Initial Management of Critical
Airway and Breathing
Emergencies
Does he need to be intubated? If yes, when and how?
How would you manage this patient?
58 y/o in shock and respiratory failure
Four airway questions
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Is the airway open?
Is breathing adequate?
Is oxygenation adequate?
Is the airway protected?
Indications for intubation
Do these patients need to be
intubated?
• Failure to maintain and/or protect airway
• Failure to oxygenate and ventilate
• Facilitate therapy or diagnostic procedures
When to do the intubation?
When to intubate?
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Now?
Within 10 minutes?
Within 30 minutes?
Almost all patients can be managed initially
with good BVM ventilation
– proper equipment
– good technique
– airway adjuncts
What is the safest and best
method to intubate?
• Rapid Sequence Intubation
• Awake intubation techniques
– Blind nasotracheal intubation
– Awake oral intubation
– Fiber optic guided intubation
– Retrograde intubation over a catheter
• Surgical technique
Rapid Sequence Intubation (RSI)
Simultaneous administration of a potent
sedative (anesthetic) and a
neuromuscular blocking agent to
facilitate endotracheal intubation
History of emergency airway
management
• Most ER intubations performed on
unresponsive patients
• Sedation without paralytics
• C-spine concerns in trauma
• Blind nasotracheal vs. RSI in the ED
Rapid Sequence Intubation
“the method of choice for emergency
airway management in most patients”
RK Knopp: Ann Emerg Med 1998
Rapid Sequence Intubation - 9 Ps
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2.
3.
4.
5.
6.
Preparation
Preoxygenate
Premedicate
Push sedative (Anesthetic)
Paralyze
Position airway: head/neck position; laryngeal
manipulation, BURP, cricoid pressure as needed
7. Pass the tube (intubate)
8. Patent airway assessment
9. Post-intubation plan
RSI: Timing
• Five minutes before intubation: Preparation including
selection of drugs & doses, equipment check and team
roles; preoxygenation; premedication.
• 45 - 60 seconds before intubation: administer sedative
and paralytic, start laryngeal manipulation 45 - 60
seconds after drugs, introduce laryngoscope, intubate
and immediately prove tracheal intubation.
This is the Rapid Sequence!
• Intubate + 1 minute: Post intubation care
Preparation
• Check equipment
– Laryngoscopes, ET tubes,
suction, introducer
– Back up airway
• Attach monitors - cardiac,
oximetry
• Establish IV (prefer 2), gather
drugs
• Assign tasks to team
members
Preparation
• Airway drugs
– Draw up drugs
– Label syringes
– Use ET Flow sheet
Shamrock Dispenser
Preoxygenate
100% O2 by mask for 3-5 mins
or
3 - 4 vital capacity breaths
Undesirable responses to
intubation
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Increases ICP
Bronchospasm
Bradycardia in children
Hypertension/tachycardia
Fasciculation's with Succinylcholine
Pretreatment: attenuation of
physiologic response to intubation
• Lidocaine
– May block increase in ICP
– May attenuate bronchospasm
• Atropine
– Blocks vagal response in children
• Opioids (Fentanyl)
– Blocks cardiovascular response
• Non-depolarizer
– Blocks fasciculation
RSI Drugs - pretreatment
• Lidocaine - head injury,
asthma (1.5 mg/kg)
• Atropine - children <8
(0.02 mg/kg)
• Fentanyl - 1-2
micrograms/kg
RSI Drugs - sedation
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Etomidate (Amidate)
Thiopental
Midazolam (Versed)
Ketamine
Propofol (Diprivan)
Etomidate (Amidate)
Ultrashort-acting nonbarbiturate hypnotic
Dose:
Onset:
Duration:
Advantages:
0.3mg/kg
30-60 seconds
3-5 minutes
Short acting, lowers ICP,
with no adverse
cardiovascular effects,
Disadvantages: Nausea, myoclonus,
? Cortisol suppression
Etomidate and septic shock
current (2010) controversy
• Etomidate known to suppress cortisol secretion
• Ability to mount a cortisol response is thought
to be important to outcome in septic shock
• No studies to date clearly link Etomidate and
increased mortality in septic shock
• Recommended approach:
– Use another sedative?
