OXYGEN DELIVERY DEVICES

Nasal Prongs Low flow delivery system Flow rate: 1 - 6 L/min FiO2 starts at 24% for 1L/min and increases 4% for each L/min up to 44% for 6 Lmin Well tolerated Must be low flow rate: > 6 L/min cause nasal mucosal drying Use: minimal or no respiratory distress or oxygenation problem Simple (Hudson) Face Mask (Rebreather) Low flow delivery system Flow rate b/w 5 - 8 L/min FiO2: 5 - 6 is 40%, 6 - 7 is 50%, 7 - 8 is 60% Mask doesnt need tight seal Use: as per nasal prongs but require higher concentrations Venturi Mask High flow delivery system Flow rate b/w 4 - 12 L/min FiO2 can be set specifically with different flow rate and air ports Fi02 can be 24, 28, 31, 35, and 40% Use: COPD patient that requires specific oxygen concentrations to administer high Fi02 but not too high such that the hypoxic drive to breath is blunted; titrate to keep sats about 88% Non-Rebreather with Resevoir Bag High flow delivery system Flow rate b/w 6 - 10 L/min Proper use at 10 L/min supplies 70% Fi02 Requires tight fitting mask Should be used when 50% oxygen required Use: any spontaneously breathing patient who requires highest [02] possible (carbon monoxide poisoning, trauma, etc) Puritan Face Mask High flow delivery system Flow rate > 10 L/min Fi02 with single setup are 35 - 50%, double setup are 50 - 80+% Provides highest level of humidified oxygen Flow rates of up to 30L/min can be achieved w/ double set up Should be used when > 50% oxygen required Bag Valve Mask FiO2 depends on the type of bag Good seal, bag with exhalation portion in proper position, you can get Fi02 to 90%

IDENTIFICATION OF A DIFFICULT AIRWAY

L.E.M.O.N.
Look, Listen, Feel ASK THE PATIENT: What is your name? Do you know where you are? Where does it hurt? Look LOC: responsiveness, mental status, agitated resp effort: RR, cyanosis, retractions, trauma: blood, deformity, upper airway burn (singed hair, soot) look in mouth for blood/sputum/vomit/FB, swelling of tongue, physical features: small mandible, obese, short neck, prominent upper incisors, prominent/anterior larynx, Listen stridor hoarse voice gurgling normal voice indicates intact upper airway function and ability to inhale/exhale Feel maxillofacial trauma laryngeotracheal trauma subQ emphysema trachea midline Evaluate with 1-2-3 Test 1 - when pt opens mouth, should be able to put one finger in TMJ 2 - pt should be able to open mouth at least two fingers wide 3 - thyromental distance should be at least three fingers Mallampati Pt opens mouth as wide as possible and protrudes tongue and you look in the mouth I - significant space b/w tip of uvula and surface of tongue II - small space b/w tip of uvula and surface of tongue III - tip of uvula obscured by base of tongue IV - cannot see uvula Obstruction Is there any indication of possible lower airway obstruction? Hoarseness, stridor, previous airway injury, previous airway surgery, tracheal scars? Neck Mobility Can the patient put neck into the sniffing postion Is there history of neck arthritis (OA or RA), ankylosing spondylitis,fusion, injury? Cervical spine immobilization +/- injury

A lot of this is not possible in a rushed intubation. However, a 30 second evaluation while you are assembling equipment, drawing drugs/etc should be considered MANDATORY with every non-crash intubation.

BASIC AW Mx
Ddx of AW obstruction Trauma: blood, edema, fragments esp laryngotracheal, emphysema, penetratn Infection/Inflammation: angioedema, burns, PTA, RPA, epiglotitis, croup, tracheitis, diptheria, ludwigs angina, caustics, inhalational injury Decreased LOC FB Tumor Laryngospasm Problem Recognition Altered LOC is at particular risk: unconscious, HI, alcohol, drugs Maxillofacial trauma _ midface and mandible #s cause AW problems including foreign bodies, bleeding, loss of AW structural support _ patient who refuses to lie down b/c supine position obstructs the AW Neck trauma _ bleeding, laryngeal or tracheal compression or fracture _ require definitive AW and a surgical AW is likely Laryngeal trauma _ (i) hoarseness (ii) subQ emphysema (iii) palpable fracture _ acute AW obstruction _ attempt intubation, then go to surgical AW Pulsoximetry Measures the saturation of Hb NOT the PaO2 but >95% suggests >70mmHg PaO2; requires intact peripheral perfusion and cannot distinguish b/w oxyHb and carboxyHb or methemoglobin which limits its usefulness in the severly vasoconstricted pt and in the pt w/ CO poisoning. Profound anemia and hypothermia also limit the effectiveness of the pulsoximeter. Ventilation Pitfalls Vomiting pt must be rolled to the side; also have suction ready Gastric distension from B-V-M may induce vomiting or distension of the stomach against the vena cava thus producing hypotension and bradycardia Obtunded or unconscious patients shound be tracheally intubated Agitated pts may require rapid sequence induction w/ succinylcholine or diazepam Bag-Valve-Mask should be performed by two people whenever possible to ensure a good seal Must ventilate pt b/w intubation attempts (max 30s)

Management of airway includes maintenance of C-spine control which is imperative (remember that a collar does not protect C-spine well

HIERARCHY OF AIRWAY MANAGEMENT

NONDEFINITIVE AIRWAY MANAGEMENT Basics Recovery position Suction Foreign body removal: blind finger sweep for foreign body is acceptable in adults but is NOT acceptable in peds Maintenance of C-spine control imperative in trauma Maneuvers Head tilt - chin lift: NOT acceptable with possible C-spine injury Jaw thrust - chin lift: acceptable with possible C-spine injury Heimlick Oropharyngeal Airway Use: temporary ventilation of unconscious patient while preparing to intubate Not be tolerated by conscious patient b/c gag reflex and produces vomiting Proper size: corner of mouth to external auditory canal Nasopharyngeal Airway Use: temporary airway management in pt who would not tolerate an oropharyngeal airway or if it is difficult to insert (trismus, mouth trauma, etc); less likely to induce vomiting Jet Insufflation (Needle Cricothroidotomy) Short term oxygenation until more definitive AW can be established 14 gauge (16 - 18 in children) cannula thru cricothyroid membrane, connect to wall O2 at 15L/min, intermittent insufflation w/ 1sec on and 4sec off can be achieved by placing thumb over open end of Y connector. Can ventilate pt for 30 - 45min; problem is that there is limited expiration :. C02 accumulates Rural location without proper equipment: use 14 gauge iv for cannula, use 5cc syringe to connect to iv, connect oxygen to syringe, cut hole in oxygen tube and occlude for 1 sec and let off for 4 seconds Other Esophageal Obturator AW (EOA), Esophogastric Tube AW (EGTA), Pharygotracheal Lumen AW (PTLA), Esophageal Tracheal Combitube (ETC) DEFINITIVE AIRWAY MANAGEMENT Endotracheal Intubation Awake vs Rapid Sequence Induction Nasotracheal Intubation Requires a spontaneously breathing patient Good for pt with tightly clenched teeth, unstable C-spine injury

Contraindications: apneic patient, severe maxillofacial fractures, suspected basilar skull fracture (racoon eyes, battle signs, ottorhea, rhinorhea, hemotympanum, nasal fracture) Surgical Cricothryoidotomy NOT recommended for children < 12yo b/c of potential damage to the cricoid cartilage which is the only circumferential support to the upper trachea Other: Fiberoptics, laryngeal mask, Tracheostomy: time consuming but indicated in ER for disrupted larynx or cervical trachea

ENDOTRACHEAL INTUBATION
GENERAL CONSIDERATIONS Anticipate a difficult airway: nonspecific and LEMON evaluation of airway Cervical collar and/or spine board immobilization, combative pat, children, short neck, prominent upper incisors, receding mandible, limited jaw opening, limited cervical mobility, UAW pathology (edema), facial or laryngeal trauma ETT sizes/position Adult male 7.5 - 9.0 (8.0) and should be at 21 - 24 cm Adult female 7.0 - 8.5 (7.0) and should be at 18 - 22 cm Pediatrics age/4 +4 (size of pinky or nostril) Uncuffed tubes < 8yo Confirmation of placement Is chest rising? Does reservoir bag fill? What is the pulsox? Is the tube fogging up? Listens over lung fields and epigastrium End - Tidal C02 CXR: tip should be way b/w thoracic inlet and carina (at level of aortic knob) C-spine Immobilization Must protect C-spine Loosening of hard collar to allow for movement of the mandible will greatly facilitate visualization of the cords with minimal cervical mobility Assume a full stomach Use sellicks maneuver to occlude the esophagus and decrease aspiration Also helps to visualize cords BURP to help visualize cords: Push Back and Up with the Right Pressure Choose a method of intubation Rapid Sequence Induction (RSI) is easiest and most popular method and should be used unless a difficult airway is expected where there is suspicion that both intubation and bag-valve-mask ventilation after paralysis may be difficult Awake oral intubation: preferred method if difficult airway suspected Unconscious patients for whatever reason (even cardiac arrest) do NOT require pretreatment, induction, or paralysis Equipment Suction: stiff tonsillar sucker Oxygen 100% connected to bag-valve-mask Laryngoscope handle and blades: curved (Macintosh) or straight (Magill or

Miller) or combination (Seward); use size 3 (most common) or 4; check light Endotracheal tube: at least two of expected size plus one size bigger & smaller Stylet: lubricate, tip proximal to murphys eye Surgical airway equipment: needle and surgical cricothryoidotomy Drugs for RSI Drugs via ETT = NAVEL Narcan, Atropine, Ventolin, Epinephrine: 10 mls of 1:10000, Lidocaine

BURP MANEUVER Manipulation of the thyroid cartilage Purpose is to improve laryngoscopic view Start when you are performing laryngoscopy and you cant see didly

SELLICKS MANEUVER Pressure on the cricoid ring to occlude the esophagus. Purpose is to decrease aspiration. Use the cricoid ring because it is the only complete tracheal ring. Start when paralytic goes in.

