Airway

(Our Notes from the National Emergency Airway Course http://www.theairwaysite.com, Emergency Airway Management 4th ed, and The Airway Cam Guide to Intubation) RSI evidence review (Can J Anesth 2007;54(9):748) AirwayCam Videos Levitan Pocket Guide http://vam.anest.ufl.edu/airwaydevice/videolibrary/index.html#airtraq http://groups.msn.com/DrMAGBOULAIRWAYPAGE/homepage.msnw www.airway911.com Airway Academy

Three Emergent Indications for Intubation

Can’t Protect Airway

(Gag reflex is absent in up to 37% of population, so a poor predictor of airway protection (J Accid Emerg Med 16(6):444, 1999) Lancet. 1995 Feb 25;345(8948):487-8,Clin Otolaryngol. 1993 Aug;18(4):303-7)

• Can they talk?
• Can they swallow and manage secretions?

Can’t Maintain Ventilation/Oxygenation

• SaO2 <90% on High Flow O2 or PaO2<60 on FiO2>40%
• PaCO2 >55 if baseline is normal, or >10 increase from baseline
• Respiratory Rate

Expected decline in Clinical Status

• Deterioration/Impending Compromise
• Transport
• Airway protection during procedures (ie. endoscopy)

Other Reasons include:

• Supply/Demand imbalance of perfusion. Patients with compromised perfusion (elevated lactate) do not need the metabolic load of tachypnea when 50% of the body’s oxygen may be used to perfuse the lungs
• Mechanical Obstruction, or need for Core
• Rewarming,
• Inadequate respiratory compensation for met acidosis CO2 should=(1.5 [HCO3-] + 8) ± 2) (J Trauma 2004;57(5):993-997)

Study that drunks and tox folks can stay non-intubated even with low GCS. Only 73 pts. (J Emerg Med 2009 Nov;37(4):451-5.)

Assess for Potential Difficult Airway

The difficult airway is something you can predict, the failed airway is something that happens to you. Perform the difficult airway assessment on any patient who has any chance of needing intubation during their stay in the ED.  

Difficult to Bag

Beard Obesity No Teeth Elderly (>55) Snores Results: During a 24-month period, 22,660 attempts at MV were recorded. 313 cases (1.4%) of grade 3 MV, 37 cases (0.16%) of grade 4 MV, and 84 cases (0.37%) of grade 3 or 4 MV and difficult intubation were observed. Body mass index of 30 kg/m2 or greater, a beard, Mallampati classification III or IV, age of 57 yr or older, severely limited jaw protrusion, and snoring were identified as independent predictors for grade 3 MV. Snoring and thyromental distance of less than 6 cm were independent predictors for grade 4 MV. Limited or severely limited mandibular protrusion, abnormal neck anatomy, sleep apnea, snoring, and body mass index of 30 kg/m2 or greater were independent predictors of grade 3 or 4 MV and difficult intubation. Conclusions: The authors observed the incidence of grade 3 MV to be 1.4%, similar to studies with the same definition of difficult MV. Presence of a beard is the only easily modifiable independent risk factor for difficult MV. The mandibular protrusion test may be an essential element of the airway examination. (Anesthesiology 105(5), November 2006, pp 885-891)

Difficult to Intubate (validated Emerg Med J 2005; 22:99-102)

Look at head and neck Evaluate 3-3-2 Mallampati (Using Samsoon and Young mod, which added class IV, 1987) Obstruction=hot potato voice, can’t handle secretions, and Stridor (if audible=90% obstruction) Neck Mobility S for saturation reserve (Ann Emerg Med June 2006)

Difficult Extraglottic Device

• Restricted Mouth Opening
• Obstruction: at or below the level of the larynx

• Disrupted or distorted airway. If the seat or seal of the device is disrupted

• Stiff lungs or cervical spine. Poor lung compliance or inability to extend neck may hamper seal

Difficult Cricothyrotomy

• Surgery/Disrupted Airway
• Mass-Hematoma, abscess, or any other mass
• Access/Anatomy Problems- (Can’t get to neck)-obesity, sub-q emphysema, infection, edema
• Radiation
• Tumor-may be external mass as above, but may also be internal (hence separate letter)

MA of difficult airway prediction (Anesthesiology 2005; 103:429–37) best values from combo of mallampati and thyromental distance, but still crappy.   Surveys indicate 10-25% of patients with trisomy 21 have AAI. Two thirds of these cases are due to laxity of transverse ligament, whereas one third are due to abnormal odontoid development. Although this association has been depicted on radiographs, the clinical incidence of serious cervical spine injury is not increased in this population compared with other populations. About 25% of patients with rheumatoid arthritis have atlantoaxial instability, which is thought to be due to chronic inflammation. Congenital skeletal dysplasias may cause resultant odontoid hypoplasia. Marfan syndrome may involve to ligamentous laxity, and acute inflammatory processes can affect the retropharyngeal, neck or pharyngeal spaces. Rheumatoid Arthritis destroys ligaments causing increased movement of dens in spinal canal   A physical examination may reveal the characteristic stigmata of OSAS including a short thick neck, nasal obstruction, tonsillar hypertrophy, narrow oropharynx, retrognathia, and obesity. Although these clinical features are typical, they are not reliable predictors of the presence of severity of the disease.49 Physical examination and laboratory studies may also reveal the presence of unexplained right heart dysfunction or erythrocythemia, suggesting the severity of OSAS. (Laryngoscope 1989)   Obstructive Sleep Apnea Syndrome and Postoperative Complications. Clinical Use of the STOP-BANG Questionnaire. Arch Otolaryngol Head Neck Surg. 2010;136(10):1020-1024.

Additional info on prediction of difficult airway

Miscellaneous Statistics

The incidence of failed airways is 10x greater in term pregnant women, they should always be considered a difficult airway. Intubation must displace the tongue somewhere, that somewhere is the submandibular space, if that space is occupied by infection/tumor or entirely absent=difficult airway   Failed Laryngoscopy (with 3 attempts) : 1 in 200-300 intubations Can’t intubate/can’t ventilate (CICV): 1 in 10,000-20,000 intubations PGY 1 or 2: 65% successful on 1st attempt of laryngoscopy PGY 3/4/Attending 85% successful on 1st attempt of laryngoscopy   We performed as well as anesthesiologists in trauma intubations (Academic Emergency Medicine Volume 11, Number 1 66-70)(Ann Emerg Med. 2004;43:48-53)

Complications in 1000 trauma intubations for absolute and relative indications

J Trauma 2009;66(1):32)

The Seven Ps of Rapid Sequence Intubation

Preparation of equipment All equipment at the bedside, including backup devices (should be present at every intubation) Have RSI and post-intubation meds already drawn up. An amp of phenylephrine is also a nice thing to have at the bedside in case the intubating agents cause vasodilatory hypotension.   Mnemonic for Equipment during routine intubation (Weingart)

Bag

Airway (oral airway)

Suction (preferably two)

Intubating equipment (tube, blades, etc.)

