Samir Patel Airway Disasters
5% of intubations in the ED are considered difficult
2% of intubations in the ED are failed (Defined by first 3 attempts fail)
You have to be prepared for this. It eventually will happen to you.
Treat every airway as a difficult airway
Prior planning before starting intubation is the key to success.
* Algorithm for Difficult Airway
Indications for Intubation:
Hypoxic or hypercapnic respiratory failure
Anticipated deteriorating course of illness
Work of Breathing (tachypneic, septic patients are using 30% of their cardiac output for diaphragm contraction)
*MOANS Predictors of Difficult BVM
*Lemon Law Predictors of Difficult Laryngoscopy
*Mallampati Score Class 1 and Class 2 predict reasonable airway visualization. Class and 3 and Class4 predict poor airway visualization.
A Major Rule is: Don’t have any pride when working with a difficult airway. Get help from ICU, anesthesia, surgery and other EM physicians. Whoever you need. There is no shame in getting help.
Sedated Nasal fiber -optic Intubation
Start with 4% nebulized lidocaine
Afrin and glycopyrrolate can help dry secretions
Ketamine for sedation
Warm the ET tube in warm water. It makes the tube more malleable
When you visualize the cords with the fiberoptic scope have someone spray the cords with lidocaine so you don’t get laryngospasm
Apneic Oxygenation (basically a nasal cannula running at 15 liters per minute or more during intubation) prolongs your safe apnea time. High flow nasal oxygen devices are even better than nasal cannula but it is more bulky.
*Delayed Sequence Intubation. Give Ketamine slowly to avoid apnea. The ketamine will calm an agitated patient allowing you to better pre-oxygenate and prepare.
Avoid IV Ativan in patients with respiratory distress. It reduces their respiratory drive and it may force you to intubate before you are ready.
Lovell Airway Devices
To lessen your anxiety during a difficult intubation, it is useful to have familiarity with the airway tools you are using. So practice with different devices so you are comfortable using them.
You always need to have a supraglottic device and a surgical option in your armamentarium as rescue devices.
Elise’sMinimum List of Devices every Intubating physician needs to have available and be comfortable using:
Fiberoptic device (Really CMOS/digital camera technology. It is more durable than fiberoptic technology)
The difficulty with the Glidescope is properly passing the tube once you get a great view. You need to pop back the stylet once you have the ET tube at the glottis to appropriately position the ET tube thru the cords.
Elise discussed many advanced airway devices available on the market.
The biggest error with cricothyrotomy is waiting too long to start doing it.
If the O2 sat is dropping and you have a failed intubation, stabilize with an LMA. Based on your ability to oxygenate with an LMA you either must rapidly do a cricothyroidotomy or if you can oxygenate OK, attempt intubation thru the LMA.
If the patient is in a HALO, initial intubation attempt should be with video laryngoscopy.