WHO NEEDS INTUBATION? (Think of the ABCDEs) A - AIRWAY Obstruction: stridor, vomiting, bleeding, foreign body, GCS < 8, burn, infection, epiglotitis, abscess, anaphylaxis, etc Obstruction risk: decreased LOC, early burn, neck hematoma, facial trauma Aspiration risk: bleeding, vomiting, unconscious B - BREATHING Apnea Oxygenation failure: CHF, PE, pneumonia, ARDS, pneumo, hemo, flail chest, asthma, COPD, PE, pulmonary contusions, etc Ventilation failure: asthma, COPD, etc C - CIRCULATION Shock (any cause): intubation/ventilation decreases work of breathing D - DISABILITY Decreased LOC: GCS < 8 is rough guide Increased Intracranial pressure E - EXPECTED CLINICAL COURSE Expected clinical course dictates that intubation required Going to CT Going to OR Expected deterioration: burn, anaphylaxis, neck hemaotma, declining The asshole!! drunken head whach, needs sedation for CT, gets so much sedation that you should tube him before sending him to the radiologists!!

NOTES Gag reflex is an unreliable indicator of airway reflexes and should not be used

Swallowing is better indicator of airway reflexes but has not been studied Narcan reversal of opiate overdose may avoid intubation Defibrillation should take place before intubation Clinical evaluation more important than ABG for deciding intubation

SPECIFIC CRITERIA FOR INTUBATION Subjective Criteria for Intubation/Ventilation Airway obstruction real or impending (epiglotitis, burn, tumors, etc) Aspiration real or impending (decreased LOC, drug OD, etc) Clinical respiratory failure (tacchypnea, tacchycardia, AMU, indrawing, cyanosis, diaphoresis, decreased LOC, pulsus paradosus) Tracheal bronchial toilet (unable to clear secretions; COPD w/ pneumonia) Shock not responsive to medical management w/i 30 min (resp muscles may use up to 25% of cardiac output; septic shock is an example) Anesthesia indications Objective Criteria for Intubation/Ventilation (less important than clinical criteria) Oxygenation (Pa02 measures oxygenation) Pa02 < 70 mmHg with Fi02 at least 70% A - a gradient > 350 mmHg (normal 15, up to 37 w/ age) Ventilation (PC02 measures ventilation) PaCO2 > 60 mmHg in normal adults (not COPD) RR > 35/min in adults PaC02 > 35 mmHg in status asthmaticus pH < 7.20 in COPD (cant rely on PC02 b/c of chronic reten) Mechanics Vital capacity < 15 ml/kg (normal is 70 ml/kg) CRITERIA FOR EXTUBATION Think ABCDEs ETT no longer required for A-B-C-D-E ETT no longer required to prevent airway obstruction or aspiration, ventilation, oxygenation, tracheobronchial toilet Should be able to protect airway with gag and cough reflexes Hemodynamically stable RR > 8 and < 35 /min Pa02 at least 60 mmHg on 50% Fi02 Tobin Ratio An ICU thing that you dont need to know specifically for emerg RR/tidal volume (L) < 100 predicts successful intubation

CONFIRMATION OF ENDOTRACHEAL TUBE PLACEMENT Clinical Features (unreliable) Visualized tube through the cords End-Tidal C02 should No gurgling over stomach with ventilation be considered the Bilateral AE best proof of correct Chest expansion placement. In an Fogging of tube arrested patient, Appropriate resistance with ventilation youll have to use NOTE: studies of direct visualization by the other means. EP after placement by EMS have shown to be about 90% sensitive (ie: not 100%!!) Radiology AP of chest can assess depth NOT esophageal placement Lateral films not reliable and time consuming Pulsox Desaturation if esophageal Can be delayed minutes b/c of preoxygenation Not preferred method of confirmation End - Tidal CO2 Detection C02 confirms the presence in the trachea Absence of C02 suggests esophageal placement (except cardiac arrest due to lack of production of C02 b/c of arrest) Tube above the glottis could give false +ve C02 (rare) BVM before intubation could push some gas into the stomach but the C02 will decrease after a few breaths (washout phenomenon) Carbonated beverages will not lead to enough C02 to fool detector (rare) Misconception: asthmatics cannot have enough bronchoconstriction to limit gas exchange enough to prevent C02 detection if in trachea Colorimetric (Qualitative) Purple -------> Yellow with C02 detection Tan is intermediate color: indeterminate, assume esophageal May not turn yellow in cardiac arrest even if in trachea Light - Emitting Diodes (Qualitative) Small device that can be inserted into airway circuit Audible alarm may sound when inadequate C02 is detected for a period of time May work better if there isnt enough light to see color detector (prehospital) Greater potential for malfunction, loss of power Capnography (Quantitative ETC02 Detectors) Cyclical recording of ETC02

Aspiration Techniques Not as reliable as ETC02 detectors and should be considered 2nd line May be preferred in cardiac arrest b/c of lack of C02 production Trachea: easy aspiration of air Esophagus: delayed or no aspiration of air (walls collapse) Bulb Turkey baster: Trachea> immediate reexpansion Syringe device: 20ml syringe attached to ETT adapter 90% sensitive for detecting esophageal intubation

AWAKE ORAL INTUBATION

TECHNIQUE Approaches Drugs Approach Totally awake: local anesthestic only Limited sedation: a touch of sedation RSS: rapid sequence sedation (same as RSI steps except no paralytic) Have RSI drugs drawn up so you can go there if you need to! Sedative: versed, fentanyl, valium, morphine Topical anesthetic: xylocaine Prepare: good oxygenation, check equipment, explain to patient Anesthetize the airway nebulize 4cc 4% lidocaine spray liberally with xylocaine spray just before Sedate the patient midazolam 1 - 2mg fentanyl 50 - 100ug propofol ketamine thipentothal etomodate Pass the tube gentle laryngoscopy while talking to pt, advance to cords, insert tube or do RSI depending on circumstances, ?placement

RAPID SEQUENCE INTUBATION (RSI)

INTRODUCTION Definition = administration of a potent induction agent followed immediately by a neuromuscular blocking agent to induce unconsciousness and paralysis for tracheal intubation Basis: decrease aspiration (pt not fasted) and increase success of intubation (easier) The patient is preoxygenated to allow a period of apnea and intubation of the trachea without interposed asssisted BVM ventilation (increases risk of aspiration) Indications Control of airway Control of patient Facilitate ventilation Contraindications to the Procedure (not the drugs) Absolute Predicted difficult INTUBATION and VENTILATION Lack of airway experience or back up devices Relative Foreign body in the airway (partial > complete obstruction) Underlying severe pulmonary disease (limits ability to preoxygenat) Cardiac tamponade: cardiac output is dependant on preload which is dependant on -ve intrathroacic pressure generated by inspiration; paralysis will decrease venous return and drop BP Goals Mazimize the change of successful and rapid placement of ETT Minimize the risk of aspiration Obtund the adverse CVS responses to intubation Obtund the ICP responses to intubation Assumptions Patient has a full stomach: give preoxygenation with 100% 02 but try NOT to bag pt before intubation, use Sellicks maneuver Master the art of BVM, airway back up devices available, ready for surgical AWbagging and be prepared for surgical airway MUST have surgical AW equipment ready MUST have intact facial structure to allow BVM if it fails Airway and ventilation complete responsibility of EP if it fails General Ideal Technique of RSI (may only use succ if very emergent) Preparation

Preoxygenation Pretreatment Paralysis after Induction Protection and positioning Placement with proof Post intubation management

SEVEN Ps OF RSI

Timing Full RSI takes 10 min; often this isnt possible Eight full breaths decreases preoxygenation time Pretreatment can be shortened to 2 min rather than 3 Can eliminate pretreatment altogether Success Rates National Emergency Airway Registry: overall 99% success rate MC complications are related to intubation: esophageal, RMB, etc Most catastrophic is unrecognized esophageal intubation Aspiration uncommon

PREPARATION
ASSESS THE AIRWAY Look - Listen - Feel Evaluate Mallampati Obstruction Neck Mobility DECIDE ON AIRWAY ALGORITHM Crash intubation Easy Difficult airway Failed Is RSI contraindicated? Are there any drug contraindications PREPARE EQUIPMENT Suction Oxygen Laryngoscope Endotracheal tube Stylet

Others: Bougiee, LMA, stylet, Miller, Mac4 General: Monitors, iv access, airway cart at bedside, medications drawn

Preparation is the KEY to successful ED airway managment......... BE READY FOR THE WORST