Capnometer

Lubricating the ET tube cuff may lower rates of aspiration (anesthesiology 2001;95:377)     Straight to cuff with 35 degree bend probably is best (ACADEMIC EMERGENCY MEDICINE2006;13:1255–1258)

Preoxygenation

Eliminate all the N2 in the FRC Some BVMs allow active breathing by the patient of 100% O2 while others will give only ~30%. Need duckbill one way valve and an exhalation port. Do not let the patient take a single room air breath from the beginning of this phase. Kids desaturate much more quickly than adults. So they are not just little adults, they are little, fat adults 8 vital capacity breaths while wearing a non-rebreather mask is also an alternative. These masks can be augmented to provide near 100% FiO2 by placing a valve over both vents, providing flow at 15 lpm, and tightly fitting the mask to the face (Resuscitation, April 2003, 57:1, 69 – 72) When a patient is at <90% saturation, be scared, as this level is right at the nose dive point of the oxygen desaturation curve   Benumof’s seminal study on time to desaturation (pdf) and where he actually go the calculations (Br J Anaesth 1996;76:284) Abandon the “hold your breath while intubating” method, it just leads to added stress and underestimates the amount of time you have to intubate Maximum oxygen in lungs is 87% as 6.5% taken up by CO2 and 6.5% by water vapor. While the fast track (8 vital capacity breaths) method will cause this 87% concentration, it will not fill the tissue and venous compartments. Therefore the traditional method will in various studies allow up to 3 minutes of extra time (Benumoff Lecture)   The fast track method   NRB only provides 70-80% fiO2 at best   Much longer time to desat in the obese if you preoxygenate in sitting position (British Journal of Anaesthesia 2005 95(5):706-709) better laryngeal exposure as well (Lee BJ, Kang JM, Kim DO (2007) Laryngeal exposure during laryngoscopyis better in the 25 degrees back-up position than in the supine position. Br J Anaesth 99:581–586)   Patients who can not preoxygenate well with mask should be placed on NIV (Am J Respir Crit Care Med 2006;174:171)   Can then use Vent to continue oxygenation until ready to intubate (JEM 2006;30(1):63) Place on AC: IFR-30 LPM, FiO2-100%, RR-15, Vt-500 cc, PEEP-based on situation attach a ETCO2 line to set-up   Two rcts showed better preox when it is preceded with maximal exhalation(Anesth Analg 2003;97:1533) and (Can J Anesth 2000;47:1144) functional recovery time of 8.5 min after 1 mg/kg of Sux (Anesthesiology 1997;87:979)   Airway press <15 cm H20 rarely causes insufflation >25 will often cause it (Br J Anaesth 1987;59:315 and Acta Anaesthesiol Scand 1961;5:107) Can J Anaesth. 2007 Jun;54(6):448-52. Click here to read Links Efficacy of preoxygenation using tidal volume and deep breathing techniques with and without prior maximal exhalation. Nimmagadda U, Salem MR, Joseph NJ , Miko I. Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 W. Wellington Avenue, Chicago, IL 60657, USA. PURPOSE: We evaluated the influence of prior maximal exhalation on preoxygenation in 15 adult volunteers using tidal volume breathing (TVB) for five minutes and deep breathing (DB) for two minutes with and without prior maximal exhalation. METHODS: Inspired and end-tidal oxygen, nitrogen and carbon dioxide were monitored continuously and recorded during room air breathing and at 30-sec intervals during 100% oxygen TVB or DB (rate of 8 breaths.min(-1)). RESULTS: Tidal volume breathing with prior maximal exhalation resulted in an end-tidal oxygen concentration (ETO(2)) slightly higher (P = 0.028) at 0.5 and 1.0 min as compared with TVB without prior maximal exhalation at the same time periods. Regardless of whether TVB was preceded by maximal exhalation or not, 2.5 min was required to reach a mean ETO(2) value of 90% or higher. With DB, there were no differences in ETO(2) values at any time period and 1.5 min was required to reach an ETO(2) of 90% or greater, with or without prior maximal exhalation. CONCLUSIONS: Maximal exhalation prior to TVB slightly steepens the initial rise in ETO(2) during the first minute, but confers no real benefit if maximal preoxygenation is the goal. Maximal exhalation prior to DB has no added value in enhancing preoxygenation.     Study of 3 minutes vs 4 deep breaths vs 8 deep breaths (Anesth 2003;99:841)   comparison of Self-inflating manual resuscitators (SIMRs, i.e. bvms) for preox If there is not a one-way exhalation valve, useless for preox(Anesthesiology 2000;93:693)   Preox for claustrophobic Pt (Anesthesiology 104(2))   Nasal Cannula (Fio2 increases 4% per lpm from 24-44%) Benumof’s Airway Management Mask with reservoir bag (10 lpm = > 80 %) Benumof’s   Finger pulse oximeter lags in poor perfusion states (Can J Anesth 2004;51(5):432)   Can also use a SGA for preox and then take it out to intubate a la Darren Braude

Keep them in semi-fowlers

• Normal values of functional residual capacity in the sitting and supine positions. Intensive Care Med 8:173–177
• Pre-oxygenation in the obese patient: effects of position on tolerance to apnoea. Br J Anaesth 95:706–709
• Laryngeal exposure during laryngoscopy is better in the 25 degrees back-up position than in the supine position. Br J Anaesth 99:581–586

Apneic Oxygenation

a new article on the morbidly obese shows extension of time to desat if left on nasal cannula (J Clin Anesth 2010;22:164)

Pretreatment

Who needs pretreatment? · Tight Brain (Elevated ICP/Head Injury/CVA) · Tight Vessels (Aortic Dissection/AAA) · Tight Heart (ACS) · Tight Lungs (Asthma) In TBI severity of brain injruy doesn’t predict the lack of need for pharmacologic blunting of increase in MAP or ICP (Journal of Trauma and Acute Care Surgery Issue: Volume 74(4), April 2013, p 1074–1080)

Reflex responses to intubation

The larynx one of the most richly innervated areas in the body, this is a primitive airway protection scheme. · Bronchospasm can result from laryngoscopy and from intubation. Stimulation of the carina also causes Bronchospasm. · Laryngoscopy and intubation also cause increased ICP, both directly and by the catecholamine surge. Succinylcholine increases

ICP by causing more afferent traffic to brain, increasing metabolic activity. · Catecholamine surge from adrenal cortex during laryngoscopy and intubation. Hypercapnia and hypoxia are causes of huge catecholamine surge.

Non-Pharmacologic Methods to Blunt Reflex Response

· Limit time of laryngoscopy · Atraumatic laryngoscopy

Pretreatment Meds (LOAD)

Optimally, give premedications 3-5 minutes before RSI

· Lidocaine

o Use in tight brain to attenuate reflex increase in ICP from laryngoscopy/intubation o Use in tight lungs to blunt bronchospastic response o 1.5 mg/kg Rapid IVP While there is evidence that it blunts ICP rise and cough response, there is no good evidence that this has clinical results (Robinson N. Emerg Med Journal 2001; 18(6):453- 7.) Literature is pretty good on endotracheal suctioning. Not hemodynamically active in this study (Am J Emerg Med. 2012 May 23.Lin CC)

· Opiates

o Use in tight brain/tight vessels/tight heart to blunt catecholamine surge o Fentanyl 3 ug/kg slow IVP       At this stage, Emergency Airway Course only recommends Lidocaine and Fentanyl: LOAD is dead     Intralingual succinylcholine injection provides a rapid onset of muscle relaxation in an emergency.Anaesthesia. 2001 Dec;56(12):1213.

Reglan

in GI bleeds/full stomachs

Esmolol

1-2 mg/kg ~ 3min beforehand

1. Feng CK, Chan KH, Liu KN, et al. A comparison of lidocaine, fentanyl, and esmolol for attenuation of cardiovascular response to laryngoscopy and tracheal intubation. Acta Anaesthesiol Sin. Jun 1996;34(2):61-7. [Medline].
2. Helfman SM, Gold MI, DeLisser EA, et al. Which drug prevents tachycardia and hypertension associated with tracheal intubation: lidocaine, fentanyl, or esmolol?. Anesth Analg. Apr 1991;72(4):482-6.

