Download Airway Assistant

#1
Essential Emergency Airway CareAirway Preparation
Andrew Brainard, MD, MPH, FACEM, FACEM
www.thesharpend.org
[email protected]
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#1 Pre-arrival preparation of Team, Plan, Room,
and Equipment
• Learning Objectives:
•
– Prepare TEAM
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•
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Assign team leader (jacket, roles, plan)
Primary airway operator
Backup airway operator
Airway assistant
Drug provider
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–
•
– Prepare ROOM
• Move bed, Resus tower, and Airway
cart
– Prepare EQUIPMENT
•
•
•
•
•
Monitor
BVM, Adjuncts, Oxygen, Suction
Laryngoscopes, ETT, Bougie
Backups (SGA/Video/Cric)
Drugs
•
No signs of trauma, OSA
GCS 5, RR 6, SaO2 88%, pulse 100, BP 100/60.
Team should prepare for critical patient
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–
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– Basic Pre-Arrival PLAN
• Possible A, B, C, and D
• Likely Medications
• Ensure team members understand and
are skilled in their roles
R40: 50y/o F found down and
unresponsive at home.
Team
Plan
Room
Equipment
Conduct a Detailed Tour of ED resus area
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Wear Jacket
Bed (Move Bed, Apply Brakes, Head Elevation)
Resus Tower (BVM, Suction, Oxygen, SaO2, ET CO2)
Airway Cart (Top Through Bottom Drawer)
Medications (Cart, Intubation Box, Pyxis)
Airway Aids (Posters, Checklist)
Video laryngoscope
Ventilators, CPAP/BiLevel
Store Room
•
–
Trach, spare ETT, other supplies
Paed Dose Calculator on Computer
Managing the Airway Team
3
Plan AInitial oxygenation plan
If ≤93%, re-oxygenate
2 person BVM w/ OPA/NPA
Plan BBackup oxygenation plan
If ≤93%, re-oxygenate
2 person BVM w/ OPA/NPA
Plan CMaintain oxygenation
and ventilation
Go to plan D if Sats ≤85%
Continue with BVM/LMA
Plan D-
!
Declare:
!
Can’t Intubate
Can’t Oxygenate
!
!
Always'Op*mize'for'Success'
Prepare'for'FAILURE'
Specific'Backup'Plans…'
•
'
Contact'Help?'
Paediatrics*+
Neonatology*+
Surgery*+
(Modified+from+the+Difficult+Airway+Society)+
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Medications
Primary Airway
Operator
• Team Leader
• Primary Airway Operator
Backup
Airway
Operator
– Backup Airway Operator
• Airway Assistant
• Manual In-line Stabilization
Drugs
• Drug Provider
• Runner/Scribe/Other
• Intensive Care
Team Leader
Intensive Care
5
Preparing the room and equipment
• Locate your personnel
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–
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–
Resus Nurse(s)
ED SMO(s)
ED Reg(s)
Charge Nurse
• ICU
• Anesthetics
• Prepare the Room
– Move the bed
– Move the airway cart
– Move the resus tower
• Prepare the Resus Tower
– Prepare the Monitor
• Prepare the Airway Cart
• Drugs
• Locate your backup stuff
– Video-laryngoscope etc..
