|
|
|
(Adapted from the National Emergency Airway Course http://www.theairwaysite.com and The Airway Cam Guide to Intubation)
RSI evidence review (Can J Anesth 2007;54(9):748)
http://vam.anest.ufl.edu/airwaydevice/videolibrary/index.html#airtraq
http://groups.msn.com/DrMAGBOULAIRWAYPAGE/homepage.msnw
Hemodynamic Compromise post-intubation
Universal
Main
Crash
Failed
Difficult
Scanned from Manual of Emergency Airway Management by Walls et al.
(Gag reflex is absent in up to 37% of population, so a poor predictor of airway protection (J Accid Emerg Med 16(6):444, 1999)
Lancet. 1995 Feb 25;345(8948):487-8,Clin Otolaryngol. 1993 Aug;18(4):303-7)
Can they talk?
Can they swallow and manage secretions?
SaO2 <90% on High Flow O2 or PaO2<60 on FiO2>40%
PaCO2 >55 if baseline is normal, or >10 increase from baseline
Respiratory Rate
Deterioration/Impending Compromise
Transport
Airway protection during procedures (ie. endoscopy)
Other Reasons include:
Study that drunks and tox folks can stay non-intubated even with low GCS. Only 73 pts. (J Emerg Med 2009 Nov;37(4):451-5.)
The difficult airway is something you can predict, the failed airway is something that happens to you. Perform the difficult airway assessment on any patient who has any chance of needing intubation during their stay in the ED.
Beard
Obesity
No Teeth
Elderly (>55)
Snores
Results: During a 24-month period, 22,660 attempts at MV were recorded. 313
cases (1.4%) of grade 3 MV, 37 cases (0.16%) of grade 4 MV, and 84 cases (0.37%)
of grade 3 or 4 MV and difficult intubation were observed. Body mass index of 30
kg/m2 or greater, a beard, Mallampati classification III or IV, age of 57 yr or
older, severely limited jaw protrusion, and snoring were identified as
independent predictors for grade 3 MV. Snoring and thyromental distance of less
than 6 cm were independent predictors for grade 4 MV. Limited or severely
limited mandibular protrusion, abnormal neck anatomy, sleep apnea, snoring, and
body mass index of 30 kg/m2 or greater were independent predictors of grade 3 or
4 MV and difficult intubation.
Conclusions: The authors observed the incidence of grade 3 MV to be 1.4%,
similar to studies with the same definition of difficult MV. Presence of a beard
is the only easily modifiable independent risk factor for difficult MV. The
mandibular protrusion test may be an essential element of the airway
examination. (Anesthesiology 105(5), November
2006, pp 885-891)
Look
at head and neck
Evaluate
Mallampati
Obstruction=hot potato voice, can't handle secretions, and Stridor (if audible=90% obstruction)
Neck Mobility
S for saturation reserve (Ann Emerg Med June 2006)
Restricted Mouth Opening
Surgery/Disrupted Airway
Hematoma
Obese/Access Problems (Can't get to neck)
Radiation
Tumor
MA of difficult airway prediction (Anesthesiology 2005; 103:429–37) best values from combo of mallampati and thyromental distance, but still crappy.
Surveys indicate 10-25% of patients with trisomy 21 have AAI. Two thirds of
these cases are due to laxity of transverse ligament, whereas one third are due
to abnormal odontoid development. Although this association has been depicted on
radiographs, the clinical incidence of serious cervical spine injury is not
increased in this population compared with other populations.
About 25% of patients with rheumatoid arthritis have atlantoaxial instability,
which is thought to be due to chronic inflammation. Congenital skeletal
dysplasias may cause resultant odontoid hypoplasia. Marfan syndrome may involve
to ligamentous laxity, and acute inflammatory processes can affect the
retropharyngeal, neck or pharyngeal spaces.
Rheumatoid Arthritis destroys ligaments causing increased movement of dens in spinal canal
A physical examination may reveal the characteristic stigmata of OSAS including a short thick neck, nasal obstruction, tonsillar hypertrophy, narrow oropharynx, retrognathia, and obesity. Although these clinical features are typical, they are not reliable predictors of the presence of severity of the disease.49 Physical examination and laboratory studies may also reveal the presence of unexplained right heart dysfunction or erythrocythemia, suggesting the severity of OSAS. (Laryngoscope 1989)
The incidence of failed airways is 10x greater in term pregnant women, they should always be considered a difficult airway.
Intubation must displace the tongue somewhere,
that somewhere is the submandibular space, if that space is occupied by infection/tumor or entirely absent=difficult airway
Failed Laryngoscopy (with 3 attempts) : 1 in 200-300 intubations
Can't intubate/can't ventilate (CICV): 1 in 10,000-20,000 intubations
PGY 1 or 2: 65% successful on 1st attempt of laryngoscopy
PGY 3/4/Attending 85% successful on 1st attempt of laryngoscopy
We performed as well as anesthesiologists in trauma intubations (Academic Emergency Medicine Volume 11, Number 1 66-70)(Ann Emerg Med. 2004;43:48-53)
J
Trauma 2009;66(1):32)
Equipment Preparation
All equipment at the bedside, including backup devices
(should be present at every intubation)
Have RSI and post-intubation meds already drawn up. An amp of
phenylephrine is also a nice thing to have at the bedside in case the intubating
agents cause vasodilatory hypotension.
Mnemonic for Equipment during routine intubation (Weingart)
Lubricating the ET tube cuff may lower rates of aspiration (anesthesiology
2001;95:377)
Straight to cuff with 35 degree bend probably is best (ACADEMIC EMERGENCY MEDICINE2006;13:1255–1258)
Eliminate all the N2 in the FRC
Some BVMs allow active breathing by the patient of 100% O2
while others will give only ~30%. Need duckbill one way valve and an exhalation
port.
Do not let the patient take a single room air breath from the beginning of this
phase. Kids desaturate much more quickly than adults. So they are not just
little adults, they are little, fat adults
8 vital capacity breaths while wearing a non-rebreather mask is also an
alternative. These masks can be augmented to provide near 100% FiO2 by
placing a valve over both vents, providing flow at 15 lpm, and tightly fitting
the mask to the face (Resuscitation, April 2003, 57:1, 69 - 72)
When a patient is at <90% saturation, be scared, as this level is right at the nose dive point of the oxygen desaturation curve
Benumof's seminal study on time to desaturation (pdf) and where he actually go the calculations (Br J Anaesth 1996;76:284)
Abandon the "hold your breath while intubating" method,
it just leads to added stress and underestimates the amount of time you have to
intubate
Maximum oxygen in lungs is 87% as 6.5% taken up by CO2 and 6.5% by water vapor. While the fast track (8 vital capacity breaths) method will cause this 87% concentration, it will not fill the tissue and venous compartments. Therefore the traditional method will in various studies allow up to 3 minutes of extra time (Benumoff Lecture)
The fast track method
NRB only provides 70-80% fiO2 at best
Much longer time to desat in the obese if you preoxygenate in sitting position (British Journal of Anaesthesia 2005 95(5):706-709)
Patients who can not preoxygenate well with mask should be placed on NIV (Am J Respir Crit Care Med 2006;174:171)
Can then use Vent to continue oxygenation until ready to intubate (JEM 2006;30(1):63)
Place on AC: IFR-30 LPM, FiO2-100%, RR-15, Vt-500 cc, PEEP-based on situation
attach a ETCO2 line to set-up
Two rcts showed better preox when it is preceded with maximal
exhalation(Anesth Analg 2003;97:1533) and (Can J Anesth 2000;47:1144)
functional recovery time of 8.5 min after 1 mg/kg of Sux (Anesthesiology
1997;87:979)
Airway press <15 cm H20 rarely causes insufflation
>25 will often cause it (Br J Anaesth 1987;59:315 and Acta Anaesthesiol Scand
1961;5:107)
Can J Anaesth. 2007 Jun;54(6):448-52. Click here to read Links
Efficacy of preoxygenation using tidal volume and deep breathing techniques with
and without prior maximal exhalation.