3 mcg/kg of remifentanyl can also be used   ABC for asthma, brain, CV asthma gets lido, brain gets both, CV gets fentanyl

Old pretreatment regimens (atropine, defasiculating paralytics)

Paralysis after Induction ·     RSI Review (Can J Anesth 2007;54(9):748)   Brutane (forcing non-paralyzed musculature) is the worst choice of medications

Induction/Sedative Agents

· Etomidate or Versed .3 mg/kg · Ketamine or Propofol 1.5 mg/kg · Pentothal 3 mg/kg   Etomidate mycoclonus can be attenuated c small dose benzo   Use ½ dose of induction agents if vital signs are unstable or the patient is elderly. Consider using a dose of zero if the sympatholysis may result in decreased BP In a analysis of NEAR data, thiopental, methohexital, and propofol appeared to facilitate RSI over etomidate and versed. The postulated reason for this is that these agents allow a deeper plane of sedation making up for inadequate waiting time for paralysis. (Acad EM 10:6, 2003)   Dose based on ideal body weight; estimate by Broca index: (height in cm-100 for men, -105 for women)   ketamine for head injury review (emerg med australia 2006;18(1):37-44) (also see sedative section) best evidence from EMJ editorial on the use of ketamine in intubation ( Chest. 2007 Dec;132(6):2054)   Ketamine may be the best choice for hemodynamically unstable   Ketamine is safe and may be the preferred sepsis agent (Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial Lancet 2009)   Pharmacodynamics and kinetics of propofol in the shocked patient. Short message–give less, even if you resuscitate them, give less (Anesthes 2004;101:647) and (Anesth Analg 2006;103:1339-1340)

Sedation without Paralysis

Complications of emergency intubation with and without paralysis. (Am J Emerg Med. 1999 Mar;17(2):141-3) Do not give sedatives without paralytics, as there is a good 6 minutes of IPIST (Interval of Progressively Increasing Sphincter Tone) between administration and full sedation Can get MR free good intubating conditions with propofol 2.5 mg/kg, opioids, and 4% lidocaine spray of larynx (Acta Anaes Scand 1996;40(6):752) Most recent article; give propofol 2 mg/kg and remifentanil 2.4 mcg/kg (Journal of Clinical Anesthesia Volume 24, Issue 5, August 2012, Pages 392–397) Administered with propofol 2 mg/kg, the remifentanil dose necessary to produce acceptable intubating conditions was 2 mcg/kg (Anesth Analg 2012;114:980–6)

Not as successful

Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care 18. (6): 417-423.2002; Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 46. (4): 328-336.2005; Full TextA comparison of rapid sequence intubation and etomidate only intubation in the prehospital air medical setting. Prehosp Emerg Care 4. (1): 14-18.2000; Abstract The utilization of midazolam as a pharmacologic adjunct to endotracheal intubation by paramedics. Prehosp Emerg Care 4. 14-18.2000; Abstract even more stuff on this In the ICU, NMBs increased success and decreased hypoxemia (Crit Care Med. 2012 Jun;40(6):1808-1813)

Paralytics

Paralytics spare pupils (Shah. Emergency Neurology, p.5) and article in neuro lit

Depolarizing

Succinylcholine is the only one used in the US. Sux dosing 1.5-2 mg/kg, always better to give more than less. Action in 45 seconds, clinical duration 6-8 minutes Typically causes a rise of 0.5 mEq/L of potassium Dose based on actual not ideal body weight, gives better conditions in the fattys (Anesth Analg 2006;102(2):438)   When not to use Succinylcholine: · Any strokes with hemiparesis from 3 days to 6 months · Burns/trauma >24 hours old · NMJ Disease · Myopathies/Muscular Dystrophies Theoretical Concerns · Intraocular pressure: commonly used by anesthesiologists in this situation. (Anesth Clin North Am 1996 14:125-150 and Anesthesiology 1985; 62: 637-640) · Preexisting Hyperkalemia (Renal failure is not a contraindication): In a retrospective study of all patients with hyperkalemia (38 of 40,000) receiving sux, there were not adverse events (Anesth Analg 2002 Jul;95(1)) · Known plasma cholinesterase deficiency: (only risk is prolonged duration of action) Burns: no real risk as long as less than 7 days from the burn or several months after (after healing, return of normal appetite, and return to normal weight) Direct Muscle Damage: no risk until 4-5 days after insult Guillain-Barre: do not use during and for months afterward ICU: If chronic muscle atrophy, may be better not to use for up to a year afterwards Myopathies: Contraindicated forever if inherited (From correspondence from G. Gronert, MD) Multiple Sclerosis: Review of Sux & neuromuscular disorders (Anesth 1984;61:173) Not a great idea in patients with MS induced paresis (Curr Opin Anaes 2002;15:365) Case Series of Numerous MS Patients who received Sux (Ann Chir Gynaecol. 1984;73(5):299-303) 1 case report in the literature of hyperkalemia in MS (JAMA 1970;213:1867) After about 2 weeks in critical care, pts are at risk from sux (Anesthesia & Analgesia 115(4), October 2012, p 873–879)   Sux remains 90% effective at room temperature for 3 months, longer if not exposed to light (Rosen’s 2001) Lasts for months at room temp (Emergency Medicine Journal 2007;24:168-169) Sux can be injected intralingually if unable to obtain IV access (Intralingual/Intraoral in Adult Anaesthesia 56:12, 1213 Dec 2001)   Submental/Intralingual use of Nalaxone–23-gauge, 1.5-inch needle attached to a 3-mL syringe was inserted in the midline, midway between the mandible and the thyroid cartilage. It was directed 1 inch superior, and 2 mL of naloxone solution was injected. The SM area was then massaged for 30 seconds Intralingual naloxone injection for narcotic-induced respiratory depression. Ann Emerg Med 1987;16:572-573. Mercurio JP: Emergency submental injection. JADA 1967;74:717-719. Redden RJ, Miller M, Campbell RL: Submental administration of succinylcholine in children. Anesth Prog 1984;12:1087-1091.

If you wait 60 seconds, then induction agent is irrelevant (British Journal of Anaesthesia 2005 95(5):710-714)

A second doseof suxamethonium in the presence of masseter spasm. This shouldnot have occurred for two reasons:

1. Masseter spasm is an early sign of malignant hyperpyrexia (MH),which has a mortality rate even with dantrolene of around 5%.Suxamethonium is a significant precipitant in susceptible individuals.
2. Repeated doses of suxamethonium change the paralysing effect of the drug from one that wears off within 3–5 minutes(“Phase I block”) to one resembling a non-depolarising neuromuscularblock (“Phase II block”) which lasts significantly longer. Ithas been long established that this type of block may beginat doses of 2 mg/kg.2

IM Sux-need 4mg/kg to get 2-3 minute induction time (Anaesthesia 2007;62:757)

