry ETCO 2  15 - 38  mm Hg ETT  in  trachea
Colorimetric Capnometry ETCO 2  4 to < 15  mm Hg retained CO 2  in esophagus low perfusion deliver  6  more breaths
Colorimetric Capnometry Standard of Care Limitations: Back <ul><li>decreased cardiac output </li></ul><ul><li>low metaboli...
Bougie Lightwand LMA
Bougie
Epiglottis
Laryngoscopy Grades Cormack Lehane
Bougie
Lightwand
Lightwand Source: Laerdal
Lightwand Source: Laerdal
Laryngeal Mask Airway Source: LMA North America skip insertion technique
Laryngeal Mask Airway Source: LMA North America <ul><li>deflate the cuff  </li></ul><ul><li>apply water-soluble lubricant ...
Laryngeal Mask Airway Source: LMA North America <ul><li>press the tip of the cuff upward against the hard  palate and flat...
Laryngeal Mask Airway Source: LMA North America <ul><li>use the index finger to guide the LMA,  </li></ul><ul><li>press ba...
Laryngeal Mask Airway Source: LMA North America <ul><li>advance the LMA into the hypopharynx until a  definite resistance ...
7. Postintubation mgmt fix tube in place CXR nasogastric  / orogastric tube lab  etc Back
O2 Delivery Systems
O 2  Delivery Systems <ul><li>Nasal cannulae </li></ul><ul><ul><ul><ul><li>Double rate - add to room air FiO 2 </li></ul><...
O 2  Delivery Systems <ul><li>Simple Face Mask </li></ul><ul><ul><li>6 – 10 L / min flow </li></ul></ul><ul><ul><li>35 – 5...
O 2  Delivery Systems <ul><li>Partial </li></ul><ul><li>Rebreathing </li></ul><ul><li>Face Mask </li></ul><ul><li>reservoi...
O 2  Delivery Systems <ul><li>Non-Rebreathing Face Mask </li></ul><ul><ul><li>reservoir bag </li></ul></ul><ul><ul><li>one...
O 2  Delivery Systems <ul><li>Bag Valve Mask </li></ul><ul><li>(BVM) </li></ul><ul><li>up to 100  % FiO 2 </li></ul>
Summary
Airway Management ? ?
eMEDiUM Emergency Medicine  in the U of M emergency.mb.ca Back
HSC ED  <ul><li>Maryann Cromwell </li></ul><ul><li>MCromwell @ exchange.hsc.mb.ca </li></ul><ul><li>phone:  787-2934 </li>...
CAEP  ACEP
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Airway management

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Airway management

  1. 1. Airway Management Emergency Medicine Seminar Series
  2. 2. Michael Ha Section of Emergency Medicine 4th year Resident John Sokal Health Sciences Centre 12 years Bob Sweetland Health Sciences Centre 15 years
  3. 3. April 25, 2002 CHURCHILL ASHERN PINE FALLS
  4. 4. April 26, 2002 STEINBACH BOUNDARY TRAILS
  5. 5. May 2, 2002 BRANDON KILLARNEY PORTAGE
  6. 6. May 3, 2002 RUSSELL DAUPHIN SWAN RIVER
  7. 7. May 14, 2002 FLIN FLON LYNN LAKE THE PAS
  8. 8. eMEDiUM Emergency Medicine in the U of M emergency.mb.ca Back
  9. 9. CAEP ACEP
  10. 10. CME Objectives To discuss: <ul><ul><li>the indications for intubation </li></ul></ul><ul><ul><li>the approach to RSI </li></ul></ul><ul><ul><li>capnometry </li></ul></ul><ul><ul><li>bougies </li></ul></ul>
  11. 11. <ul><li>Intubate? </li></ul><ul><li>RSI vs. Awake </li></ul><ul><li>Preparing for patient </li></ul><ul><li>Difficult BVM </li></ul><ul><li>Difficult Intubation </li></ul><ul><li>Capnography </li></ul><ul><li>Laryngoscopy Tips </li></ul><ul><li>Bougies </li></ul><ul><li>Lightwand - LMA </li></ul>Master Preoxygenation Pretreatment O 2 Delivery Thiopental Ketamine Propofol Succinylcholine Rocuronium Finish
