Is there a Middle Way? Faculty of Pre-hospital Care Thursday 8 th July 2010 Birmingham

2. SO YOU THINK YOU KNOW ALL ABOUT VENTILATION Is there a Middle Way? Faculty of Pre-hospital Care Thursday 8th July 2010Birmingham

3. PREHOSPITAL AIRWAY MANAGEMENT IS THERE A “MIDDLE WAY”? Dr Andy Mason, Bury St Edmunds, Suffolk, UK BASICS-Accredited Immediate Care PhysicianMember, Suffolk Accident Rescue Service (1974- ; Committee 1980-2006 ; Chairman 1997-2000)Advisory Panel Member, SLAM Airway Training Institute, Dallas, Texas Airway Training Course Adviser, Santa Casa Hospital CTVA, Sao Paulo, Brazil Former Lecturer, Paramedic Training Course, East Anglian Ambulance Trust Former Prehospital Care Adviser, Intavent Orthofix Ltd, Maidenhead, UKFormer Medical Adviser, Laryngeal Mask Company, Worldwide

4. SLAM AIRWAY MANAGEMENT TEXTBOOK Dr. ANDY MASON ASSISTANT EDITOR & CHAPTER CO-AUTHOR

5. THE “MIDDLE WAY” The “Middle Way” is an ancient Buddhist concept representing a path mid-way between the extremes of self-denial and self-indulgence. Buddhists believe that this high middle path has an intrinsic value which is greater than a mere compromise The Middle Way Self-indulgence Self-denial

6. THE “MIDDLE WAY” – THE CHALLENGE Is there a similar “Middle Way” in pre-hospital care not just a compromise between Basic Airway Care and Conventional RSI but an effective method of emergency care with its own intrinsic value? ? Basic Airway Care Conventional RSI

7. THE “MIDDLE WAY” THE “MIDDLE WAY” OF PREHOSPITAL AIRWAY MANAGEMENT IS BASED ON THREE PRINCIPLES: Selection of appropriate patients Use of the most appropriate airway device Use of appropriate drugs, when necessary, to help secure the airway

8. THE “MIDDLE WAY” THE “MIDDLE WAY” OF PREHOSPITAL AIRWAY MANAGEMENT IS BASED ON THREE PRINCIPLES: Selection of appropriate patients Use of the most appropriate airway device 3. Use of appropriate drugs, when necessary, to help secure the airway

9. SELECTION OF APPROPRIATE PATIENTS The trauma.org website identifies the following categories of patient “who require a definitively secured airway” • Apnoea • Airway injury • Large flail segment or respiratory failure • Unstable mid-face trauma • GCS <9 (or sustained seizure activity) • High aspiration risk • Inability otherwise to maintain an airway or oxygenation. Source: www.trauma.org/anaesthesia/airway.html Condition-based guidelines all suffer from a lack of clarity which can result in haphazard and inappropriate selection of patients

10. SELECTION OF APPROPRIATE PATIENTS PATIENTS CAN BE SELECTED USING ‘PU-92 CONCEPT’ Those who are ‘P’ or ‘U’ on AVPU scaleAND… Also have an SpO2 reading of 92% (despite optimal efforts to improve oxygenation using ‘basic’ methods)or…Also have a respiratory rate 10 or 30 breaths-per-minute (when an SpO2 is unobtainable)

11. THE ‘PU-92 CONCEPT’ Why adopt an SpO2 threshold of 92%? • Hypoxemia occurs when SaO2 ≤90% • Most pulse oximeters have ± 2% error • Therefore, to avoid hypoxemia, the SpO2 should be maintained above 92%.

12. THE ‘PU-92 CONCEPT’ ALGORITHM

13. THE “MIDDLE WAY” THE “MIDDLE WAY” OF PREHOSPITAL AIRWAY MANAGEMENT IS BASED ON THREE PRINCIPLES: Selection of appropriate patients Use of the most appropriate airway device Use of appropriate drugs, when necessary, to help secure the airway

14. THE GOLD STANDARD The Cuffed Endotracheal Tubeis the in Emergency Airway Management GOLD STANDARD (but only when it is placed into the trachea!)

15. OBJECTS INSERTED INTO THE AIRWAYDON’T ALWAYS FOLLOW THE INTENDED ROUTE!

16. EMERGENCY VENTILATION Patients die from: A Failure to Ventilate&A Failure to Oxygenate Not from aFailure to Intubate!

