Dramatic Life Saving 2 11/5/2013 Plan Ahead Forethought - PowerPoint PPT Presentation

11/5/2013 The Difficult Airway � Anatomy • Visualization • Difficult BVM / LMA ventilation � Physiology • Unable to oxygenate • Unable to ventilate • Severe Acidosis • Hypotension Topics 2013 The Difficult Airway Drama BUT ‘REAL’ � Deciding which patient to intubate Airway management � Timing � May be the single most important topic • Stable – semi-elective in Emergency Medicine • Crashing • Crashed The area of EM with the greatest immediate breadth of outcomes within minutes: life and death 1

11/5/2013 Sexy HEROIC Dramatic Life Saving 2

11/5/2013 Plan Ahead � Forethought � Equipment � Planning � Drugs � Attention to detail � Positioning � Knowledge � Check lists… An intervention to dec complications � Presence of two operators related to EI in the ICU….. Int Care Med 2010 � Fluid Loading � Pre-oxygenation Severe Mild to Moderate � RSI drug prep Death Difficult tube � Sellick Cardiac Arrest Esophageal � Placement confirmation – capnography Severe Hypoxemia Aspiration � Pressor support Severe Cardiovascular Collapse Arrhythmia requiring RX � Longer term sedation � Protective low volume vent Dangerous agitation 3

11/5/2013 Difficult / High Risk � Hypoxic � Hypotensive � Acidotic � Shock � Obstruction � Anatomic difficulty 4

11/5/2013 Oxygenation � Preoxygenation � Positioning � DSI � Apneic Oxygenation Positioning Apneic Oxygenation � Head up 20 degrees /reverse � Prolong time to desat: • Normal BMI – by 2-3 minutes trendelenberg • Delay time to desat by about 100 seconds • BMI > 30 – by about 100 seconds � Jaw thrust 5

11/5/2013 Preoxygenation Strategies Journal of Clinical Anesthesia 2010 � NIV • USE NIV mask or BVM • 5cm of PEEP / 100% O2 / High flow • Sat >95% for >3 min • Leave Mask in place while pushing drugs • Leave NC on at all times strategies strategies � Ventilator to drive the BVM � Ventilator Vs. Bagging • Oral airway � Peep • Standard BVM vent � Atelectasis • Ventilator on AC at 550ml � Saturation • Flow at 30 L /min • 12 vent / min + 5-15 PEEP • Attach the vent to the mask 6

11/5/2013 Delayed Sequence Intubation Hydration before induction � Most critically ill are dry • Ketamine 1mg/kg slow push (glycopyrrolate) � Loss of sympathetic support • NIV / non-rebreather / LMA……. � Loss of muscle tone • Sat >95% for >3 min � Peep / Pos Pressure vent • Paralytic – leave mask while inducing � Drugs • Leave nasal cannula and intubate PLAN AHEAD � Hydration � What drugs do you have available � Phenylephrine � What tools do you have � What are you experienced and comfortable to perform 7

11/5/2013 Can you bag – valve –mask ventilate this patient? Will you be able to see cords? This pt develops stridor and sat’s begin to fall?? Oral endotracheal intubation fails – what next? Difficult Airway Management Steps (7) 1. Always assume the intubation will be difficult! ** 2. Familiarize yourself: ** Where are your airway tools located What devices are at your disposal 3. Have backup plans A B & C developed before the scairway arrives ** This asthmatic becomes agitated – her PH is 6.8 PCO2 = 110 ** MAJOR TAKE HOME POINTS 8

11/5/2013 Airway Plans A B & C More Steps A Optimize Oral Endotracheal Intubation 4. Consider the urgency of the case conditions Airway control is needed: NOW!! Within minutes Semi – elective B LMA – Combitube – Stylet guided Intubation 5.Can the patient be bag-valve-mask ventilated? C Surgical: Needle, Seldinger, or Traditional 1 ST ATTEMPT HAS More Steps FAILED � Start with back up plan A 4. Consider the urgency of the case 5. Can the patient be bag-valve-mask ventilated? 6. Assess airway anatomy 7. How great is the risk of aspiration? 9

11/5/2013 Preparing for the second Things to Do in Every Airway attempt � Positioning can make a huge difference • Raise the bed • Top of patients head at very end of gurney • Flex neck 30 o - extend head / ramp up � Change blades – or use the Mac like a Miller � BURP maneuver • B ack – U P - R ight - P ressure Alternative Airway Alternative Airway Approaches / Approaches / Devices Devices � Nasal intubation � Tactile digital intubation � Fiberoptic intubation � Retrograde intubation � Gum elastic bougie � Percutaneous transtracheal intubation � Lighted Stylet � Cricothyrotomy – traditional � Laryngeal Mask Airway (LMA) � Cricothyrotomy – needle guided � Combitube / King � Video laryngoscopes 10

11/5/2013 Personal recommendations Bougie 11

11/5/2013 Percutaneous Transtracheal Bougie 60 cm long – 15 French Ventilation (PTV) � Use a laryngoscope � Ventilation via a catheter placed through � Advance with the concavity facing anterior the cricoid membrane feel for ‘ clicks ’ as it passes over the tracheal � As the tip of the bougie enters the glottic opening • High frequency jet ventilation (small volumes of oxygen at rates of 100-200/min) rings • High pressure standard ventilation (large volumes at 50psi at a rate of 12-20.min) � Rotate the ETT counter-clockwise • Traditional bag valve ventilation (intermediate volumes, low pressure std rate) Percutaneous Google search Percutaneous Transtracheal Transtracheal Manual Jet Ventilator Ventilation Ventilation � Indications: • Rescue airway – especially in children � Contraindications: • *Complete airway obstruction • Unable to identify landmarks � Complications: • Barotrauma • Esophageal perforation • Hypercapnea 12

11/5/2013 Percutaneous Transtracheal Ketamine Ventilation (The MacGuyver Approach) Ketamine Dexmedetomidine � Can be used IM � Alpha 2 agonist � Doesn’t require refrigeration � Dissociative state � Wide safety index � Preserves airway reflexes � No apnea � Hypotension, bradycardia, nausea � Rapid onset 13

11/5/2013 Midazolam Vomiting blood � No refrigeration � 45 yr old male with hematemesis � IM � + past hx of ETOH and GI bleed � Reversible � Rapid onset � 92/64 134 26 94% � Actively vomiting blood � Awake but confused Hematemesis Hematemesis � What are the immediate issues / questions � BVM vent likely to be very difficult that need to be answered? � A secure airway is needed NOW!!! Can the pt be bag mask ventilated? � Aspiration is a major threat Is aspiration a real threat? � Too crashed for nasal (+probable coagulopathy) How difficult is traditional oral tracheal intubation likely to be? � +- one attempt at traditional oral How much time do we have? intubation …. 14

11/5/2013 Needle Cricothyrotomy Hematemesis � I recommend trying to pass a bougie if you can see some anatomy but have the ILMA and a needle cric kit ready � KETAMINE! I suggest using a # 10 blade to produce a larger skin ‘ nick ’ Needle Cricothyrotomy Needle Cricothyrotomy 15

11/5/2013 Airway Pearls Summary � DSI and NIV as a preoxygenation tool � Expect the worst and be prepared � Consider the urgency -Apneic Oxygenation should be standard � Don’t forget BVM ventilation � Balance the needs for ventilation & oxygenation vs. the risk of aspiration -The BVM – bag – holds about 2 L of air – one only needs to administer about 1/4 of the bag to � Become familiar with • LMA or Combitube ventilate • Lightwand or Bougie • Traditional or Seldinger cric -Ketamine is invaluable • PTV 16