  12. 12. Intubation Indications <ul><li>Is there a failure of </li></ul><ul><li>airway maintenance or protection? </li></ul><ul><li>Is there a failure of </li></ul><ul><li>ventilation or oxygenation? </li></ul><ul><li>What is the </li></ul><ul><ul><li>anticipated clinical course ? </li></ul></ul>Back
  13. 13. HR 125 BP 98/40 RR 20 GCS 8 O 2 Sats 100% (PRB) no injuries Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases <ul><li>45 female </li></ul><ul><li>alcoholic beverages </li></ul><ul><li>empty pill bottles </li></ul>
  14. 14. Cases <ul><li>60 VF </li></ul><ul><li>44 MVA </li></ul><ul><li>25 asthma </li></ul><ul><li>15 fall </li></ul><ul><li>28 bull </li></ul><ul><li>16 pencil </li></ul>40 fire 22 TCA 54 CRF 67 HTN 51 melena 45 overdose
  15. 15. 60 male IHD <ul><li>AMI </li></ul><ul><li>VF - defibrillated 3x </li></ul>HR 110 BP 68 / 40 RR 10 O 2 Sats 90% (BVM) Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
  16. 16. 44 female <ul><li>MVA </li></ul><ul><li>100 kph </li></ul>HR 130 BP 100 / 70 RR 28 O 2 Sats 99% (BVM) GCS 6 Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
  17. 17. 25 female asthma <ul><li>SOB 2 days </li></ul><ul><li>severe distress </li></ul>HR 145 BP 98 / 42 RR 30 O 2 Sats 80% (PRB) Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
  18. 18. 15 female <ul><li>fell from tree </li></ul>HR 110 BP 100 / 50 RR 20 O 2 Sats 99% (BVM) GCS 8 Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
  19. 19. 28 male <ul><li>playing with bull </li></ul><ul><li>blunt trauma </li></ul>HR 130 BP 80 / 60 RR 28 O 2 Sats 99% (PRB) abdomen rigid pelvic fracture Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
  20. 20. 16 male <ul><li>pencil oropharynx </li></ul><ul><li>'buddy' pulled it out </li></ul>HR 80 BP 115 / 60 RR 16 O 2 Sats 99% (room) voice change hematoma visible Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
  21. 21. 40 female <ul><li>house fire </li></ul><ul><li>prolonged exposure </li></ul>HR 115 BP 130 / 60 RR 28 O 2 Sats 96% (PRB) singed facial hair soot in mouth Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
  22. 22. 22 female <ul><li>ingestion amitryptyline </li></ul><ul><li>quantity unknown </li></ul>HR 145 BP 100 / 42 RR 14 O 2 Sats 99% (PRB) GCS 8 Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
  23. 23. 54 male CRF DM <ul><li>on dialysis holiday </li></ul><ul><li>respiratory distress </li></ul>HR 115 BP 200 / 120 RR 36 O 2 Sats 88% (NRB) peaked T's Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
  24. 24. 67 female HTN <ul><li>on ACE inhibitor </li></ul><ul><li>oral angioedema </li></ul>HR 85 BP 150 / 80 RR 20 O 2 Sats 99% (room) slight stridor Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
  25. 25. 51 male cirrhosis <ul><li>melena 2 days </li></ul><ul><li>hematemesis </li></ul>HR 165 BP 50 palpation RR 28 O 2 Sats 92% (NRB) vomiting red blood Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
  26. 26. 68 male CHF HR 125 BP 180 / 100 RR 32 O 2 Sats 86% (NRB) <ul><li>SOB over 3 days </li></ul><ul><li>worsened overnight </li></ul>Questions? Indication? Awake vs RSI? LOAD? Induction agent? Paralytic agent? cases
