Professional Documents
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Airway Management: Sarah Mcpherson Gord Mcneil July 17, 2003
Airway Management: Sarah Mcpherson Gord Mcneil July 17, 2003
Sarah McPherson
Gord McNeil
July 17, 2003
What are the indications to
intubate?
Needs intubation
yes
Unresponsive? Crash Airway
Near death?
no
yes
Predict difficult
airway? Difficult Ariway
no
RSI
Basic Airway Approach
Attempt Oral
Intubation
yes
Successful? Post-intubation
Management
no
BMV maintains no
SpO2 > 90%?
Failed Airway
yes
>3 Attempts at yes
OTI by attending
MD?
Airway Anatomy
Epiglottis
Aryepiglottic folds
Arytenoid cartilage
False vocal cords
True vocal cords
Anatomy
• Pediatric Airway Differences
– Larger tongue
– Large occiput
– Anterior larynx
– Larger epiglottis/floppier
– Subglottic area narrowest
– Less musculature
– Shorter trachea
– Narrower airway
8 Steps to a Successful RSI
• RSI 8 p’s:
– Preparation
– Peruse
– Preoxygenate
– Pretreatment
– Paralysis
– Protection
– Placement
– Post intubation management
Basic Airway Management - 8 P’s
“Prepare” – SIGMA D
What do you need for intubation?
• SIGMA D
– S = Suction
– I = Intravenous
– G= Gas
– M = Mask/Bag
– A =airway equipment (oral airway, laryngoscope,
tubes, alternative)
– D= Drugs
“Peruse” - LEMON LAW
• Zink et al
– 100 pts (no risk factors)
– Max increase 1.0 meq/L (K increased in 46pts, dropped
in 46 pts and unchanged in 8)
– 1 pt found to be in a wheelchair!, K dropped from 4.6
to 4.1
Sux - Hyperkalemia
• Conclusion
– Non high risk pts
• No problems with administration
– High risk pts
• CRF probably okay
• Others : literature is not great but we have good
NDNM blockers, therefore no point to take risk
Sux – Raised IOP
• Thought to be a contraindication to an open globe
injury!
• Pressure elevations do occur, are transient,
maximal for 2-4 min post administration
– Pressure elevations of 3-8mmHg (never been shown to
worsen globe injury
– Comparison: normal blink – increases IOP by 10-
15mmHg, forceful closure of the eyelid >70 mmHg
– Anesthesia continues to use Sux in OR with globe
injuries
– Chiu et al:
• if you want to prevent increase in IOP, can give
defasciculating dose of a NDNM blocker (rocuronium 2 min
pre RSI)
Sux – Prolonged blockade
• Pseudocholinesterase Deficiency
– Congenital
• Heterozygous : up to 25 min, homozygous up to 5 hrs after a
single dose
• Homozygous : 1 in 3000 pts
– Acquired
• Organophosphate poisoning
• Cocaine use
• CRF, severe liver disease, hypothyroidism,malnutrition,
pregnancy, cytotoxic drugs, metoclopramide, bambuturol(long
acting beta 2 anonist)
– Note: above none have prolonged blockade over 20-25 min
Sux – Trismus/Masseter muscle
Spasm
[The difficult intubation. The value of BURP and 3 predictive tests of difficult intubation] Ulrich B - Anaesthesist - 1998 Jan; 47(1): 45-50
Basic Airway Management
Positioning
Pass tube with proof
How do you know it is in????