PREOXYGENATION
PREOXYGENATION Preoxygenation is essential to the no bagging principle Do not bag the patient!! Let them spontaneously breath. Baging will increase the risk of aspiration in the patient with a full stomach (always assume) Preoxygenation w/ 100% 02 for 2 min Causes a 98% nitrogen washout thus FRC becomes and oxygen reservoir which will protect the patient from hypoxia during apnea Preoxygenation ALSO creates and oxygen surplus in the blood and tissues (not just lungs) Spontaneous preoxygenation more effective than BVM ventilation for preoxygenation Devices Non-rebreather only probably delivers 70 - 75% Fi02 BVM placed over patients face and allowing spontaneous ventilation allows the delivery of 100% Fi02 5 min of preoxygenation is ideal 8 vital - capacity breaths will roughly equal 5 min of preoxygenation Desaturation Curves See Rosens or Walls for desaturation curves

PRETREATMENT MEDICATIONS: LOAFD

RATIONALE Normal responses to laryngoscopy and intubation Stimulation of pharynx, larynx ------> afferent stimuli to brain ------> increased ICP (independent of HR/BP), autonomic stimulation thus increased HR/BP and incr airway resistance Increased duration, aggressiveness increase the response Good outcome studies have not been done to determine clinical effects CNS: increased oxygen demand, increased cerebral blood flow, increased Icp CVS in children: monosynaptic reflex > vagal stimulation, brady CVS in adults: polysynaptic reflex ----> sympathetic stimulation, increased HR, increased BP, adrenalin release from adrenals, increased reninangiotensin: problematic with ischemic heart disease, elevated ICP, aortic or intracerebral aneurysm/dissection, or penetrating trauma (shear forces) Resp: upper - airway reflexes > laryngospasm and coughing; coughing increases ICP further and is problematic for penetrating eye injuries, Resp: lower - airway reflexes ----> bronchospasm L - LIDOCAINE Mechanism of action Suppresses the cough reflex and attenuates the increase in airway resistance that is irritant in origin (ETT) - good literature Suppresses the rise in ICP related to intubation by decreasing the reflex response to laryngoscopy - good evidence Suppresses laryngospasm by blunting upper airway reflexes Suppresses the bronchospastic - conflicting evidence ? Attenuates the sympathetic response to intubation (thus prevents increased HR/BP) - weak evidence Dose 1.5 mg/kg (ave adult 100mg) Timing: 3 min before induction Toxic effects: seizures (occur at much higher doses) Indications Increased ICP (tight heads) - good evidence Bronchospasm (tight lungs) - conflicting evidence O - OPIODS (FENTANYL) Mechanism of action Blunts sympathetic response to laryngosopy: prevents increase in HR and BP in response to laryngoscopy thus indirectly prevents rise in ICP due to intubation Effect varies with dose: partial effect at 2 ug/kg, moderate effect at 6 ug/kg, complete attenuation at 15 ug/kg (used in cardiac surgery) NO direct effect on ICP Large doses may cause hypoventilation, rise in PC02, vasodilation, incr

 Dose Indications

ICP Does not release histamine NO direct effect on pulmonary response to laryngoscopy 100Xs potency of morphine, effect w/i few minutes

3 ug/kg iv 3 min before induction (ave adult 200ug) Full sympatholytic dose is 6 ug/kg Can decrease dose to 1.5 ug/kg if concerned re hypotension Should be given as last of pretreatment drugs Give over 30 - 60 seconds

Increased ICP (tight heads) Anyone where increase in HR/BP may worsen condition Aortic aneurysm (inc. BP increases the shear forces) Cerebral aneurysm Myocardial ischemia/infarction Penetrating chest trauma Adverse Effects Hypotension: central sympatholytic Respiratory depression: Muscle rigidity: ? related to dose, speed of administration, concomitant muscle relaxants; not reversed with Narcan; seen at large doses (> 500ug) and primarily affects chest/abd wall; no ED reports, avoided with defasiculator ATROPINE MOA: muscarinic acetylcholine blockade to increase HR Peds Dose: 0.02 mg/kg iv 3 min before paralytic (min 0.1mg) Adult Dose: 0.5 - 1 mg iv Indications All children < 10 yrs (high vagal tone and bradycardia much more common in response to laryngoscopy) Latest PALS recomendation: all kids < yo All second doses of Succinylcholine (risk of bradycardia) FLUID Bolus 1L NS if you think they might drop their pressure Respiratory failure, asthma, trauma, septic, etc DEFASCICULATOR Rationale Blunts rise in ICP caused by succinylcholine (prevents fasiculations) - ? evidence Do NOT attenuate the reflex sympathetic or bronchospastic responses Doses Pretx dose is 10% of paralytic dose Rocuronium (0.6 - 1mg/kg): 0.06 - 0.1 mg/kg = 5 mg ave adult Vecuronium (0.1 mg/kg): 0.01 mg/kg = 1 mg ave adult Pancuronium (0.1 mg/kg): 0.01 mg/kg = 1 mg ave adult Adverse Effects May cause weakness or apnea and may have to intubate earlier Pancuronium causes tachycardia b/c of its anticholingeric effect which

worsen the pt with increased ICP (use VEC or ROC) BETABLOCKERS Blunt sympathetic response to laryngoscopy: Concerns = increase bronchospasm, negative ionotropic effect ---------> NO reason to use b/c fentanyl dose the same with less s/e

SEDATIVE AND INDUCTION AGENTS

THIOPENTAL (Pentothal) General Ultra-short-acting barbituate MOA: binds to GABA receptor to enhance and mimics the effects of GABA; chloride channel opening and neuroinhibition by hyperpolarization Main indication = increased ICP with stable hemodynamics Safe in pregnancy unless very large doses; can be irritating to veins Pharmacology Onset: 15 - 30 seconds Duration: 3 - 5 min (redistribution) Cerebroprotective: decreases cerebral oxygen consumption, decrease cerebral blood flow, decreased ICP while maintaining CPP Hypotension: potent venodilator and myocardial depressant; more potent in chronic hypertensive patients Central respiratory depression Extravasation or intraarterial injection can cause ischemia/thrombosis: 40 mg of papaverine in 20 ml NS or 10 ml of 1% lidocaine injected intraarterially Absolute contraindications profound hypotension intermittent porphyria, variegate porphyria (can activate the enzyme responsible for precipitation an acute attack) Dose Euvolemic adults: 3 - 5 mg/kg Hypovolemic or unknown adult: 1 - 3 mg/kg Elderly, CV disease, other hemodynamic drugs: 1 - 3 mg/kg Euvolemic child/infant: 5 - 8 mg/kg Hypovolemic or unkown peds: 1 - 5 mg/kg BENZODIAZEPINES General Stimulate the BZD receptor which modulates GABA Amnesia (best amnestics) , anxiolysis, central muscle relaxation, sedation, anticonvulsant effect, hypnosis Onset: midazolam (30 - 60 sec), diazepam (60 - 90), lorazepam (60 - 120 sec) T1/2: midazolam 1.5 - 2.5hrs, lorazepam 10 - 20 hrs, diazepam 20 - 40 hrs Decreased SVR and myocardial depression at induction doses Midazolam for induction Sedation dose = 0.05 - 0.1 mg/kg (3-5 mg in ave adult) Induction dose = 0.1 - 0.3 mg/kg (7-20 mg in ave adult) Full induction dose is rarely used by people who use it. ? why Full induction dose associated with more hypotension Onset time of 1-2 min is not as rapid as etomodate, pentothal, etc

Some feel that midazolam is a POOR induction agent for these reasons Combination Fentanyl 3ug/kg + Midazolam 0.1 mg/kg commonly used Be careful with hypotension: consider Fentanyl alone if hypotensive

KETAMINE (Ketalar) General PCP derivative Analgesic, anesthesia, weak amnestic Relative of PCP thus is a dissociative analgesic (special K): emergence reaction can be prevented or treated by benzodiazepines Dissociative = disconnects the THALAMUS and the LIMBIC SYSTEM Induces analgesia while maintaining/enhancing pharyngeal reflexes Bronchospasm is a potential problem b/c of increased secretions and enhanced laryngeal reflexes: atropine 0.02 mg/kg or glycopryrolate 0.01 mg/kg can be used to decrease secretions Pharmacology Inhibits catecholamin re-uptake thus increases HR and BP if NOT already maximally stimulated (may avoid in MI/CHF) Hemodynamically stable because of catecholamine release: drug of choice in hypotensive trauma pt w/o head injury Increases cerebral activity and MAY increase ICP: debatable literature but consider CONTRAINDICATED with increased ICP Active cornoary disease may be a contraindication (increases HR/BP) Aortic dissection may be another c/i (increase sheer stress from incr HR/BP) Direct bronchodilation thus drug of choice in asthma/COPD/bronchospasm Onset 15 - 30 sec Duration: 15 - 30 min Can be given im if there is no iv access Dose: 1 - 2 mg/kg iv, 2 - 4 mg/kg im Indications Asthma/bronchospasm COPD Hypotensive trauma without head injury Cardiac tamponade Cardiac disease without ischemic heart disease (myocarditis, PE) Contraindications Absolute: increased ICP Relative: ischemic heart disease PROPOFOL Alkylphenol derivative with hypnotic properties Highly lipid soluble Attenuates rises in ICP but decreases CPP Venodilation and myocardial depressant -----> hypotension (MORE than thiopental) Rarely the induction agent of choice in ED: poor hemodynamic profile and decreases CPP Excellent sedation