  27. 27. Intubate? Custom Shows
  28. 28. Intubate? HR 125 BP 98/40 RR 20 GCS 8 O 2 Sats 100% (PRB) no injuries Indication? <ul><li>45 female </li></ul><ul><li>alcoholic beverages </li></ul><ul><li>empty pill bottles </li></ul>
  29. 29. Intubation Indications <ul><li>Is there a failure of </li></ul><ul><li>airway maintenance or protection? </li></ul>
  30. 30. Intubate? HR 135 BP 150/90 RR 10 O 2 Sats 86% (NRB) 'tight' wheezes bilaterally Indication? <ul><li>50 yo male </li></ul><ul><li>SOB over 2 days </li></ul><ul><li>worsened overnight </li></ul>
  31. 31. Intubation Indications <ul><li>Is there a failure of </li></ul><ul><li>ventilation or oxygenation ? </li></ul>
  32. 32. Intubate? HR 100 BP 105/60 RR 20 GCS 10 O 2 Sats 100% (PRB) multiple injuries transfering to HSC Indication? <ul><li>34 yo male </li></ul><ul><li>MVA </li></ul><ul><li>ejected from car </li></ul>
  33. 33. Intubation Indications <ul><li>What is the </li></ul><ul><ul><li>anticipated clinical course ? </li></ul></ul>
  34. 34. Intubation Indications <ul><li>Is there a failure of </li></ul><ul><li>airway maintenance or protection? </li></ul><ul><li>Is there a failure of </li></ul><ul><li>ventilation or oxygenation? </li></ul><ul><li>What is the </li></ul><ul><ul><li>anticipated clinical course ? </li></ul></ul>Back
  35. 35. RSI vs Awake? Custom Shows
  36. 36. Rapid Sequence Intubation a potent induction agent followed immediately by <ul><ul><li>the patient has not fasted </li></ul></ul><ul><ul><ul><ul><ul><li>at risk of aspiration </li></ul></ul></ul></ul></ul>a rapidly-acting NMB to induce unconsciousness and motor paralysis for intubation.
  37. 37. Rapid Sequence Intubation <ul><li>take nothing that </li></ul><ul><li>you cannot return or replace </li></ul><ul><li>approach every airway as </li></ul><ul><li>a potential difficult airway </li></ul><ul><li>be prepared </li></ul>
  38. 38. The 7 P’s <ul><li>P reparation </li></ul><ul><li>P reoxygenation </li></ul><ul><li>P retreatment </li></ul><ul><li>P aralysis with induction </li></ul><ul><li>P ositioning with protection </li></ul><ul><li>P lacement with proof </li></ul><ul><li>P ostintubation management </li></ul>
  39. 39. Awake Intubations <ul><li>“ Awake” means that patient can: </li></ul><ul><ul><ul><li>follow simple instructions </li></ul></ul></ul><ul><ul><ul><li>provide feedback </li></ul></ul></ul><ul><ul><ul><li>can respond to events </li></ul></ul></ul><ul><ul><ul><ul><li>sedation – versed, fentanyl </li></ul></ul></ul></ul><ul><ul><ul><ul><li>topical lidocaine </li></ul></ul></ul></ul><ul><ul><ul><ul><li>oral, nasotracheal, fiberoptic </li></ul></ul></ul></ul>
  40. 40. Choices… paralyze? Paralysis contraindications <ul><li>prediction of difficulty </li></ul><ul><ul><ul><li>difficult BVM </li></ul></ul></ul><ul><ul><ul><li>difficult intubation </li></ul></ul></ul><ul><li>lack of equipment </li></ul><ul><li>unnecessary </li></ul><ul><li>inexperience </li></ul>
  41. 41. Preparation Difficult Airways Custom Shows
  42. 42. Preparation STOP IC BARS S staff, suction T tube O oxygen P pharmacology (meds)
