Airway Management
Course Objectives
 Define Rapid Sequence Intubation
 Identify patients that may benefit from RSI
 General overview of RSI procedure
 Discuss methods for identifying patients with possible difficult airways.
 Discuss pharmacology associated with RSI
 Discuss the use of adjunct airways in failed intubation attempts
 Define Rapid Sequence Intubation
 Identify patients that may benefit from RSI
 General overview of RSI procedure
 Discuss methods for identifying patients with possible difficult airways.
 Discuss pharmacology associated with RSI
 Discuss the use of adjunct airways in failed intubation attempts
Airway Management
 Airway management is the single most important skill of emergency care providers
 Airway takes precedence over all other clinical considerations
 Without a secure airway and adequate oxygenation and ventilation, all other resuscitative measures will fail.
 Airway Anatomy – see book
Basic Airway Assessment
 Assess airway
 Is it open/patent? (look, listen, feel)
 Assess breathing
 What is the rate?
 Is it adequate?
 Do I need to breath for them, or assist their breathing?
 CAN YOU OXYGENATE YOUR PATIENT
 Intervene
 Open the airway (jaw thrust or head tilt)
 Ventilate patient if needed
Signs of Respiratory Distress
 Rapid
 Too slow
 Irregular
 Cyanosis
 Highly anxious
 Bolt upright posture
 Tripod posture
 Nasal flaring (MOST OFTEN SEEN IN CHILDREN)
Don’t forget your BLS airway adjuncts: OPA, NPA
Maintain C-spine precautions on ANY trauma patient or suspected cervical injury.
Opening the Airway
 The #1 cause of an obstructed airway in a conscious patient is food
 The #1 cause of an obstructed airway in an unconscious patient is the tongue
 If you suspect trauma, stabilize the head and use the jaw-thrust maneuver
 If you do not suspect trauma, use the head-tilt/chin-lift maneuver
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Head Tilt/Chin Lift
The head should only be tilted back slightly
Too much tilt backwards (hyperextension) can cause the trachea to collapse
Too much tilt forwards (hyperflexion) will also occlude the airway
Placing a small towel beneath the patient’s shoulders should align their head (airway) properly
Jaw Thrust
 Used when trauma is suspected
 This maneuver is not easy to maintain. Be aware you may get tired and need to switch rescuers
 You are basically giving the patient an under bite
Oropharyngeal Airway
Used to maintain the airway of an unresponsive patient who has no gag reflex (USED ON UNCONSCIOUS PATIENT)
How to Insert an OPA
 Open the patient’s mouth
 Size the OPA (corner of the mouth to the tip of the earlobe, or angle of the jaw)
 Insert OPA with the tip pointed to the roof of the patient’s mouth
 Advance until you meet resistance from the hard palate
 Rotate the OPA 180 degrees
 Flange should rest on your patient’s teeth
 Reassess the patient’s airway
Nasopharyngeal Airway
 Less likely to stimulate vomiting
 Can be used in patients that still have an intact gag reflex and are semiconscious
 This adjunct can be painful during insertion
 Sizing: measure from the tip of the earlobe to the tip of the nose; it should also fit inside the diameter of the
nose
How to Insert a NPA
 Size the NPA
 Lubricate the NPA with a water-soluble lubricant (Xylocaine jelly, K-Y jelly)
 Place the beveled edge against the septum
 If you meet resistance…..STOP
 Reassess the airway
The Decision to Intubate
 Is there a failure of airway maintenance or is integrity compromised?
 Is there a failure of ventilation and oxygenation?
 What is the anticipated clinical course?
Rapid Sequence Intubation
 The purpose of RSI is facilitate endotracheal intubation with the least likelihood of aspiration.
Contraindications
 Absolute - Lack of training by personnel
 Predicted difficult intubation is NOT a contraindication
 Establish a back-up plan
Indications for RSI
 Can the patient protect their airway? Ask the patient if he/she swallow strongly….this is due to the ability of the
epiglottis opening
 Can you oxygenate the patient?
 What is the expected clinical course?
The Technique
The 7 P’s to successful intubation
 Preparation – this is where the nurse comes into play (get all the supplies ready…always have a backup plan…if
the patient cannot be intubated)
 Preoxygenate
 Pretreatment
 Paralysis with induction
 Protection and positioning
 Placement and proof
 Postintubation management
1. Preparation
 Full patient assessment including assessing for possible difficult airway.
