Common anesthetic pitfall in ER

Associate professor TharnthipPranootnarabhal

2/9/2007

Objectives

Airway management in ER Sedation/ opioids for minor procedures Local anesthetics used IV access

Airway management Role of ED physicians in airway management

25 yrs ago :Blind nasotracheal intubation by ED doctorsAnesthesiologists used paralytic agents

1977 Institution surveyIntubation by ED physician: 45%

by anesthesia personnel 32% Both 19%

Anesth Analg1997;85:62-8

Airway management Use of NMB&RSI by ED physician Complications of emergency intubation

without NMBaspiration 15%airway trauma 28%dead 3%

No complication in RSI groups

AmJEmergMed1999;17:141-3

Difficult Airway Difficult ventilation : cannot ventilate,

SpO2 90%

Difficult intubation : cannot intubate > 3attempts

duration > 10 minutes

Rapid Sequence Intubation

1. Be prepared to perform surgical airway in the event that airwaycontrol is lost

2. Preoxygenation the patient with 100% oxygen3. Apply pressure over the cricoid cartilage4. Administer 1-2 mg/kg succinyl choline IV5. After the pateint relaxes,intubate the pati\eint

orotracheally6. Inflate the cuff and confirm tube placement7. Release cricoid pressure8. Ventilate the patient

Evaluation of Difficult AW

Anatomy Malampati classificati Mouth opening 3 cm. Movement at atlanto-occipital 35º Thyromental distance 7 cm Large incisor length Short thick neck Narrow palate

Drugs for RSI Preinduction drugs:

Fentanyl, Lidocaine, Esmolol

Induction drugs:Etomidate, Propofol, Thiopental,

Ketamine

Muscle relaxant :Succinyl choline, Rocuronium,

Preinduction drugs Fentanyl 2-3 µg/kg IV:

↓ pain masseter muscle,chest wall rigidity

bradycardia Lidocaine 1.5mg/kg IV :

↓ hypertensive response ↓ airway reactivity prevent ↑ICP ↓dysrhythmia from intubation hypotension

Esmolol 2mg/kg :

↓tachycardia, hypertention

airway reactivityBe careful in traumatic hypovolemia

Induction drugs

Etomidate 0.15-0.3mg IV

stable CVS

Inhibit cortisol synthesis

↓ Threshold of focal seizure Propofol 0.5-2 mg/kg IV :

BP ↓ , allergy Thiopental 1.5-3 mg/kg

bradycardia, BP ↓ Ketamine 2mgkg : in asthma, COPD

Muscle relaxant

Succinyl choline 1.5mgkg :MH, Diff.AW, K+↑ myopathy,chronic nephropathy, burn >24hrs.CRF, crush inj. >3d,sepsis >7d

Rocuronium high dose 1mg/kgdifficult AWallergy to aminosteroid NMB

,

Preparation for Intubation Mnemonic

Mnemonic Description Y Yankauer suction B Bag-valve mask A Access vein G Get your team, get help if predict a difficult

airway P Position patient (sniffing, position if no

contraindications) and place on monitor

E Endotracheal tubes and check cuff with syringe O Oxygen, oropharyngeal airway available P Pharnacy: draw up adjunctive medications,

induction agent, and neunomuscular blocker

L Laryngoscope and blades: ensure a variety and that they are working

E Evaluate for difficult airway: look for

obstruction, assess theyromental distance < 3 finger breadth,

interincisor distance < 2 finger breadths, neck immobilization

Airway equipment

Airway :

Oropharyngeal airway

Nasopharyngeal airway

LMA

Surgical Airway

Cricothroidotomy

Tracheostomy

Face mask

Airway equipmentEndotracheal tube

Orotracheal tube

Nasotracheal tube

Combitube

Laryngoscope

Bullard

McCoy

Light wand

FOB

Airway burn patient

Maxillofacial trauma : Lefort II, III

Caution!

Sedation in ER

Minimum Sedation

Moderate Sedation

Deep Sedation

Preparation for sedation S uction O xygen A irway Pharmacy ที่��จำ��เป็นต้�องใช้� : adrenalin,

atropine, ephedrine, amiodarone, lidocaine, flumazenil (ต้��นฤที่ธิ์��กลุ่��ม benzodiazepine) naloxone

M onitor E quipment เช้�น อ�ป็กรณ์�ก�รช้�วยช้�ว�ต้

ย�ที่��ใช้� sedation

Propofol 100-200g/kg/min IV หร!อ Etomidate

Midazolam 0.5-0.75 mg/kg IV Chloral hydrate 25-100 mg/kg ร"บป็ระที่�นในเด็&กไม�

เก�น 2 gm. Ketamine 1-1.5 mg/kg IV, 4-5 mg/kg IM Fentamyl 1.0g/kg

ย�ต้��นฤที่ธิ์��

Naloxone 0.1 mg/kg IM ที่�ก 2 น�ที่�ไม�เก�น 2 mg

Flumazenil 0.02 mg/kg IV. ที่�ก 1 น�ที่�

ไม�เก�น 1 mg.ต้�อคร")ง

Selection of patient

1. Painless procedures

2. Painful procedures

3. Be careful of AWO, ↑ ICP, Change of consciousness, intestinal obstruction, CHF, allergy, not cooperate

4. Pediatric patient : Ketamine + Topical

Midazolam + Ketamine

Local anesthetics

Lidocaine

Dose 5 mg/kg (plain)

7 mg/kg (with epinephrine)

Bupivacaine

Dose ต้�อคร")ง 175mg (plain)

250mg (with epinephrine)

IV access

External jugular vein , Internal jugular vein

Femoral vein

Evaluation of circulating volume

Thank you