  43. 43. Preparation I intravenous lines C connect to monitors B blades, bougies A alternate (lightwand) R rescue (LMA, combitube) S surgical (cricothyroidotomy) STOP IC BARS Back
  44. 44. Difficult Mask Ventilation B eard
  45. 45. Difficult Mask Ventilation O bese
  46. 46. Difficult Mask Ventilation O lder T oothless
  47. 47. Difficult Mask Ventilation S nores
  48. 48. Preparation Assessment for Difficult Mask Ventilation BOOTS B beard O obese O older T toothless S snores Back
  49. 49. Difficult Mask Ventilation reposition OP / NP airway 2 person change mask ? obstruction Back
  50. 50. Repositioning Oral – Pharyngeal - Laryngeal Axes
  51. 51. Repositioning Head extended on neck
  52. 52. Repositioning “ Sniffing” position
  53. 53. Repositioning “ Sniffing” with extension Back
  54. 54. Preparation Assessment for a difficult intubation Lemon Law L look E evaluate (3-3-1 rule) M Mallampati O obstruction N neck mobility Back
  55. 55. 3-3-1 Rule Back 3 3 fingers mouth opening 1 finger anterior jaw subluxation 3 1 3 fingers hyomental distance (room for tongue)
  56. 56. Mallampati Back
  57. 57. Preparation Preoxygenation Pretreatment
  58. 58. Preoxygenation is the establishment of an oxygen reservoir. <ul><ul><li>“ no bagging ” principle of RSI </li></ul></ul><ul><ul><li>“ apnea time ” concept </li></ul></ul><ul><ul><li>100% O 2 for 5 minutes </li></ul></ul><ul><ul><li>effect of body size & metabolic demands </li></ul></ul>
  59. 59. Apnea Time Back
  60. 60. Pretreatment is the administration of drugs to mitigate the adverse effects associated with intubation. L idocaine O piodes A tropine D efasciculation Back
  61. 61. Induction Agents
  62. 62. Paralysis after induction thiopental ketamine propofol etomidate versed succinylcholine rocuronium skip drug section
  63. 63. Thiopental <ul><li>cerebroprotective </li></ul><ul><li>potent vasodilator </li></ul><ul><li>myocardial depressant </li></ul>Contraindication: porphyria INDUCTION
  64. 64. Thiopental Back INDUCTION Onset: 15 - 30 seconds Dose: 3 - 5 mg / kg (euvolemic) 1 - 3 mg / kg (hypovolemic) Duration: 5 - 10 minutes
  65. 65. Ketamine <ul><li>analgesia - amnesia </li></ul><ul><li>bronchodilation </li></ul><ul><li>catecholamine release </li></ul>hypovolemic - hypotensive agent of choice INDUCTION <ul><li>ICP (significance ?) </li></ul><ul><li>( cerebroprotective ??) </li></ul><ul><li>stimulating effects: laryngeal reflexes </li></ul><ul><ul><ul><ul><ul><li>secretions </li></ul></ul></ul></ul></ul>
  66. 66. Ketamine lower dose if profound shock: maximal sympathetic stimulation already - ketamine has intrinsic CV depression Back INDUCTION Onset: 15 - 30 seconds Dose: 1 - 2 mg / kg Duration: 15 - 30 minutes
  67. 67. Propofol <ul><li>dose-dependant sedation - amnesia </li></ul><ul><li>no analgesic properties </li></ul><ul><li>airway reflexes: dose-dependant depression </li></ul><ul><li>potent vasodilator , myocardial depressant </li></ul><ul><li>(effect may exceed that of thiopental) </li></ul><ul><li>cardiac & respiratory depression related to </li></ul><ul><li>rate of administration as well as dose </li></ul>INDUCTION <ul><li>cerebroprotective </li></ul>ICP CPP
