Post on 23-Jan-2016
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#1Essential Emergency Airway Care-
Airway Preparation
Andrew Brainard, MD, MPH, FACEM, FACEMwww.thesharpend.org
abrainard01@gmail.com
#1 Pre-arrival preparation of Team, Plan, Room,and Equipment
• Learning Objectives:– Prepare TEAM
• Assign team leader (jacket, roles, plan)• Primary airway operator • Backup airway operator • Airway assistant• Drug provider
– Basic Pre-Arrival PLAN• Possible A, B, C, and D• Likely Medications• Ensure team members understand and
are skilled in their roles– Prepare ROOM
• Move bed, Resus tower, and Airway cart– Prepare EQUIPMENT
• Monitor• BVM, Adjuncts, Oxygen, Suction • Laryngoscopes, ETT, Bougie • Backups (SGA/Video/Cric)• Drugs
• R40: 50y/o F found down and unresponsive at home. – No signs of trauma, OSA – GCS 5, RR 6, SaO2 88%, pulse 100, BP 100/60.
• Team should prepare for critical patient– Team– Plan– Room– Equipment
• Conduct a Detailed Tour of ED resus area– Wear Jacket– Bed (Move Bed, Apply Brakes, Head Elevation)
– Resus Tower (BVM, Suction, Oxygen, SaO2, ET CO2)
– Airway Cart (Top Through Bottom Drawer)
– Medications (Cart, Intubation Box, Pyxis)
– Airway Aids (Posters, Checklist)
– Video laryngoscope– Ventilators, CPAP/BiLevel– Store Room
• Trach, spare ETT, other supplies
– Paed Dose Calculator on Computer
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Managing the Airway Team
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Airway Assista
ntPrimary Airway
Operator
Medications
Team Leader
Backup Airway
Operator
Intensive Care
Drugs
• Team Leader• Primary Airway Operator– Backup Airway Operator
• Airway Assistant• Manual In-line Stabilization
• Drug Provider• Runner/Scribe/Other• Intensive Care
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Preparing the room and equipment• Locate your personnel
– Resus Nurse(s)– ED SMO(s)– ED Reg(s)– Charge Nurse
• ICU• Anesthetics
• Prepare the Room– Move the bed– Move the airway cart– Move the resus tower
• Prepare the Resus Tower– Prepare the Monitor
• Prepare the Airway Cart• Drugs• Locate your backup stuff
– Video-laryngoscope etc..
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Preparing the Resus Tower and Monitor
TowerSuction TestedUnder Pt’s R shoulder
Oxygen MaskNasalBVM
BVM O2 onReservoir bagPEEP
Monitoring1st monitor onSaO2Not on BP arm
ETCo2 TestedOn BVM
2nd monitor on
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Airway Cart
Adjuncts
Laryngoscope x2
ETT x2
Bougie/Stylet
Lube/syringe/tie
LMA/Cric
Sucti
on
Preparing the Airway Cart
• Cart Location– Pt’s right– Orientation (able to open drawer)
• Top– Set up as needed
• Side– Bougie, Tube Exchanger
• 1st Drawer– Adjuncts: OPA, NPA, Suction, Mask
• 2nd & 3rd Drawer– Primary: Laryngoscopes, ETCo2, 3rd Drawer– ETT, Tie
• 4th Drawer– AirQ SGA (3 sizes) w/ stabilizer
• 5th Drawer– I-LMA, I-LMA ETT, w/ stabilizer
• Bottom drawer– Scalpel– Cric Pack
• pen, scalpel, 6-0 cuffed ETT, disinfectant, gauze, lube,
– Cook Melker Surgical + Percutaneous Cric Kit
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Resus Tower/Gantry
Airway Cart
Adjuncts
Laryngoscope x2
ETT x2
Bougie/Stylet
Lube/syringe/tie
LMA/Cric
CirculationIVFluidsA-lines
VentilatorOxygenPower
Monitor
SaO2
ETCo2
BP/ECG
2nd M
onitor
MedicationsRSI meds
Tower/GantrySuction
TestedUnder R shoulder
Oxygen MaskBVMNasal
BVM O2Reservoir bagPEEP
CartTop
Adjuncts (OPA/NPA)Laryngoscope Lights tested2 sizesETTLubedStylet shapedSmaller size readySyringe/tie
DrawersLMA/AirQ sizedCric kit located
Monitoring1st monitor onSaO2
Not on BP armETCo2
TestedOn BVM
2nd monitor on
Sucti
on
Important Equipment Checks:
VideoscopeETTStyletOn
Resus Tower/GantrySuctionOxygenMask/BMV/Nasal
RoomBed
PositionHeightLocked
TowerPositionHeight
Videoscope
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*Airway Assistant*Prep airway table
Suction, Adjuncts, Laryngoscopy, ETT, Bougie, LMA, Cric Kit, Place nasal O2External laryngeal
manipulationHandles tube/bougieAssists with securing tube
*Primary Airway Operator*Assure oxygenationFormal airway assessmentVocalize plan A, B, C, DPrimary airway procedure
MedicationsPrep RSI medsPrep IV fluidPrep maintenance meds
Team LeaderPrepare room/staffLeads resuscitation
MonitoringPrep RoomMonitoring
SaO2, ETCo2, BP, ECG
*Backup Airway Operator*Examine patientPosition patientExternal laryngeal manipulationBackup airway proceduresPerform cricothyroidotomy
Intensive CareContinuity of CareTransport
*Drugs*IV/IO x2 Administer RSI meds
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Indications for advanced airway management
• Goals of Care– Non-futile treatment– Able to complete continuity of care
• Unprotected airway – Obtunded, GCS <8, Cardiac arrest, Trauma
• Oxygenation or ventilation– Not appropriate for BVM/CPAP/BiLevel
• Clinical course – Agitated patient needing sedation for patient and staff safety– Expected future airway difficulty
• trauma, burns, infection, angioedema
– Need for pain control in patients during future procedures• Theatre, CT, etc.
