Carrie de Moor, MD

Associate Medical Director/ED Trauma Director

JPS Health Network
4/21/2012
 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
 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)
 Positioning
 Assistance at bedside (nursing/RT)
 Time to prepare and plan
 Fasting patient
 Ability to abort the procedure
 Anesthesia/surgical back up available
 Intact, clear airway
 Wide open mouth
 Pre-Oxygenated
 Intact respiratory drive
 Normal dentition
 Normal and Easily identifiable anatomy
 Good Neck Mobility
 This ideally should occur before you attempt!
 Review Past Medical History
 Physical Exam
 Mallampati Classification
 Thyromental Distance
 Obvious deformities/Trauma
 Signs of obstruction
 Neck Mobility
 Previous Difficult Intubations
 Previous Surgical Airway
 Congenital Conditions- Pierre Robin Syndrome
 Arthritis- Rheumatoid, Ankylosing Spondylitis
 Prior C-spine/Neck Surgeries
 Head and Neck tumors
 Limited Neck Mobility
 Facial Instability
 Burns
 Obesity or very small.
 Short Muscular neck
 Receding Jaw
 Signs of Anaphylaxis
 Stridor/FBAO
 Scars from Previous Surgeries
 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?
 Consider Alternatives for Airway Support
 CPAP/BiPAP
 Call Backup/Intubation in controlled OR setting

 Prepare for need to change equipment

 Different blades
 Different tube sizes
 Bougie
 LMA/Combitube
 Advanced Airway Equipment- Glidescope, Fiberoptics
etc
 Prepare for Surgical Airway
 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)
 BURP : “backward-upward-rightward
pressure” of the larynx
 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
 Sniffing Position
 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
 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

 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
 Video
“Hey Doc.. We’re out of Etomidate”
 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

 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
 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
 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.
 Dosage needs vary from patient to patient
 Onset of action can be unpredictable
 Poor choice for true Rapid Sequence Intubation
 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
 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
 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
 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