  68. 68. Propofol Onset: 30 - 40 seconds 1 - 3 mg / kg (induction) Dose: Duration: 5 - 10 minutes Combo: ketamine 50 mg propofol 50 mg Back Contraindication: egg, soybean allergies INDUCTION
  69. 69. Etomidate <ul><li>most hemodynamically stable </li></ul><ul><li>minimal cardiac & respiratory depression </li></ul><ul><li>cortisol suppression ( no ED cases) </li></ul><ul><li>myoclonus / hiccups </li></ul><ul><li>30% - 40% nausea / vomiting </li></ul><ul><li>does not block BP response to intubation </li></ul>INDUCTION <ul><li>cerebroprotective </li></ul>ICP
  70. 70. Etomidate Back Onset: 20 - 30 seconds Dose: 0.2 - 0.3 mg / kg INDUCTION Duration: 5 - 15 minutes
  71. 71. NMB
  72. 72. Choices… paralyze? Paralysis contraindications <ul><li>prediction of difficulty </li></ul><ul><ul><ul><li>difficult BVM </li></ul></ul></ul><ul><ul><ul><li>difficult intubation </li></ul></ul></ul><ul><li>lack of equipment </li></ul><ul><li>unnecessary </li></ul><ul><li>inexperience </li></ul>
  73. 73. Choices… SUX or ROC? SUX contraindications <ul><li>difficult BVM or intubation </li></ul><ul><li>neuromuscular disorders </li></ul><ul><li>hyperkalemia </li></ul><ul><li>24 hours post-burns </li></ul><ul><li>7 days post-crush </li></ul><ul><li>7 days post-denervation </li></ul><ul><li>malignant hyperthermia </li></ul>
  74. 74. Succinylcholine <ul><li>duration of action is dependant on: </li></ul><ul><ul><ul><li>rapid hydrolysis - pseudocholinesterase </li></ul></ul></ul><ul><ul><ul><li>diffusion away from motor end plate (no pseudocholinesterase at end plate) </li></ul></ul></ul><ul><li>only a fraction of dose ever reaches end plate </li></ul><ul><ul><ul><li>give large doses </li></ul></ul></ul><ul><ul><ul><li>no harm giving too much </li></ul></ul></ul><ul><ul><ul><li>problem when incompletely paralyzed </li></ul></ul></ul><ul><ul><ul><li>give extra 20% (2 mg / kg) </li></ul></ul></ul>PARALYSIS <ul><li>depolarizing NMB fasciculations </li></ul>
  75. 75. Succinylcholine Onset: 10 - 15 seconds (fasciculations) 45 - 60 seconds (paralysis) Dose: 1 - 2 mg / kg (adults) 2 mg / kg (children) 3 mg / kg (newborns) Duration: 3 - 5 minutes (some resps) 8 - 10 minutes (adequate) PARALYSIS
  76. 76. Succinylcholine Side- Effects <ul><li>fasciculations </li></ul><ul><li>hyperkalemia </li></ul><ul><li>bradycardia </li></ul><ul><li>malignant hyperthermia </li></ul><ul><li>prolonged blockade </li></ul><ul><li>trismus - masseter muscle spasm </li></ul>Back PARALYSIS
  77. 77. Succinylcholine Fasciculations <ul><li>nicotinic receptor stimulation </li></ul><ul><li>inhibiting fasciculations - little evidence </li></ul>side-effects <ul><li>occurs same time as ICP </li></ul>PARALYSIS
  78. 78. Succinylcholine SUX-induced Hyperkalemia <ul><li>under normal situations, increase of: 0.5 mEq/L K + </li></ul><ul><li>small risk of dysrythmia: </li></ul><ul><ul><ul><li>CRF </li></ul></ul></ul><ul><ul><ul><li>severe acidosis </li></ul></ul></ul><ul><ul><ul><li>rhabdomyolysis </li></ul></ul></ul>Preexistent K + PARALYSIS
  79. 79. Succinylcholine <ul><li>increased extrajunctional receptors: </li></ul><ul><li>5 - 10 mEq/L K + </li></ul><ul><ul><li>prolonged depolarization </li></ul></ul><ul><ul><li>refractory to non-depolarizing NMB, may require large doses </li></ul></ul>Exaggerated release of K + PARALYSIS
