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Airway Management in The Emergency Department and ICU
Airway Management in The Emergency Department and ICU
Global Assessment
Assess underlying need for airway control
Duration of intubation
- Nasal intubation less advantageous for potentially prolonged ventilator
requirements
Permanent support
- Underlying advanced intrinsic lung or neuromuscular disease
Temporary support
Anesthesia
Presence of reversible intrinsic lung or neuromuscular disease
Protection of the airway due to depressed mental status
Presence of reversible upper airway pathology
Patient care needs (e.g., transport, CT scan, etc.)
Significant comorbidities
Aspiration potential or increased respiratory secretions
Hemodynamic issues such as cardiac disease or sepsis
Renal or liver failure
Global Assessment
Pathophysiology of the respiratory failure
Hypoxic respiratory failure
- In case of hypoxic respiratory failure, different noninvasive oxygen delivery
devices can be used.
- The severity of hypoxia and presence or absence of underlying disease (such
as COPD) will dictate the device of choice.
Global Assessment
Oxygenation
Respiratory rate and use of accessory muscles
- Is the patient in respiratory distress?
Airway
Anatomy
- Will this patient be difficult to intubate?
Patency
- Is there a reversible anatomical cause of respiratory failure as opposed to
intrinsic lung dysfunction?
Nasal Cannula
4% increase in FiO2 for each 1 L of flow (e.g., 4 L flow = 37% or 6 L flow
= 45%)
Face tent
At most delivers 40% at 10-15 L flow
Ventimask
Small amount of rebreathing
8 L flow = 40%, 15 L flow = 60%
Nonrebreather mask
Attached reservoir bag allows 100% oxygen to enter mask with
inlet/outlet ports to allow exhalation to escape - does not guarantee
100% delivery.
BiPAP allows for an inspiratory and expiratory pressure to support and improve
spontaneous ventilation
Nasal or oral (full face) mask can be used; less aspiration potential with nasal.
Pulse oximetry
O2 saturation less than 92% on 60 - 100% oxygen can suggest the need
for intubation based on whether there is anything immediately reversible
which could improve ventilation.
Temporizing Measures
Naloxone for narcotic overdose
40 mcg every minute up to 200 mcg with:
- 45 minutes to one hour duration of action
0.4 - 2 mg of naloxone is indicated in patients with respiratory arrest and
history suggestive of narcotic overdose
- There is a potential for pulmonary edema, so large dose is reserved
for known overdose and respiratory arrest
Caution in patients with history of narcotic dependence
Naloxone drip can be titrated starting at half the bolus dose used to
obtain an effect
- Manufacturer recommended 2 mg in 500 ml of normal saline or D5
gives 0.004 mg/ml concentration
Oral/Nasal Airways
Pulmonary embolus
Pulmonary artery and right ventricle already have high pressure and
dependent on preload
Application of controlled ventilation may deteriorate oxygenation and
systemic pressure.
Prayer Sign
About one third of diabetics characterized by short stature, joint rigidity, and tight waxy skin
Positive prayer sign with an inability to oppose fingers
Mallampati Score
Class I:
Class II:
Class III:
Class IV:
Comorbidities
Potential for aspiration requires rapid sequence intubation with
cricoid pressure
Clear liquids < 4 hours
Particulate or solids < 8 hours
Acute injury with sympathetic stimulation and diabetics may have prolonged
gastric emptying time.
Organ failure
Renal and hepatic failure will limit medication used.
Potential for preexisting pulmonary edema and airway bleeding from
manipulation
Induction Agents
Sodium Thiopental
3 - 5 mg/kg IV
Profound hypotension in patients with hypovolemia, histamine release,
arteritis
Dose should be decreased in both renal and hepatic failure.
Etomidate
Induction Agents
(cont'd)
Propofol
2 - 3 mg/kg IV
Hypotension, especially in patients with systolic heart dysfunction,
bradycardia, and even heart block
Unlikely to have prolonged effect in organ failure
Ketamine
1 - 4 mg/kg IV, 5 - 10 mg/kg IM
Stimulates sympathetic nervous system
Requires atropine due to stimulated salivation and midazolam for
potential of dysphoria
Avoid in patients with loss of autoregulation and closed head injury
Neuromuscular Blockers
Succinylcholine
1 - 2 mg/kg IV, 4 mg/kg IM
Avoid in patients with malignant hyperthermia, > 24 hours out from burn or
trauma injury, upper motor neuron injury, and preexisting hyperkalemia
Rocuronium
0.6 - 1.2 mg/kg, highest dose required for rapid sequence
Hemodynamically stable, 10% renal elimination
Vecuronium
0.1 mg/kg
Hemodynamically stable, 10% renal elimination
Cisatricurium
0.2 mg/kg
Mild histamine release, Hoffman degradation, not prolonged in renal or
hepatic failure
Y BAG PEOPLE
(Reference #6)
Cricoid Pressure
Cricoid is circumferential
cartilage
Pressure obstructs
esophagus to prevent
escape of gastric
contents
Maintains airway patency
Sniffing Position
Align oral, pharyngeal, and laryngeal axes to
bring epiglottis and vocal cords into view.