Nimmagadda U, Salem MR, Joseph NJ , Miko I.
Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 W.
Wellington Avenue, Chicago, IL 60657, USA.
PURPOSE: We evaluated the influence of prior maximal exhalation on
preoxygenation in 15 adult volunteers using tidal volume breathing (TVB) for
five minutes and deep breathing (DB) for two minutes with and without prior
maximal exhalation. METHODS: Inspired and end-tidal oxygen, nitrogen and carbon
dioxide were monitored continuously and recorded during room air breathing and
at 30-sec intervals during 100% oxygen TVB or DB (rate of 8 breaths.min(-1)).
RESULTS: Tidal volume breathing with prior maximal exhalation resulted in an
end-tidal oxygen concentration (ETO(2)) slightly higher (P = 0.028) at 0.5 and
1.0 min as compared with TVB without prior maximal exhalation at the same time
periods. Regardless of whether TVB was preceded by maximal exhalation or not,
2.5 min was required to reach a mean ETO(2) value of 90% or higher. With DB,
there were no differences in ETO(2) values at any time period and 1.5 min was
required to reach an ETO(2) of 90% or greater, with or without prior maximal
exhalation. CONCLUSIONS: Maximal exhalation prior to TVB slightly steepens the
initial rise in ETO(2) during the first minute, but confers no real benefit if
maximal preoxygenation is the goal. Maximal exhalation prior to DB has no added
value in enhancing preoxygenation.
Study of 3 minutes vs 4 deep breaths vs 8 deep breaths (Anesth 2003;99:841)
comparison of Self-inflating manual resuscitators (SIMRs, i.e. bvms) for preox If there is not a one-way exhalation valve, useless for preox(Anesthesiology 2000;93:693)
.jpg)
Preox
for claustrophobic Pt (Anesthesiology 104(2))
Nasal Cannula (Fio2 increases 4% per lpm from 24-44%) Benumof's Airway Management
Mask with reservoir bag (10 lpm = > 80 %) Benumof's
Finger pulse oximeter lags in poor perfusion states (Can J Anesth 2004;51(5):432)
Can also use a SGA for preox and then take it out to intubate a la Darren Braude
a new article on the morbidly obese shows extension of time to desat if left on nasal cannula (J Clin Anesth 2010;22:164)
|
P |
retreatment
· Tight Brain (Elevated ICP/Head Injury/CVA)
· Tight Vessels (Aortic Dissection/AAA)
· Tight Heart (ACS)
· Tight Lungs (Asthma)
The larynx one of the most richly innervated areas in the body, this is a primitive airway protection scheme.
· Bronchospasm can result from laryngoscopy and from intubation. Stimulation of the carina also causes Bronchospasm.
· Laryngoscopy and intubation also cause increased ICP, both directly and by the catecholamine surge. Succinylcholine increases ICP by causing more afferent traffic to brain, increasing metabolic activity.
· Catecholamine surge from adrenal cortex during laryngoscopy and intubation. Hypercapnia and hypoxia are causes of huge catecholamine surge.
· Limit time of laryngoscopy
· Atraumatic laryngoscopy
Optimally, give premedications 3-5 minutes before RSI
o Use in tight brain to attenuate reflex increase in ICP from laryngoscopy/intubation
o Use in tight lungs to blunt bronchospastic response
o 1.5 mg/kg Rapid IVP
While there is evidence that it blunts ICP rise and cough response, there is no good evidence that this has clinical results (Robinson N. Emerg Med Journal 2001; 18(6):453- 7.) Literature is pretty good on endotracheal suctioning.
o Use in tight brain/tight vessels/tight heart to blunt catecholamine surge
o Fentanyl 3 ug/kg slow IVP
At this stage, Emergency Airway Course only recommends Lidocaine and Fentanyl: LOAD is dead
Intralingual succinylcholine injection provides a rapid onset of
muscle relaxation in an emergency.
Anaesthesia. 2001 Dec;56(12):1213.
in GI bleeds/full stomachs
1-2 mg/kg ~ 3min beforehand
Feng CK, Chan KH, Liu KN, et al. A comparison of lidocaine, fentanyl, and
esmolol for attenuation of cardiovascular response to laryngoscopy and
tracheal intubation. Acta Anaesthesiol Sin. Jun 1996;34(2):61-7. [
Helfman SM, Gold MI, DeLisser EA, et al. Which drug prevents tachycardia and hypertension associated with tracheal intubation: lidocaine, fentanyl, or esmolol?. Anesth Analg. Apr 1991;72(4):482-6.
3 mcg/kg of remifentanyl can also be used
|
P |
aralysis after Induction
·
RSI Review (Can J Anesth 2007;54(9):748)
Brutane (forcing non-paralyzed musculature) is the worst choice of medications
· Etomidate or Versed .3 mg/kg
· Ketamine or Propofol 1.5 mg/kg
· Pentothal 3 mg/kg
Etomidate mycoclonus can be attenuated c small dose benzo
Use ½ dose of induction agents if vital signs are unstable or the patient is elderly. Consider using a dose of zero if the sympatholysis may result in decreased BP
In a analysis of NEAR data, thiopental, methohexital, and propofol appeared to facilitate RSI over etomidate and versed. The postulated reason for this is that these agents allow a deeper plane of sedation making up for inadequate waiting time for paralysis. (Acad EM 10:6, 2003)
Dose based on ideal body weight; estimate by Broca index: (height in cm-100 for men, -105 for women)
ketamine for head injury review (emerg med australia 2006;18(1):37-44) (also see sedative section)
editorial on the use of ketamine in intubation ( Chest. 2007 Dec;132(6):2054)
Ketamine may be the best choice for hemodynamically unstable
Ketamine is safe and may be the preferred sepsis agent (Etomidate versus ketamine for rapid sequence intubation in
acutely ill patients: a multicentre randomised controlled trial Lancet 2009)
Pharmacodynamics and kinetics of propofol in the shocked patient. Short message--give less, even if you resuscitate them, give less (Anesthes 2004;101:647) and (Anesth Analg 2006;103:1339-1340)
Complications of emergency intubation with and without paralysis. (Am J Emerg Med. 1999 Mar;17(2):141-3)
Do not give sedatives without paralytics, as there is a good 6 minutes of IPIST (Interval of Progressively Increasing Sphincter Tone) between administration and full sedation
Can get MR free good intubating conditions with propofol 2.5 mg/kg,
opioids, and 4% lidocaine spray of larynx (Acta Anaes Scand 1996;40(6):752)
Rapid sequence intubation for pediatric emergency airway management. Pediatr
Emerg Care 18. (6): 417-423.2002; Airway management by US and Canadian emergency
medicine residents: a multicenter analysis of more than 6,000 endotracheal
intubation attempts. Ann Emerg Med 46. (4): 328-336.2005; Full Text
A
comparison of rapid sequence intubation and etomidate only intubation in the
prehospital air medical setting. Prehosp Emerg Care 4. (1): 14-18.2000; Abstract
The utilization of midazolam as a pharmacologic adjunct to endotracheal
intubation by paramedics. Prehosp Emerg Care 4. 14-18.2000; Abstract
Paralytics spare pupils (Shah. Emergency Neurology, p.5)
and article in neuro lit
Succinylcholine
is the only one used in the
Sux dosing 1.5-2 mg/kg, always better to give more than less.
