Dr. Mohammad Reza Khajavi

Department of Anesthesiology, Tehran University of Medical Sciences, Sina Hospital

Goals

The goal of emergency airway management is to ensure adequate oxygenation and ventilation while protecting the patient from the risks for aspiration

Signs and symptoms of airway compromise • High index of suspicion

• Change in voice / sore throat

• Noisy breathing (snoring and stridor)

• Dyspnea and agitation

• Tachypnea

• Abnormal breathing pattern

• Low oxygen saturation (late sign)

Remember …. ● Agitated patient

● Rule out Hypoxia =Sao2<90%

Obtunded patient

● Rule out Hypercarbia =Paco2>40mmhg

Indication for intubation Cardiac or respiratory arrest

Respiratory insufficiency

Airway protection

Need for deep sedation or analgesia, up to and including general anesthesia

Ventilation management of patients with space-occupying intracranial lesions and evidence of increased intracranial pressure (ICP)

Delivery of a 100% fraction of inspired oxygen (FiO2) to patients with carbon monoxide poisoning

Facilitation of the diagnostic workup in uncooperative or intoxicated patients

Appropriate equipment

Monitoring Standards for Airway Management :

Electrocardiogram (ECG), Blood pressure, Oximetry, and Capnometry

Appropriate equipment, including an oxygen source, bag-valve-mask ventilating system, mechanical ventilator, suction, and a variety kind of laryngoscope blade

APPROACH TO ENDOTRACHEAL INTUBATION

Endotracheal intubation is best accomplished in almost all cases with a modified rapid sequence approach by an experienced clinician

Anesthetics and neuromuscular drugs

Rapid sequence intubation (RSI) is the virtually

simultaneous administration of a sedative and a

neuromuscular blocking (paralytic) agent to render a

patient rapidly unconscious and flaccid in order to

facilitate emergent endotracheal intubation and to

minimize the risk of aspiration

CONTRAINDICATIONS Absolute:

Cardiopulmonary arrest present/imminent

Operator inexperience

Relative:

Anticipated technical difficulties with laryngoscopy

and/or intubation

modified rapid sequence approach Preoxygenation

anesthetics and muscle relaxant injection

Low tidal volume ventilation with low peak inspiratory ventilation

Cricoid pressure for prevention of aspiration

cricoid pressure should be released in the trauma patient if likely to facilitate intubation attempts.

ANESTHETICS AND INDUCTION OF ANESTHESIA

Propofole :Dosage must be adjusted in trauma and hemorrhagic patients

Etomidate administered in a range of 0.2 to 0.3 mg/kg is associated with hemodynamic stability and has an onset/duration profile like that of succinylcholine.

Ketamine is also a frequently used induction agent for hypotensive trauma patients due to its centrally mediated increase in sympathetic tone and catecholamine release

Hemorrhage and Hypotension The dose of anesthetic must be decreased in the presence of hemorrhage,

including no anesthetic at all in patients with life-threatening hypovolemia.

Rapid sequence induction of anesthesia and endotracheal intubation may proceed with muscle relaxants alone

NEUROMUSCULAR BLOCKING DRUGS Succinylcholine remains the neuromuscular blocker with fastest onset—

less than 1 minute—and shortest duration of action—5 to 10 minutes.

Adverse consequences: Hyperkalemia-ICP- IOP

Alternatives to succinylcholine include rocuronium 0.9 to 1.2 mg/kg-onset 1-2 min

PROTECTION OF THE CERVICAL SPINE Standard practice dictates that all victims of blunt trauma be assumed to

have an unstable cervical spine until this condition is ruled out.

Stabilization of the cervical spine will generally occur in the prehospital environment, with the patient already having a rigid cervical collar in place.

manual in-line stabilization This approach allows removal of the front of the cervical collar to facilitate

wider mouth opening and jaw displacement.

Direct laryngoscopy,

Video laryngoscopy,

Fiberoptic intubation,

Blind nasal intubation,

Cricothyrotomy

PERSONNEL Three providers are required to:

1-ventilate the patient and manage the airway

2-administer medications

3-provide manual in-line stabilization

4-A fourth provider may be needed to provide cricoid pressure if deemed appropriate.

5-Additional assistance may be required to restrain a patient who is combative because of intoxication or traumatic brain injury (TBI).

Equipment to facilitate difficult intubation

The equipment available depends on the preferences AND Experiences of the anesthesiologist

The gum elastic bougie, intubating stylet-

Supraglottic airway (SGA) devices, such as the laryngeal mask airway (LMA)

The LMA is an appropriate rescue device for a difficult airway situation in trauma, provided no major anatomic injury or hemorrhage is present in the mouth and larynx.

Intubating stylet

FACIAL AND PHARYNGEAL TRAUMA An injury to the face or neck can lead to acute airway obstruction

secondary to swelling and hematoma.

Laryngeal edema is also a risk in patients who have suffered chemical or thermal injury to the pharyngeal mucosa.

Intraoral hemorrhage, pharyngeal erythema, and change in voice are all indications for early intubation.

Patients with Faciomaxillary Trauma In general, both maxillary and mandibular fractures will make ventilation

by mask more difficult

Palpation of the facial bones before manipulation of the airway will alert the anesthetist to these possibilities.

A patient arriving at the ED in the sitting or prone position because of airway compromise is best left in that position until the moment of anesthetic induction and intubation.

Patients with Faciomaxillary Trauma Have at least 2 large-bore rigid suction catheters.

Minimize positive-pressure ventilation

Suction-assisted laryngoscopy airway decontamination

VL is considered the best option

An awake approach, although not always practical, should be considered

Allow patients to assume a position of comfort when safe to do so.

Prehospital Airway devices All intubations done in the field should be immediately confirmed using

capnometry- direct laryngoscopy or video laryngoscopy

When an SGA device is used in the prehospital setting, the positioning and ability to ventilate should be confirmed by capnometry, presence of breath sounds, and chest movement