• Thru cords
• Misting
• Chest rising and falling
• ETCO2
• Esophageal detector
Pass tube with proof
Position of Tube During Intubation
End Tidal CO2
• Qualitative
– Colorimetric
• When color change (yellow = yes) virtually 100% specific
• False negative with cardiac arrest
• Quantitative
– Capnography
• Measures amount of CO2 in the expired air (direct indicator of
CO2 elimination by the lungs)
• Again false negative with cardiac arrest
Esophageal Detection Devices
(EDD)
• Premise
– Esophagus will collapse with suction
– Trachea rigid structure with lots of air (no
collapse
• Not as reliable as end tidal CO2 therfore should be
used as a 2nd line device to confirm tube
placement
Bulb Aspiration
• “Turkey baster”
– Round compressible ball
– Deflate the bulb and attach to end of ETT
– Esophagus: delayed or sluggish inflation
– Trachea: expands rapidly (within 2 seconds)
Syringe Technique
• Same principle
• Use larger volume of air
• Withdraws 30 cc of air
• Use rapid aspiration os syringe
“Post-intubation”
• D: Dislodged
• O: Obstruction
• P: PTX
• E: Equipment failure
Difficult Airway
• Emergency Physicians
– National Emergency Airway Registry
– 6294 intubations
– 85% successful on first attempt
– 99% ultimately successful
– 1% failed airway requiring rescue
maneuvers
Difficult Airway
• Sakles Jc et al Ann Emergency Med 1998
• Intubations over 1 yr in their ED (N=610)
– 569 (93%)by staff/residents
– 515(84%) used RSI
– 98.9% intubated successfully
Difficult Airway
• Paralytics and Aeromedical Transport
– Program A (RSI) success rate: 93.5%
– Program B (no RSI) : 66.7%
• Same program after institution if RSI
• Success: 90.5%
Difficult Airway – BARF
• Cormack-Lehane
laryngoscopy grading
system
• Grade 1 & 2 low
failure rates
• Grade 3 & 4 high
failure rates
Blade Change
• Macintosh (curved)
– McCoy – articulating tip
• Miller (straight)
– Use with children younger than 8y/o, and
people with anterior larynx (short mental-
hyoid distance)
– Wisconsin and Guedel blades
• Larger more rounded barrel
Blade Change
• Laryngoscopy and Intubation
– “the single greatest obstacle to successful
intubation is the tongue… the tongue is the
enemy”
– Paraglossal technique
• Step 1 (blind) insert blade blindly into the esophagus
• Step 2 (visual) withdraw blade until you visualize
the cords /epiglottis
Alternative Airway technique
• LMA
• Orotracheal or nasotracheal
• Lighted stylet
• Digital
• Retrograde
• Fibreoptic
Alternative Airway - Laryngeal
Mask
• Does not constitute
definitive airway
management
• Temporizing measure
in the ED
• Size :
– #3 teenagers and small
female adults
– #4 average size adult
– #5 large adults
Alternative Airway-Laryngeal
Mask
• Inflate cuff
– #3 – 20cc
– #4 – 30cc
– #5 – 40cc
– Or until no leak
Note: no literature
describing the
success rate in the
ED(OR success >95%)
Alternative Airway - LMA
Zideman D - Ann Emerg Med - 01-Apr-2001; 37(4 Suppl): S126-36
• Not studied in infant/child resuscitation
• Complications more frequent in peds
• Correct size
– 1 = smallest; 3-4 = adult female; 4-5 = adult male
• May be dislodged during transport/CPR
• Aspiration – little protection
Alternative Airway Nasotracheal
Intubation
• Indication
– A potentially difficult intubation who is spontaneously
breathing - epiglottitis
– Pt you do not want to paralyze
• Contraindicated
– Combative pts
– Anatomically deranged airway
– Neck hematomas
– Raised ICP
– Severe facial trauma
– Coagulopathy
Alternative Airway Nasotracheal
Intubation
• Pearls
– Sniffing position
– Pull tongue forward by grasping with gauze
– Only 60-70% successful on first attempt (10-
20% of NTI’s are simply not possible
Alternative Airway
Lighted Stylet
• Use if cannot directly
visualize the larynx with
laryngoscopy
• Relies on
transillumination of the
soft tissues of the neck
• Trachea: well defined
glow
• Esophagus: diffuse light
glow
Alternative Airway
Lighted Stylet
• Lidocaine spray
• 5cc 4% lido neb
• 4% lidocaine on pledgets
• Titrated dose of midazolam and fentanyl
• Take a look - can turn into a formal RSI
Pediatric Pointers
• Broselow tape
• Avoid 2nd dose of sux
– infants/children exquisitely sensitive
intractable brady/arrest
• Pierre Robin and Treacher Collins’ syndrome
– Small mandibles and posteriorly fixed tongues
• Down syndrome - large tongue
Positioning the Peds patient
• NB-6 months
– neutral or elevation of the shoulders
• 6 mo-5yr
– elevate head, no to minimal head extension
• 5-10 yrs
– elevate and extend head
Peds airways
• BVM
– be careful not to put pressure on the
submandibular tissues because you may cause
obstruction
– use an oral airway whenever possible
– be careful not to put pressure over the eyes
• children will desat faster so preoxygenation
phase to intubation must be shorter
• decompress the stomach with an NG tube
• under age of 8 use uncuffed tubes
Case #1
• 30 yo male brought to ED after MBA. He
has blood coming from his ears, GCS 5 and
is ina C-collar. His vitals are HR = 110, BP
120-50, RR 25, O2 Sat 94%