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Preparing the Resus Tower and Monitor
Monitoring
1st monitor on
SaO2
Not on BP arm
ETCo2
Tested
On BVM
2nd monitor on
Tower
Suction
Tested
Under Pt’s R shoulder
Oxygen
Mask
Nasal
BVM
BVM
O2 on
Reservoir bag
PEEP
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Preparing the
Airway Cart
•
Cart Location
•
Top
– Set up as needed
•
Side
Suction
– Pt’s right
– Orientation (able to open drawer)
– Bougie, Tube Exchanger
•
1st Drawer
– Adjuncts: OPA, NPA, Suction, Mask
•
2nd
& 3rd Drawer
– Primary: Laryngoscopes, ETCo2, 3rd Drawer
– ETT, Tie
•
4th Drawer
– AirQ SGA (3 sizes) w/ stabilizer
•
5th Drawer
– I-LMA, I-LMA ETT, w/ stabilizer
•
Bottom drawer
– Scalpel
– Cric Pack
•
pen, scalpel, 6-0 cuffed ETT, disinfectant, gauze, lube,
– Cook Melker Surgical + Percutaneous Cric Kit
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Important Equipment Checks:
Medications
Resus Tower/Gantry
Suction
Oxygen
Mask/BMV/Nasal
RSI meds
Ventilator
Suction
Oxygen
Power
Videoscope
ETT
Stylet
On
Circulation
2nd Monitor
IV
Fluids
A-lines
Room
Bed
Position
Height
Locked
Tower
Position
Height
Videoscope
Monitoring
1st monitor on
SaO2
Not on BP arm
ETCo2
Tested
On BVM
nd
2 monitor on
Tower/Gantry
Suction
Tested
Under R shoulder
Oxygen
Mask
BVM
Nasal
BVM
O2
Reservoir bag
PEEP
Cart
Top
Adjuncts (OPA/NPA)
Laryngoscope
Lights tested
2 sizes
ETT
Lubed
Stylet shaped
Smaller size ready
Syringe/tie
Drawers
LMA/AirQ sized
Cric kit located
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Medications
Prep RSI meds
Prep IV fluid
Prep maintenance meds
*Airway Assistant*
*Primary Airway Operator*
Assure oxygenation
Formal airway assessment
Vocalize plan A, B, C, D
Primary airway procedure
Prep airway table
Suction, Adjuncts, Laryngoscopy,
ETT, Bougie, LMA, Cric Kit,
Place nasal O2
External laryngeal manipulation
Handles tube/bougie
Assists with securing tube
Monitoring
Prep Room
Monitoring
SaO2, ETCo2, BP, ECG
Intensive Care
Continuity of Care
Transport
*Backup Airway Operator*
Examine patient
Position patient
External laryngeal manipulation
Backup airway procedures
Perform cricothyroidotomy
*Drugs*
IV/IO x2
Administer RSI meds
Team Leader
Prepare room/staff
Leads resuscitation
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Indications for advanced
airway management
• Goals of Care
– Non-futile treatment
– Able to complete continuity of care
• Unprotected airway
– Obtunded, GCS <8, Cardiac arrest, Trauma
• Oxygenation or ventilation
– Not appropriate for BVM/CPAP/BiLevel
• Clinical course
– Agitated patient needing sedation for patient and staff safety
– Expected future airway difficulty
• trauma, burns, infection, angioedema
– Need for pain control in patients during future procedures
• Theatre, CT, etc.
– Expected multi-organ failure or severe sepsis
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Different urgency of airway control
• Crash– Extreme time pressure
– Forced-to-act
• Difficulty oxygenating and ventilating
• Emergent– Substantial time pressure
– Can be oxygenated
• Allows for some preplanning and preparation
• Semi-Elective– Minimal time pressure on stable patient
• Full assessment and planning time
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Airway Assessment
• MOANS (Mask)
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M: mask seal
O: obstruction / obesity
A: age (>55)
N: no teeth
S: stiff lungs or c-spine
• LEMON (Intubation)
– L: look
– E: evaluate 3-3-2
– M: mallampati
– O: obstruction / obesity
– N: neck
• RODS (SGA/LMA)
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R: restricted mouth
O: obstruction
D: disrupted or distorted
S: stiff lungs or c-spine
• SHORT (Surgical Airway)
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S: surgery
H: haematoma
O: obesity
R: radiation
T: tumor
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Airway
Assistant
Airway Assistant
Drugs
Drugs
Primary
Airway
Primary Airway
Operator
Operator
Team
Team
Leader
Leader
*Confirm that people understand their roles*
Primary
•Formal Airway
Assessment**
•Plan A, B, C, D
•Pullout Criteria
Backup
•Backup
Criteria
•Cric
plan
Airway Assistant
•External Laryngeal
Manipulation
•Bougie/tube
procedure
•Equipment names
& sizes
Drugs
• Access
• Drugs
• Dose
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The Pre-arrival briefing
Suggested NZEMN ED Airway Algorithm
Direct laryngoscopy
Plan ARSI$
Drugs:$Consider)Contraindications!))
bougie+7.5 tube
Initial oxygenation plan
typical
Seda: ve%
• We have a 40 y/o female who has taken a large poly-overdose
with a decreased level of responsiveness. She is reported to
have vomited several times and is ventilating poorly.