Action in 45 seconds, clinical duration 6-8 minutes
Typically causes a rise of 0.5 mEq/L of potassium
Dose based on actual not ideal body weight, gives better conditions in the fattys (Anesth Analg 2006;102(2):438)
When not to use Succinylcholine:
·
Any strokes with hemiparesis from 3 days to 6
months
· Burns/trauma >24 hours old
· NMJ Disease
·
Myopathies/Muscular Dystrophies
Theoretical Concerns
· Intraocular pressure: commonly used by anesthesiologists in this situation. (Anesth Clin North Am 1996 14:125-150 and Anesthesiology 1985; 62: 637-640)
· Preexisting Hyperkalemia (Renal failure is not a contraindication): In a retrospective study of all patients with hyperkalemia (38 of 40,000) receiving sux, there were not adverse events (Anesth Analg 2002 Jul;95(1))
·
Known plasma cholinesterase deficiency: (only
risk is prolonged duration of action)
Burns: no real risk as long as less than 7 days from the burn or several months after (after healing, return of normal appetite, and return to normal weight)
Direct Muscle Damage: no risk until 4-5 days after insult
Guillain-Barre: do not use during and for months afterward
ICU: If chronic muscle atrophy, may be better not to use for up to a year afterwards
Myopathies: Contraindicated forever if inherited
(From correspondence from G. Gronert, MD)
Multiple Sclerosis: Review of Sux & neuromuscular disorders (Anesth 1984;61:173)
Not a great idea in patients with MS induced paresis (Curr Opin Anaes 2002;15:365)
Case Series of Numerous MS Patients who received Sux (Ann Chir Gynaecol. 1984;73(5):299-303)
1 case report in the literature of hyperkalemia in MS (JAMA 1970;213:1867)
Sux remains 90% effective at room temperature for 3 months, longer if not exposed to light (Rosen’s 2001)
Lasts for months at room temp (Emergency Medicine Journal 2007;24:168-169)
Sux can be injected intralingually if unable to obtain IV access (Intralingual/Intraoral in Adult Anaesthesia 56:12, 1213 Dec 2001)
Submental/Intralingual use of Nalaxone--23-gauge, 1.5-inch needle attached to a 3-mL syringe was inserted in the midline, midway between the mandible and the thyroid cartilage. It was directed 1 inch superior, and 2 mL of naloxone solution was injected. The SM area was then massaged for 30 seconds
Intralingual naloxone injection for narcotic-induced
respiratory depression. Ann Emerg Med 1987;16:572-573.
Mercurio JP: Emergency submental injection. JADA 1967;74:717-719.
Redden RJ, Miller M, Campbell RL: Submental administration of succinylcholine in children. Anesth Prog 1984;12:1087-1091.
If you wait 60 seconds, then induction agent is irrelevant (British Journal of Anaesthesia 2005 95(5):710-714)
A second dose of suxamethonium in the presence of masseter spasm. This should not have occurred for two reasons:
IM Sux-need 4mg/kg to get 2-3 minute induction time (Anaesthesia 2007;62:757)
Sux and Hyperkalemia
Anesthesiology 2006; 104:158–69 (massive review down to receptor level)
Ped Emerg Care 2000;16(6):441--can not blunt hyperkalemia with non-depols
Chest 1992;102(4):1259--can not blunt hyperkalemia with non-depols
Seminars in Anesthesiology 1985;4:65--same
Anesth 1975;43:89--article references by Anesth 2006
JAMA 1969;210:490
Anesthesiology. 1973 Jul;39(1):13-22.--The response of denervated skeletal muscle to succinylcholine, using canine muscles both normal and denervated
25. R.E. Tobey, P.M. Jacobsen, C.T. Kahle, R.J. Clubb and M.A. Dean, The serum
potassium response to muscle relaxants in neural injury. Anesthesiology 37
(1972), pp. 332–337. View Record in Scopus | Cited By in Scopus (8)
26. A.A. Birch, G.D. Mitchell, G.A. Playford and C.A. Lang, Changes in serum
potassium response to succinylcholine following trauma. JAMA 210 (1969), pp.
490–493. View Record in Scopus | Cited By in Scopus (10)
27. G.A. Gronert, Potassium response to succinylcholine. JAMA 211 (1970), p. 300.
Anaesth Intensive Care. 1990 Feb;18(1):92-101.Links
Suxamethonium and hyperkalaemia.
review including 0.7-1.2 rise in renal pts
Benzylsoquinolones-curare, atracurium. These cause histamine release
Aminosteroids
Vecuronium- Priming dose for vecuronium .01 mg/kg followed by .15 mg/kg will make it act quicker or use high dose vecuronium .3 mg/kg (Acta Anaes Scand 1993;37(5):465)
Pancuronium-Only if others not available
Rocuronium-ignore package dosing and use 1 mg/kg (46 min paralysis at this dose)
Gantacurium-new extremely short acting non-depolarizing???
cisatracurium 0.15 mg/kg intubating, 0.005 mg/kg pretreatment, Onset 5 minutes, duration 45 min
d
It seems ketamine is a better for rapid intubation situation that priming dose when using rocuronium and propofol (Can J Anesth 2010;57:113) They used 0.5 mg/kg
is being tested; it binds to roc and completely reverses its effects
Phase II Study: Anesthesiology 2007;106:935-43
| Ephedrine 70 ug/kg | Placebo | Esmolol 0.5 mg/kg | |
| CO | 9.1 | 8 | 5.5 |
| Onset of Roc 0.6 mg/kg in sec | 52 | 87 | 114 |
(Acta Anaesthesiol Scand. 2003 Oct;47(9):1067-72.)
Aspiration is less likely with NMBA
1 mg/kg of Sux will give excellent intubating conditions 63-80% of time
Time until diaphragmatic movement were the same between 1 mg/kg and 0.5 mg/kg dose (Donati, François - Muscule Relaxation for Rapid Sequence Induction IARS 2006 Review Course Lectures)
Prefasic dose of Rocuronium is 0.03 mg/kg 3-5 min before intubation
You must increase dose of sux to 2mg/kg if prefasic dose of non-depol is given
Corrugator Supercillii, which moves the eyebrow in response to facial nerve stim has response to NMBAs similar to vocal cords and diaphragm.
Article on intubating without paralysis (Br J Anaesth 2005;94(2):150)
lidocaine sprayed on cords
remifentanyl 2 mcg/kg
ROCURONIUM VERSUS SUCCINYLCHOLINE FOR RAPID SEQUENCE
INDUCTION INTUBATION
Background
Rapid sequence induction (RSI) of anaesthesia is a method of quickly producing
optimal conditions for intubation in the emergency situation. Classically,
succinylcholine (also known as suxamethonium) is the muscle relaxant used
because of its rapid onset and brief duration. Contraindications for its use
include severe burns, major crush injuries, neurological disease involving acute
wasting of major muscle and family history of malignant hyperthermia. Rocuronium
is another rapid onset muscle relaxant with fewer contraindications than
succinylcholine but its duration is significantly longer. The aim of this
meta-analysis was to assess whether rocuronium is as effective as
succinylcholine at producing ideal intubating conditions during RSI.
Results
Twenty six studies were identified that met the inclusion criteria.
Succinylcholine produced a small but statistically significant increase in the
number of excellent versus non-excellent intubation conditions (relative risk
(RR) 0.87; 95% CI 0.81 to 0.94). There was no significant difference between the
two agents when comparing excellent or good intubating conditions with poor
conditions or failure to intubate. When propofol was used in place of
thiopental, there was no difference in the numbers of excellent conditions
produced by either rocuronium or succinlycholine.
SOCRATES says
Succinylcholine produces excellent intubation conditions more consistently than
rocuronium and remains the first choice muscle relaxant for RSI. In cases where
it is contraindicated, rocuronium is a valid alternative, especially if combined
with propofol.
