Advanced Airway

Lynn K. Wittwer, MD, MPD

Clark County EMS
 Advanced Airway
Anatomic Considerations
Rapid Sequence induction
Induction Agents
Intubation tricks
 Indications for Definitive Airway
Need for Airway Protection Need for Ventilation
Unconscious Apnea
Neuromuscular Paralysis
Unconscious
Severe Maxillofacial fx’s Inadequate Respiratory Effort’
Tachypneal
Hypoxia
Hypercarbia
Cyanosis
Risk for aspiration Severe closed head injury with need
Bleeding for hyperventilation
Vomiting
Risk for obstruction
Neck hematoma
Laryngeal, tracheal injury/burn
Stridor
 ANATOMIC CONSIDERATIONS FOR
INTUBATION
Mouth:
– Tongue :
variable in size (angioedema)
attached inferior to epiglottis
– Mandible
– Uvula
Pharynx
– Tonsils
– Merges with larynx anterior, esophagus posterior
– Epiglottis high long flaccid and narrow in child
 ANATOMIC CONSIDERATIONS FOR
INTUBATION (cont.)
The Larynx
– High relative to mandible in child
– Cricoid smaller in child, narrow part of airway
– vocal cord narrow part of adult airway
– arytenoid cartilages
Netter; Atlas of Human Anatomy
 ANATOMIC CONSIDERATIONS FOR
INTUBATION (cont.)

Trachea
– 12-15 cm. Adult
– 4 cm. Newborn
– right mainstem
larger,shorter and
less angle Anderson; Grant’s Atlas of Anatomy
 ANATOMIC CONSIDERATIONS FOR INTUBATION (cont.)
Anderson; Grant’s Atlas of Anatomy
 OTHER CONSIDERATIONS FOR
INTUBATION (cont.)
– Tube Sizes (Kids)
Fit through nose
Age(years)/4 + 4
Oral tube length
– Age(years)/2 + 12 cm.
– Nasal add 3 cm.
No cuff under 6 to 8 years
 OTHER CONSIDERATIONS FOR
INTUBATION (cont.)
Difficult tubes
– Immobilized trauma patient
– Combative patient
– Children, esp. Infants
– Short neck
– Prominent upper incisors
– Receding mandible
– Limited jaw opening, limited
cervical mobility
– Upper airway conditions
– Facial, laryngeal trauma
Correct Placement for intubation (b)
Patient in correct position for intubation (sniffing position)
Incorrect airway position (hyperflexed)
 Rapid Sequence Induction

Indications
– Ventilatory failure
– Airway maintenance/protection
– Treatment and evaluation
neuro resuscitation(hyperventilate)
shock
drug overdose
 Rapid Sequence Induction

Contraindications
– Cardiac arrest
– Adequate ventilation
– Deeply comatose patient, absent tone
– Post-intubation sedation
 Rapid Sequence Induction

Contraindications
(cont.)
– Intubation likely
unsuccessful
Partially obstructed
airway
Severe facial Whitten; Anyone Can Intubate
abnormality(trauma,
etc.)
McIntyre; The difficult tracheal intubation
 Rapid Sequence Induction

Maintain adequate oxygenation

Airway protection
– Prevent regurgitation, aspiration
Obtund adverse cardiovascular and ICP
response to intubation
Better early than late
Hypoxemia and acidosis effects
 Rapid Sequence Induction

Treatment Algorithm
– Preparation
– Pre-oxygenation( functional reserve capacity)
– Pre-medication
– Sedation
– Cricoid pressure
– Paralysis
– Intubation
 DO NO HARM!

