The Emergency Airway National Review Course in Emergency Medicine

1. The Emergency Airway National Review Course in Emergency Medicine Kirk Magee MD, MSc, FRCPC Associate Professor Dalhousie Department of Emergency Medicine

3. Outline: • Recognition: is this an airway question? • Cases

4. Case • A 35 year old female presents to the ED with an altered LOC. She was found surrounded by empty pill bottles • Vital Signs: HR 130, BP 115/78, sats 98%, GCS 6/15 • Is this an airway question?

5. Types of Airway questions • Recognition of the need for an airway • Description of RSI and recognition of relative contraindications • Recognition and management of a difficult airway • Post intubation management • Approach to the failed airway

6. How to drive an examiner nuts… • “I would perform an RSI with a double set-up”

7. Exam triggers to the difficult airway: • Morbidly obese • Trauma to head or neck • Burns • Stridor • Prior unsuccessful attempts • Asthma • Anaphylaxis

8. Beware… BMV Laryngoscopy

9. Difficult Mask Ventilation • Beardmask seal issues • Obeselung/chest wallcompliance • Older head/neck position • Toothlessmask seal • Snores/Stridorobstruction ‘BOOTS’

10. Predicting Difficult Laryngoscopy and Intubation MMAPthe airway: • Mallampati and Measure 3-3-1 • A-O extension • Pathologicconditions ‘MMAP’

11. Lets get ready to rumble!

12. Cases

13. Case 1 • 34 yo asthmatic presents with severe respiratory distress • Normal airway • VS: 122, 32, 156/90

14. Special Considerations • Percipitating causes: • Pneumothorax, mucous plug • Role of epinephrine • Difficult/impossible to BMV • Permissive hypercapnea • Ketamine • Apneic oxygenation

15. Apneic Oxygenation

16. Pre-oxygenation combining high flow nasal canula and a non-rebreather mask • Measured inspired oxygen NRBM @ 15 lpm only 60-70% • Pt’s expired gasses are mixing with applied O2 in nasopharynx • High flow nasal O2 flushes the nasopharynx with O2 • When pt inspires, inhale higher percentage of inspired O2 • Small changes in FiO2 create dramatic changes in the availability of O2 at the aveolus

17. Apneic Oxygenation • Alveoli will continue to take up O2 even without diaphragmatic movments • Optimal circumstances: PaO2 can be maintained at > 100 mmHg for up to 100 minutes without a single breathe!

18. “NO DESAT” Nasal Oxygen During Efforts Securing ATube

19. “If you enter the exam as a resident, that is how you will leave, but if you enter as a consultant…” Be decisive!

20. Case 2 • 4 yo presents with a 3 day hx of fever and “flu-like” symptoms • Unable to arouse • VS: 139, 6, 60/40

21. Special Considerations • Not just “little adults”

22. The Pediatric Airway • Smaller airway • Large occiput • Tongue is larger • Larynx is relatively cephalad in position • Epiglottis is more floppy • < 10 yrs, narrowest portion of airway is below vocal cords • Higher basal metabolic rate • bradycardia

23. Important pediatric numbers: Age 4 • ET Tube size: • ET Tube depth: + 4 Age 2 + 4 Breslow Tape

24. Case 3 • 26 yo Type 1 diabetic • Florid DKA, not protecting his airway • VS: 127, 28, 95/66, 95%

26. Special Considerations • Hyperkalemia • Post-intubation still need high respiratory rate • DKA • ASA overdose

27. Contraindications to Sux • Hyperkalemia • Burns > 10% BSA • Crush injury • Denervation • Neuromuscular disease • ALS, MS • Malignant hyperthemia

28. Case 4 • 50 yo pulled from burning car • Significant burns to face, stridor • VS: 112, 28, 132/88, 88%

29. Special Considerations • Difficult airway • Toxicology • CO • CN

30. MMAP:Pathological Obstructing Conditions… e.g. Periglottic edema e.g. Glottic trauma

31. MMAP:Pathologically Obstructing Conditions… …with deep sedation may be impossible to BMV or intubate !!

32. Can’t Intubate Can Ventillate Can’t Intubate Can’tventillate Two Possible Scenarios

33. What are your options? • If not contraindicated, RSI may actually improve success rate • Double set-up • Are you the right person, is the ED the right location? • Awake intubation

34. Advantages Airway maintained Breathing continues Stable hemodynamics Disadvantages Can be difficult Cooperation Adverse reflexes (GI/CNS/CVS) ‘Awake’ intubation …Intubation with topical airway anesthesia and light sedation.

35. Rescue device: Glide Scope®

36. Rescue ventilation devices: LMA www.lmana.com

37. Rescue ventilation devices: I-LMA

38. Rescue devices: Lighted Stylet

39. Rescue techniques • Glide Scope® • LMA • I-LMA • Lighted Stylet • EsophagotrachealCombitube • Retrograde Intubation • Fiberoptic Intubation

40. Can’t ventilate, Can’t intubate

41. Cricothryotomy Contraindications: • Distorted neck anatomy • Pre-existing infection • Coagulopathy • +++ difficult in pts < 10 yrs of age Relative Contraindications!

42. What equipment do you need? • Scalpel • Tracheal dilator (Trousseau dilator) or spreader • Tracheal hook • Portex or Shiley tube (No. 5-6 in adult)

43. Decribe how you would perform a cricothyrotomy

44. Case 5 • 72 yo with altered LOC and urosepsis • Normal airway • VS: 124, 20, 70/40

45. Special Considerations • CBA not ABC! • Maximize BP first • Relative contraindication for etomidate?

46. “If only I had been a vet…”

47. Case 6 • 26 yo mountain biker “clothes-lined” on wire fence at high speed • Pt is unable to talk; obvious respiratory distress • Edema and echymosis evident at his neck • VS: 115, 26, 160/85, 88%

48. Special Considerations • The “most difficult” airway! • Patent airway may be lost with deep sedation/paralysis • How does the scenario change with: • Time from injury • Community vs Urban ED • “stable” vs. “unstable”

49. Your 1st attempt should not be in Ottawa at the exam centre!

50. Putting it all together • Preparation – predictors of difficult BMV/laryngoscopy • Preoxygenate – no BMV • Paralysis and induction agent • Placement of tube and confirmation • Post tube management