Sux and Hyperkalemia Anesthesiology 2006; 104:158–69 (massive review down to receptor level) Ped Emerg Care 2000;16(6):441–can not blunt hyperkalemia with non-depols Chest 1992;102(4):1259–can not blunt hyperkalemia with non-depols Seminars in Anesthesiology 1985;4:65–same Anesth 1975;43:89–article references by Anesth 2006 JAMA 1969;210:490 Anesthesiology. 1973 Jul;39(1):13-22.–The response of denervated skeletal muscle to succinylcholine, using canine muscles both normal and denervated 25. R.E. Tobey, P.M. Jacobsen, C.T. Kahle, R.J. Clubb and M.A. Dean, The serum potassium response to muscle relaxants in neural injury. Anesthesiology 37 (1972), pp. 332–337. View Record in Scopus | Cited By in Scopus (8) 26. A.A. Birch, G.D. Mitchell, G.A. Playford and C.A. Lang, Changes in serum potassium response to succinylcholine following trauma. JAMA 210 (1969), pp. 490–493. View Record in Scopus | Cited By in Scopus (10)   27. G.A. Gronert, Potassium response to succinylcholine. JAMA 211 (1970), p. 300.   Anaesth Intensive Care. 1990 Feb;18(1):92-101.Links Suxamethonium and hyperkalaemia. review including 0.7-1.2 rise in renal pts

Nondepolarizing

• Benzylsoquinolones-curare, atracurium. These cause histamine release
• Aminosteroids
  • Vecuronium- Priming dose for vecuronium .01 mg/kg followed by .15 mg/kg will make it act quicker or use high dose vecuronium .3 mg/kg (Acta Anaes Scand 1993;37(5):465)
  • Pancuronium-Only if others not available
  • Rocuronium-ignore package dosing and use 1 mg/kg (46 min paralysis at this dose)
  • Gantacurium-new extremely short acting non-depolarizing???
  • cisatracurium 0.15 mg/kg intubating, 0.005 mg/kg pretreatment, Onset 5 minutes, duration 45 min

  d

• It seems ketamine is a better for rapid intubation situation that priming dose when using rocuronium and propofol (Can J Anesth 2010;57:113) They used 0.5 mg/kg

Sugammadex

is being tested; it binds to roc and completely reverses its effects Phase II Study: Anesthesiology 2007;106:935-43     Ephedrine 70 ug/kg Placebo Esmolol 0.5 mg/kg CO 9.1 8 5.5 Onset of Roc 0.6 mg/kg in sec 52 87 114 (Acta Anaesthesiol Scand. 2003 Oct;47(9):1067-72.)   Aspiration is less likely with NMBA 1 mg/kg of Sux will give excellent intubating conditions 63-80% of time Time until diaphragmatic movement were the same between 1 mg/kg and 0.5 mg/kg dose (Donati, François – Muscule Relaxation for Rapid Sequence Induction IARS 2006 Review Course Lectures)   Prefasic dose of Rocuronium is 0.03 mg/kg 3-5 min before intubation You must increase dose of sux to 2mg/kg if prefasic dose of non-depol is given   Corrugator Supercillii, which moves the eyebrow in response to facial nerve stim has response to NMBAs similar to vocal cords and diaphragm.     Article on intubating without paralysis (Br J Anaesth 2005;94(2):150) lidocaine sprayed on cords remifentanyl 2 mcg/kg   ROCURONIUM VERSUS SUCCINYLCHOLINE FOR RAPID SEQUENCE INDUCTION INTUBATION Background Rapid sequence induction (RSI) of anaesthesia is a method of quickly producing optimal conditions for intubation in the emergency situation. Classically, succinylcholine (also known as suxamethonium) is the muscle relaxant used because of its rapid onset and brief duration. Contraindications for its use include severe burns, major crush injuries, neurological disease involving acute wasting of major muscle and family history of malignant hyperthermia. Rocuronium is another rapid onset muscle relaxant with fewer contraindications than succinylcholine but its duration is significantly longer. The aim of this meta-analysis was to assess whether rocuronium is as effective as succinylcholine at producing ideal intubating conditions during RSI. Results Twenty six studies were identified that met the inclusion criteria. Succinylcholine produced a small but statistically significant increase in the number of excellent versus non-excellent intubation conditions (relative risk (RR) 0.87; 95% CI 0.81 to 0.94). There was no significant difference between the two agents when comparing excellent or good intubating conditions with poor conditions or failure to intubate. When propofol was used in place of thiopental, there was no difference in the numbers of excellent conditions produced by either rocuronium or succinlycholine. SOCRATES says Succinylcholine produces excellent intubation conditions more consistently than rocuronium and remains the first choice muscle relaxant for RSI. In cases where it is contraindicated, rocuronium is a valid alternative, especially if combined with propofol. Perry J, Lee J, Wells G. Rocuronium versus succinylcholine for rapid sequence induction intubation. In: The Cochrane Database of Systematic Reviews. 2005 Issue 4 CD 002788

Train of Four

Number of Twitches After Stimulation Amplitude Corresponding Level of Neuromuscular Blockade 4-all 4 equal-0% (no blockade) 4-declining-< 75% 3-declining-75-85% 2-declining-85-90% 1-single weak-91-99% 0-none-100% 4:1 50% same 70% occupied 2-3 twitches same 75-85% occupied 1 twitch weak >90% Post tetanic twitching >5 occurs just beofre rgaining 1 twitch of TOF   To Reverse, Need 1 twitch Neostigmine 0.07 mg/kg, mix in same syringe with equal volume of glycopyrolate A better chart from anaestricks:   Lifting arm and flushing with 20 ml of saline made onset of vec sig. quicker ( Issue Anaesthesia Anaesthesia Volume 68, Issue 9, pages 904–907, September 2013)   Paralytics actually increase LES tone (Br J Anaesth 1984;56:37)   Sux without pretreatment causes quicker desatuaration than rocuronium or sux with pretreatment (Anaesthesia 2010;65:358) and here again in obese patients (Acta Anaesthesiologica Scandinavica Volume 55, Issue 2, pages 203–208, February 2011)

Perceptions of Paralysis

First article from Bronx VA The experience of paralysis when awake is not so bad, but hypercarbia seems to suck (J Clin Anesth. 1993 Sep-Oct;5(5):369-74.) 2nd article used anesthesiologists as patients   Med Dosing in the Obese Patient Protection and Positioning

Cricoid Pressure (Sellick’s) NOT RECOMMENDED

from 20-30 seconds after drugs until tube confirmation. Have assistant apply with third finger and thumb. Place their index finger on the thyroid cartilage, this will allow you to move it during laryngoscopy to retain BURP pressure. The proper amount of cricoid pressure can be learned by pushing on the bridge of your nose with middle finger and thumb until it hurts.   But perhaps, the proper amount is no amount at all. All studies are inconclusive. (Canad J Anesthesia 1997;44:414 in JB) and it often screws up tube placement (Airway·Cam Book) and fiberoptic intubation (Acta Anaesthesiologica Scandinavica Volume 57, Issue 3, pages 358–363, March 2013) and fiberoptic laryngoscopy (Videographic Analysis of Glottic View With Increasing Cricoid Pressure Force Ann Emerg Med. 2013 Apr;61(4):407-13)

Position the patient

· Leave patient sitting until last moment in CHF/Reactive Airway Disease · Do not bag unless sat starts to fall below 90. If you bag with paralysis and properly performed cricoid pressure, 1-2 cc of air is insufflated per tidal volume ventilation. · Also consider bagging patients with increased ICP. · Never bag without an oral airway, just as you would not perform a rectal exam without a glove     Placement and Confirmation Wait till defasiculations cease if using Succinylcholine; flick the mandible to see if pt sufficiently blocked and