Minimal cortical suppression Reports as induction agent with asthma Dose 0.5 - 1.2 mg/kg Hypotension is main reason that its ED use for induction is limited

ETOMIDATE (Amidate) Pharmacology Imidazole derivative Primarily a hypnotic: exact mechanism unknown (No analgesic properties) Very hemodynamically stable (most of any induction agent) Minimal respiratory effects: apnea in 10% (short duration of 20-60 seconds); no histamine release thus will not aggravate bronchospasm Cardiovascular: average decrease in SBP is 10% thus still can lead to hypotension; only seen essentially in patients that are already hypotensive; average decrease BP is 20% in patients with aortic and mitral disease; suggested to use dose in hypotensive patient Decreases ICP and prevents ICP rise in response to intubation by decreasing cerebral blood flow and cerebral metabolic oxygen demand without adversely affecting CPP (evidence for cerebroprotection based on studies with large doses and continuous infusions so may not be as applicable to ED use) NO change in MAP + decreased ICP = increased CPP IDEAL agent for hypotensive, head injured Onset 20 - 30 sec (excellent! Some give it after succ b/c so rapid) Duration 7 - 14 min (short duration due to redistribution) Dose 0.3 mg/kg = 20 mg iv in average adult Dose 0.15 mg/kg = 10 mg iv if hypotensive (can still decrease BP) Bergen 1997: Summary of anesthesia experience Smith DC, J Emerg Med 2000: Only prospective trial for intubation Side - effects N/V in 30% on emergence Pain at injection due to propylene glycol diluent: administer in large vein Hiccups 11-beta-hydroxylase inhibition: decreases serum cortisol and aldosterone; only reported with infusions in ICU; no reports of clinically sisgnificant adrenal suppression after single ED use Seizures can occur but majority are probably myoclonus not seizures Myoclonic activity Brain stem disinhibition?? Commonly mistaken for seizure but isnt b/c no sz on EEG 30% incidence but likely reporting bias Prevention by pretreatment with fentanyl or BZD hypothesized Should not see this when paralyzed Benzodiazepine will mitigate Contraindications Pregnancy: does cross placenta, effects unknown Pediatrics: no literature to support or refute; dont use < 10 yo Prior seizures: ? decreases seizure threshold

Poor adrenal function: adrenal suppression

PARALYTICS/NEUROMUSCULAR BLOCKADE
DEPOLARIZING NEUROMUSCULAR BLOCKADE = SUCCINYLCHOLINE (Anectine) General Ideal agent b/c of rapid onset and short duration Agent of choice for RSI unless contraindicated Safe: National Emergency Airway Registry ----> succinylcholine used safely in > 99% Pharmacology Onset < 45 sec and duration, 10 min Structure: two acetylcholine molecules MOI: stimulates all acetylcholine receptors; nicotinic (NMJ) and muscarinic (parasympathetic nervous system); binds to Ach receptor and depolarizes the membrane but stays binded and thus membrane no longer responsive; initial stimulation is reason for fasciculations Action and duration are dependant on (i) plasma pseudocholinesterase and (ii) diffusion out of the NMJ (more imp) which is devoid of pseudocholinesterase Very little drug actually reaches NMJ thus always give large doses; incomplete paralysis is dangerous and the side-effects Onset: fasciculations in 15 seconds, paralysis in 45 - 60 seconds Storage: room temperature for up to three months then refrigerate Atropine 0.02 mg/kg for children < 10 yo to prevent bradycardia Atropine prn to adults Negative ionotropy not clinically significant Histamine release not clinically significant Metabolite (succinylmonocholine) sensitizes the cardiac muscarinic receptors thus bradycardia is more of a concern in repeat doses in adults Dosing: do not under - dose the patient!!

CHILDREN ADULT NEONATES IM DOSE

Fasiculations

2.0 mg/kg 1.5 mg/kg 3.0 mg/kg 3.0 mg/kg

Stimulation of nicotinic Ach receptors Etiology of muscle pain, increased IOP/ICP/IGP (?) Inhibited by defasiculating dose of nondepolarizer Muscle pain can occur despite defasiculator (? mechanism) Increased IGP: never been shown to be clinically significant Increased IOP: questionable clinical significance; succ increases IOP by 5 - 10 mmHg; blinking increases IOP by 10 - 15 mmHg; traumatic intubation

will increase IOP much more; defasiculator may help; airway management more important Increased ICP: probably only relevant consequence; prevent with defasiculator Defasiculators: Rocuronium: 0.1 mg/kg; Vecuronium: 0.01 mg/kg; Pancuronium: 0.01 mg/kg; Succinylchonine: 0.15 mg/kg

Hyperkalemia Normally raises serum K+ 0.5 mEq/L, peaking at 5 min, lasting 15 min Increased Ach receptor density and sensitivity: may raise K+ by 5 - 10 mEq/L Why? Ach stimulation leads to depolarization of muscle membrane by an inflow of Na+ and and outflow of K+ Neurologic diseases Central or peripheral nerve processes: lower risk because there is increased Ach receptors at the NMJ but the K+ increase is not a severe as with myopathic processes Myopathic processes are high risk: Ach receptors will be spread over the entire muscle not just at the NMJ thus there is a massive K+ release Evidence Zink studied normal patients, 46% with increase K, 46% with decrease in K, 8% with no change, max change was 1.0 mEq/L Clinical situations Burns: extrajunctional receptor sensitization at 24hrs; %BSA not always predictive (reports with 10%); can be at risk until healing complete (up to 1 - 2yrs) Crush injuries: data scant; 7days - complete healing (2mo) Denervation event (SCI or CVA): 7 days - 6 months Neuromuscular disorders: MS, ALS, muscular dystrophy: indefinately at risk depending on state of underlying disease Myopathies are the BIGGEST PROBLEM: massive K+ release (even more than SC or peripheral nerve dz); deaths secondary to undiagnosed Muscular Dystrophy Rhabdomyolysis is essentially a myopathy: avoid succ (sympathomimetic, found down X days) Pre-existing hyperkalemia Chronic Renal failure: likely little risk unless currently running high K+; little data to say how much risk there is with this Severe intra-abdominal infections > 7 days until resolution: : case reports, significance unknown Case: agitated, aggressive, cocaine ingestion, needs sedation and intubation: use rocuronium (hyperkalemic, acidotic, may have rhabdo) IF IN DOUBT, USE ROCURONIUM!!!!!

SUDDEN CARDIAC ARREST AFTER INTUBATION AND SUCCINYLCHOLINE----->THINK HYPERKALEMIA

Bradycardia

Due to stimulation of Ach muscarinic receptors Most commonly seen in kids b/c of higher basal vagal tone Can also be worsened by vagal response to airway manipulation Prevented or treated by atropine Atropine 0.02 mg/kg recommended for all < 10yo Repeat doses of succ at increased risk b/c of metabolite sensitization of heart Prolonged NM blockade (see box 1-5) Pseudocholinesterase deficiency: lack of enzyme in serum to degrade drug thus duration lasts until drug diffuses out of NMJ Congenital: genetic absence or abnormal enzyme; paralysis lasts hours Acquired: organophosphate poisoning and cocaine are the MCC (CRF, liver failure, cancer, hypothyroid, pregnancy, maxeran, bambuturol, cytotoxic drugs can all cause minor deficiency and increase duration) Trismus/masseter spasm Rare complication; more common in kids Normally small rise in masseter tone occurs but is short and not noticed Rarely occurs in isolation to a significant extent Administer a competitive agent (ROC, VEC, PAV, RAP) and BVM until intubation is possible Could be a sign of MH if severe or progressive Malignant Hyperthermia Genetic skeletal muscle membrane abnormality Triggered by halogenated anesthetics, Succinylcholine, vigorous exercise, emotional stress Onset acute or delayed for hours following precipitant Mortality 60% Muscular rigidity, autonomic instability, hypoxia, hypotension, severe lactic acidosis, hyperkalemia, myoglobinemia, DIC, hyperthermia (LATE) Masseter spasm = ? hallmark of MH (but succ can cause masseter spasm without full MH, especially in kids) Personal or Fhx of MH is absolute contraindication to use of succ Never reported from ED use of succ Treatment ABCDs Airway, Breathing, Circuation Ds: discontinue precipitatant, Dantrolene: 2.5 mg/kg iv, repeat q5min until muscle relaxation or max of 10 mg/kg,

no side-effects, give ASAP, prevents calcium release w/o preventing reuptake, Discuss with anesthesia

Absolute Contraindications Airway skills lacking: cant intubate and cant bag, Lack of back up equipment Allergy Burns > 48hrs Crush > 48hrs CNS disease > 48hrs CRF with suspected hyperkalemia Malignant hyperthermia or fhx Myopathies: muscular dystrophy, rhabdomyolysis Relative Contraindications Known plasma pseudocholinesterase deficiency Organophosphate overdose: inhibition of acetylcholinesterase will lead to prolonged action of succ b/c it will have to diffuse out of the NMJ Foreign body in airway: partial > complete obstruction Cardiac tamponade > loss of preload and will drop pressure Penetrating eye trauma debatable Succ increases the IOP by 3-8 mmHg Blinking increases the IOP by 10-15 mmHg Forceful eye closing increases the IOP by 60-70 mmHg Bucking during intubation will increase IOP way more than suc Defasciculating dose of NMB will prevent IOP rise This is NOT a big issue!