– Supplemental steroids if Etomidate used?
– Draw cortisol level and give steroids if low?
Midazolam (Versed)
Short acting benzodiazepine
Dose:
0.1-0.3 mg/kg (larger dose /kg in kids; 10
mg usual max single dose for adults)
Onset:
30-60 seconds
Duration:
30-80 minutes
Cautions: Reduces SVR, myocardial depressant
Ketamine
Dose:
1-2 mg/kg IV, may give 4mg/kg IM
Advantages:
Bronchodilator as well as
anesthetic; induction agent of
choice in asthma.
Disadvantages: Emergence reactions in adults
(age > 15), increases ICP so
contraindicated in head injury
*For most RSI - other sedatives are preferable
RSI Drugs – neuromuscular
blockers (paralytics)
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Depolarizing NMBA
– Succinylcholine
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Non-depolarizing NMBA
– Vecuronium (Norcuron)
– Rocuronium (Zemuron)
Succinylcholine
Ultra short-acting depolarizing neuromuscular blocker
Dose:
2.0 mg/kg IV
Onset:
45-60 seconds
Duration:
4-6 minutes
Precautions:
Burns or crush injuries greater
than one week, increased
intraocular pressure, hyperkalemia
Succinylcholine-induced
hyperkalemic cardiac arrest
• Acetylcholine Receptor Up-regulation
– Extensive burns, extensive muscle trauma (crush
injuries)
– Denervation: spinal cord injury, stroke, GuillainBarre
– Extensive atrophy or prolonged immobilization
• Myopathic Processes
– Muscular dystrophy
– Rare Idiopathic
Granert, Anesthesiology. March 2001
K+ = 8
Rocuronium (Zemuron)
Competitive nondepolarizing agent
Dose:
0.6 – 1.0 mg/kg IV
Onset:
70 seconds
Duration:
30 minutes
Indications:
When Succinylcholine is
contraindicated, post-intubation
paralysis
Vecuronium (Norcuron)
Competitive non-depolarizing agent
Dose:
0.1 mg/kg IV
Onset:
2-3 minutes
Duration:
45 minutes
Indications:
When succinylcholine is
contraindicated, post-intubation
paralysis
Whatever drugs and equipment you
decide to use, always use a written
reference or at least a calculator for
drug doses, volumes and equipment
needs
The rapid sequence
• Push sedative
• Push paralytic
• Position airway ( Sellick's maneuver may be
used)
• Wait 45 seconds
• Do not ventilate unless the patient is hypoxic
• Laryngoscope and pass the tube
• Check the tube
Pass the tube (intubate)
• Wait 45-60 seconds after
Succinylcholine
• Position airway after
Succinylcholine
• Maintain in-line cervical
immobilization in patients
with suspected C-spine
injury
Laryngoscopy
• Laryngeal anatomy (epiglottis, glottis,
aryepiglottic folds, posterior cartilages,
interarytenoid notch, vocal cords)
• Patient positioning, mouth opening, tongue
• Blade selection / light source
• Laryngeal manipulation / cricoid pressure
• Stylet shaping, ET tube railroading
• Pediatric, obese
Laryngoscopy practice
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Training videos
Laryngoscopy courses
Operating room opportunities
Discuss cases with colleagues
• In studies, ED & OR intubation success rates
increased from 40-90+% with training
Practice will improve first pass success!
