Objectives

• Explain anatomy and basic equipment used in EM Clerkship: airway management • Describe ppproper sizin g and insertion of airwa y Airways adjuncts •Exppplain potential indications for endotracheal intubation (ETI) • Describe methods for predicting difficult airways • Describe the steps one should take in preparation for intubation

THE HUMAN AIRWAY: A CONTINUUM… Positioning

• Awake & Alert: No Intervention • Inadequate? • Extend the ppgy(gp)atient’s head slightly (‘sniffing position’) – Positioning • Do NOT do this with C-Spine precautions – Head Tilt / Jaw Thrust •Jaw Thrust – Nasopharyngeal Airway • OK to do this with C-Spine precautions – Oropharyngeal Airway – Bag Valve Mask Ventilation  ‘Head-Tilt Jaw-Thrust’ – Laryngeal Mask Airway – Endotracheal Intubation • “Impossible?”  then one of the following… • Oppjtional or Adjunctive  Place towels under the – Jet Insufflation patient’s head (to position the ear level with the sternal – Surgical Airway: Cricothyroidotomy > 8-12 yo notch)

Bagging a Patient: HdHead-Tilt Chin Lift Bagging a Patient: Jaw Thrust Sizing & Placing an Oral Airway: Sizing & Placing an Oral Airway:

Angle of the mandible to corner of the lips

Start upside down Start upside down and rotate 180° and rotate 180 ° mid-insertion mid-insertion

Sizing Nasal Trumpet(s): Bagging a Patient: 1 or 2 hands

Measure from nare to earlobe

Bagging a Patient: 1 hand Bagging a Patient: 1 hand Bagging a Patient: 2 hands Bagging a Patient: 2 hands

The Bag Valve Mask Bagging a Patient: Equipment

• BVM with reservoir • Oxygen connector tubing • Oxygen source (turn it all the way up) • Suction (check it!) • Nasal pharyngeal airway (NPA = ‘trumpet’) • Oral pharyngeal airway (OPA)

Indications for Endotracheal THE HUMAN AIRWAY: A CONTINUUM… IItbtintubation (ETI) • Awake & Alert: No Intervention • Definitive Airway: A • Inadequate tube secured in the – Positioning trachea with cuff – Head-Tilt / Jaw-Thrust inflated – Nasopharyngeal Airway – Surgical, Nasal and – Oropharyngeal Airway Oral Endotracheal – BVlMkVtiltiBag Valve Mask Ventilation Intubation – Laryngeal Mask Airway • Decision to intubate is – Endotracheal Intubation based on clinical • “Impossible?”  then one of the following… judgment not absolute – Jet Insufflation – Surgical Airway: Cricothyroidotomy > 8-12 yo criteria Indications for Endotracheal Airway Compromise/ Inability to ItbtiIntubation PtProtect tAi Airway • Airway Compromise/ • Functional versus • Depressed level of Inability to Protect Mechanical Obstruction: Consciousness: how do Airway – Functional: Obtunded you assess whether patient airway reflexes are • Predicted Airway – Mechanical: edema, intact? Compromise trauma, foreign body – Gag Reflex? Unreliable, – If obstruction cannot milislea ding. • Failed Oxygenation/ quickly be reversed – Ability to Swallow: when Ventilation (narcan, removal of foreign present reassuring body) ETI is indicated • Predicted Clinical – GCS < 8: increased likelihood of aspiration Deterioration

Indications for Endotracheal Predicted Airway Compromise ItbtiIntubation • Does the natural history • Failure to maintain adequate oxygenation/ of the injury or illness ventilation with non-invasive measures predict development of (supplemental oxygenation, NPPV) airway compromise? (penetrating neck injuries, • Predicted Clinical Deterioration? epiglotitis, etc) – Agitated/ Intoxicated trauma patient requiring • Physical: expanding neck significant sedation for imaging/ procedures hematoma, stridor – Patients with shock requiring massive volume (predicts > 50% reduction resuscitation of airway caliber) obvious tracheal disruption.