CONTRA-INDICATIONS TO SUX A Airway skills/equip lacking A Allergy B Burns > 48hrs C Crush > 48hrs C CNS dz > 48hrs H Hyperkalemia (known or suspected) M Malignant hyperthermia

COMPLICATIONS OF SUCC Bradycardia Paralysis and failed intubation Prolonged paralysis Masseter spasm Malignant Hyperthermia Muscle pain/cramps Hyperkalemia Fasciculations Increased IOP Increased ICP

NON - DEPOLARIZING (COMPETETIVE) NEUROMUSCULAR BLOCKADE General MOI: direct binding to NMJ and competitive inhibition No fasiculations Indications = contraindication to succinylcholine, post intubation paralysis, pretreatment to prevent fasiculations Disadvantages: slower onset, longer duration (MAJOR disadvantage) Advantages: no fasiculations thus no increased ICP or IOP; no hyperkalemia Major disadvantage = long duration Aminosteroid based: pancuronium (Pavulon), vecuronium (Norcuron), rocuronium (Zemuron), Rapacuronium (Raplon, RAP) Benzylisoquinolinium: tubocurare (Curare), metocurine, atracurium (Tracurium), cisatracurium (Nimbex), mivacurium (Mivacron) Steriod based: no histamine release thus less hypotension, tachycardia, bronchoconstriction Benzylisoquinolinium: histamine releases thus more hypo hypotension, tachycardia, bronchoconstriction Reversal by edrophonium/physostigmine/neostigmine Rapacuronium (Raplon, RAP) -----> Withdrawn from market b/c of bronchospasm and deaths (related to excessive histamine release) Dose: 1.5 mg/kg - 2.5 mg/kg
Onset: 60 seconds (very similar to succ); most rapid onset except succ Duration with reversal: 8-10 min (reversal = neostigmine 0.05 mg/kg with glycopyrrolate 0.01 mg/kg given 2 min after administration of RAP)

Rocuronium (ROC) Aminosteroid Dose: 1 mg/kg for RSI Study of varying doses of rocuronium for intubation Conditions improved with 1 mg/kg vs 0.6 mg/kg Need higher dose for rapid onset Post intubation paralysis dose is 0.6 mg/kg Onset: 60 seconds (second fastest nondepolarizer) Duration: 30 min (0.6mg/kg), 40 - 60 min (1 mg/kg) Long duration is major disadvantage: reversal shortens duration to 30 min Side-effects: no hypotension, no increased potassium, no malignant hyperthermia Supply: 50 mg vials Priming principle not effective or necessary Vecuronium (VEC) Aminosteroid Dose: 0.1 mg/kg Onset: 2 - 3 min (major disadvantage - patient desaturates before paralysis and needs to be bagged which defeats the purpose of RSI)

Duration: 40 - 60 min (longer than RAP, ROC) Side-effects: no hyperkalemia, no hypotension Two ways to decrease onset Large dose: 0.3 mg/kg; paralysis in 60 - 90 sec; duration 2hrs Priming principle: pretreatment with 0.01 mg/kg 2-3 min before the paralytic dose of 0.1 mg/kg will reduce onset to 60 - 90 sec; be ready to intubate with pretx dose b/c can cause full paralysis Pancuronium (Pavulon) Aminosteroid Onset: 3 min Duration 89 min Dose: 0.1 mg/kg Pretx dose: 0.01 mg/kg Side-effects: significant tachycardia by cardiac muscarinic blockade Timing Principle Give rocuronium first and induction agent second Rationale: onset of rocuronium is longer than induction agent Give rocuronium, wait until paralysis starts to take effect, then push induction agent, wait 30-40 seconds then go for tube This probably isnt necessary as onset with 1 mg/kg of rocuronium is pretty quick Reversal All non-depolarizers can be reversed Neostigmine (Prostigmine): 0.06 - 0.08 mg/kg Add glycopyrrolate 0.2 mg iv to counter actmuscarinic secretions Neostigmine works by inhibiting acetylcholinesterase thus increasing the amount of Ach to compete with the drug at the NMJ Clinical recovery will NOT occur until 40% spontaneous recovery has occurred thus reversal is not reliable and should not routinely be used routinely

IS INDUCTION NECESSARY IF YOU ARE USING A PARALYTIC? (1) Improves patient comfort and decreases recall (2) Induction agents help to blunt ICP, HR, BP rises, bronchospastic response (3) Induction agents result in decreaed time to ideal intubation condition Peak effect of succinylcholine occurs after 3 minutes (onset of paralysis occurs after 45 seconds) Intubation conditions with succinylcholine thus will not be ideal until 3 mintues which is too long Adding an induction agent allows ideal intubation conditions at 45-60 seconds There are several studies documenting improved early intubation conditions with the addition of appropriately dosed induction agents to paralytics

PROTECTION AND POSITIONING

Sellick Maneuver START after loss of consciousness (20 seconds) 10lb of cricoid pressure Application to early may induce vomitin Different than BURP maneuver END when tube in position, cuff inflated, and position verified Release if patient vomits (shouldnt happen b/c they are paralyzed) AVOID bagging to also help decrease aspiration (unless sats drop < 90%)

PLACEMENT AND PROOF

Placement Wait 45 seconds until paralysis has taken effect Apnea will be tolerated b/c of preoxygenation Only bag if sats drop < 90% Laryngoscopy Use BURP with right hand to help visualize Place ETT, remove stylet, inflate cuff, confirm placement, d/c cricoid pressure

POSTINTUBATION MANAGEMENT
Secure tube Ventilate Repeat vitals Bradycardia = esophageal intubation UPO Hypertension: usually inadequate sedation Sedation: midazolam or haldol +/- Paralysis: rocuronium Hypotension Induction agent related: fluid challenge, watch, phenylephrine 50 - 100ug Tension pneumo: increased PIP, difficult bagging, poor AE, drop in sats High intrathoracic pressures: decreased venous return (esp asthma and COPD): usually seen in patients with high PIPs secondary to high intrathoracic pressure: treat airway resistance (bronchodilators), decrease RR/TV/PIP/I:E ratio and squeeze the chest Myocardial ischemia Acidosis Volume depletion (resp failure, etc) Hypoxia = esophageal intubation UPO D Dislodged tube O Obstructed tube P Pneumothorax E Equipment problem: check from wall to patient G Gastric distension (unique to pediatrics)

Evaluation of

intubated patient that is desaturating (WALL to PATIENT) Is the tube connected to oxygen or air? Is the oxygen on? Is the oxygen tank empty? Is there a leak or a kink in the tubing? Is the ventilator or bagging unit connected to the ETT? Is the ETT in the esophagus? Is the ETT in the right main stem? Is the ETT obstructed with secretions, blood, aspirate, etc? Is there a pneumothorax? Is there a distended stomach or abd compartment syndrome? Is the underlying condition worsening?

SUMMARY OF RSI
T-10: T-5: T-3: PREPARE Evaluate the airway: LEMON Decide on crash, difficult, RSI Assemble equipment: SOLESD Assemble drugs: pretx, induction, paralytic PREOXYGENATE NRB: 75% BVM: 90% 5 min or 8 VC breaths PRETREATMENT L - Lidocaine 1.5 mg/kg: tight heads, tight lungs O - Fentanyl 3 ug/kg: tight heads, ischemia/MI, aortic dissection, aneurysm, chest penetration A - Atropine 0.02 mg/kg: all < 10yo or 2nd dose of succ F- Fluid if you think they might drop their BP D - Defasiculator/Rocuronium 5mg: increased ICP

ZERO: PARALYSIS AFTER INDUCTION INDUCTION Pentothal: avoid in hypotension Midazolam Ketamine: good in asthma and hypotension Etomidate PARALYSIS Succinylcholine 1.5 mg/kg Rocuronium 1.0 mg/kg T + 20s: PROTECTION and POSITION

 T+45s: T + 1:

Sellicks maneuver after LOC Position for laryngoscopy PLACEMENT Laryngoscopy BURP if needed Place ETT Remove stylet Inflate cuff Confirm position D/C Sellicks

POSTINTUBATION Ms Ventilate Sedation Paralysis Complications

SUMMARY OF RSI
T-10 min: PREPARE Evaluate the difficulty of the airway Decide on crash, difficult, RSI Assemble equipment: Suction Oxygen Laryngosocpy, ETT, Stylet, Drugs Assemble drugs: pretx, induction, paralytic Attach cardiac, BP, pulsoximeter monitoring T-5 min: PREOXYGENATE NRB: 75% BVM: 90% 5 min or 8 VC breaths T-3 min: PRETREATMENT L - Lidocaine 1.5 mg/kg: tight heads, tight lungs O - Fentanyl 3 ug/kg: tight heads, ischemia/MI, aortic dissection, aneurysm, chest penetration A - Atropine 0.02 mg/kg: all < 10yo or 2nd dose of succ F- Fluid if you think they might drop their BP D - Defasiculator/Rocuronium 5mg: increased ICP (generally unnecessary) TIME ZERO: PARALYSIS AFTER INDUCTION INDUCTION Pentothal: avoid in hypotension Midazolam: avoid in hypotension Ketamine: good in asthma and hypotension, avoid in increased ICP Etomidate: best agent in trauma (stabile for BP and ICP) Propofol: avoid in trauma re hypotension PARALYSIS Succinylcholine 1.5 mg/kg (know contraindications) Rocuronium 1.0 mg/kg (use if contraindications to succinylcholine)