  80. 80. Succinylcholine Exaggerated release of K + <ul><li>functional denervation of muscle: </li></ul><ul><ul><ul><li>stroke </li></ul></ul></ul><ul><ul><ul><li>spinal cord injury </li></ul></ul></ul><ul><li>extensive burns </li></ul><ul><li>massive crush injuries </li></ul><ul><li>neuromuscular disorders </li></ul>side-effects PARALYSIS
  81. 81. Succinylcholine PARALYSIS Receptor Recruitment & Sensitization Onset: 7 days Duration: 2 - 3 months Crush: Onset: 7 days Duration: 6 months Denervation: Onset: 24 hours Duration: 2 years Burns: (% burn does not determine response)
  82. 82. Succinylcholine Neuromuscular disorders: SUX contraindicated side-effects PARALYSIS Receptor Recruitment & Sensitization <ul><li>If give SUX: </li></ul><ul><ul><li>intractable cardiac arrest may occur </li></ul></ul><ul><ul><li>(even if recognize and treat K +) </li></ul></ul>
  83. 83. Succinylcholine Bradycardia <ul><li>cardiac muscarinic receptor stimulation </li></ul><ul><li>succinylmonocholine (a metabolite) sensitizessinus node receptors to repeat doses </li></ul><ul><li>consider atropine if: age < 10 </li></ul><ul><li>repeating dose </li></ul>side-effects <ul><li>children have vagal tone </li></ul>PARALYSIS
  84. 84. Succinylcholine Prolonged Neuromuscular Blockade <ul><li>congenital absence </li></ul><ul><li>of pseudocholinesterase </li></ul><ul><li>presence of an atypical form </li></ul><ul><ul><ul><ul><li>may last hours </li></ul></ul></ul></ul>PARALYSIS
  85. 85. Succinylcholine <ul><li>acquired absence: </li></ul><ul><ul><ul><li>cocaine </li></ul></ul></ul><ul><ul><ul><li>metoclopramide (Maxeran) </li></ul></ul></ul><ul><ul><ul><li>CRF </li></ul></ul></ul><ul><ul><ul><li>severe liver disease </li></ul></ul></ul><ul><ul><ul><li>hypothyroidism </li></ul></ul></ul><ul><ul><ul><li>malnutrition </li></ul></ul></ul><ul><ul><ul><li>pregnancy </li></ul></ul></ul><ul><ul><ul><li>cytotoxic drugs </li></ul></ul></ul><ul><ul><ul><li>organophosphates </li></ul></ul></ul>Prolonged Neuromuscular Blockade PARALYSIS
  86. 86. Succinylcholine <ul><li>acquired absence: </li></ul><ul><ul><ul><li>even worst of acquired not reported </li></ul></ul></ul><ul><ul><ul><li>to last > 25 minutes </li></ul></ul></ul><ul><ul><ul><li>SUX not contraindicated </li></ul></ul></ul>Prolonged Neuromuscular Blockade side-effects PARALYSIS
  87. 87. Succinylcholine <ul><li>mortality 60% </li></ul><ul><li>onset can be acute or delayed for hours </li></ul>Malignant Hyperthermia <ul><li>genetic skeletal muscle abnormality </li></ul><ul><li>can be triggered by: </li></ul><ul><ul><ul><ul><li>SUX </li></ul></ul></ul></ul><ul><ul><ul><ul><li>stress </li></ul></ul></ul></ul><ul><ul><ul><ul><li>vigorous exercise </li></ul></ul></ul></ul><ul><ul><ul><ul><li>halothane </li></ul></ul></ul></ul>PARALYSIS
  88. 88. Succinylcholine <ul><ul><li>muscle rigidity </li></ul></ul><ul><ul><li>autonomic instability </li></ul></ul><ul><ul><li>hypotension </li></ul></ul><ul><ul><li>hypoxia </li></ul></ul><ul><ul><li>severe lactic acidosis </li></ul></ul><ul><ul><li>myoglobinemia </li></ul></ul><ul><ul><li>DIC </li></ul></ul><ul><ul><li>fever - late manifestation </li></ul></ul>Malignant Hyperthermia side-effects PARALYSIS
