DAsH1A
Bill Hinckley elaborated our goal for airway management
Definitive Aiway sine Hypoxemia on the 1st Attempt
Back to topAirway Progression
Validation study of the algorithm
Back to topAbsorption Atelectasis during Preoxygenation
Even preox with 100% did not seem to affect FRC (J Anesth DOI 10.1007/s00540-012-1547-7)
Back to topLevitan’s Complexity Article
Complexities of Tracheal Intubation (Ann Emerg Med 2011;57(3):240)
Back to topFormulation of a CICO Algorithm
Back to topEach Attempt Makes Things Worse
Hasegawa et al. showed at 3 attempts, things got bad (Ann Emerg Med 2012;60:749)
Sackles JC et al. showed that >1 attempt radically increased complications (ACADEMIC EMERGENCY MEDICINE 2013; 20:71–78)
Mort demonstrated this in the ICU, after two attempts risk of crit desat (70%) is huge and assoc. with cardiopulm arrest (Anesth Analg 2004;99:607)
Mort has further elaboration re: the dangers of intubation in the critically ill (J Inten Care Med 2007;22(4):208)
Back to topCricothyrotomy
Prehospital Meta-analysis (Prehosp Emerg Care 2010;14:515)
Surgical cric is sig. better!
Can we find the membrane with a needle? Not so much (Anaesthesia, 2010, 65, pages 889–894)
Bougie-Aided Cricothyrotomy (Air Medical J 28(4):191
Need for Preoxygenation
If the saturation was 93% or less at the start, the patient is very likely to desaturate and the rapidity of desaturation is predicted by this initial starting sat (Davis PREHOSPITAL EMERGENCY CARE 2008;12:46–51)
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Tube Depth
Conclusion Less experienced clinicians should rely more on tube insertion depth than on auscultation to detect inadvertent endobronchial intubation. But even experienced physicians will benefit from inserting tubes to 20-21 cm in women and 22-23 cm in men, especially when high ambient noise precludes accurate auscultation (such as in emergency situations or helicopter transport). The highest sensitivity and specificity for ruling out endobronchial intubation, however, is achieved by combining tube depth, auscultation of the lungs, and observation of symmetrical chest movements. (BMJ 2010; 341:c5943 )
then get a chest xray
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Roc Vs. Sux
Same when dosed high (Academic Emergency Medicine Volume 18, Issue 1, pages 10-14, January 2011)
Back to topBVMs cannot be used for Spont Ventilation
They can so long as they don’t have duckbill valves like Mercury Medical. (Fact or Fiction: the patient cannot spontaneously breathe via the bag valve mask apparatus. Arekapudi A., et al. SAM 2012)
Back to topMask Ventilation
When rocuronium was adminsitered compared to placebo, mask ventilation got better (Anaesthesia, 2011, 66, pages 163167)
You need two hands on the mask (One Hand, Two Hands, or No Hands)
Back to topGastric Tubes
My practice is to place gastric tubes prior to intubating GI bleeders or alcoholics. The question is whether this decreases the esophageal sphincter opening pressure
Answer is it doesn’t (Gastroenterology 1976;70:301; Arch Surg 1978;113:721)
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Ketamine-Only Intubation
Emerg Med J 2011;28:521 71 Patients, 18 didn’t get paralysis
Injury 1997;28:41
Am J Emerg Med 2007;25:977
Back to topComplications of the airway management of the critically Ill
Start worrying at 70%, pt may die below 60% (J Intensive Care Med 2007 22: 208 Mort)
Hemodynamics (J Intensive Care Med 2007 22: 157)
Complications rise at the 3 mor more attempt mark (Anesth Analg 2004;99:60713)
Tube passage attempts are worse than blade passage attempts
Patients who start off on vasopressors have a high risk of peri-intubation codes (Anesthesiol 1995;82:367) and assoc of hypotension post-tube and death (J Crit Care. 2012 Aug;27(4):417)
Most recent study shows a dismally high rate of complications in a French ICU (Early Identification of Patients at Risk for Difficult Intubation in the Intensive Care Unit Am J Respir Crit Care Med. 2013 Apr 15;187(8):832-9)
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Prehospital Intubations
Resuscitation. 2011 Apr;82(4):378-85. Epub 2011 Feb 1. Out-of-hospital airway management in the United States. Wang HE, Mann NC, Mears G, Jacobson K, Yealy DM.
Source
Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL 35249, United States. hwang@uabmc.edu
Abstract
OBJECTIVE:
Prior studies describe airway management by single EMS agencies, regions or states. We sought to characterize out-of-hospital airway management interventions, outcomes and complications across the United States.
METHODS:
Using the 2008 National Emergency Medical Services Information System (NEMSIS) Public-Release Data Set containing data from 16 states, we identified patients receiving advanced airway management, including endotracheal intubation (ETI), alternate airways (Combitube, Laryngeal Mask Airway (LMA), King LT, Esophageal-Obturator Airway (EOA)), and cricothyroidotomy (needle and open). We examined airway management success and complications in the full cohort and in key subsets (cardiac arrest, non-arrest medical, non-arrest injury, children <10 and 10-19 years, rapid-sequence intubation (RSI), population setting and US census region). We analyzed the data using descriptive statistics.
RESULTS:
Among 4,383,768 EMS activations, there were 10,356 ETI, 2246 alternate airways, and 88 cricothyroidotomies. ETI success rates were: overall 6482/8418 (77.0%; 95% CI: 76.1-77.9%), cardiac arrest 3494/4482 (78.0%), non-arrest medical 616/846 (72.8%), non-arrest injury 417/505 (82.6%), children <10 years 295/397 (74.3%), children 10-19 years 228/289 (78.9%), adult 5829/7552 (77.2%), and rapid-sequence intubation 289/355 (81.4%). ETI success was success was lowest in the South US census region. Alternate airway success was 1564/1794 (87.2%). Major complications included: bleeding 84 (7.0 per 1000 interventions), vomiting 80 (6.7 per 1000) and esophageal intubation 12 (1.0 per 1000).
CONCLUSIONS:
In this study characterizing out-of-hospital airway management across the United States, we observed low out-of-hospital ETI success rates. These data may guide national efforts to improve the quality of out-of-hospital airway management.
and more likely to cause VAP (Eur J Emerg Med 2013;20:61)
Back to topNumber of Tubes to be Competent
Probably close to 200 (Acta Anaesthesiol Scand 2012; 56: 164–171)
Back to topPulse Ox Lag
Latency of up to 120 s has been demonstrated in conditions producing peripheral vasoconstriction (doi:10.1016/j.jemermed.2011.06.127)
Back to topShock Dosing of Sedative Agents
No reduction to get same brain levels of etomidate, 50% for fentanyl, 80-90% for propofol (Anesthesio 2004;101:567)
Predicting Obstructive Sleep Apnea (OSA)
STOP-Bang Score (Br J Anaes 2012;108(5):768)
Advantages of an awake look using remifentanil (J Clin Anesthesia 2012;24:19)
Back to topA clarification on when the crit ill risk of sux kicks in
Anesth Analg. 2012 Jul 4. [Epub ahead of print] The Limits of Succinylcholine for Critically Ill Patients. Blanié A
~16 days
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