17. WHEN IT FIRST APPEARED THE LMA WAS DESCRIBED AS “THE MISSING LINK” Endotracheal Tube Bag-Valve-Mask Device Laryngeal Mask Airway1987

18. LMA Classic™(Class IIa) Combitube™(Class IIa) BUT WHICH SUPRAGLOTTIC AIRWAY DEVICE (SAD) TO CHOOSE? Slide courtesy of Dr Harald V Genzwürker, University Hospital Mannheim, Germany harald.genzwuerker@anaes.ma.uni-heidelberg.de

19. BUT WHICH SUPRAGLOTTIC AIRWAY DEVICE (SAD) TO CHOOSE? LMA Fastrach The LMA Fastrach and LMA CTrach are the only two SADs that act both as rescue ventilation devices AND offer seamless progression to tracheal intubation without any interruption in ventilation and oxygenation

23. NATIONAL CONFIDENTIAL ENQUIRY INTOPATIENT OUTCOME AND DEATH - 2007 “The current structure of prehospital management is insufficient to meet the needs of the severely injured patient. There is a high incidence of failed intubation and a high incidence of patients arriving at hospital with a partially or completely obstructed airway. Change is urgently required to provide a system that reliably provides a clear airway with good oxygenation and control of ventilation. This may be through the provision of personnel with the ability to provide anaesthesia and intubation in the prehospital phase or the use of alternative airway devices.” NCEPOD Report , Chapter 6 (Airway & Breathing), 2007

24. LMA™ RANGE OF SADs Single-useLMA Flexible Single-useLMA Fastrach Single-useLMA Unique LMA Flexible LMA Fastrach LMA Classic LMA ProSeal We are Family!

25. LMA CTrach™ Re-usable intubating LMA with twin fibreoptic channels and detachable full-colour viewer

26. LMA SUPREME™ Single-use LMA with gastric port anatomically-curved airway tube and redesigned cuff LMA Supreme™

27. Anatomically-curvedstainless steel airway tube Handle Cuff inflation line Silicone coating on airway tube Epiglottic elevating bar Cuff inflation valve (with pilot balloon) Silicone cuff RE-USABLE LMA FASTRACH™ (iLMA)

28. RE-USABLE LMA FASTRACH™

29. SINGLE-USE LMA FASTRACH™

30. 12 REASONS WHY THE LMA FASTRACH™IS SUITABLE FOR PREHOSPITAL USE No need for laryngoscopy Head & neck must be kept in neutral alignment for insertion Neuromuscular blockade not necessary At least as easy to insert as the standard LMA Requires an inter-dental gap of only 20mm Can be introduced blindly with one hand from any position No need to insert a finger into patient’s mouth Rigid airway tube resists occlusion by biting Suitable as a rescue ventilation device in its own right Facilitates seamless progression to tracheal intubation Permits ventilation between/during intubation attempts Available as disposable single-use device.

31. THE “MIDDLE WAY” THE “MIDDLE WAY” OF PREHOSPITAL AIRWAY MANAGEMENT IS BASED ON THREE PRINCIPLES: Selection of appropriate patients 2. Use of the most appropriate airway device 3. Use of appropriate drugs, when necessary, to help secure the airway

32. Drug Management All drugs require careful titration and all can worsen the physiological parameters especially hypotension Midazolam has become the drug used to facilitate the insertion of the LMA A sliding scale based upon the patient’s GCS score has been developed

33. Drug Management 0.5 mg of midazolam given IV for every point on the GCS score above 3, repeated after 3 minutes if conditions are still unsuitable for LMA insertion Thus a patient with a GCS of 8 would receive 0.5 x 5 mg Giving a starting dose of 2.5mg This may be repeated after 3 minutes To give a maximum of 5mg A paper from USA - Swanson ER, Fosnocht DE, Jensen SC. Comparison of etomidate and midazolam for prehospital rapid-sequence intubation. PrehospEmerg Care 2004 Jul-Sep;8(3):273-9) – supports such doses

34. Drug Management

35. Drug Management Having gained airway security For the journey to hospital A mixture of midazolam and fentanyl may be used

36. LMA FASTRACH™ Trapped Trauma Case Serieswith LMA Fastrach™

37. ACKNOWLEDGEMENT ACKNOWLEDGEMENTGRATEFUL THANKS TO THOSE PATIENTS AND RELATIVES WHO GAVE PERMISSION FOR PHOTOGRAPHS TO BE USEDIN THIS PRESENTATION

41. LMA FASTRACH™

45. The Beck Airway Airflow Monitor (BAAM) Can take up to a size 8 ET tube Chandy Manoeuvre The ILMA can be removed; best done in hospital Picture courtesy Life-Assist Inc., Rancho Cordova, CA, USA