 All fall back plans established.
 Cardiac monitoring, BP monitoring, SaO2.
 Gathering of equipment.**
2. Preoxygenation
 Preoxygenation is essential to RSI (use a nonrebreather mask)
 Preoxygenation is required to establish the oxygen reservoir
 100% O2 for approximately 5 mins
 Provide Oxygen
Nasal Cannula
Face Mask
24% - 44% O2
with reservoir
60% - 100%
Bag valve mask
 Important skill for healthcare providers
 Dependent on adequate seal and patent airway
 Can deliver high concentrations of oxygen
 Two types
- self inflating – big blue bubble bag (gives 100% O2)
- flow inflating
 Oxyhemoglobin Dissociation Curve
3. Pretreatment
 The administration of drugs to mitigate adverse effects associated with intubation. Should be given
approximately 3 mins prior to intubation.
 LOAD - Lidocaine 1.5 mg/kg **
Opiate (fentanyl)**
Atropine 0.02 mg/kg (pediatric)
Defasciculation 0.01 mg/kg
4. Paralysis with induction
 Administration of induction agent (Etomidate or Versed) to produce rapid LOC followed by a Neuromuscular
blocking agent.
 Administration should be RAPID IV push.
5. Protection and Positioning
 LOC should be present after 30 sec.
 Sellick’s maneuver should be applied. Pressure on the cricoid cartilage to prevent passive regurgitation of gastric
contents. – very very important for a Nurse to know and do Remember BURP (back, up, right, pressure) – helps
to see the opening of the vocal cords
How should you maintain cricoid pressure? Do not let up on pressure until tube is in place, cuff is inflated
6. Placement and Proof
 Placement and Proof
 Approximately 45 seconds after the administration of neuromuscular blocking agent, the tube should be placed.
 Techniques for confirmation
Feeling of going through cords
Bilateral breath sounds
End tidal CO2 (gold standard) -- Capnography Misting Pulse oximetry Breath Sounds
Colormetric end tidal CO2
Aspiration techniques
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Postintubation Management
Administration of appropriate sedating agent should be given 1 min following OETT placement.
Bradycardia post intubation should be assumed attributed to esophageal intubation until proven otherwise.
Hypertension usually indicates inadequate sedation.
A (LONG TERM) sedative agent and neuromuscular blocking agent should be administered according to protocol.
Tips and Timing
 Ideal time required for each RSI step.
 Preoxygenation should be 5 mins or 8 vital capacity breaths.
 Pretreatment drugs should be given 3 mins before the administration of the sedative and neuromuscular
blocking agent.
Common Mistakes
Making the difficult airway more difficult
1. Rushing
2. Poor equipment preparation (including lack of suction)
IN REVIEW
 Preparation
 Preoxygenate
 Pretreatment
 Paralysis with induction
 Protection and positioning
 Placement and proof
 Postintubation management
What if I lose SaO2?
Remember…….. DOPE!!!!!
Dislodged
Obstructed
Pneumothorax
Equipment failure
Adjunct Airways
CombiTube
Laryngeal Mask Airway (LMA)
CombiTube
 Indications
Failed airway which is not due to foreign body obstruction. When skill level of personnel does not permit intubation.
When endotracheal intubation is felt to be impossible.
 Contraindications
Pt is responsive
Intact gag reflex
Known esophageal disease
Ingestion of caustic substances
Upper airway obstruction due to foreign body.
Laryngeal Mask Airway (LMA)
 Designed to cover the supraglottic area.
 Used as a temporizing agent in a failed airway situation.
 Patient must be sedated.
LMA Disadvantages
 Not a definitive airway device
 Does not protect against aspiration.
 Different sizes needed.