T + 20 sec: PROTECTION and POSITION Sellicks maneuver after LOC Position for laryngoscopy T+45 sec: PLACEMENT Laryngoscopy BURP if needed Place ETT Remove stylet Inflate cuff Confirm position D/C Sellicks T + 1 min: POSTINTUBATION Ms Ventilate Sedation Paralysis Complications

HYPOTENSIVE TRAUMA PATIENT PRE Tx INDUCTI ON Ketamine or Etomodate (Low dose pentothal nd is 2 choice) Succinylcholine Etomidate, midazolam, propofol, pentothal will all drop your BP

HEAD INJURED NORMAL BP Lidocaine Fentanyl Pentothal or Etomodate

HEAD INJURED HYPOTENSIVE Lidocaine Fentanyl Etomodate or nothing

STATUS ASTHMATIC or COPD Lidocaine Ketamine

CARDIOGENIC SHOCK/PULM EDEMA

Ketamine Etomodate

PARALY SIS KEYS

Succinylcholine

Succinylcholine

Succinylcholine Could also pretreat with atropine if concerned re respiratory secretions

Succinylcholine

THE DIFFICULT AND FAILED AIRWAY

APPROACH TO THE DIFFICULT AIRWAY (see algorithm) Blind Naso - Tracheal Intubation

Good option when there is limited oral access Not a good option when there is hypopharyngeal pathology Patient needs to be breathing May be particularly good option when pathology is primarily in mouth (angioedema) Most physicians are no longer familiar with this procedure Awake intubation or Sedation only intubation Preoxygenation, topical lidocaine, +/- light sedation, direct laryngoscopy Makes sense when the condition causing the airway to be difficult is the same condition that mandates intubation Burn Neck hematoma Anaphylaxsis, angioedema Neck trauma Triple Set up Preoxygenate, topical lidocaine +/- light sedation, RSI drugs ready, cric ready This allows you the chance to (i) place tube if you get a good view the first time (ii) back off and give succ if you see enough that you know you will be able to get it

INCIDENCE NEAR DATA

National Emergency Airway Registry 1-3% of ED patients are difficult via direct laryngoscopy NEAR II: 10,000 emergency intubations Emergency intubations: 97% are done by Eps RSI used in 85% of non-arrested patients Nasal intubations 5%

Oral RSI intubation success rate 99.6% Anesthesia literature 4% of predicted successful intubations are difficult 0.1-0.4% cannot be intubated Cannot intubate + cannot ventilate with BVM is rare (1:10,000)

DEFINITIONS Failed Airway = Cannot maintain sats > 90% despite BVM or 3 attempts at intubation have failed MEASURING DIFFICULT AIRWAY Mallampati (see above); Intubation Difficulty Scale (see Box 1-3) Cormack - Lehane laryngoscopy grading scale I - entire glottis seen (70%) II - only part of glottis seen - (a) can see part of cords - (b) can only see arytenoids III - only epiglottis seen IV - cant see epiglotis

PREDICTORS OF DIFFICULT BVM

B O N E S

Beards Obstructive sleep apnea Obesity No teeth Neck or face trauma Expecting (pregnant) Snores

DIFFICULT INTUBATION + DIFFICULT BVM

Anatomic abnormality of face or head/neck Facial or neck trauma Morbid obesity

OH SHIT! I CANT SEE ANYTHING

B.U.R.P. maneuver Bigger blade Bouigee Big hockey stick on the stylet Best physician Back ups 2nd MD/anesthesia Trach light LMA I-LMA Retrograde Fiberoptic Combitube Surgical airways

SPECIFIC PATIENT PROBLEMS

CERVICAL SPINE INJURY Do not waste time obtaining a lateral C spine before intubation Concern of manipulation of the c-spine during direct laryngoscopy led to the prior use of BNTI and surgical cricothyrotomy as a back up Several large series and one fluoroscopic study show no evidence that properly performed RSI with inline cervical immoblization presents any risk to the patient, even in the presence of a cervical # RSI is preferred as it limits the patients movement Precise cervical immobilization must be maintained throughout the intubation ASTHMA and COPD General RSI is the preferred method to rapidly take control of the airway while minimizing the possibility of epistaxis, laryngospasm, increased bronchospasm, vomiting, and aspiration Best physician should intubate as failed laryngoscopy will be a big deal Leave the patient sitting and push the drugs; lie supine when the paralysis kicks in Lidocaine has a theoretical advantage Avoid morphine pretreatment (histamine release); fentanyl OK Ketamine may be the best induction agent (bronchorrhea can be a problem) Place the largest tube possible to allow for less resistance May want to place cuffed tube in pediatrics because of high airway pressures Keep sedated and paralyzed after intubation to maintain the ventilation parameters Initial vent settings and approach ACV, sedation, paralysis RR 8-10 bpm Volumes 6 ml/kg, Fi02 100% Inspiratory flow rate 100 L/min (usual is 60 L/min) Permissive hypercapnia = goal is pH > 7.2, dont care what the CO2 is Keep plateau pressures under 30 cm H20 Keep peak inspiratory pressures under 50 cm H20 Ventilation pressures Peak Inspiratory pressure: ideally should be kept under 50 cm H20; is not consistently predictive of barotrauma; sudden rise should lead to search for pneumo, mucous plug; sudden decrease suggest tube disconnection or extubation Plateau pressure: 0.4 second end-inspiratory pause pressure; best reflection of barotrauma; should be kept under 30 cm H20 How to decrease pressures? Lower rate and tidal volume Switch to PCV and increase I:E ratio Squeeze the chest and leave apneic for 1-2 minutes Increase inspiratory flow rate Sedation and paralysis Hypotension Tension pneumo, high intrathoracic pressure, volume depletion, cardiac ischemia, acidosis, induction agents Apnea test: dont bag, squeeze the chest, wait for a minute (should improve if high intrathoracic pressures are the problem)

DISTORTED AIRWAY ANATOMY Infectious causes Epiglottitis Croup Parapharyngeal abscess Lingular tonsilitis (lingual tonsil is a rare but real congenital anomaly) Abscess of tongue or floor of mouth Neoplastic causes Laryngeal carcinoma Hypopharyngeal carcinomas Physical/Chemical agents Foreign body Inhalation injury Caustic ingestion Allergic causes Anaphylaxsis Angioedema Traumatic causes Blunt mouth or neck trauma Penetrating or neck trauma Approach Triple set up is probably the best: lidocaine neb, lidocaine spray, have a look with RSI drugs drawn up and ready and neck prepped and draped for cric Taking a look is not a good idea in a primary laryngeal disorder where the visualization of the larynx is incomplete (fiberoptic is better here) TTJV is not an option with near total obstruction of the upper airway b/c there is no route for the gas to excape and +++ barotrauma (is death better?) LMA and combitubes are last resorts as they are less likely to work with distorted anatomy Heliox may by you time! (improved laminar flow; limited by 20% oxygen mixture) Fiberoptic is very good choice here if you are skilled or if anesthesia available A stable patient is likely better in the OR for these intubations Tracheostomy is the preferred surgical airway for blunt laryngeal injury, zone II/III penetrating injuries, and tracheal transection Laryngeal or pharyngeal tumors are best intubated with fiberoptics TRAUMA - FACIAL SMASH Difficult airway algorithm Can you bag the patient? Is there underlying anatomy really tough? Oral ETT with RSI is usually successful and should be first option If patients anatomy looks really tough, try awake or with sedation only; can back off and do RSI if the look is OK. Must have bouigee, trach light, and cric ready to go Low threshold to go to cric if the facial smash is bad Fiberoptic not likely to be easy given blood in airway

ACUTE PULMONARY EDEMA General Preoxygenation is essentially not possible as the patient has little or no FRC Patients may be unable to lie flat Foamy secretions may make visualization of the airway difficult High airway resistance will make bagging difficult Cardiac reserve varies: hypertensive patients can tolerate most induction agents; normotensive or hypotensive patients may not Intubation is likely to worsen bronchospasm Specific Tips Preoxygenate as much as possible with 100% Leave patient sitting until just before intubation Choice induction agents carefully: what will the BP do? RSI drugs: lidocaine + fentanyl, etomodate or ketamine, succ is probably best option Have a pressor ready to go: dopamine probably best for alpha and beta, phenylephrine is pure alpha and will increase SVR without increasing ionotropy Awake intubation: try awake if you think it will be difficult or may fail RSI: go the full RSI if you think you can rapidly place the tube Be careful of right main stem intubation as it will NOT be tolerated well Add PEEP to ventilation Cardiogenic Shock Same comments as above Any cardiodepressant can be a problem Etomodate and Ketamine are the most cardiostable drugs but you may have to go with no induction agent if the person is very hypotensive Again, have your pressor ready to go, or preferrably already started Why do they go into bradysystolic arrest with intubation? Well documented cases of bradysystolic arrest with intubation Is this succinylcholine, lying them flat, or related to laryngosocpy? Nobody knows; likely a combination of all three Likely related to fact that the adrenals are rung out because of maximal sympathetic output thus parasympathetic response to laryngoscopy predominates Succinylcholine induced bradycardia; again no sympathetic response left Lying flat: huge venous return that the heart cant handle Induction agent may also be involved Should you still use succ? Yes, they wont tolerate long periods of hypoxia thus you need to get them down rapidly and succ is the best agent (roc would be 2nd choice) ANY CRITICALLY ILL PATIENT Response to laryngoscopy Sympathetic response: increased HR, BP, ICP; ventricular arrythmias Parasympathetic response: bronchoconstriction, bronchorrhea, bradycardia Balance of response The sympathetic response usually predominates Kids may have a predominant parasympathetic response, especially if already hypoxic (high vagal tone in kids, strong vagal response to hypoxia, reason for atropine use) KEY IMPLICATION FOR CRITICALLY ILL PATIENTS Their sympathetic response is already maximized and they have rung

out their adrenals from the critical illness The response to laryngoscopy thus can be represented as bradycardia, hypotension, etc Induction agents which decrease the sympathetic response will have MUCH more of an effect than in a non-critically ill patient Take home point is to be ready for bradycardic, asystolic arrests during intubation, use hemodynamically stable induction agents, have pressors ready to go