Perry J, Lee J, Wells G. Rocuronium versus succinylcholine for rapid sequence
induction intubation. In: The Cochrane Database of Systematic Reviews. 2005
Issue 4 CD 002788
|
Number
of Twitches After Stimulation |
Amplitude |
Corresponding Level of Neuromuscular Blockade |
|
4 |
all 4 equal |
0% (no blockade) |
|
4 |
declining |
< 75% |
|
3 |
declining |
75-85% |
|
2 |
declining |
85-90% |
|
1 |
single weak |
91-99% |
|
0 |
none |
100% |
| 4:1 50% | same | 70% occupied |
| 2-3 twitches | same | 75-85% occupied |
| 1 twitch | weak | >90% |
| Post tetanic twitching >5 occurs just beofre rgaining 1 twitch of TOF |
To Reverse, Need 1 twitch
Neostigmine 0.07 mg/kg, mix in same syringe with equal volume of glycopyrolate
Paralytics actually increase LES tone (Br J Anaesth 1984;56:37)
Sux without pretreatment causes quicker desatuaration than rocuronium or sux with pretreatment (Anaesthesia 2010;65:358)
First article from Bronx VA
The experience of paralysis when awake is not so bad, but hypercarbia seems to suck (J Clin Anesth. 1993 Sep-Oct;5(5):369-74.)
2nd article used anesthesiologists as patients
|
P |
rotection and Positioning
from 20-30 seconds after drugs until tube confirmation. Have assistant apply with third finger and thumb. Place their index finger on the thyroid cartilage, this will allow you to move it during laryngoscopy to retain BURP pressure. The proper amount of cricoid pressure can be learned by pushing on the bridge of your nose with middle finger and thumb until it hurts.
But perhaps, the proper amount is no amount at all. All studies are inconclusive. (Canad J Anesthesia 1997;44:414 in JB) and it often screws up tube placement (Airway·Cam Book)
· Leave patient sitting until last moment in CHF/Reactive Airway Disease
· Do not bag unless sat starts to fall below 90. If you bag with paralysis and properly performed cricoid pressure, 1-2 cc of air is insufflated per tidal volume ventilation.
· Also consider bagging patients with increased ICP.
· Never bag without an oral airway, just as you would not perform a rectal exam without a glove
|
P |
lacement and Confirmation
Wait till defasiculations cease if using Succinylcholine; flick the mandible to see if pt sufficiently blocked and
see below
ETCO2 Detector-yellow is mellow. If tan, give 6 breaths. If still tan probably in trachea, but
consider direct laryngoscopy to confirm.
Purple with a Pulse, Pull the tube. If purple without a pulse, confirm with
direct laryngoscopy.
If using wave-form CO2, then tracheal intubation should produce waveform.
Vinegar in an animal model turned permanently turned indicator yellow (Journal
of Emergency Medicine
Volume 28, Issue 1 , January 2005, Pages 5-11)
The colour ranges for the Portex® device (Smiths Medical ASD, Keene, NH)
Primary assessment (Lung sounds) more for tube depth than confirming tracheal placement.
Self-Inflating Bulb-reliable even with uncuffed tubes (Acad Emerg Med April 2003, 10:4)
Can confirm depth by ballotment. Location of the
Endotracheal Tube by Pilot Balloon-Cuff
Counter-Ballottement (Anesth Analg. 1995 Jul;81(1):135-8)
If confirming in a coded patient, first attempt to verify with DL-Displace tube posteriorly to be able to see it going through the cords (Benumoff 2nd ed)
Also can place a boughie down tube, if you hit a stop point, it is in the bronchi and tube is between the cords. But you need to know what you are doing to get to 100% (American Journal of Emergency Medicine (2005)23:754–758
We probably inflate too much (Academic Emergency Medicine Volume 11, Number 5 490-491)
Emergency Physicians Cannot Inflate or Estimate Endotracheal Tube Cuff Pressure Using Standard Techniques (Annals EM 44:4 Oct 2004) and (AJEM 2006;24:139)
15-25 mmHg is optimal
1. Knowlson GTG, Bassett HFM. The pressure exerted on the trachea by
endotracheal
inflatable cuffs. Br J Anaesth 1970;42:834e7.
2. Seegobin R,
van Hasselt GL. Endotracheal cuff pressure and tracheal mucosal blood
flow:
endoscopic study of effects of four large volume cuffs. BMJ 1984;288:965e8.
3. Susuki N, Kooguchi K, Mizobe T, et al. Postoperative hoarseness and sore
throat
after tracheal intubation (effect of low intracuff pressure of
endotracheal tube and
usefulness of cuff pressure indicator). Masui
1999;48:1091e5.
4. Pelc P, Prigogine T, Bisschop P, et al.
Tracheo-oesophageal fistula: A case report and
review of literature. Acta
Otorhinolaryngol Belg 2001;55:273e8.
5. Spittle N, McCluskey A. Tracheal
stenosis after intubation. BMJ 2000;321:1000e2.
6. Friis J, Turner A, Da
Fonseca J. Overinflated tracheal tube cuff. Emerg Med J
2009;26:182
Distally placed pulse ox has a 60-90 second lag from true
saturation
|
|
Ativan 4-6 mg
Versed 0.1 mg/kg bolus, then 0.1 mg/kg/hr 2-5 mg/hr (Drip 50 mg in 250 cc NS, Start at 10-25 cc/hr)
Propofol .5-1 mg/kg then 25-100 mcg/kg/min, start at 10 cc (100 mg)/hr which correlates with 1 mg/kg/hour
HOB 30°
Big Tubes
Secure ‘em
NGT
HME
ABG
Inline Suction
ETCO2
BVM c peep valve
Cuff Pressure
Avoid post-intubation paralytics
Vecuronium .1 mg/kg then .03 mg/kg q25-45 min or 1-2 mcg/kg/min
use 2 electrodes over the ulna nerve, give train of four. shoot for 2 twitches while holding the thumb in abduction
Acute quadriparetic myopathy syndrome (AQMS) can result in longstanding paresis if NMBAs are given in doses which are too high.
Assume hypoxia and therefore tube displacement until proven otherwise
Displaced tube
Obstruction-pass suction catheter through tube
Pneumothorax
Equipment failure-take off vent and bag patient
if all of the above have been evaluated, consider shunt physiology
Always use an oral airway
· Take mask off of bag
·
Lay over nose and let fall on the face
· Place thumb and first finger on mask with port against thumb web
· Attach the bag
·
Use the other fingers to grasp along mandible,
pulling face into mask
2 hand method: place both thumbs on
mask, facing the patient’s feet. Index
fingers on mentum of chin. Other fingers
performing jaw thrust.
Use 2 nasal and oral airway if difficult to ventilate.