– Expected multi-organ failure or severe sepsis
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Different urgency of airway control• Crash-– Extreme time pressure – Forced-to-act• Difficulty oxygenating and ventilating
• Emergent- – Substantial time pressure– Can be oxygenated • Allows for some preplanning and preparation
• Semi-Elective- – Minimal time pressure on stable patient• Full assessment and planning time
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Airway Assessment• MOANS (Mask)– M: mask seal– O: obstruction / obesity– A: age (>55)– N: no teeth– S: stiff lungs or c-spine
• LEMON (Intubation)– L: look– E: evaluate 3-3-2– M: mallampati
– O: obstruction / obesity– N: neck
• RODS (SGA/LMA)– R: restricted mouth– O: obstruction– D: disrupted or distorted– S: stiff lungs or c-spine
• SHORT (Surgical Airway)– S: surgery– H: haematoma– O: obesity– R: radiation– T: tumor
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Airway Assistant Primary Airway Operator
DrugsTeam
Leader
Primary Airway Operator
Airway Assistant
Team Leader
*Confirm that people understand their roles*
Primary•Formal Airway Assessment**•Plan A, B, C, D•Pullout Criteria
Backup•Backup Criteria•Cric plan
Airway Assistant•External Laryngeal Manipulation•Bougie/tube procedure•Equipment names & sizes
Drugs
Primary•Formal Airway Assessment**•Plan A, B, C, D•Pullout Criteria
Backup•Backup Criteria•Cric plan
Airway Assistant•External Laryngeal Manipulation•Bougie/tube procedure•Equipment names & sizes
Drugs• Access• Drugs• Dose
Drugs• Access• Drugs• Dose
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AirQ 3.5
Direct laryngoscopy bougie+7.5 tube
Video laryngoscopy stylet+7.5 tube
The Pre-arrival briefing• We have a 40 y/o female who has taken a large poly-overdose
with a decreased level of responsiveness. She is reported to have vomited several times and is ventilating poorly. • If we think airway management is indicated and our formal
airway assessment indicates it is appropriate to proceed, our plan will be to intubate her.
• The team will be: –Me as team leader– Fred as primary airway operator – Linda as backup airway operator – Viola as airway assistant– I will also push the drugs
• Assuming no contraindications, we will RSI with Thio and Sux, with dose to be determined. • Our plan will be:
A- Direct laryngoscopy with bougie+7.5 tubeB- Video laryngoscopy with stylet+7.5 tubeC- AirQ size #3.5D- Cric for Sats <80% and dropping
• We will use all our “best practice” techniques.
• Everyone understand their roles?
• Questions or suggestions?
• Let’s make sure everything is ready for this patient’s arrival.
Airway Assistant•External Laryngeal
Manipulation•Bougie/tube
procedure•Equipment names
& sizes
Primary•Formal Airway
Assessment**•Plan A, B, C, D•Pullout Criteria
Backup•Backup Criteria•Cric plan
Drugs•Access•Drugs•Dose
*Confirm that people understand their roles*
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Tips for managing the team
• Knowledge• Experience• Respect• Seniority• Mannerisms• Age• Gender
• Introduce yourself • Ask for everyone’s name• Assign roles• Preplan• Practice• Volume
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Brief Preparation References:• George Kovacs and J. Adam Law: Airway Management in Emergencies, 2nd Ed, 2011
• Walls RM and Murphy MF. Manual of Emergency Airway Management, 4th Ed, 2012
• Chris Nickson: Own the Airway- Life in the Fast Lane (http://lifeinthefastlane.com/own-the-airway/) (accessed on 15/6/2014)
• Reuben Strayer. Free Emergency Medicine Talks: Contemporary Strategies in Airway Management http://freeemergencytalks.net/wp-content/uploads/2012/07/2012-06-29-D3T3-1430-Contemporary-Strategies-in-Airway-Management.mp3 (Accessed on 1/06/13)
• Tim Leeuwenburg. SMACCGold: Checklists in Airway Management (http://vimeo.com/89997364) (18min) (accessed on 15/6/2014)
• The Difficult Airway Society Guidelines (http://www.das.uk.com/guidelines/guidelineshome.html) (accessed on 15/6/2014)
• Nicholas Chrimes & Peter Fritz- The Vortex Approach http://www.vortexapproach.com/Vortex_Approach/Vortex.html (accessed on 15/6/2014)
• Javier Benitez, Academic life in emergency medicine. Mnemonics for difficult airway predictors- http://academiclifeinem.com/mnemonics-for-difficult-airway-predictors/ (accessed on 15/6/2014)