Mask Ventilation
Mask ventilation crucial,
especially in patients who are
difficult to intubate
Sniffing position with tight
mask fit optimal
May require two hands
Mask ventilation crucial,
especially in patients who are
difficult to intubate
Sniffing position with tight
mask fit optimal
May require two hands
Standard ETT
Grade 1:
Grade 2:
Grade 3:
Grade 4:
Confirmation of Placement
Direct visualization
Humidity fogging the endotracheal tube
End tidal CO2 which is maintained after > 5 breaths
Low cardiac output results in decreased delivery of CO2
Additional Considerations
Always have additional personnel and an experienced
provider as backup available for potential failed
intubation
Always have suction available
Never give a muscle relaxant if difficult mask ventilation
is demonstrated or expected
Awake intubation should be considered in the following:
If patient is so hemodynamically unstable that induction drugs cannot be
tolerated (topicalize airway)
If patient has a history or an exam which suggests difficult mask
ventilation and/or direct laryngoscopy
Alternative Methods
Blind nasal intubation
Eschmann stylet
Fiber optic bronchoscopic intubation
Light wand
Retrograde intubation
Through cricothyrotomy
Surgical tracheostomy
Combitube
Eschman Stylet
Use especially if Grade III
view achieved
Direct laryngoscopy is
performed
Place Eschman where
trachea is anticipated
May feel tracheal rings
against stiffness of stylet
Thread 7.0 or 7.5 ETT
over stylet with the
laryngoscope still in place
Fiberoptic Scope
Essentially what is used to do a
bronchoscopy
Can be used to thread an
endotracheal tube into the
trachea either while the patient
is asleep or on an awake
patient with a topicalized airway
Via laryngeal mask airway in
place due to inability to intubate
with DL:
LMA Placement
Guide the LMA along the
palate
Eventual position should
be underneath the
epiglottis, in front of the
tracheal opening, with the
tip in the esophagus
FOB placement through
LMA positions in front of
trachea
Martin S, et al. J Trauma Injury, Infection Crit Care.
1999;47(2):352-357.
Retrograde Intubation
Puncture of the
cricothyroid membrane
with retrograde passage of
a wire to the trachea
Endotracheal tube guided
endoscopically over the
wire through the trachea
Catheter through the
cricothyroid can be used
for jet ventilation if
necessary.
Wesler N, et al. Acta Anaes Scan. 2004;48(4):412-416.
Combitube
Emergency airway used mostly by
paramedics and emergency
physicians for failed endotracheal
intubation
Ventilation confirmed through blind
blue tube
Combitube
(cont'd)
Removal prior to DL or FOB should be done with caution after thorough airway
evaluation
Cricoid pressure should be maintained and emergency tracheostomy equipment
available
Tracheostomy
Surgical airway through
the cervical trachea
Emergent procedure
carries risk of bleeding
due to proximity of
innominate artery
Can be difficult and time
consuming in emergent
situations
Case Scenario #1
The patient is 70 kg with a 20-year history of diabetes.
On exam, the patient has intercisor distance of 4 cm,
thyromental distance is 8 cm, neck extension is 45
degrees, and mallampati score is 1.
Your staff wants to use thiopental and pancuronium.
Do you have any further questions for this patient or
would you proceed with your staff?
Case Scenario #2
43-year-old patient with HIV, likely PCP pneumonia who
had been prophylaxed with dapsone
RR is 38, oxygen saturation is 90% on 100% NRB mask
The patient is on his way to get a CT scan.
Is it appropriate to proceed without intubation?
Case Scenario #3
40-year-old, 182-kg man has a history of sleep apnea
and systolic ejection fraction of 25%. He has a Strep
pneumonia in his left lower lobe and progressive
respiratory insufficiency.
He extends his neck to 50 degrees and has a mallampati
score of 2.
Would you proceed with an awake FOB?
References
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