PREGNANT PATIENTS Exam question: why are pregnant patients more difficult to intubate and ventilate? Weight gain during pregnancy Upper airway edema and congestion (especially with toxemia) Reduced FRC thus less able to preoxygenate Increased oxygen requirement thus quicker desaturation Increased intra-abominal pressure thus higher risk of aspiration Vena caval compression thus supine hypotension Difficult BVM b/c of airway edema and increased pressure on abdomen which makes the diaphragm harder to move Specific tips Preoxygenate as much as possible Avoid pretreatment drugs Avoid Etomodate: unknown safety Cricoid pressure to decrease aspiration Have patient under a pillow on one side to tilt off IVC

HYPOTENSION Fentanyl does not cause vasodilation (no histamine release) but it is sympatholytic thus if a patient is relying on sympathetic drive to maintain BP, it can result in hypotension Ketamine is a good choice if no head injury Etomodate is the best choice if head injured and hypotensive May use NO induction agent if very hypotensive FOREIGN BODY Incomplete airway obstruction Transfer to the OR for fiberoptic removal may be the best option: risk of dealing with it in ED is transforming a partial obstruction into a complete obstruction; once the FB is below the vocal cords, a rigid bronchoscope is required for removal If transfer to the OR is not an option, prepare for a difficult intubation Lidocaine neb then lidocaine spray Perform cautious laryngoscopy: advance 1cm, look, advance 1cm etc and be ready with Magill forceps; may use light sedation to facilitate laryngoscopy

Removal of a ball: may not be able to grasp with Magill: use towel clip or pelvic speculum If the airway becomes completely obstructed, manage as below Complete airway obstruction Call for help, difficult airway cart, cric kit, surgeon ABILITY TO PHONATE = incomplete airway obstruction INABILITY TO PHONATE = complete airway obstruction If patient is conscious, heimlick maneuver until it dislodges or pt becomes unconscious If the patient becomes unconscious: This is a crash airway but a dose of succ may be reqd to get a look Laryngoscopy identifies the FB Remove FB with Magills, towel clip, etc Immediate cricothyrotomy if FB is visualized cannot be removed Laryngoscopy does NOT identify the FB (must be below the cords) Cricothyrotomy will NOT be helpful if the FB is below the cords Can you bag the patient? Yes, transfer to OR for rigid bronchoscopic removal of the FB NO, intubate the patient and try and push the FB down to the right main stem; advance the ETT to the hub and then pull back to the appropriate depth If you cant push the FB down, you have MINUTES to get it removed by fiberoptics: STAT ICU, respirology, surgery Pediatric Pearl: narrowest point in the airway is the cricoid ring thus if you cant see the FB above the cords it may be lodged at the cricoid ring; TTJV distal to the cricothyroid membrane (ie; go through the trachea) may be life-saving

PEDIATRIC AIRWAY MANAGEMENT

DIFFERENCES BETWEEN ADULTS AND CHILDREN LOCATION HEAD DIFFERENCE Large occiput SIGNFICANCE May lead to overflexion of the c-spine and make the positioning poor or even obstruct the airway Towel under neck + gentle chin lift to

LOCATION ORO PHARYNX

DIFFERENCE Large intra-oral tongue Large tonsils Large adenoids Sharp angle b/w epiglottis and glottis Large, floppy epiglotis Prominent teeth generally NOT a concern More anterior larynx Higher tracheal opening C1 infants C3 at 7yo C5 in adults Cricoid ring is narrowest point of airway (vocal cords in adults) Small cricothyroid membrane Neck tissue generally soft and flexible Neck mobility generally NOT a concern More anatomic variation with age Fewer anatomic variation b/w kids of same age Fewer antomic variation with body habitus Congenital anomalies more of a problem Higher metabolic rates Smaller FRCs Higher tidal volume (10-15 ml/kg vs 8-10 ml/kg) Gastric inflation with BVM is more common

SIGNFICANCE create sniffing position

BNTI - bleeding BNTI - failure Straight blade preffered More acute angle between the oropharynx and larynx The cords are closer to you and the tendency will be to go too deep Uncuffed tubes preferred Correct tube size more important TTJV preferred over cric Easy inadvertent extubation Cric pressure can obstruct airway

NECK

GENERAL

PHYSIOLOGY

Rapid desaturation and preoxygenation wont give you as long Use cric pressure during bagging

BRASLOW IS YOUR FRIEND!

OXYGEN SUPPLEMENTATION Nasal prongs: 24% for 1L/min up to 44% for 6L/min Simple Hudson face mask: 40% at 5L/min up to 60% at 8L/min Non-Rebreather: misconception that this obtains 100%; best that can be realistically achieved with a good seal is probably 75% with flow rates 10-12 L/min BVM: depends heavily on the type of bag and where the exhalation port is; a good bag with a good seal can attain a Fi02 of up to 90%

Face Tent/Shield: High flow 02 provides about 40% 02 Oxygen hood: can get Fi02 up to 80-90%, not used > 1yo b/c of size Oxygen supplementation often irritates children thus blow - bye is often used: who knows what Fi02 you are delivering when this is done but having a child more settled is often more important

BAG-VALVE-MASK VENTILATION Crucial to know how to do this properly C shape over mouth E shape over mandible (keep fingers on mandible NOT soft tissues as you can occlude the airway) Can be difficult because small position changes can have big effect Can be difficult because kids will desaturate faster Mask size is a unique concern Tip! If you dont have a small mask, use a big one and turn it upside down Trouble bagging -----> two nasal trumpets, oral airway, then bag Vomiting during bagging ----> place OG or NG, empty stomach, continue bagging Self inflating bag or manual inflating resevoir bags are both option Pop-off pressure valves generally go off at > 40 cmH20; these should be manually disable for ventilation of patients with higher airway pressures COMMON MISTAKE: too much pressure is used in an attempt to make a seal and the airway is actually obstructed by the person doing the bagging (white-knuckle sign); proper technique should lift the jaw into the mask to (jaw thrust) create a seal Tidal Volumes Generally 10-15 ml/kg (a bit higher than adults) Clinically enough to get adequate chest expansions How big should the resevoir bag be? Neonate: 250 ml Infant: 500 ml Children: 1-2L Adults: 3-5L SUCTION See Braslow for sizes Flexible suction catheters are BETTER than stiff Yonker suction (generally 10 French) Flexible suction catheter down into stomach, quickly before intubation attempt will help in a child that has been vomiting

CHILDREN ARE DIFFERNT AIRWAYS, NOT DIFFICULT AIRWAYS

TUBE SELECTION The best is probably the Braslow Tape Always have one size up and one size down ready Several Formulas to select tube size

 Age/4 +4 (Age + 16)/4 Size of kids pinky Size of kids nostril Tube selection in the neonate and infant <28 weeks: 2.5 28-34 weeks: 3.0 34-term: 3.5 Generally UNCUFFED TUBES in < 8yo Cricoid cartilage provides a functional cuff Uncuffed tubes should have an air leak at peak inspiratory pressure NB: this has never been studied! Consider cuffed tubes in younger patients for expected high ventilation pressures Asthma/bronchospasm Post drowning Severe ARDS BLADE SELECTION See braslow for sizes Miller vs Mac Generally recommended to use straight blades under 2 yo Reality is that what ever you prefer is fine Straight blade theoretically better to elevate the large, floppy epiglottis Blade Size Premie 0 0 - 2 yo 1 2 - 10yo 2 > 10 yo 3 TUBE POSITION AND DEPTH See Braslow for tube depth Much more important to pay attention to this than in adults Small movements can make a big difference Children desat more quickly with RMS intubations Children are easily inadvertently extubated with positioning and movement: secure that tube and move the patient cautiously Rule of thumb for depth Tube size X 3 Age/2 + 12 Vocal cords at marker