• comparison of 4 standard bags with
high-flow oxygen
• Duck-bill mask with one-way valve gives
FiO2 >0.9, other bags ~0.3
• Laerdal Silicone Resuscitator®,
Mallinckrodt Capno-Flo® > 0.9
• Sims-Intertech 1st Response®, Vital Signs
Code Blue® < 0.4
• Know your bag well: they’re different
Nimmagadda
U et al. Efficacy of preoxygenation with tidal volume breathing: Comparison of
breathing systems. Anesthesiology
2000 Sep 93 693 -698
(Ron Wall's Lecture)
Esophageal sphincter is 20-25 cm H2O in normal healthy, less in sick or dead
Better technique may be to use mask and ventilator (Journal of Emergency Medicine 2006;30(1):63)
Airway pressure < 15 cmH20 rarely causes insufflation, but > 25 often will (Br J Anaesth 1987;59:315 and Acta Anaes Scand 1961;5:107)
Nasopharyngeal Airways
Short Female Size 6 (pin 1cm from flange)
Average Female/Short Male Size 6
Tall Female/AVerage Male Size 7
Tall Male Size 8
width does not matter, only length so that it is above cricoid but below tongue
(Emerg Med J 2005;22:394-396)
NRB = ~65-80%
Ø BVM = > 90%
• New Hi-Ox® Mask >80% @ 8L/min
New smart bag limits IFR (Intensive Care Medicine Volume 34, Number 2 / February, 2008)
Article on proper way to open the jaw and hold the mask
Facemask position ofr edentulous patients (see image above) Anesthesiology May 2010 - Volume 112 - Issue 5 - pp 1190-1193
The tongue is your enemy, the epiglottis is your friend.
for direct laryngoscopy and tracheal intubation (Anaesthesia 2008;63:156)
When passing the tube, first touch the hard palette with the tube’s bevel lying horizontally. Guide the tube to the soft palette. Approach the cords from the right so as not to obscure your view. At the last second, rotate the tube counterclockwise 90° to allow narrowest area to go through the cords.
Macintosh must indirectly lift the epiglottis by use of the hyoepiglottic ligament. If the macintosh blade is too short for the patient, you may be able to reach the valeculla, but have inadequate traction to lift the epiglottis.
Teach residents by telling them to life the head off of the bed with the blade rather than tilting the head back with the blade
| Task | Task Completion |
| Position Patient | Ears to Notch |
| Open Mouth | Translation of Mandibles |
| Place Blade | 1" of blade centered in mouth |
| Find Epiglottis | Sliver of epiglottis seen |
| Press thyroid backwards | Valeculla transforms from potential to actual space |
| Seat blade tip | epiglottis lifts |
| Lift laryngoscope | head lifts off bed |
| Place Tube | See tube anterior to notch |
Increased head elevation/neck flexion results in much better view (Annals EM 2003;41(3):322)
Mike Murphy agrees with editorial in same issue (Ann Emerg Med 2003;41(3):338)
Another review article showing same in pregnant, obese woman (Can J Anaesth 1989;36(6):668)
RCT with crossover of extension vs. 7cm head elevation, trend towards better with ramp, sig. better in obese or poor head extenders (Anesth 2001;95:836)
Laryngeal exposure was superior at 25° than supine (Br J Anaesth 2007;99:581)
Laryngoscopy with straight blade allowed better view, but intubating conditions were better with the curved blade. (Can J Anesth 2003, 50:5 p. 501-506)
For difficult laryngoscopy, can try the left-molar approach. It may offer an improved laryngeal view. It can also be used to augment fiberoptic intubation attempts. (Anes 92:1, Jan 2000) and (Anaes 2002 57:1028-1044)
Consider having assistant grab the tongue with a 4x4 before the insertion of the blade.
BURP and mandibular advancement gave the best visualized view. Either one alone helped over none in inexperienced laryngoscopists (Anesthesiology 2004; 100:598–601)
Comparision of cricoid/burp/bimanual laryng. (Ann EMerg Med 2006;47(6):548): on cadaver models, only bimanual consistently improved view
Cormack-Lehane is scale for view of cords
Plastic Blades result in lower number of successful intubations (Anesthesiology 2006;104(1):60)
Nearly Dead, Newly Dead
Still may consider using Sux if any muscle tone at all
If BVM and intubation are predicted to be successful, do double set-up RSI with failed airway equipment already set up and cric set open
Sigma configuration for tube (Anesthesiology 2007;106(5):1069)
Give intubating dose of propofol, perform laryngoscopy, give paralytics if a good view is obtained
Consider awake BNTI in a predicted difficult airway
start with 32 french trumpet anesthetize through it to get post pharynx
Facilitated by neutral head position and ET tube cuff inflation to 15cc. This study used trachlite without guidewire (Can J Anesth 50(5):511, May 2003)
depth is 26-28 cm at nares
aim towards contralateral nipple
(Anesthesiology 2006;104(1):48)
Best Attempt Definition:
Performed by a reasonably experienced laryngoscopist
No significant muscle tone
Use of optimal sniff position
Use of external laryngeal manipulation
One change in length of blade
One change in type of blade
Pass till 20 cm at the teeth, you will feel it sliding over tracheal rings. Railroad the tube over the Eschmann while the laryngoscope is still in the mouth.
The laryngoscopist obtains the optimal laryngeal view. The bougie is then passed below the epiglottis and through the vocal cords. This should elicit a clicking feel at the distal end of the GEB due to the "hockey stick" angled distal end [5]. If clicking is not felt distinctly, the GEB is advanced further until it "holds up" at the carina or when it comes in contact with a peripheral airway of a smaller diameter [5]. Advancement always must be gentle. The laryngoscope blade is left in place as the ETT is inserted over the GEB and into the trachea. It is important to rotate the ETT 90 degrees counterclockwise before the tip of the ETT passes through the vocal cords. This maneuver prevents the beveled tip of the ETT from catching on the right arytenoid process, aryepiglottic fold, right vocal cord, or epiglottis. Clicking and holding up are cardinal signs of tracheal insertion by the GEB, both of which were noted during the insertion of the GEB in our patient with the open zone II neck injury.
Possible complications from a bougie insertion are pharyngeal perforation, mediastinal emphysema, and pneumothorax. (JEM April 2003)
The obstruction is caused by impingement of the tube on the right vocal cord complex and arytenoids [2]. Cossham [3] described a pre-emptive 90° anti-clockwise rotation of the tube (90CCWR), the Cossham twist
Am J Emerg Med. 2004 Oct;22(6):479-82. Links
Use of the endotracheal bougie introducer for difficult intubations.
A difficult to intubate patient occurs infrequently in the emergency department.
The endotracheal tube introducer or gum elastic bougie is a device used by
British anesthesiologists in difficult airways. The device is inexpensive, has
few complications and is easy to use. Similar to the Seldinger technique for
gaining access to a large central vein, the endotracheal tube introducer is used
to assist in cannulating the trachea and acts like the wire in central vein
access.
PMID: 15520943 [PubMed - indexed for MEDLINE]
Anaesthesia. 1988
Jun;43(6):437-8.Links
Successful difficult intubation. Use of the gum elastic bougie.
Kidd JF, Dyson A, Latto IP.
Department of Anaesthesia, University Hospital of Wales, Heath Park, Cardiff.
The reliability of two signs of tracheal placement of a gum elastic bougie was
studied. These signs were clicks (produced as the tip of the bougie runs over
the tracheal cartilages) and hold up of the bougie as it is advanced (when the
tip reaches the small bronchi). Ninety-eight simulated and two genuine Grade 3
difficult intubations were attempted with the aid of a gum elastic bougie.
Seventy-eight tracheal and 22 oesophageal placements of the bougie resulted. No
clicks or hold up occurred with the bougie in the oesophagus. Clicks were
recorded in 89.7% of tracheal placements of the bougie. Hold up at between 24-40
cm occurred in all tracheal placements. We conclude that these signs are
reliable and that they should be taught as part of any difficult intubation
drill in which the gum elastic bougie is used.
From Seth Manoach "
From an abstract Julio and colleaugues wrote and sent me a few yearsHold right above yellow balloon
Use thumb to press tongue out of way
Place until teeth between two black lines
Inflate blue cuff until lower black line moves above the
teeth (relative amount)
Inflate white for 12 cc (absolute amount)
Blue is first for everything (inflation, deflation, ventilation)
I agree that DL is the best way to place a SGA, also Combitube /Easytube.