Intubate

• see below

Confirm Placement

ETCO2 Detector-yellow is mellow. If tan, give 6 breaths. If still tan probably in trachea, but consider direct laryngoscopy to confirm. Purple with a Pulse, Pull the tube. If purple without a pulse, confirm with direct laryngoscopy. If using wave-form CO2, then tracheal intubation should produce waveform. Vinegar in an animal model turned permanently turned indicator yellow (Journal of Emergency Medicine Volume 28, Issue 1 , January 2005, Pages 5-11)   The colour ranges for the Portex® device (Smiths Medical ASD, Keene, NH) are blue, green, green-yellow, and yellow, which correspond to levels of 0–1, 1–2, 2–5, and >5% CO2, respectively. Normally, end-tidal CO2 is > 4%.1,2   Primary assessment (Lung sounds) more for tube depth than confirming tracheal placement.   Self-Inflating Bulb-reliable even with uncuffed tubes (Acad Emerg Med April 2003, 10:4)   Can confirm depth by ballotment. Location of the Endotracheal Tube by Pilot Balloon-CuffCounter-Ballottement (Anesth Analg. 1995 Jul;81(1):135-8)   If confirming in a coded patient, first attempt to verify with DL-Displace tube posteriorly to be able to see it going through the cords (Benumoff 2nd ed)   Also can place a boughie down tube, if you hit a stop point, it is in the bronchi and tube is between the cords. But you need to know what you are doing to get to 100% (American Journal of Emergency Medicine (2005)23:754–758

Tube Cuff Pressure

We probably inflate too much (Academic Emergency Medicine Volume 11, Number 5 490-491) Emergency Physicians Cannot Inflate or Estimate Endotracheal Tube Cuff Pressure Using Standard Techniques (Annals EM 44:4 Oct 2004) and (AJEM 2006;24:139)   15-25 mmHg is optimal   Cuff Pressure Journal Club   1. Knowlson GTG, Bassett HFM. The pressure exerted on the trachea by endotrachealinflatable cuffs. Br J Anaesth 1970;42:834e7.2. Seegobin R, van Hasselt GL. Endotracheal cuff pressure and tracheal mucosal bloodflow: endoscopic study of effects of four large volume cuffs. BMJ 1984;288:965e8. 3. Susuki N, Kooguchi K, Mizobe T, et al. Postoperative hoarseness and sore throatafter tracheal intubation (effect of low intracuff pressure of endotracheal tube andusefulness of cuff pressure indicator). Masui 1999;48:1091e5.4. Pelc P, Prigogine T, Bisschop P, et al. Tracheo-oesophageal fistula: A case report andreview of literature. Acta Otorhinolaryngol Belg 2001;55:273e8.5. Spittle N, McCluskey A. Tracheal stenosis after intubation. BMJ 2000;321:1000e2.6. Friis J, Turner A, Da Fonseca J. Overinflated tracheal tube cuff. Emerg Med J2009;26:182   (From Cliff on resus.me) A study from China tested the hypothesis that an appropriate tracheal tube cuff (ETTc) pressure even in short procedures would reduce endotracheal intubation–related morbidity. They compared bronchoscopic appearance of tracheal mucosa, and patient symptoms of tracheal injury, in two groups of elective surgical patients anaesthetised and intubated between 120 and 180 minutes: a control group without measuring ETTc pressure, and a study group with ETTc pressure measured and adjusted to a range 15-25 mmHg. The endoscopist was blinded to the study group allocation. The mean ETTc pressure measured after estimation by palpation of the pilot balloon of the study group was 43 +/- 23.3 mm Hg before adjustment (the highest was 210 mm Hg), and 20+/- 3.1 mm Hg after adjustment (p< 0.001). The incidence of postprocedural sore throat, hoarseness, and blood-streaked expectoration in the control group was significantly higher than in the study group. As the duration of endotracheal intubation increased, the incidence of sore throat and blood-streaked expectoration in the control group increased. The incidence of sore throat in the study group also increased with increasing duration of endotracheal intubation. Fiberoptic bronchoscopy showed that the tracheal mucosa was injured in varying degrees in both groups, but the injury was more severe in the control group than in the study group. So..time to get a cuff manometer for your ED or helicopter? Perhaps you already have one. What do you think? Correlations Between Controlled Endotracheal Tube Cuff Pressure and Postprocedural Complications: A Multicenter StudyAnesth Analg. 2010 Nov;111(5):1133-7

Pulse Ox

Distally placed pulse ox has a 60-90 second lag from true saturation

Postintubation Management

• Secure Tube

Knots to secure airway devices

(Anaesthesia 2013;Volume 68, Issue 11, pages 1204–1205)   November 2013 Additional Information(Show All) How to CiteAuthor InformationPublication History No external funding and no competing interests declared. SEARCH Search Abstract Article References Cited By Get PDF (100K) https://eresources.library.mssm.edu:2117/getit.gif When securing a tracheal tube or laryngeal mask airway with cotton ties, the knots used should: (i) grasp the stem of the device securely to prevent it slipping out of position (both inwards or outwards), even when wet; (ii) be easy and quick to tie, with minimal chance of tying incorrectly; and (iii) allow quick removal of the device in case of malposition or if the patient begins to gag or cough. The clove hitch has been advocated to grip the stem of the airway device [1], but can slip or spill unless secured with additional half-hitches around the standing part, and does not grip as securely as the constrictor knot, which is the best knot for this purpose [2]. This application has been suggested previously [3, 4], but the method of tying is unclear. Therefore, I here illustrate two methods in detail in the hope that this will encourage more widespread adoption of this excellent solution. Following insertion of the airway device, the constrictor knot may be made ‘in the bight’, where the tie is twisted in the horizontal plane to form two loops, which are crossed to form a figure of eight, the loops being then folded backwards and dropped over the stem (Fig. 1a). The airway device is connected to the breathing system and the knot tightened once the correct position has been confirmed. image Figure 1. Method of securing airway device with a cotton tie. Alternatively, the constrictor knot may be tied around the stem of the airway device without disconnecting the patient from the breathing system, using the ‘end’ method (Fig. 1b). The end of the tie is passed around the stem, under the standing end, and around the stem in the same direction a second time. It is then tucked under itself, and then under the first turn to complete the knot. The tie may then be secured around the patient’s head using a slipped reef knot [5] over the patient’s mandible (Fig. 2). The first half-knot allows the loose ends of the tie to be joined under gentle tension without the knot slipping. The second half-knot incorporates a single bight (loop or ‘bow’). Pulling on the free end (arrowed) instantly releases the knot to allow removal of the airway device with attached tie. The above methods are effective, easily learned, and can be performed rapidly after minimal practice.

• Post Intubation Medications

Ativan 4-6 mg Versed 0.1 mg/kg bolus, then 0.1 mg/kg/hr 2-5 mg/hr (Drip 50 mg in 250 cc NS, Start at 10-25 cc/hr) Propofol .5-1 mg/kg then 25-100 mcg/kg/min, start at 10 cc (100 mg)/hr which correlates with 1 mg/kg/hour

• C-XR, NGT, and ABG.
• If possible place pt at 45°

HOB 30° Big Tubes Secure ‘em NGT HME ABG Inline Suction ETCO2 BVM c peep valve Cuff Pressure You must have your 4th and 5th digit on the blade to properly intubate (Anaesth Intensive Care 2009; 37: 791-801) Avoid post-intubation paralytics Vecuronium .1 mg/kg then .03 mg/kg q25-45 min or 1-2 mcg/kg/min use 2 electrodes over the ulna nerve, give train of four. shoot for 2 twitches while holding the thumb in abduction Acute quadriparetic myopathy syndrome (AQMS) can result in longstanding paresis if NMBAs are given in doses which are too high.

