1 Essential Emergency Airway Care Airway Preparation Andrew

#1 Essential Emergency Airway Care. Airway Preparation Andrew Brainard, MD, MPH, FACEM www. thesharpend. org abrainard 01@gmail. com 1

#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 – No signs of trauma, OSA – GCS 5, RR 6, Sa. O 2 88%, pulse 100, BP 100/60. • • Possible A, B, C, and D • Likely Medications • Ensure team members understand • 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 R 40: 50 y/o F found down and unresponsive at home. 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, Sa. O 2, ET CO 2) Airway Cart (Top Through Bottom Drawer) Medications (Cart, Intubation Box, Pyxis) Airway Aids (Posters, Checklist) Video laryngoscope Ventilators, CPAP/Bi. Level Store Room • Trach, spare ETT, other supplies – Paed Dose Calculator on Computer

Managing the Airway Team 3

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Medications t n a t s i • Team Leader • Primary Airway Operator ss A y Primary Airway Operator a w Air Backup Airway Operator – Backup Airway Operator • Airway Assistant • Manual In-line Stabilization Drugs • Drug Provider • Runner/Scribe/Other • Intensive Care Team Leader Intensive Care 5

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. . 6

Preparing the Resus Tower and Monitoring 1 st monitor on Sa. O 2 Not on BP arm ETCo 2 Tested On BVM 2 nd monitor on Tower Suction Tested Under Pt’s R shoulder Oxygen Mask Nasal BVM O 2 on Reservoir bag PEEP 7

Preparing the Airway Cart • Cart Location • Top – Set up as needed • Side – Bougie, Tube Exchanger • 1 st Drawer – Adjuncts: OPA, NPA, Suction, Mask • 2 nd & 3 rd Drawer Cart Airway cts Adjun x 2 oscope Laryng ETT x 2 /Stylet Bougie tie yringe/ Lube/s ric LMA/C Suction – Pt’s right – Orientation (able to open drawer) – Primary: Laryngoscopes, ETCo 2, 3 rd Drawer – ETT, Tie • 4 th Drawer – Air. Q SGA (3 sizes) w/ stabilizer • 5 th 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 8

Important Equipment Checks: Resus Tower/Gantry Medications Suction Oxygen Mask/BMV/Nasal RSI meds Oxygen Power Cart Airway cts Adjun Sa 2 ETCo G C E BP/ x 2 oscope Laryng ETT x 2 /Stylet Bougie tie yringe/ Lube/s ric LMA/C Suction Ventilator itor Mon O 2 Videoscope ETT Stylet On Circulation 2 nd Monitor IV Fluids A-lines Room Bed Position Height Locked Tower Position Height Videoscope Monitoring 1 st monitor on Sa. O 2 Not on BP arm ETCo 2 Tested On BVM nd 2 monitor on Tower/Gantry Suction Tested Under R shoulder Oxygen Mask BVM Nasal BVM O 2 Reservoir bag PEEP Cart Top Adjuncts (OPA/NPA) Laryngoscope Lights tested 2 sizes ETT Lubed Stylet shaped Smaller size ready Syringe/tie Drawers LMA/Air. Q sized Cric kit located 9

Medications Prep RSI meds Prep IV fluid Prep maintenance meds *Airway Assistant* *Primary Airway Operator* Assure oxygenation Formal airway assessment Vocalize plan A, B, C, D Primary airway procedure Prep airway table Suction, Adjuncts, Laryngoscopy, ETT, Bougie, LMA, Cric Kit, Place nasal O 2 External laryngeal manipulation Handles tube/bougie Assists with securing tube Monitoring Prep Room Monitoring Sa. O 2, ETCo 2, BP, ECG Intensive Care Continuity of Care Transport *Backup Airway Operator* Examine patient Position patient External laryngeal manipulation Backup airway procedures Perform cricothyroidotomy *Drugs* IV/IO x 2 Administer RSI meds Team Leader Prepare room/staff Leads resuscitation 10

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/Bi. Level • 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 11

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 12

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 13

Airway Assistant Drugs Primary Airway Operator 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 Drugs • External Laryngeal • Access Manipulation • Drugs • Bougie/tube • Dose procedure • Equipment names & sizes 14

The Pre-arrival briefing Direct laryngoscopy bougie+7. 5 tube • 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 Video laryngoscopy stylet+7. 5 tube Air. Q 3. 5 • 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 tube B- Video laryngoscopy with stylet+7. 5 tube C- Air. Q size #3. 5 D- Cric for Sats <80% and dropping • We will use all our “best practice” techniques. *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 • Access • Drugs • Dose • Everyone understand their roles? • Questions or suggestions? • Let’s make sure everything is ready for this patient’s arrival. 15

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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 17

Brief Preparation References: • George Kovacs and J. Adam Law: Airway Management in Emergencies, 2 nd Ed, 2011 • Walls RM and Murphy MF. Manual of Emergency Airway Management, 4 th 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 -D 3 T 3 -1430 -Contemporary -Strategies-in-Airway-Management. mp 3 (Accessed on 1/06/13) • Tim Leeuwenburg. SMACCGold: Checklists in Airway Management (http: //vimeo. com/89997364) (18 min) (accessed on 15/6/2014) • The Difficult Airway Society Guidelines (http: //www. das. uk. com/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 predictorshttp: //academiclifeinem. com/mnemonics-for-difficult-airway-predictors/ (accessed on 15/6/2014) 18