Just to line out a few points for alleviating elective use/training of Combitube
/Easytube:
1) Use DL
2) Insert Combitube /Easytube "flat" along the
tongue parallel to outer surface of patients' body (not along the hard palate)
3) Inflate upper balloon (blue pilot balloon No. 1) with 25 to 75 ml in 10 ml
incremental steps until you get a tight seal as described by Dr. Gaitini several
years ago.
This "minimal volume inflation technique" minimizes the stress to
the pharyngeal mucosa. However, prevention of accidental extubation is also
reduced.
When using Combitube /Easytube in a manikin, make sure the
device is well lubricated. Combitube /Easytube work best in manikins such as
SimMan, Bill, VBM manikin, and/or Laerdal.
Ambu is not suitable for Combitube
/Easytube. Then, insertion and first ventilation are possible within 15 to 30
seconds.
Michael Frass
Inventor of Combitube
·
Cut Tube to 27 cm and reattach connector. Lube wire and lube stylet
·
Bulb should be flush with distal part of bevel, it should just touch your finger.
·
Hold like a cup of tea (between thumb and index
finger, pinky up is your choice)
·
In Peds, only pull
back 2-3 cm on wire
·
Must bend 90 or it will not work
· Touch it to the patient’s chest in midline and then rotate it in while performing a jaw thrust.
· Patient’s head can be in neutral position
Several tips have been suggested in the literature for
improving the success of Trachlight®-guided intubation. These include lifting
the tongue with the thumb of the nondominant hand or having an assistant pull
the tongue while the intubator continues to provide a jaw thrust, lubricating
the wand and the stylet,1 dimming operating room lights, using smaller size
endotracheal tubes, inserting the wand side-on, or providing at least a 90° bend
to the wand.2 Others have suggested gauging the appropriate "bent length" by
measuring the distance from the thyroid prominence to the angle of the
mandible.3 Patients with buck teeth may benefit from the addition of another
bend to the wand at the level of the buck teeth.4
Following repeated use, the internal rigid stylet sometimes assumes a
"snake-like" bend that poses difficulty in retraction of the wand. In such
situations, it has been suggested that the stylet be straightened, if possible,
before reuse, failing which it needs to be disposed. 5 We have also encountered
a similar situation leading to difficulty in withdrawing the wand along with the
rigid internal stylet after successfully negotiating the endotracheal tube-Trachlight®
assembly into the trachea. We have noticed that the snake-like bend of the
stylet poses a problem when it crosses the endotracheal tube connector, which
happens to be not only the narrowest, but also the most rigid portion of the
endotracheal tube-connector assembly. We have successfully overcome "hold up" at
this level by separating the endotracheal tube connector from the endotracheal
tube prior to withdrawal of the wand-stylet assembly. The distal 90° bent
portion of the wand-stylet assembly is the other point at which difficulty is
encountered during withdrawal of the stylet, especially in the pediatric age
group due to the small size of the tube and its connector. Our suggestion
provides a solution to this problem also. We therefore recommend that the
connector be routinely separated from the endotracheal tube to facilitate smooth
removal of the stylet and possibly prolong the life of the stylet. We have
applied this technique of removal of the endotracheal tube connector to aid in
Trachlight®-guided oral intubation using the Ring Adair Elwyn (Mallinckrodt
Medical, Athlone, Ireland) tube also.
In obese individuals, the midline tissues of the neck may be obscured by folds
of fat arising either from a double-chin above, or from the anterior chest wall
below, posing difficulty in appreciation of the circumscribed glow in front of
the neck. Dimming the operating room lights and placing a support under the
shoulder to extend the neck often improves success of Trachlight®-guided
intubation in obese patients. We have found that having an assistant retract the
fold of fatty tissue down and away from the neck so as to avoid formation of
skin folds over the neck helps in shortening the time to obtain the classical
well-circumscribed midline glow.
Since its introduction in 1959, the lightwand has proven its utility in several
clinical situations. Our experience gleaned from the use of the Trachlight® for
more than 350 intubations has prompted us to share some of the practical
solutions that we have used to overcome problems that we have commonly
encountered during its use. (Can J Anesth 2007;54:398-399)
More maneuvers to facilitate tracheal intubation with the GlideScope®
David C. Kramer, MD and Irene P. Osborn, MD
Mount Sinai Medical Center, New York, USA, E-mail: david.kramer@msnyuhealth.org
To the Editor:
The GlideScope® (Diagnostic Ultrasound Corporation,Bothell, WA, USA), is a
videolaryngoscope, whichincorporates a fibreoptic and digital camera systeminto
the blade.1 The blade displays a video output to adedicated monitor. The flange
of the blade has a 60°angulation, which facilitates better exposure of the
larynxthan traditional Macintosh blades.2,3 Some authorshave reported difficulty
intubating the trachea despitethe superior view offered by the GlideScope®.1 In
thelargest series of Glidescope use (728 patients), 14 ofthe 26 failed
intubations occurred in spite of achievinga Cormack-Lehane grade 1 view.4 In
that study,failures resulted not from an inability to view the larynx,but in
directing the endotracheal tube throughthe glottic opening. In our experience,
the device hasbeen successful in over 500 patients, especially thosewith large
tongues, relatively small mouths, and inpatients with limited neck mobility. We
have used thedevice for conventional induction, in rapid sequenceintubation, and
for awake intubation. Because theGlideScope lifts the tongue rather than
displacing itinto the submental space, patients with Mallampaticlass III and IV
airways are usually afforded Cormack-Lehane grades 1 or 2 glottic views.
We have found the following maneuvers to be helpful when intubating the trachea
with the GlideScope
Can J Anaesth. 2007 Nov;54(11):891-6.
The GlideScope-specific rigid stylet and standard malleable stylet are equally effective for GlideScope use.
Letter to editor on glidescope use (Journal of Clinical Anesthesia, Volume 22, Issue 2, Pages 152-154)
Look down, up, down, up (Anesth Anal 2007;104:1611)
CLINICAL SKILLS FOR THE PREHOSPITAL USE OF THE LMA
Similar to the first laryngoscopy,41 the first LMA insertion attempt should be
optimized.
Is the Correct LMA Size Selected?
The LMA Classic is available in six sizes. The manufacturer recommends two size
selection criteria: weight based (for adults patients: size 3, 30 to 50 kg, size
4, 50–70 kg, size 5, 70–100 kg, and recently size 6 for >100 kg) and gender
based (size 4 for female and size 5 for male adults). The manual also recommends
that clinical judgment should be used in selecting the size.
Is the LMA Ready to Use?
The device is prepared (deflation and lubrication of the dorsal surface with a
water soluble lubricant), stored, and used in an uncontrollable and
unpredictable environment. The LMA, water soluble lubricant and a syringe should
be packaged together. The disposable LMA-Unique (sizes #3, #4, and #5) (LMA
North America, San Diego, Calif.) offers this advantage.
Is the Patient Ready to Accept the LMA?
Insertion of the LMA during inadequate level of anesthesia is a common mistake.
A patient who is not “deep enough” (gagging, coughing …) will fight the LMA
insertion and discourage the rescuer from inserting the index finger deep into
the mouth resulting in misplacement of the device. A misplaced LMA is more
likely to be dislodged or to trigger reflexes (laryngospasm, glottic closure,
vomiting, or hiccups).42
In the OR the loss of motor response to the “jaw thrust” is considered more
reliable to assess adequate “depth” than the loss of verbal contact with the
patient.43 Unwanted effects of the jaw thrust may include cervical spine
mobilization and stimulation of the patient.