Abnormal Vital Signs Postintubation

Bradycardia

Assume hypoxia and therefore tube displacement until proven otherwise

Desaturation

Displaced tube Obstruction-pass suction catheter through tube Pneumothorax Equipment failure-take off vent and bag patient   if all of the above have been evaluated, consider shunt physiology

Hypotension

• Pneumothorax
• Decreased Venous Return from PPV, disconnect from vent for 30-60 seconds and observe for increased BP and decreased pulse. Consider reducing PEEP and decreasing Vt. Auto-PEEP in obstructive airway disease.
• Induction Agents-diagnosis of exclusion, give fluid bolus
• Cardiogenic-fluid bolus

Skills of Airway Management

Using a BVM

Always use an oral airway · Take mask off of bag · Lay over nose and let fall on the face · Place thumb and first finger on mask with port against thumb web · Attach the bag · Use the other fingers to grasp along mandible, pulling face into mask 2 hand method: place both thumbs on mask, facing the patient’s feet. Index fingers on mentum of chin. Other fingers performing jaw thrust.   Use 2 nasal and oral airway if difficult to ventilate. • comparison of 4 standard bags with high-flow oxygen • Duck-bill mask with one-way valve gives FiO2 >0.9, other bags ~0.3 • Laerdal Silicone Resuscitator®, Mallinckrodt Capno-Flo® > 0.9 • Sims-Intertech 1st Response®, Vital Signs Code Blue® < 0.4 • Know your bag well: they’re differentNimmagadda U et al. Efficacy of preoxygenation with tidal volume breathing: Comparison of breathing systems. Anesthesiology 2000 Sep 93 693 -698 (Ron Wall’s Lecture)   Esophageal sphincter is 20-25 cm H2O in normal healthy, less in sick or dead   Pressures < 16.5 cm H20 are unlikely to cause gastric insufflation (Br J Anaes 1987;59:315) Once the LES is opened, much lower pressures will cause continued insufflation (Arch Dis Child 1983;58:373)     Better technique may be to use mask and ventilator (Journal of Emergency Medicine 2006;30(1):63)   Airway pressure < 15 cmH20 rarely causes insufflation, but > 25 often will (Br J Anaesth 1987;59:315 and Acta Anaes Scand 1961;5:107)

Nasopharyngeal Airways

Short Female Size 6 (pin 1cm from flange)

Average Female/Short Male Size 6

Tall Female/Average Male Size 7

Tall Male Size 8

Width does not matter, only length so that it is above cricoid but below tongue

(Emerg Med J 2005;22:394-396)

NRB = ~65-80% Ø BVM = > 90% • New Hi-Ox® Mask >80% @ 8L/min   New smart bag limits IFR (Intensive Care Medicine Volume 34, Number 2 / February, 2008)     Article on proper way to open the jaw and hold the mask   Facemask position ofr edentulous patients (see image above) Anesthesiology May 2010 – Volume 112 – Issue 5 – pp 1190-1193   Two hand mask grip is better than one hand (Anesthesiology 2010; 113:873–9)   Paralysis augments the ability to mak ventilate (Anaesthesia 2011;66:163) and further validation in a huge study of a difficult airway algorithm (ANESTHESIOLOGY. 2011;114:25–33)

Laryngoscopy and Intubation

The tongue is your enemy, the epiglottis is your friend.

A proposed model

for direct laryngoscopy and tracheal intubation (Anaesthesia 2008;63:156)     When passing the tube, first touch the hard palette with the tube’s bevel lying horizontally. Guide the tube to the soft palette. Approach the cords from the right so as not to obscure your view. At the last second, rotate the tube counterclockwise 90° to allow narrowest area to go through the cords.   Macintosh must indirectly lift the epiglottis by use of the hyoepiglottic ligament. If the macintosh blade is too short for the patient, you may be able to reach the valeculla, but have inadequate traction to lift the epiglottis.   Teach residents by telling them to life the head off of the bed with the blade rather than tilting the head back with the blade Visual acuity improves as the laryngoscope illuminance increases up to 700 lux. No statistically significant improvement was measured by increasing the illuminance up to 2000 lux. Subjectively, anesthesiologists favor illuminance of 2000 lux for direct laryngoscopy. It is a near-sighted activity (Anesth Analg 2013;116:343–50)

Cognitive Tasks of Intubation

Task Task Completion

1. Position Patient Ears to Notch
2. Open Mouth Translation of Mandibles
3. Place Blade 1″ of blade centered in mouth
4. Find Epiglottis Sliver of epiglottis seen
5. Press thyroid backwards Valeculla transforms from potential to actual space
6. Seat blade tip epiglottis lifts
7. Lift laryngoscope head lifts off bed or Glottic Structures Visualized
8. Place Tube See tube anterior to notch

Increased head elevation/neck flexion results in much better view (Annals EM 2003;41(3):322) Mike Murphy agrees with editorial in same issue (Ann Emerg Med 2003;41(3):338) Ideal positioning causes the external auditory meatus to be on the same horizontal line as the sternal notch. If this is accomplished using the ramp method in this photo, obesity will not cause difficulty (Obesity Surgery 2004;14:1171)   Another review article showing same in pregnant, obese woman (Can J Anaesth 1989;36(6):668)   RCT with crossover of extension vs. 7cm head elevation, trend towards better with ramp, sig. better in obese or poor head extenders (Anesth 2001;95:836) Validation of the ears to sternal notch in anesthesia patients (Journal of Clinical Anesthesia (2012) 24, 104–108) Laryngeal exposure was superior at 25° than supine (Br J Anaesth 2007;99:581)   Laryngoscopy with straight blade allowed better view, but intubating conditions were better with the curved blade. (Can J Anesth 2003, 50:5 p. 501-506)   For difficult laryngoscopy, can try the left-molar approach. It may offer an improved laryngeal view. It can also be used to augment fiberoptic intubation attempts. (Anes 92:1, Jan 2000) and (Anaes 2002 57:1028-1044) Consider having assistant grab the tongue with a 4×4 before the insertion of the blade.   BURP and mandibular advancement gave the best visualized view. Either one alone helped over none in inexperienced laryngoscopists (Anesthesiology 2004; 100:598–601)   Comparision of cricoid/burp/bimanual laryng. (Ann EMerg Med 2006;47(6):548): on cadaver models, only bimanual consistently improved view       Cormack-Lehane is scale for view of cords   Plastic Blades result in lower number of successful intubations (Anesthesiology 2006;104(1):60)

How to actually placed the tube

Crash Airway

Nearly Dead, Newly Dead   Still may consider using Sux if any muscle tone at all

The Predicted Difficult Airway

If BVM and intubation are predicted to be successful, do double set-up RSI with failed airway equipment already set up and cric set open   Sigma configuration for tube (Anesthesiology 2007;106(5):1069)

Quick Look

Give intubating dose of propofol, perform laryngoscopy, give paralytics if a good view is obtained

Blind Nasotracheal Intubation

Retrograde Intubation

(Anesthesiology 2006;104(1):48)

Awake Intubation and Fiberoptic Intubation

Failed Airway

Can’t Intubate/Can’t Ventilate or three failed attempts

Best Attempt Definition:

1. Performed by a reasonably experienced laryngoscopist
2. No significant muscle tone
3. Use of optimal sniff position
4. Use of external laryngeal manipulation
5. One change in length of blade
6. One change in type of blade