Failed airway
• Always be prepared for a failed airway
• First try to ventilate, then try again
– Bag/valve/mask, Combitube/King tube, LMA
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If able to ventilate, try another technique
– Fiberoptic intubation
– Retrograde intubation
– Use of bougie
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Unable to intubate or ventilate, then surgical
airway
Patent airway assessment
• This is done immediately after intubation
• CO2 detection with capnography or colorimetric
device
• Suction device (esp. in cardiac arrest)
• Breath sounds, oximetry and X-ray confirm
proper placement
Post intubation management
• Secure tube
• Chest X-ray
• Continued SEDATION (Midazolam 0.1 mg/kg)
and PARALYSIS (Vecuronium 0.15 mg/kg )
• Maintain cervical spine immobilization
• Pass OG tube
Post-intubation management II
• Be aware of malignant hyperthermia: rare but lethal
• Check temperature at least once 15 -30 minutes after
intubation and/or before transfer
• Watch for muscular rigidity especially masseter spasm,
unexplained tachycardia, labile BP, increased End tidal
CO2 and increased temperature
• If suspected, follow CALS protocol and notify
anesthesia/critical care/referral center
Anticipate the difficult airway
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Severe facial trauma
Penetrating or blunt neck trauma
Laryngeal edema or inhalation injuries
Short neck, receding mandible
Prominent upper incisors
Limited mouth opening
Limited ability to extend at atlanto-occipital joint
Mallampati airway classification
How would you handle this airway?
Management of Difficult Airway
Tracheal tube introducer
Blind nasotracheal
intubation
• Requires breathing, somewhat cooperative patient
• Anesthetize the airway with 4% Lidocaine and 1/2%
Neo-synephrine
• Mild sedation
• Use standard ET tube without the stylet
• Pass tube gradually listening for increasing breath
sounds
• Pass tube through cords on inspiration
Awake oral intubation
• Requires breathing, somewhat cooperative patient
• Anesthetize the airway with 4% Lidocaine and 1/2%
Neo-synephrine
• Conscious sedation with Midazolam and Fentanyl
• Perform gentle laryngoscopy to attempt to visualize
the cords
• May then give neuromuscular blocker
• If cords are seen, may attempt to pass the tube at
that time or perform RSI
Case: Head injury
9 y/o fell off bicycle, hit head on large rock.
Unconscious at scene.
On arrival he was semi-conscious, moaning, and
withdrawing to any painful stimulation. GCS = 10.
BP 100/60, HR 102, R 16, SpO2 100% on 10 LPM
by NRB mask. Lungs clear with good air
movement. Pupils - 3 mm, reactive. Motor exam withdraws all extremities symmetrically.
Does he need to be intubated? If yes, when and how?
Head injury - 9 yr old
Preoxygenate:
100% O2
Pretreatment:
Lidocaine 1.5 mg/kg
Atropine 0.02 mg/kg
Sedation:
Etomidate 0.3 mg/kg
Paralytic:
Succinylcholine 2 mg/kg
Post intubation: Versed 0.1 mg/kg
Vecuronium 0.15 mg/kg
Case: Asthma
5 y/o child with a history of asthma presents with
severe difficulty breathing. On arrival she is only able
to gasp out one word at a time. She appears mildly
cyanotic on room air.
BP 120/60, HR 160, R 30. O2 started with Albuterol
neb. IV established. ABGs pending. She becomes
obtunded with decreasing respiratory effort.
How would you manage this patient?
Asthma: 5 yr old
Preoxygenate: 100% O2
Pretreatment:
Lidocaine 1.5 mg/kg,
Atropine 0.02 mg/kg
Sedation:
Ketamine 1 - 2 mg/kg
Versed 0.1 mg/kg
Paralytic:
Succinylcholine 2.0 mg/kg
Post intubation: Versed 0.1 mg/kg
Vecuronium 0.15 mg/kg
58 y/o in shock and respiratory failure
Nebulize: 4% Lidocaine, 0.5% phenylephrine
Insert endotracheal tube into nose
Successful awake intubation
Summary
• Most patients can and should be managed
initially by good basic airway techniques
• Many critically ill or injured patients will
benefit from intubation
• Intubation may be accomplished by several
different techniques: RSI, blind nasal
tracheal, cricothyrotomy, etc.
– Always a planned procedure
– Always a foolproof rescue plan