  89. 89. Succinylcholine <ul><li>prevents Ca ++ release from sarcoplasmic reticulum of skeletal muscle </li></ul>Dantrolene for MH <ul><li>essential to resuscitation </li></ul><ul><li>give as soon as Dx suspected </li></ul><ul><li>free of serious side-effects </li></ul>side-effects Dose: <ul><li>2.5 mg/kg IV q5min </li></ul><ul><li>until muscle relaxation, or max 4 doses </li></ul>PARALYSIS
  90. 90. Succinylcholine Trismus - Masseter Muscle Spasm <ul><li>rise in jaw muscle tension is normal </li></ul><ul><ul><ul><li>should not affect laryngoscopy </li></ul></ul></ul><ul><li>pretreatment will not prevent </li></ul><ul><li>if severe, or progresses to other muscles: </li></ul><ul><ul><ul><li>consider malignant hyperthermia </li></ul></ul></ul><ul><ul><ul><li>spasm is not pathonomonic for MH </li></ul></ul></ul><ul><li>if occurs - administer non-depolarizing NMB (Rocuronium) </li></ul>side-effects PARALYSIS
  91. 91. Rocuronium <ul><li>Nondepolarizing, </li></ul><ul><li>does not stimulate receptor </li></ul><ul><ul><ul><ul><li>no fasciculations </li></ul></ul></ul></ul><ul><li>minimal hemodynamic effects </li></ul><ul><li>do not need priming dose </li></ul>PARALYSIS
  92. 92. Rocuronium Dose: 0.6 - 1.2 mg / kg PARALYSIS Onset: 60 - 90 seconds Duration: 30 - 60 minutes Defasiculating: 0.05 mg / kg
  93. 93. Comparing NMB SUX ROC PARALYSIS ONSET 30 - 60 60 - 90 sec DURATION 3 - 10 20 - 60 min rapid rapid no priming CVS stability advantages precautions K +
  94. 94. Comparing NMB PARALYSIS sec min VEC 150 - 180 25 - 30 no histamine release PAN 120 - 180 60 - 90 histamine release ATRA 120 - 150 20 - 35 histamine release
  95. 95. Positioning Proof
  96. 96. Positioning with protection You are asked to apply: cricoid pressure (Sellick’s maneuver)
  97. 97. BURP B ackwards U pwards R ightward P ressure <ul><li>distinct from Sellick’s maneuver </li></ul><ul><ul><li>second assistant </li></ul></ul><ul><ul><li>first assistant’s other hand </li></ul></ul>
  98. 98. Maneuvers Back
  99. 99. Laryngoscopy
  100. 100. Laryngoscopy
  101. 101. Laryngoscopy
  102. 102. Laryngoscopy
  103. 103. Laryngoscopy
  104. 104. Placement with proof methods of confirmation chest rise air entry fogging of ETT 60 cc syringe * capnometer
  105. 105. Colorimetric Capnometry exhaled CO2 simple color change from purple to yellow
  106. 106. Colorimetric Capnometry NEGATIVE POSITIVE
  107. 107. Colorimetric Capnometry ETCO 2 < 4 mm Hg ETT not in trachea inadequate perfusion (ineffective CPR)
  108. 108. Colorimetric Capnometry ETCO 2 15 - 38 mm Hg ETT in trachea
  109. 109. Colorimetric Capnometry ETCO 2 4 to < 15 mm Hg retained CO 2 in esophagus low perfusion deliver 6 more breaths
  110. 110. Colorimetric Capnometry Standard of Care Limitations: Back <ul><li>decreased cardiac output </li></ul><ul><li>low metabolic CO 2 production </li></ul><ul><ul><li>ex. hypothermia </li></ul></ul>
  111. 111. Bougie Lightwand LMA
  112. 112. Bougie
  113. 113. Epiglottis
  114. 114. Laryngoscopy Grades Cormack Lehane
  115. 115. Bougie
  116. 116. Lightwand
  117. 117. Lightwand Source: Laerdal