Difficult Airway Assessment The Difficult Airway

Difficult Difficult Difficult BMV* Laryngoscopy Surgical • Unless it is a “crash” intubation, one should AiAirway always perform an airway assessment  Beard  Reduced  Obesity  Elderly mouth  Anterior  Edentulous opening neck • Identification of difficult airway features allows  Perioral  Receding hematoma trauma that chin  Surgical one to fllformulate plan to a ddress potent ilial affects  Obstruction disruption mask seal (neck (radical neck problems  Mandible - hematoma, dissection, Fracture stidor, tongue etc)  Obesity swelling)  Neck • What defines a difficult airway?: no consensus  Significant  Large tongue irradiation tongue  Obesity  Overlying trauma/  Reduced neck neck abscess • Best to think of difficult airways in terms of edema mobility (C-  Obstruction/ collar, diffi cul ty wi th: B ag M ask V en til ati on , debris/ Ankylosing airway Spondylitis) Laryngoscopy, Surgical Airway, and Extraglottic hemorrhage Devices (LMA, Combi-tube, etc) Difficult Airway Assessment The 3-3-2Rule2 Rule

• Have a system for assessment and use it • “LEMON” or “LEON”: common assessment tools • L: Look Externally (beard, trauma, prominent incisors, etc) • E: Evaluate 3-3-2 Rule (see next slide) • M: Mallampati (of limited utility in ED) • O: Obesity , signs of Obstruction • N: Neck mobility (c-collar, RA, Ankylosing Spondylitis) UptoDate

Preparing to Intubate: “The 7 TheThe7Ps 7 Ps P”Ps” •Preparation: • Pre-treatment – Equipment Check: suction, monitor, pulse oximetry, • Paralysis with Induction: careful consideration of range of ETT sizes, range of laryngoscopes, oral and induction agent and paralytic based on patient nasal airways , patent IV chiiharacteristics – Back-up plan: alternative intubating device, rescue ventilation, surgical airway • Positioning • Pre-oxygenation: > 3 minutes FiO2 100% – Aligning the “airway axis”: sternal notch to tip of ear lobe – Best achieved with sealed mask using Anesthesia – In - line stabilization for C-spine precautions bag or BMV – Sellick Maneuver – NRB masks? FiO2 of only 65 to 70% – Begin pre-oxygenation during preparation phase • Placement with Proof – Avoid BMV unless patient apneic or persistently • Post-Intubation Management hypoxic

Special Circumstances The Airway Axis PditiPediatrics • Sizing – (Age in years + 16)/4 – Diameter of patient ’ s little finger • Cuffed vs Uncuffed Tubes – GffGenerally uncuffed <8yo – High Volume, Low pressure cuffs available Special Circumstances Special Circumstances TPtitTrauma Patients TPtitTrauma Patient • Maintain in-line cervical spine • May require special equipment immobilization – Video laryngoscopy (Glidescope/Stortz) – 1 person assigned to this role – Eschmann/bougie • Avoid cervical hyperextension

Cases Cases

•58 yyp/o male presents with lower extremity cellulitis and hypotension (60/p). • Should this patient be intubated? Why or why He has received 5 liters not? of LR, and has become progressively tachypneic • Is there further information you wish to know? and hypoxic ( SaO2 = • Other options short of intubation? 88% on 100% NRB) • You are seeing this • What indications are there that this patient could patient in a rural, 5 bed be a diffi cul t in tubati on? Diffi cul t BMV? ED. You suspect a • How will you prepare for intubation? necrotizing soft tissue infection and will be transporting the patient by air to a tertiary care facility

Cases References

• A 5 year old is hit by a car and is • Manual of Emerggyency Airwa y Mana gement – RM Walls, MF Murphy, RC Luten. 3rd Edition, Lipponcott, unconscious with bloody airway Williams and Wilkins, 2008. – What size endotracheal tube should be used – Discuss position and stabilization of patient during intubation