Carrie de Moor, MD
Associate Medical Director/ED Trauma Director
JPS Health Network
4/21/2012
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Recognize potential difficult airways
Review Techniques for Advanced Airway
Management
Understand options for sedation in RSI during
a national shortage of Etomidate
Become familiar with new advanced airway
management tools
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Poor oxygenation or ventilation
Inability to protect the aiway (Decreased
LOC/GCS, secretions, swelling, severe facial
trauma)
Potential for rapid deterioration
Patient/Staff safety ( The acutely agitated
patient)
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Positioning
Assistance at bedside (nursing/RT)
Time to prepare and plan
Fasting patient
Ability to abort the procedure
Anesthesia/surgical back up available
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Intact, clear airway
Wide open mouth
Pre-Oxygenated
Intact respiratory drive
Normal dentition
Normal and Easily identifiable anatomy
Good Neck Mobility
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This ideally should occur before you attempt!
Review Past Medical History
Physical Exam
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Mallampati Classification
Thyromental Distance
Obvious deformities/Trauma
Signs of obstruction
Neck Mobility
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Previous Difficult Intubations
Previous Surgical Airway
Congenital Conditions- Pierre Robin Syndrome
Arthritis- Rheumatoid, Ankylosing Spondylitis
Prior C-spine/Neck Surgeries
Head and Neck tumors
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Limited Neck Mobility
Facial Instability
Burns
Obesity or very small.
Short Muscular neck
Receding Jaw
Signs of Anaphylaxis
Stridor/FBAO
Scars from Previous Surgeries
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Is there blood in the airway?
Is the patient actively vomiting?
Are there teeth missing?
Is there clinical suspicion for Epiglottitis, RPA,
or Ludwig’s Angina?
Is the patient immobilized?
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Consider Alternatives for Airway Support
CPAP/BiPAP
 Call Backup/Intubation in controlled OR setting
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Prepare for need to change equipment
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Different blades
Different tube sizes
Bougie
LMA/Combitube
Advanced Airway Equipment- Glidescope, Fiberoptics
etc
Prepare for Surgical Airway
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Sellick’s Maneuver/Cricoid Pressure ( +/-)
BURP maneuver
Good Positioning- Sniff position
Always have a bougie in your pocket
Cricothyrotomy
• Application of pressure to a patient’s cricoid cartilage during
endotracheal intubation to prevent aspiration
• Pitfalls:
• Potential for Airway obstruction
• Evidence that it actually prevents aspiration is lacking
• A 2007 study published in Annals of Emergency Medicine
recommended that “the removal of cricoid pressure be an
immediate consideration if there is any difficulty either in
intubating or ventilating the ED patient.” (Ellis)
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BURP : “backward-upward-rightward
pressure” of the larynx
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Displaces the thyroid cartilage dorsally so that the
larynx is pressed against cervical vertebrae’s body
Ideally two centimeters in cephalic direction, until
resistance is felt
Next it should be displaced 0.5 cm -2.0 cm rightward
When used with Sellick’s may actually worsen
view
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Sniffing Position
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First Described in 1936 by Bannister and MacBeth- to
align oral, pharyngeal, laryngeal axes to provide
optimal exposure of the glottis
Pitfalls: Inadequate for the morbidly obese
patient, not an option with suspected cervical
spine injury
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Ear-to-sternal notch positioning improves the
mechanics of ventilation, both with
spontaneous breathing, and with mask
ventilation.
In the obese patient: shoulders are elevated, the
head and neck are extended, and the external
auditory meatus is in line with the sternal
notch
Figure 1. Elevated head-up position.
Zvara D A et al. Anesth Analg 2006;102:1592-1592
©2006 by Lippincott Williams & Wilkins
Figure 2. Whelan-Calicott position.
Zvara D A et al. Anesth Analg 2006;102:1592-1592
©2006 by Lippincott Williams & Wilkins
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Atlanto-occipital extension is necessary to
bring the vocal cords within line-of-sight of the
mouth, manual axial in-line stabilization
reduces this movement by 60%.
Bougie for Intubation
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Video
“Hey Doc.. We’re out of Etomidate”
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There are a number of options for RSI- choose
wisely
Succinylcholine vs. Rocuronium/Vecuronium
Consider potential for awake
intubation/sedated but not paralyzed
intubation
Know your drugs and your doses
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Dosage: 2-3 mg/kg IV Push
Onset of action: < 1 minute
Duration 3-10minutes
Benefits: Rapid onset, brief duration, amnestic
Caution: Causes cardiovascular depression and
hypotension
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Dosage: 1-2mg/kg slow IVP
Onset: 30 seconds to 1 minute
Duration: 5-10 minutes
Benefits: Potent Bronchodilator, leaves
protective airway reflexes intact, maintains
cardiovascular stability
Caution: Old Dogma regarding elevated ICP
with use, increases sympathetic tone,
emergence delirium common
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Often underutilized due to old dogma regarding
ICP
Ketamine is a non-competitive NMDA receptor
antagonist and has neuroprotective effects
Studies claiming ketamine should be avoided in
head injury are based on 3 studies from the 1970’s,
recent studies have shown no convincing evidence
that these claims are valid
Acute agitation and emergence reactions may be of
concern for conscious sedation. However, in the
RSI population where continued sedation with
benzodiazepines is possible, this is of less concern.
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Dosage needs vary from patient to patient
Onset of action can be unpredictable
Poor choice for true Rapid Sequence Intubation
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Cost: $11,000 for the Cobalt
Benefits: Easy to use, easy to observe
student/resident procedures, minimal need to
manipulate the neck
Features- Pediatric and Adult Sizes, unique 60
degree blade, disposable and reusable options
3 options: Cobalt, Ranger, GVL
Pitfalls: Expensive, limited visibility with
significant secretions or blood
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Cost: $700-800
Benefits: Easily portable, affordable, no need
for special stylette
Pitfalls: Lower resolution than glidescope, less
useful in teaching scenarios due to size of
screen
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Cost: $60,000
Benefits: Maintains the same curvature are the
basic MAC blade, may be used for
conventional direct laryngoscopy or with video
assistance, benefits for teaching scenarios
Pitfalls: Price, mobility
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Abrams K.J., Grande C.M. "Airway Management of the trauma patient with cervical spine
injury", Current Opinion in Anesthesiology 1994;7:184-190
The BURP Maneuver . Images in Anesthesiology .Vol. 31. No. 1 January-March 2008 pp
63-6
Cattano, D. Cavallone, L. Airway Management and Airway Positioning: A Clinical
Perspective. Anesthesiology News. 2010:35-40.
Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid
sequence tracheal intubations: A risk-benefit analysis. Annals of Emergency
Medicine. 2007;50:653-665
EmCrit. “Use of the Bougie for Intubation” http://youtu.be/E7Lo1JD2Brk
Hastings R.H., Marks J.D. "Airway Management for Trauma Patients with Potential Cervical
Injuries", Anesth Analg 1991;73:471-82.
Zvara D A et al. Positioning for Intubation in Morbidly Obese Patients Anesth Analg
2006;102:1592-1592