Optimal Insertion of the LMA
The rescuer will insert the LMA in variable positions: standing (emergency
room), kneeling (scene, ambulance), sitting (helicopter), and from the patient’s
side (difficult extrication). Experienced anesthesiologists need at least 2 cm
distance between the upper and the lower incisors to insert the LMA.44 The
kneeling position is suboptimal for the ETT placement but advantageous for the
LMA insertion. The standard index finger technique is used when standing or
kneeling at the patient’s head. This technique is superior to any other
insertion techniques.45 The thumb technique is useful when the victim is trapped
(motor vehicle crash) or difficult to reach from above the head. The rescuer
standing by the side of the patient will use the thumb of the dominant hand that
substitutes the index finger to guide the LMA along the palato-pharyngeal path.
The insertion success rate of the thumb technique is lower than the index finger
technique.46
The most common error made during the early learning phase with the standard
technique is the insertion of the LMA straight into the mouth without using the
hard palate as a slide and with the index finger not inserted deep enough into
the mouth, misplacing the LMA. Other reasons for failure are: choice of wrong
LMA size, incomplete cuff deflation, inability to get the mask past the teeth,
inability to advance the cuff past the base of the tongue, insufficient air, or
overinflation of the LMA cuff.47 An automated voice advisory manikin may correct
these predictable mistakes.48
Neutral head position, CP, and MILS can complicate the LMA insertion. Insertion
of the LMA should be attempted with the anterior half of the cervical collar
removed and MILS applied. Brimacombe recommends that LMA insertion with CP
applied should be attempted only if the oxygen saturation (SpO2) is >95%. If
insertion fails, CP should be released for the second attempt. If the SpO2 is
<95% initial insertion should be with CP released as ventilation/oxygenation is
more important than preventing aspiration.13
Optimal Cuff Inflation
Inflate the cuff with two-thirds of the maximum volume recommended (marked on
the LMA tube), then, add 3 to 5 mL of air, as needed up to the maximum volume
recommended. A rigid over inflated cuff will loose its ability to mold on the
soft periglottic tissues: over inflation will not compensate for malposition but
will further compromise the seal and the use of PPV. The manufacturer recommends
the use of a pressure gauge for optimal cuff inflation. All current literature
pertinent to supraglottic airway devices (SGD) standardizes cuff inflation
pressure to 60 cm H2O.
LMA Ventilation
Pharyngeal and esophageal leaks are expected with airway pressure over 20 cm
H2O. Overzealous ventilation with no airway pressure monitoring can lead to a
“misperceived” leak in an otherwise correctly placed LMA. Chest movement with
small TV may be difficult to evaluate in a dressed victim, with chest trauma or
strapped chest. Auscultation (chest, neck, and epigastrum) with small TV in a
noisy environment may be deceiving. The use of the inflatable bulb (esophageal
detector device) with the LMA is discouraged.49
In the OR the most specific test to detect LMA misplacement (defined
fiberoptically) was the ability to generate airway pressure of 20 cm H2O without
a leak whereas, the ability to ventilate manually (movement of the chest,
condensation of expired gases, adequacy of expired gas volume and the feel of
the bag) had the highest overall accuracy.
Is the Patient Ready for Transport?
Tape the LMA firmly in the midline to the upper jaw without bending the tube
toward the forehead; keep the LMA tube in a neutral position (bended toward the
chin) being vigilant not to dislodge the device during transport or manipulation
of the resuscitation bag. A bite block will increase the device’s stability.50
Asai et al. considers that although CP applied after correct placement of the
LMA significantly decreases the incidence of gastric insufflation, it also
decreases the adequacy of ventilation.51
Ventilation should be reassessed after the application of the anterior cervical
collar. If monitored, the airway pressure should be kept under 20 cm H2O.
Regurgitation in the LMA Tube
Brain considers the LMA cuff protective by filling the pharyngeal space
otherwise filled with aspirate and should not be removed; also the LMA tube
represents a path of minimal resistance, an alternative to the trachea.52
In the event of regurgitation/aspiration disconnect the breathing tube and allow
regurgitated material to drain, and then gently ventilate using small tidal
volumes (TV) with 100% Fio2. Place the patient with cervical spine precautions
in Trendelenburg position. Sedate and/or paralyze the patient that is “too
light.” Oxygenation should be maintained during the incident.
Suction the LMA tube. There is no predictable continuum between the LMA tube and
the glottic opening.53 A suction catheter will most likely not penetrate the
trachea (for the same reason rescue medications administered through the LMA
will not reach consistently the trachea). If the LMA fails (reduced chest wall
movement, deteriorating O2SAT and ETCO2, increased airway pressure) other airway
management options should be considered.
LMA Seal Breakdown
25 cm H20
BVM
100
Combitube 45
Incredibly low aspiration rate when LMA used for general (Anaes 2009;64:1289)
opening pressure ~21 with LMAS (21 J.F. Heuer, M. Stiller
and J.
Rathgeber et al., Evaluation of the new supraglottic airway devices
Ambu AuraOnce and Intersurgical I-gel. Positioning, sealing, patient
comfort
and airway morbidity, Anaesthesist 58 (2009), pp. 813–820
Inflate LMAs to less than 44 mmHg
· Lubricate the tip of the tube.
· Hold et tube at black line and insert and withdraw until lube on tube is totally spread, so there is no resistance.
·
Lift and tilt back on handle until minimum air
leak when ventilating, this is the position the tube should be passed in.
Pull back a few cm, jaw thrust, push forward
The Chandy maneuver (Figure 2) was developed by Dr. Chandy Verghese and significantly improves the effectiveness of the ILMA (25). It incorporates two maneuvers that improve lung ventilation and tracheal intubation using the ILMA. Part one of the Chandy maneuver facilitates positioning of the ILMA in the upper airway so that lung ventilation is maximized through the device. This is done by grasping the ILMA by the handle and moving it back and forth in the sagittal plane while observing the patient's tidal volume and/or the capnographic waveform (if ventilation is being controlled manually). However, if the patient is breathing spontaneously, an airway whistle (e.g., Patil intubation guide [Anesthesia Associates, San Marcos, CA] or Beck Airway Airflow Monitor [Great Plains Ballistics, Lubbock, TX]) can be attached to the proximal portion of the ILMA to optimize ventilation through it. The whistle will sound with each breath the patient takes. The ILMA is then moved slowly back and forth in the sagittal plane using part one of the Chandy maneuver until maximal whistling is attained. Maximal whistling indicates optimal positioning of the ILMA. The second part of the Chandy maneuver involves aligning the ILMA to facilitate smooth passage of the endotracheal tube (ETT) into the trachea.
A special Euromedical ETT is provided with the ILMA. The ETT has a longitudinal
line, which should be oriented to face the patient's nose superiorly. Proper
orientation of the longitudinal line causes the ETT to exit the ILMA at an angle
that eases its passage into the trachea. The ETT also has a circumferential line
at a distance from the distal tip of the ETT that is equal to the length of the
ILMA from the proximal to the distal port. At the point where the
circumferential line is advanced to the proximal port of the ILMA, the distal
tip of the ETT will be in contact with the epiglottic elevator bar (which covers
the distal port of the ILMA). The epiglottic elevator bar raises the epiglottis
so that the ETT can enter the glottis unimpeded. Just before the distal tip of
the ETT contacts the epiglottic elevator bar, the second part of the Chandy
maneuver is performed. This involves lifting the handle of the ILMA at a 45°
angle to the patient's chest. This helps align the trajectory of the ETT into
the trachea inferiorly and usually facilitates smooth passage of the ETT into
the trachea.