TAKE AWAY NOTHING FROM

THE PATIENT YOU CANNOT
REPLACE
 Rapid Sequence Induction

Anticipate the difficulties

– Identify in advance the patient who may
require RSI
– Identify the patient with anatomic difficulty
– Have sufficient skill and training
– Have a preformulated plan for potential
disaster
 Airway Evaluation

Problem Airway

epiglottis Vocal cords

 Rapid Sequence Induction

Be prepared:
– Competence with all equipment
– Working equipment
– Be prepared for surgical
management
– Master the art of bagging
– Have at least one, if not two,
working IV lines
 Rapid Sequence Induction
Equipment:
– Suction, Oxygen
– Laryngoscope, ET Tubes, Stylet
– BVM
– Pharmacologic agents, mixed and ready
– Monitoring equipment
Continuous cardiac monitoring
Pulse oximeter (continuous)
Auto BP (ideal)
CO2 device (ET confirmation device)
 Rapid Sequence Induction

Pre-oxygenation:
– Functional residual capacity
– Oxygen 6-10 l/min via snug mask
– Three minutes ideal if spontaneous breathing
– In “crash”, may use RSI agents and O2 by
BVM with mandatory Sellick
 Rapid Sequence Induction

Pre-medication:
– Atropine
All children under 12 years
Adults with heart rate 100 or less ***
Second dose of Succinylcholine
Dosage: 0.5 to 1.0 mg adult
Dosage 0.01 to 0.02 mg child (1 mg max)
Give ideally 2-3 minutes prior to intubation
 Rapid Sequence Induction

Pre-medication (cont.)
– Lidocaine
Decrease adrenergic and physiologic response to
laryngoscopy and intubation
Decreases ICP response
Mucosal anesthesia
Dosage: 1.0-1.5 mg/kg IV 2-5 minutes prior to
intubation
 Rapid Sequence Induction

Paralytics Have No Sedative Quality

Sedation Agents
– Selection of agent(s)
perfusion state
presence of head injury
clinical diagnosis
Paramedic drug box
 Rapid Sequence Induction

Selection of Sedative (cont.)

– Benzodiazepines
Amnestic and at high dose, anesthetic
Little cardiovascular depression
– Diazepam
Slow onset/longer lasting
3-5 mg IV (adult)
0.2 to 0.4 mg/kg (kids) titrate
 Rapid Sequence Induction

Benzodiazepines (cont.)
Midazolam
– Rapid onset
– Potent amnestic
– Moderate decrease in ICP
– 1-3 mg IV (adult)
– 0.1 mg.Kg titrated in kids
 Rapid Sequence Induction
Selection of Sedative (cont.)
– Narcotics
Potent analgesics/sedatives
Rapid onset w/ brief duration
Effect can be reversed!
– Morphine
2-20 mg IV
May cause refractory bradycardia/hypotension
 Rapid Sequence Induction
Selection of Sedative (cont.)
– Butyrophenones:
Useful as anxiolytics
May cause EPS
Minimal cardiac effect
– Haloperidol
Potentiates effect of narcotics
EPS more common
2.5-5.0 mg IV/IM
 Rapid Sequence Induction
Selection of Sedative (cont.)
– Etomidate
Non-barbiturate hypnotic
Rapid onset of action, short duration
Does not blunt sympathetic response to intubation
Dose:
– 0.3 mg/kg IV
20 mg maximum dose
Not indicated for peds <10 years
 Induction Agents

Neuromuscular Junction
ACh binds to post
synaptic receptors
causing depolarization …
Contraction of muscle