Devices and Techniques for the Failed/Difficult Airway

Eschmann/Gum Rubber Bougie/Gum Elastic Bougie

Pass till 20 cm at the teeth, you will feel it sliding over tracheal rings. Railroad the tube over the Eschmann while the laryngoscope is still in the mouth.   The laryngoscopist obtains the optimal laryngeal view. The bougie is then passed below the epiglottis and through the vocal cords. This should elicit a clicking feel at the distal end of the GEB due to the “hockey stick” angled distal end [5]. If clicking is not felt distinctly, the GEB is advanced further until it “holds up” at the carina or when it comes in contact with a peripheral airway of a smaller diameter [5]. Advancement always must be gentle. The laryngoscope blade is left in place as the ETT is inserted over the GEB and into the trachea. It is important to rotate the ETT 90 degrees counterclockwise before the tip of the ETT passes through the vocal cords. This maneuver prevents the beveled tip of the ETT from catching on the right arytenoid process, aryepiglottic fold, right vocal cord, or epiglottis. Clicking and holding up are cardinal signs of tracheal insertion by the GEB, both of which were noted during the insertion of the GEB in our patient with the open zone II neck injury. Possible complications from a bougie insertion are pharyngeal perforation, mediastinal emphysema, and pneumothorax. (JEM April 2003)   The obstruction is caused by impingement of the tube on the right vocal cord complex and arytenoids [2]. Cossham [3] described a pre-emptive 90° anti-clockwise rotation of the tube (90CCWR), the Cossham twist   Am J Emerg Med. 2004 Oct;22(6):479-82. Links Use of the endotracheal bougie introducer for difficult intubations. A difficult to intubate patient occurs infrequently in the emergency department. The endotracheal tube introducer or gum elastic bougie is a device used by British anesthesiologists in difficult airways. The device is inexpensive, has few complications and is easy to use. Similar to the Seldinger technique for gaining access to a large central vein, the endotracheal tube introducer is used to assist in cannulating the trachea and acts like the wire in central vein access. PMID: 15520943 [PubMed – indexed for MEDLINE]   Anaesthesia. 1988 Jun;43(6):437-8.Links Successful difficult intubation. Use of the gum elastic bougie. Kidd JF, Dyson A, Latto IP. Department of Anaesthesia, University Hospital of Wales, Heath Park, Cardiff. The reliability of two signs of tracheal placement of a gum elastic bougie was studied. These signs were clicks (produced as the tip of the bougie runs over the tracheal cartilages) and hold up of the bougie as it is advanced (when the tip reaches the small bronchi). Ninety-eight simulated and two genuine Grade 3 difficult intubations were attempted with the aid of a gum elastic bougie. Seventy-eight tracheal and 22 oesophageal placements of the bougie resulted. No clicks or hold up occurred with the bougie in the oesophagus. Clicks were recorded in 89.7% of tracheal placements of the bougie. Hold up at between 24-40 cm occurred in all tracheal placements. We conclude that these signs are reliable and that they should be taught as part of any difficult intubation drill in which the gum elastic bougie is used. From Seth Manoach “ From an abstract Julio and colleaugues wrote and sent me a few years ago I learned the tricks of using the larygoscope to lift the epiglottis enough during ETT placement so the lip of the epiglottis does not catch the ETT as it is railroaded over the bougie. With this the more often described corkscrewing of the ETT during introduction to sneak the beveled edge of the tube under the epiglottis. Both of course are ways to contend with the main bougie problem, circumferential bougie:tube size mismatch. These tricks changed my relationship to the device and are to me like the up and down and chandy maneuvers with the fastrach/ilma — shouldn’t really talk about success rates without them.”

Combitube

Hold right above yellow balloon Use thumb to press tongue out of way   Place until teeth between two black lines Inflate blue cuff until lower black line moves above the teeth (relative amount) Inflate white for 12 cc (absolute amount) Blue is first for everything (inflation, deflation, ventilation) Combitube Video   I agree that DL is the best way to place a SGA, also Combitube /Easytube. Just to line out a few points for alleviating elective use/training of Combitube /Easytube:1) Use DL2) Insert Combitube /Easytube “flat” along the tongue parallel to outer surface of patients’ body (not along the hard palate) 3) Inflate upper balloon (blue pilot balloon No. 1) with 25 to 75 ml in 10 ml incremental steps until you get a tight seal as described by Dr. Gaitini several years ago.This “minimal volume inflation technique” minimizes the stress to the pharyngeal mucosa. However, prevention of accidental extubation is also reduced.When using Combitube /Easytube in a manikin, make sure the device is well lubricated. Combitube /Easytube work best in manikins such as SimMan, Bill, VBM manikin, and/or Laerdal.Ambu is not suitable for Combitube /Easytube. Then, insertion and first ventilation are possible within 15 to 30 seconds.Michael FrassInventor of Combitube

Trach Light

· Cut Tube to 27 cm and reattach connector. Lube wire and lube stylet · Bulb should be flush with distal part of bevel, it should just touch your finger. · Hold like a cup of tea (between thumb and index finger, pinky up is your choice) · In Peds, only pull back 2-3 cm on wire · Must bend 90 or it will not work · Touch it to the patient’s chest in midline and then rotate it in while performing a jaw thrust. · Patient’s head can be in neutral position     Several tips have been suggested in the literature for improving the success of Trachlight®-guided intubation. These include lifting the tongue with the thumb of the nondominant hand or having an assistant pull the tongue while the intubator continues to provide a jaw thrust, lubricating the wand and the stylet,1 dimming operating room lights, using smaller size endotracheal tubes, inserting the wand side-on, or providing at least a 90° bend to the wand.2 Others have suggested gauging the appropriate “bent length” by measuring the distance from the thyroid prominence to the angle of the mandible.3 Patients with buck teeth may benefit from the addition of another bend to the wand at the level of the buck teeth.4 Following repeated use, the internal rigid stylet sometimes assumes a “snake-like” bend that poses difficulty in retraction of the wand. In such situations, it has been suggested that the stylet be straightened, if possible, before reuse, failing which it needs to be disposed. 5 We have also encountered a similar situation leading to difficulty in withdrawing the wand along with the rigid internal stylet after successfully negotiating the endotracheal tube-Trachlight® assembly into the trachea. We have noticed that the snake-like bend of the stylet poses a problem when it crosses the endotracheal tube connector, which happens to be not only the narrowest, but also the most rigid portion of the endotracheal tube-connector assembly. We have successfully overcome “hold up” at this level by separating the endotracheal tube connector from the endotracheal tube prior to withdrawal of the wand-stylet assembly. The distal 90° bent portion of the wand-stylet assembly is the other point at which difficulty is encountered during withdrawal of the stylet, especially in the pediatric age group due to the small size of the tube and its connector. Our suggestion provides a solution to this problem also. We therefore recommend that the connector be routinely separated from the endotracheal tube to facilitate smooth removal of the stylet and possibly prolong the life of the stylet. We have applied this technique of removal of the endotracheal tube connector to aid in Trachlight®-guided oral intubation using the Ring Adair Elwyn (Mallinckrodt Medical, Athlone, Ireland) tube also. In obese individuals, the midline tissues of the neck may be obscured by folds of fat arising either from a double-chin above, or from the anterior chest wall below, posing difficulty in appreciation of the circumscribed glow in front of the neck. Dimming the operating room lights and placing a support under the shoulder to extend the neck often improves success of Trachlight®-guided intubation in obese patients. We have found that having an assistant retract the fold of fatty tissue down and away from the neck so as to avoid formation of skin folds over the neck helps in shortening the time to obtain the classical well-circumscribed midline glow. Since its introduction in 1959, the lightwand has proven its utility in several clinical situations. Our experience gleaned from the use of the Trachlight® for more than 350 intubations has prompted us to share some of the practical solutions that we have used to overcome problems that we have commonly encountered during its use. (Can J Anesth 2007;54:398-399)