If the patient is breathing spontaneously, an airway whistle attached to the
proximal end of the ETT will sound with each ventilation. As the tip of the ETT
enters the trachea, the volume of the whistle increases. When the cuff of the
ETT is inflated, the volume of the whistle will increase even more, heralding
the sealing of the ETT within the trachea and securement of the patient's
airway. Tracheal intubation should always be confirmed with an evidence-based
method, using a carbon dioxide detector if the patient has a perfusing cardiac
rhythm or a self-inflating bulb if the patient does not have a perfusing cardiac
rhythm (39). Additionally, auscultation of bilateral breath sounds will confirm
that the ETT is lying in a midtracheal position. The ILMA can then be removed
over the ETT using the stabilizing rod (Figure 1) or left in place with the mask
deflated until the trachea is extubated. (Proc Bayl Univ Med Cent 2005 July;
18(3): 220–227. James M. Rich, CRNA, MA)
The two steps of the Chandy maneuver. (a) After insertion
of the LMA-Fastrach, optimal ventilation is established by slightly rotating the
device in the sagittal plane, using the metal handle, until the least resistance
to bag ventilation is achieved. This helps to align the internal aperture of the
device with the glottic opening, (b) Just before blind
intubation, the LMA-Fastrach is slightly lifted (but not tilted) away from the
posterior pharyngeal wall using the metal handle. This prevents the endotracheal
tube (ETT) from colliding with the arytenoids and facilitates the smooth passage
of the ETT into the trachea. Reprinted from reference
25 with permission.
sort of of a simplified combitube (Brit Journal Anaes 2005;95(6):729)
ours is the bonfils
from Levitan course:
turn tube 90 clockwise off stylet
pull stylet not straight back
20 minute cidex scope
Follow the existing passage, don't try to make you're own with fiberoptic
devices
Perspective
Step back
Stand at pt’s right (if you are right hand dominant, otherwise reverse all sides)
Left hand holds thyroid cartilage with index finger touching membrane.
Make a vertical incision from thyroid cartilage to above jugular notch.
Make horizontal stab incision through cricothyroid membrane
Drop trach hook into incision with pointy hook facing towards the ceiling
Then turn the hook to grasp thyroid cartilage and hand it to an assistant
Put in trousseau dilator with blades at caudad/cephalad positions.
Dilate the airway.
Put tube between blades of the trousseau with the tube lumen facing towards the patient’s left.
Rotate the trousseau with the tube so that the
lumen faces the patient’s feet.
The trach kit supplied at EHC is good, in case you accidentally cut off the patients head and have to sew it back on. Otherwise you are probably better off taking out the scalpel, trousseau, and trach hook and repackaging them.
Minimum training for successful cric should include mannequin practice for 5 attempts or until the procedure can be performed in less than 40 seconds or less (Anesthesiology 98(2):349, Feb 2003)
Homemade Cric trainer (Anaesthesia 2004;59:1012)
Article showing wire cric is incredibly slow (Anaesth Anal 2010;110(4):1083) and (Anaesth 2006;61:565)
bougie
Can use nasal canula c 02 on 15 lpm as jet insufflator. Put one prong in catheter and the other as valve
aim flow perpendiculat to cannula to effect venturi effect--bench research (Anaest 2009;64:1353)
wall flow was better than bvm, no sig. difference between a 13G and 16G catheter (AMERICAN JOURNAL OF EMERGENCY MEDICINE Volume 22, Number 4 July 2004)
Or attach 3-0 ET tube adapter to 14 g angiocath for needle cric FOR PEDS ONLY
Resuscitation Volume 72, Issue 1 , January 2007, Pages 164-166
Manual specifically states the oxygen source must be high pressure (capable of a
driving pressure of 50 psi).
A wall oxygen flowmeter provides a maximum flow of 15 L/min at a pressure of up
to 400 kPa (58 psi) dependant on the resistance to flow.
that connects directly to the piped oxygen supply at 400 kPa (58 psi) and
provides sufficient flow for effective ventilation.Hospital wards have
wall-mounted oxygen flowmeters or oxygen cylinders, from which the maximum
driving pressure is 400 kPa (58 psi).
Failure to connect the equipment described in Figure 1 to an appropriate oxygen
source may waste valuable time following emergency needle cricothyroidotomy. We
propose the following clarification to the information provided in the ALS
Student Manual:
“When performing emergency needle cricothyroidotomy the cannula should be
connected to either the wall oxygen flowmeter directly to a jet ventilator or to
an oxygen cylinder and not to the common gas outlet of an anaesthetic machine.”
Wall O2 flowmeters have enough pressure, but only if you turn them up way beyond 15 lpm (Anesth Anal 2010;110:94)
Extrapolated to the clinical situation, these data suggest that low-pressure
devices will not deliver adequate MVs via a cannula cricothroidotomy and should
no longer be advocated.
Purpose-made devices should be available in all areas
where anaesthesia is administered or airway interventions are performed. (Br J
Anaesth 2009; 103: 891–5)
Possibility of using bedside percutaneous dilatational trachs (PERCUTANEOUS DILATATIONAL TRACHEOSTOMYFOR EMERGENT AIRWAY ACCESS. Ault MJ,Ault B, Ng PK. J Intensive Care Med 2003;18(4):222–226)
Push on chest to get air bubble if airway is full of secretions/blood
Rotational technique can be used for L mainstem with 50% success rate. Rotate 90 towards bronchus you want to intubate, then advance. (Acad Emerg Med 2004;11(10):1105.
Systematic Review (Emerg Med J 2006;23:3-11)
Use RSI (B)
In-line Stabilization with anterior portion of collar removed
Tracheal tube introducer for ALL intubations; use routinely, not as rescue (B)
Variety of sizes and shapes of blades should be available
LMA as temporary adjunct for failed airway
Review Article of intubation and its effects on c-spine injuries (Anesthesiology 2006;104(6):1293)
Now an article in the lit extolling ketamine as the ideal agent for head injury RSI (CJEM 2010;12(2):154)
Open endotracheal tubes may be safely left on an ED airway cart for 48 hours.
(Am J Emerg Med. 2005 Jul;23(4):548-51.)
CONCLUSION: It appears that opening, preparing, and
storing ETTs in an ED airway cart for up to 48 hours does not increase the risk
of bacterial contamination of the ETTs.
Sterility of prepared drug syringes
Driver et al (Anesth Analg 1998;86:994‑7) evaluated the sterility of drug
syringes used in the obstetric operating room. Most anesthesia departments draw
up these drugs fresh every 24 hours in order to be prepared for the emergent
situation where general anesthesia has to be rapidly induced. Drugs commonly
prepared are atropine, succinylcholine, thiopental, ephedrine and oxytocin.
The authors of this study prepared 756 syringes and stored them for eight days.
They then sampled 42 syringes of each drug randomly selected on days 1,4 and 8.
None of the 756 drug syringes grew any organisms. The results of this study
imply that one can retain drug syringes for longer periods of time than has been
traditionally done.
As the cost of the drugs that are daily prepared is minimal, and the risk of
forgetting to change drugs if left for a longer period of time is considerable,
I would not consider changing my pattern of practice.
RSI but with SGA, possibly the best idea for the prehospital environment (from Darren Braude's RSI/RSA Book)
A group of interventions for airway and post-intubation management improved severe complications
2 operators
fluid loading pre-tube
prep of post sedation beforehand
preox with bi-pap if needed
RSI
sellick
capnography
norepi if low diastolic bp (<35)
long-term sedation
lung protective vent
Walls RM et al. Manual of Emergency Airway Management. Lippincott, 2000.
Shah SM et
al. Emergency Neurology.
The Airway Site. http://www.theairwaysite.com
Ovassapian, A et al. Fiberoptic endoscopy and the difficult airway, 2nd ed. Philadelphia : Lippincott-Raven, 1996.
Benumof J. Airway management : principles and practice. St. Louis ; New York : Mosby, 1996.
Brimacombe JR et al. The laryngeal mask airway : a review and practical guide. Philadelphia: W.B. Saunders, 1997.
Management of the difficult and failed airway Hung/Murphy
Home | Disclaimer | Contact | Podcast