• If we think airway management is indicated and our formal
airway assessment indicates it is appropriate to proceed, our
plan will be to intubate her.
If ≤93%, re-oxygenate
2 person BVM w/ OPA/NPA
• The team will be:
Plan B-
– Me as team leader
– Fred as primary airway operator
– Linda as backup airway operator
– Viola as airway assistant
– I will also push the drugs
Video laryngoscopy
stylet+7.5 tube
Backup oxygenation plan
%
If ≤93%, re-oxygenate
2 person BVM w/ OPA/NPA
Plan C-
AirQ 3.5
Maintain oxygenation
and ventilation
Go to plan D if Sats ≤85%
Continue with BVM/LMA
typical
Paraly: c%
Plan D-
!
Declare:
Can’t Intubate
Can’t Oxygenate
!
!
%
%
!
Always'Op*mize'for'Success'
Prepare'for'FAILURE'
Specific'Backup'Plans…'
•
'
Contact'Help?'
Paediatrics*+
Neonatology*+
Surgery*+
(Modified+from+the+Difficult+Airway+Society)+
! Post%
Intuba:
• Assuming no contraindications, we will RSI with Thio and Sux,
with dose to be determined.
• Our plan will be:
A- Direct laryngoscopy with bougie+7.5 tube
B- Video laryngoscopy with stylet+7.5 tube
C- AirQ size #3.5
D- Cric for Sats <80% and dropping
• We will use all our “best practice” techniques.
on%
Care%
!
! people understand their roles*
*Confirm that
!
Primary
Backup
!
• Formal Airway • Backup Criteria
!
%
Assessment**
• Cric plan
• Plan A, B, C, D!
• Pullout Criteria
!
! Debrief%
!
Airway Assistant
• External Laryngeal
Manipulation
• Bougie/tube
procedure
• Equipment names
& sizes
Drugs
• Access
• Drugs
• Dose
• Everyone understand their roles?
• Questions or suggestions?
• Let’s make sure everything is ready for this patient’s arrival.
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Final%
Difficulty?%
Prepare%
for%
FAILURE%
TEAM%
%
Specific%
Backup%
Plans…%
%
Help?%
%
EQUIPMENT%
RSI$Drugs:$Consider)Contraindications!))
typical
Seda: ve%
%
%
PATIENT%
typical
Paraly: c%
%
%
DRUGS%
! Post%
Intuba:
%
PLAN%
for%FAILURE%
on%Care%
!
!
!
!
!
%
!
!
! Debrief%
!
!
Contact with questions/[email protected]
1/06/14
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Tips for managing the team
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Knowledge
Experience
Respect
Seniority
Mannerisms
Age
Gender
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Introduce yourself
Ask for everyone’s name
Assign roles
Preplan
Practice
Volume
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Brief Preparation References:
•
George Kovacs and J. Adam Law: Airway Management in Emergencies, 2nd Ed, 2011
•
Walls RM and Murphy MF. Manual of Emergency Airway Management, 4th Ed, 2012
•
Chris Nickson: Own the Airway- Life in the Fast Lane (http://lifeinthefastlane.com/own-the-airway/)
(accessed on 15/6/2014)
•
Reuben Strayer. Free Emergency Medicine Talks: Contemporary Strategies in Airway Management
http://freeemergencytalks.net/wp-content/uploads/2012/07/2012-06-29-D3T3-1430Contemporary-Strategies-in-Airway-Management.mp3 (Accessed on 1/06/13)
•
Tim Leeuwenburg. SMACCGold: Checklists in Airway Management (http://vimeo.com/89997364)
(18min) (accessed on 15/6/2014)
•
The Difficult Airway Society Guidelines (http://www.das.uk.com/guidelines/guidelineshome.html)
(accessed on 15/6/2014)
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Nicholas Chrimes & Peter Fritz- The Vortex Approach
http://www.vortexapproach.com/Vortex_Approach/Vortex.html (accessed on 15/6/2014)
•
Javier Benitez, Academic life in emergency medicine. Mnemonics for difficult airway predictorshttp://academiclifeinem.com/mnemonics-for-difficult-airway-predictors/ (accessed on 15/6/2014)
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