APPROACH TO THE RSI See Braslow for drug doses: Braslow should always be used (on exams and in reality) Several studies taking experience physicians and documenting high error rates when

drug dose are calculated from memory in CALM scenarios Same approach as adults Does the patient need intubation? Rapidly assess the situation and the airway Is this a crash, easy, or difficult intubation? Unable to bag sats > 90% or failed 3 attempts is a failed airway Prepare, preoxygenate, pretreat, induction, paralysis, pass the tube, position, post mx Preoxygenation Relatively MORE important as kids desat quicker (higher metabolic rates and less FRC) Pretreatment Lidocaine, Opiate, Atropine, Fluid, Defasiculation have the same indications Fentanyl: infants and small children are MORE sensitive to respiratory depression and sympatholytic effect thus either dont use or use in lower doses Atropine is indicated in all pediatric intubations < 10yo (some references say < 6yo) Why is atropine indicated? Kids have a high vagal tone; vagal response to hypoxia also more prominent than in adults The manipulation of laryngoscopy and the initial Ach receptor activation from succinylcholine can both lead to bradycardia Dose is 0.02 mg/kg Defasiculation is not indicated < 5yo (?why) and most pediatric emergency physicians do not use defasciculation pretreatment ever Induction Generally the same options except etomodate is not approved for use < 10 yo Ketamine, Midazolam, Pentothal Paralysis Succinylcholine is used at a higher dose: 2 mg/kg child, 3 mg/kg neonate Same contraindications for succinylcholine Rocuronium dose for intubation is 1 mg/kg Should rocuronium be the paralytic of choice? Some physicians feel that rocuronium should be the preferred agent over succinylcholine because of the risk of undiagnosed myopathies Advantages of succinylcholine: faster onset (45 sec), shorter duration (8min) Rocuronium has slower onset (1-2min) and longer duration (30-45 min; can be decreased to about 20 min with reversal) Extremely low incidence of undiagnosed myopathy in a previously NORMAL child does not warrant the routine use of rocuronium Post intubation HYPOXIA D Dislodged tube: more of a problem than adults O Obstructed tube: more of a problem than adults P Pneumothorax E Equipment failure; same as adults, ETT too small and ++air leak is uniqe G Gastric distention: essentially unique to kids; distended stomach with compresses the lungs and make it difficult to bag; also an increased risk of vomiting

EARLY PLACEMENT OF AN NG OR OG IN A PATIENT THAT IS DIFFICULT TO BAG IS A UNIQUE CONCERN TO THE PEDIATRIC PATIENT

POSITIONING OF THE PATIENT FOR BVM AND ETT > 10 yo: position as per adults in sniffing position (head elevation flexes the lower C-spine and extension of the upper C-spine will create the true sniffing position) Large head/occiput puts the lower C-spine into some flexion Pullow under the head will potentially add too much lower C-spine flexion Slight extension of the upper C-spine is usually all that is required; best done with slight chin lift Head can be so big that it actually cause too much flexion of the C-spine: towel underneath the neck (between head and shoulders) will prevent over - flexion of the C-spine These are guidelines only as every patient is different and if one position isnt working, try another AIRWAY ADJUNCTS FOR PEDIATRICS BVM Consider this as the first choice adjunct in pediatrics Knowledge of good BVM skills is key Correct position, C-E grip, oral airway, NP airways will help Bouigee: cant use with tube < ZZZ LMA: see Braslow tape for sizes Needle Cricothyroidotomy Indication: cant intubate, cant ventilate Contraindication (relative): foreign body aspiration that cannot be visualized by laryngosocpy (likely is at cricoid ring or below and TTJV wont help); try to intubate and push it down by advancing the ETT to the hub Procedure Supine postion, head extended, towel under shoulders to further exaggerate the extension and bring the trachea more anterior Stand on the right side of the patient Stabilize the trachea with first finger and thumb of left hand Palpate the cricothyroid membrane with the right hand; it will be difficult to palpate this landmark in infants Insert a 14 guage over-the-needle catheter Attach a ETT adapter from a #7 endotracheal tube Connect to the BVM and ventilate Expect a lot of resistance while bagging In general, bagging is preferred to jet ventilation because of high risk of excessive flow and barotrauma (especially in younger children) Trans-Tracheal Jet ventilation (TTJV) Blind NasoTracheal Intubation Uniformly discouraged Direct visualization is more commonly used (place through nose and then feed into the airway with Magill forceps under direct visualization with laryngocope) Generally considered contraindicated in children < 10 yo

Why? Sharp angle of nasopharynx and pharyngotracheal axis in children precludes a high percentage of success when done blindly Increased risk of hemorrhage from adenoid tissue

Surgical Cricothryoidotomy The cricothyroid membrane is VERY SMALL in small kids The larynx is also smaller making landmark recognition difficult Not indicated in child < 10 yo; use TTJV for surgical airway

DIFFICULT AIRWAYS IN PEDIATRICS General approach Intervene only if deterioration occurs; transfer to OR for airway managment is preferred Epiglottis Foreign body with partial airway obstruction Para-airway infections: PTA, RPA, PPA, ludwigs angina EARLY intervention in ED (expected rapid progression) Burns Anaphylaxis Angioedema Caustic ingestion Trauma Difficult airway due to different anatomy and unfamiliarity See table above regarding differences Most adjustments are relatively minor Most anatomic difference is in kids < 2yo Approach is the same as in adults Difficult airway due to acute infectious disease Common examples: epiglottitis, croup, tracheitis, pharyngeal abscesses Small airways: the resistance increases A LOT with small airways General rules of managment Transfer to OR for airway management is always preferred in the stable patient ED airway intervention is indicated if the child decompensates Pharyngeal abscess rarely have airway obstruction Croup and epiglotitis are clinically easy to distinguish (cough vs no cough) and croup should be treated hard with racemic epi Epiglotitis Usually present before airway obstruction Transfer to OR for fiberoptic intubation is preferred If patient obstructs airway, start with BVM, call for back up, call for difficult airway cart, get ready for oral intubation and needle cric BVM will work in most patients; use 2 people and 2 nasal trumpets Attempt oral ETT: usually can do, use one tube size smaller, be ready with suction, press on chest if you cant see the glottis and go for the bubble = bubble trick Cant intubate, cant bag ----------> needle cric indicated LMA unlikely to work with a big swollen epiglottis Croup Usually a gradual decline Hit hard with racemic epi before intubation if there is time

Decompensation: BVM, attempt ETT Expect high pressures when bagging prior to intubation Select ETT one size smaller than normal Needle cric less likely to work because obstruction is distal to the cricothyroid membrane; should attempt if last resort

Difficult Airways due to Non-Infectious Causes Includes: FB aspiration, burns, anaphylaxis, angioedema, caustic ingestions, truma FB aspiration Partial obstruction: transfer to OR for bronchoscopic removal is likely the best option; if transfer to the OR is not an option, prepare for a difficult intubation, topical lidocaine, cautious laryngoscopy and be ready with Magill forceps; may use light sedation to facilitate laryngoscopy Complete obstruction Conscious patient: heimlick maneuver if big enough otherwise back blows and chest compressions Unconscious patient: laryngoscopy and remove FB; immediate TTJV if FB is visualized above the cords and cannot be removed; if you cant see the FB try to push it down by inserting an ETT as deep as possible (Cric will NOT be helpful if FB is below cords); If you cant push the FB down, try to bag, you have MINUTES to get it removed by fiberoptics: STAT ICU, respirology, surgery Pediatric Pearl: narrowest point in the airway is the cricoid ring thus if you cant see the FB above the cords it may be lodged at the cricoid ring; TTJV distal to the cricothyroid membrane (ie; go through the trachea) may be life-saving Difficult Airway due to Congenital Abnormalities Uncommon to encounter in general ED BVM and oral ETT should still be main options Pierre - Robin Downs Syndrome jdflkj

SPECIAL PROBLEMS Blocked Trach Suction trach - 3ml NS down, suction Bag trach Suction trach Bag trach ? Remove inner cannula if present ETT: attempt oral intubation Replace trach as last resort TTJV as ditch effort Should paramedics intubate kids? See Marian Gausches paper JAMA 2000 RCT of intubation vs BVM and transport Even/odd day randomization was a bit poor Intubated kids had worse neurologic outcomes The rates of intubation were low They had short transport times Prehospital field intubation of kids is not necessary unless there are long transport times Kid with fever, cough, lethargy, is found to be lethargic and bradycardic with a pulse What is the cause? Hypoxia, hypoxia, hypoxia, hypoxia What is the treatment? Bag, bag, bag, bag Good BVM is more appropriate for the initial airway management; bag the kid up as you get prepared to intubate, some will even turn around and not need intubation Asthmatic Kid that you intubate SLOW rate LOW volume (8-10 ml/kg vs usual 10-15 mg/kg) Permissive hypercapnia Be ready for pneumos and Breat1h stacking!

INDICATIONS FOR INTUBATION: Think ABCDEs

PRIMARY SURVEY A FACTORS Actual Obstruction: stridor, vomiting, bleeding, foreign body, GCS < 8, burn, infection, epiglotitis, abscess, anaphylaxis, etc Obstruction risk: decreased LOC, early burn, neck hematoma, facial trauma Aspiration risk: bleeding, vomiting, unconscious Apnea Oxygenation failure: pneumothorax, hemothorax, pulmonary contusion, flail chest, aspiration pneumonitis, fat embolism, atelectasis, pulmonary hemorrhage Ventilation failure: as above Severe shock (any cause) GCS < 8 Expected clinical course: transfer to tertiary care center, transfer to CT, transfer to angiography, transfer to OR, expected deterioration of condition

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