Dailey; The airway: emergency management

ACh removed by
acetylcholinesterase and
by diffusion ….
Relaxation of muscle
 Induction Agents
Mechanism of action:
– Nondepolarizers
Competitive
Block ACh receptors … paralysis
– Depolarizers
Noncompetitive
Persistent stimulation …fasciculations
Unresponsiveness to ACh….Paralysis
Dailey; The airway: emergency management
 Induction Agents
Depolarizing
– Succinylcholine
Vagal effects
– Excessive bronchial secretions
Negative inotropic and chronotropic, esp. with
repeated dose and in children
Fasciculations (amelioration)
Malignant hyperthermia?
Complete paralysis w/in 30-45 sec. Lasting 4-6
min
– 1.5 mg/kg IV
 Induction Agents
– Succinylcholine (cont.)
Metabolized via Cholinesterase
– 0.3% defective enzyme
Contraindications
– Absolute - none
– Hyperkalemia
Renal failure
Crush injury
Burns
Myotonia
Paraplegia
 Induction Agents
•Non-depolarizing
–Vecuronium
•Minimal cardiovascular effect
•Long duration of action (may exceed 90 mins)
•Shorter onset than Pancuronium
•0.1 mg/kg
 RAPID SEQUENCE INTUBATION
INDICATIONS:
Need for immediate intubation assumed with failed intubation attempt
PROCEDURE:
Protect C-Spine prn
O2 100% w/ BVM assist (hyperventilate pt. if possible)
Suction prn
IV w/ balanced salt solution; EKG
*** Cricothyroidotomy equipment available ***
Lidocaine 1 mg/kg IV
Atropine 05 mg IV adults w/ HR <80
(001 mg/kg IV All kids <12 )
Etomidate 03 mg/kg max 20 mg-5 mg IV Adults and peds >10 yr for sedation.
Succinylcholine 15 mg/kg IV bolus
*** Sellick until intubation successful and ETT cuff inflated ***
Perform intubation (once fasciculations stop)
If relaxation inadequate in 60-120 secs, repeat Succinylcholine 15 mg/kg IV
reattempt intubation
Confirm placement by auscultation, capnography Secure ETT
Ventilate w/ BVM & 100% O2
Maintain EtCO2 35-40 mm/Hg
If further paralysis required:
Vecuronium 01 mg/kg
Versed 25-5 mg IV for sedation
(peds 01mg/kg)
Airway Management
Airway Management
Airway Management
 Intubation Tricks

Digital
Tactile
Intubation
Eschmann
Lighted
stylette
Fiberscope
BURP
 SURGICAL AIRWAYS
•Cricothyrotomy
–Indications (Identified need for intubation)
•Maxillofacial trauma
•Oropharyngeal obstruction
–Edema
–FBAO
–Mass Lesion
–Cancer
•Unsuccessful oral/nasal tracheal
•Difficult anatomy
•Massive hemorrhage/regurgitation
 SURGICAL AIRWAYS
•Cricothyrotomy (cont..)
–Contraindications:
–Age <10-12
–Laryngeal crush injury
–Laryngeal tumor/stricture
–Tracheal transsection
–subglottic stenosis
–Expanding hematoma
–Coagulopathy
–Unfamiliar w/ procedure
 SURGICAL AIRWAYS
Anatomy:
– Thyroid cartilage
– Cricoid ring
– Cricoid cartilage
– Thyroid gland
– Trachea
– Major vessels
SURGICAL AIRWAYS

Netter; Atlas of Human Anatomy

 SURGICAL AIRWAYS
Procedure:
– Identify thyroid cartilage
Cricothyroid membrane
– Vertical incision through skin
Prep prior
Incise membrane
– Open incision
Dilator/tracheal hook
– Insert ETT/Trach tube
Ventilate patient
 SURGICAL AIRWAYS
Complications:
– Incorrect placement
– Long execution time
– Hemorrhage
– Passage sub Q
– Plugging
– Pneumomediastinum
– Aspiration
– etc.
Anderson; Grant’s Atlas of Anatomy
SURGICAL AIRWAYS
 SURGICAL AIRWAYS
Retrograde Tracheal Intubation (RTI):
– Indications
Abnormal anatomy
– Pt. W/ epiglottitis
– Severe kyphosis
– Cervical spondylosis
Trauma
Reasonable alternative to Surg and Needle
Crike
 SURGICAL AIRWAYS
RTI (cont...):
– Contraindications
Trismus (w/o paralytic)
Coagulopathy
Enlarged thyroid
– Procedure:
Supplemental O2
Catheter over needle into CTM
Insert guidewire through catheter
Visualize guidewire and pass tube
Dailey; The airway: emergency management
 SURGICAL AIRWAYS
Needle Cricothyrotomy
– Indications
Same as for any surgical airway
Considered safer and quicker than surgical
crike
Will not compromise c-spine in trauma pt.
– Contraindications
Total obstruction at or near the cords
– Complications
Misdirection
Puncture tracheal wall
Local cord damage
Does not prevent aspiration!
 SURGICAL AIRWAYS
Needle Cricothyrotomy
– Procedure
Supplemental O2
Catheter over needle into CTM (at least 14 ga)
Attach to high pressure O2 source (50psi)
Ventilate using valve or “interrupter type device