Glidescope

More maneuvers to facilitate tracheal intubation with the GlideScope® David C. Kramer, MD and Irene P. Osborn, MD Mount Sinai Medical Center, New York, USA, E-mail: david.kramer@msnyuhealth.org To the Editor: The GlideScope® (Diagnostic Ultrasound Corporation,Bothell, WA, USA), is a videolaryngoscope, whichincorporates a fibreoptic and digital camera systeminto the blade.1 The blade displays a video output to adedicated monitor. The flange of the blade has a 60°angulation, which facilitates better exposure of the larynxthan traditional Macintosh blades.2,3 Some authorshave reported difficulty intubating the trachea despitethe superior view offered by the GlideScope®.1 In thelargest series of Glidescope use (728 patients), 14 ofthe 26 failed intubations occurred in spite of achievinga Cormack-Lehane grade 1 view.4 In that study,failures resulted not from an inability to view the larynx,but in directing the endotracheal tube throughthe glottic opening. In our experience, the device hasbeen successful in over 500 patients, especially thosewith large tongues, relatively small mouths, and inpatients with limited neck mobility. We have used thedevice for conventional induction, in rapid sequenceintubation, and for awake intubation. Because theGlideScope lifts the tongue rather than displacing itinto the submental space, patients with Mallampaticlass III and IV airways are usually afforded Cormack-Lehane grades 1 or 2 glottic views. We have found the following maneuvers to be helpful when intubating the trachea with the GlideScope

• Using a stylet, bend the endotracheal tube (ETT) into a “hockey stick” shape; this usually facilitates tracheal intubation if one obtains a Cormack-Lehane grade 1 view. If the larynx appears anteriorly, bending the ETT into a steeper curve is helpful. This can be achieved by emulating the bend of the GlideScope® flange and handle.
• Introduce the ETT through the mouth in a horizontal plane, and once the tube has passed the flange of the GlideScope®, rotate the ETT to the vertical position.
• If the ETT advances posteriorly to the arytenoids, the following is helpful: With the ETT held between the fingertips, pull it superiorly, rotate the ETT over the left arytenoid, and gently twist the tube over the epiglottic aperture.
• If the ETT abuts the glottic lip, rotate the ETT clockwise into the glottic aperture, while with-drawing the stylet.5
• A midline approach and positioning to achieve an optimal laryngeal view is also important. The described maneuvers have helped the authors facilitate introduction of the ETT into the mouth, past the GlideScope®, and decrease the risk of trauma to the posterior larynx and tracheal glottis. These approacheshave also been very helpful in teaching proper use of the GlideScope®, and in managing failed tracheal intubations at our institution.

Can J Anaesth. 2007 Nov;54(11):891-6. The GlideScope-specific rigid stylet and standard malleable stylet are equally effective for GlideScope use.   Letter to editor on glidescope use (Journal of Clinical Anesthesia, Volume 22, Issue 2, Pages 152-154) Look down, up, down, up (Anesth Anal 2007;104:1611)

Video Laryngoscopy

Anaesthesia. 2010 Sep 30. Comparison of three videolaryngoscopes: Pentax Airway Scope, C-MAC™, Glidescope(®) vs the Macintosh laryngoscope for tracheal intubation* All work same

AirTraq

Anaesthesia Volume 64, Issue 3, pages 315–319, March 2009

Fiberoptic Stylet

ours is the bonfils from Levitan course: turn tube 90 clockwise off stylet pull stylet not straight back 20 minute cidex scope Follow the existing passage, don’t try to make you’re own with fiberoptic devices Perspective Step back

Fiberoptic Scope

Trach

Possibility of using bedside percutaneous dilatational trachs (PERCUTANEOUS DILATATIONAL TRACHEOSTOMYFOR EMERGENT AIRWAY ACCESS. Ault MJ,Ault B, Ng PK. J Intensive Care Med 2003;18(4):222–226)

Random Tidbits

Push on chest to get air bubble if airway is full of secretions/blood   Ventilating through airway exchange caths can cause barotrauma/pneumo (Can J Anesth/J Can Anesth (2011) 58:560–568)

Sigma shape for ease of tube placement in difficult airway

anesth 2007-106-1069

Research

NEAR Database

Selective Intubation

Rotational technique can be used for L mainstem with 50% success rate. Rotate 90 towards bronchus you want to intubate, then advance. (Acad Emerg Med 2004;11(10):1105.

Trauma Intubation

Systematic Review (Emerg Med J 2006;23:3-11) Use RSI (B) In-line Stabilization with anterior portion of collar removed Tracheal tube introducer for ALL intubations; use routinely, not as rescue (B) Variety of sizes and shapes of blades should be available LMA as temporary adjunct for failed airway   Review Article of intubation and its effects on c-spine injuries (Anesthesiology 2006;104(6):1293)

Head Injury Intubation

Now an article in the lit extolling ketamine as the ideal agent for head injury RSI (CJEM 2010;12(2):154)

Pediatric Airway

Ventilators

Extubation and Weaning

Rapid Sequence Airway

RSI but with SGA, possibly the best idea for the prehospital environment (from Darren Braude’s RSI/RSA Book)

Airway Intervention Study

A group of interventions for airway and post-intubation management improved severe complications

• 2 operators
• fluid loading pre-tube
• prep of post sedation beforehand
• preox with bi-pap if needed
• RSI
• sellick
• capnography
• norepi if low diastolic bp (<35)
• long-term sedation
• lung protective vent

Review of Aspiration Pneumonia and Prevention

Anesthesia and Analgesia August 2001 vol. 93 no. 2 494-513

Obstructed Trachea

Push down with et into one of the mainstems and then pull the tube back (Emerg Med Australas. 2011 Dec;23(6):776-8)

References Not Cited in Body

1. Walls RM et al. Manual of Emergency Airway Management. Lippincott, 2000.
2. Shah SM et al. Emergency Neurology. CambridgeUniversity Press, 1999.
3. The Airway Site. http://www.theairwaysite.com
4. Ovassapian, A et al. Fiberoptic endoscopy and the difficult airway, 2nd ed. Philadelphia : Lippincott-Raven, 1996.
5. Benumof J. Airway management : principles and practice. St. Louis ; New York : Mosby, 1996.
6. Brimacombe JR et al. The laryngeal mask airway : a review and practical guide. Philadelphia: W.B. Saunders, 1997.
7. Management of the difficult and failed airway Hung/Murphy

How to Handle Laryngospasm from Anaestricks

• 100% O2
• Laryngospasm notch pressure
• CPAP or positive pressure ventilation
• Lignocaine on the cords
• Induction dose of propofol
• Suxamethonium IV (1 to 2mg/kg) or IM (4mg/kg)

PS – Laryngeal notch pressure: Firm pressure to the notch behind the earlobe, bounded by the mastoid process, base of skull and condyle of mandible. Pressure on both sides in a cephalad and medial direction can terminate laryngospasm. The jaw should move anteriorly. Mechanism unknown. Larson C. Anesthesiology. 1998 Nov,(5):1293-4