Pharmacology
Premedications - Fentanyl
Sedatives and Induction Agents
- Benzodiazepines (Versed, Valium, Ativan)
- Etomidate
Muscle Relaxants (paralytics)
- depolarizing neuromuscular blocking
- nondepolarizing neuromuscular blocking
Pretreatment
Lidocaine
Opioid
Atropine
Defasciculation
 Pretreatment
Lidocaine
-1.5mg/kg 3 mins prior to intubation
- increases depth of anesthesia
- decreases cerebral oxygen demand
- decreases cerebral blood flow
- suppresses cough reflex (important because with patient with head injury, this will decrease ICP)
Premedications
 Fentanyl (Sublimaze) 100 times more potent than Morphine
Classification – Opioid analgesic
Binds with the opiate receptors in the CNS
No direct effect on ICP
Suppress respiratory effort (hypercarbia)
Potential for hypotension
Dose 1-3 mcg/kg
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Sedatives and Induction Agents
midazolam (Versed)
etomidate (Amidate)
propofol (Diprivan)
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Etomidate (Amidate)
A carboxylated imidazole-containing hypnotic anesthetic (induction agent)
Dose: 0.2-0.4 mg/kg IV only
Onset: 15-45 seconds
Duration: 3-12 minutes
Contraindications: none (except in pedi)
Effects
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pain on injection, venoirritation
involuntary myoclonic movements due to brain stem stimulation
anticonvulsant properties
decreased CBF, ICP
adrenal suppression (5-8 hrs duration)
no histamine release
minimal cardiorespiratory depression
no blunting of sympathetic response unless combined with opioid
Midazolam (Versed)
 Benzodiazepine Very important to monitor BP while using this medication
 IV, PO, IM, PR, intranasal
 Onset: 2-3 minutes, duration of IV dose ~ 2 hours
 Uses:
 Anxiolytic
 Induction of anesthesia
 Sedation
 Anticonvulsant
 Amnestic
 Dosages:
 Sedation: IV bolus: 1-2 mg IV Q 2 min
 Infusion: 1-7 mg/hr
 Anticonvulsant: 1-2 mg IV Q 2 min
 Induction of anesthesia: 0.3 mg/kg IVP
 Reduce dosage in elderly, pt’s with hepatic failure
 Contraindications:
 Allergy
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Propofol (Diprivan)
Alkylphenol derivative - hypnotic agent
Indicated for induction of anesthesia
Good procedural drug
Significant hypotension
Some myocardial depression
Dose range 10-100 mcg/kg/min
Muscle Relaxants (Paralytic)
Muscle Relaxants (2 classifications)
- depolarizing neuromuscular blocking
- non-depolarizing neuromuscular blocking
Muscle Relaxants does not have a analgesic affect, YOU MUST USE A SEDATIVE AND PAIN CONTROL
 Succinylcholine (clears in 3-5mins)
Noncompetitive Depolarizing NMBA
Binds with Nicotinic acetylcholine receptors resulting in depolarization of the muscle
Benefits
-Rapid onset
- Short duration
- Low histamine release
Pharmacokinetics of Succs
 Succinylcholine binds with and depolarizes nicotinic acetylcholine receptors to cause paralysis.
Side Effects of SCh
 Fasciculations – involuntary muscle twitching caused by the stimulation of acetylcholine receptors.
 Hyperkalemia****
 Refractory bradycardia
 Hypotension (histamine release)
 Prolonged neuromuscular blockage
 Malignant hyperthermia****
 Trismus
Contraindications to SCh
 Anyone with ongoing or suspected hyperkalemia
 Progressive ongoing neuromuscular disease
 Renal considerations
 Malignant hyperthermia
Dosing SCh
Dose – 1.5mg/kg to 2mg/kg IV
Onset - 45-60 sec
Return of spontaneous resp. – 3-5 mins
NEVER REDOSE!!
Competitive, non depolarizing NMBA
Compete and block the action of acetylcholine at the neuromuscular junction.
Does not cause fasciculations.
Major drawback is the longer onset of action and the longer duration of action.
May be reversed by acetylcholinesterase inhibitors such as neostigmine.
Mivacron, Vecuronium, Rocuronium, Pavulon
 Vecuronium
Competitive non-depolarizing NMBA
Onset - 2-3 minutes
Dose – 0.1 mg/kg
Duration – 30-45 minutes
Higher dose of 0.3 mg/kg may be used to reduce onset to 90 sec.
Vecuronium considerations
 Children may require higher doses (per medical control).
 Those under 1 year of age may have pronounced effects.
 Those patients with existing neuromuscular diseases such as Myasthenia gravis may have profound effects.
 Malignant Hyperthermia