  118. 118. Lightwand Source: Laerdal
  119. 119. Laryngeal Mask Airway Source: LMA North America skip insertion technique
  120. 120. Laryngeal Mask Airway Source: LMA North America <ul><li>deflate the cuff </li></ul><ul><li>apply water-soluble lubricant to the posterior surface </li></ul><ul><li>place index finger at the junction of the cuff </li></ul>skip insertion technique
  121. 121. Laryngeal Mask Airway Source: LMA North America <ul><li>press the tip of the cuff upward against the hard palate and flatten the cuff against it </li></ul>skip insertion technique
  122. 122. Laryngeal Mask Airway Source: LMA North America <ul><li>use the index finger to guide the LMA, </li></ul><ul><li>press backward toward the other hand, which exerts counter-pressure (do not use force) </li></ul>skip insertion technique
  123. 123. Laryngeal Mask Airway Source: LMA North America <ul><li>advance the LMA into the hypopharynx until a definite resistance is felt. </li></ul><ul><li>inflate the cuff </li></ul>skip insertion technique
  124. 124. 7. Postintubation mgmt fix tube in place CXR nasogastric / orogastric tube lab etc Back
  125. 125. O2 Delivery Systems
  126. 126. O 2 Delivery Systems <ul><li>Nasal cannulae </li></ul><ul><ul><ul><ul><li>Double rate - add to room air FiO 2 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>ex. 3 L / min + 21 % FiO 2 </li></ul></ul></ul></ul><ul><ul><li>= 27 % </li></ul></ul><ul><li>Limitations: </li></ul><ul><ul><li>rates > 3 L / min uncomfortable </li></ul></ul><ul><ul><li>mouth breathing </li></ul></ul>
  127. 127. O 2 Delivery Systems <ul><li>Simple Face Mask </li></ul><ul><ul><li>6 – 10 L / min flow </li></ul></ul><ul><ul><li>35 – 55 % FiO 2 </li></ul></ul><ul><li>entrainment of room air </li></ul><ul><li>through exhalation ports </li></ul>
  128. 128. O 2 Delivery Systems <ul><li>Partial </li></ul><ul><li>Rebreathing </li></ul><ul><li>Face Mask </li></ul><ul><li>reservoir bag </li></ul><ul><li>first ~ 1/3 of exhaled gas </li></ul><ul><li>is directed into bag </li></ul><ul><ul><li>(that which was in patient’s upper airway) </li></ul></ul><ul><li>up to 60 % FiO 2 </li></ul>
  129. 129. O 2 Delivery Systems <ul><li>Non-Rebreathing Face Mask </li></ul><ul><ul><li>reservoir bag </li></ul></ul><ul><ul><li>one-way valves </li></ul></ul><ul><ul><li>up to 80 % FiO 2 </li></ul></ul><ul><li>(realistically) </li></ul>
  130. 130. O 2 Delivery Systems <ul><li>Bag Valve Mask </li></ul><ul><li>(BVM) </li></ul><ul><li>up to 100 % FiO 2 </li></ul>
  131. 131. Summary
  132. 132. Airway Management ? ?
  133. 133. eMEDiUM Emergency Medicine in the U of M emergency.mb.ca Back
  134. 134. HSC ED <ul><li>Maryann Cromwell </li></ul><ul><li>MCromwell @ exchange.hsc.mb.ca </li></ul><ul><li>phone: 787-2934 </li></ul><ul><li>fax: 787-2231 </li></ul><ul><ul><ul><li>Department of Emergency Medicine </li></ul></ul></ul><ul><ul><ul><li>Health Sciences Centre </li></ul></ul></ul><ul><ul><ul><li>GF 201-800 Sherbrook Street </li></ul></ul></ul><ul><ul><ul><li>Winnipeg, MB </li></ul></ul></ul><ul><ul><ul><li>R3A 1R9 </li></ul></ul></ul>Back
  135. 135. CAEP ACEP

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