Rosen & Barkin's 5-Minute Emergency Medicine Consult (37 page)

See Also (Topic, Algorithm, Electronic Media Element)

• Alcohol Withdrawal
  
• Poisoning, Toxidromes
  
• Delirium
  

CODES

307.9 Other and unspecified special symptoms or syndromes, not elsewhere classified

BASICS

• Airway adjuncts are devices used for management of the upper airway
  
• Often used as rescue techniques/devices when unable to intubate with standard techniques and difficult to mask ventilate
  
• Oral and nasopharyngeal airways:
  
  • Lift tongue off hypopharynx
    
  • Combined with positioning aid in airway patency
    
  • Nasopharyngeal airway may be used when gag reflex intact
    
  • Oropharyngeal airway placement requires absent gag reflex
    
• Extraglottic devices (EGD):
  
  • Supraglottic (SGD) class (i.e., LMA, PAXpress, CobraPLA, iGel, etc.)
    
  • These sit above and surround the glottis
    
  • Retroglottic (RGD) or infraglottic (IGD) class (i.e., Combitube, King tube, Ruch EasyTube, etc.)
    
  • RGD/IGD ventilate at the hypopharynx and occlude the esophagus
    
• Blind insertion technique (specific to device)
  
• Less protection from aspiration compared to ET tube
  
• High success rates for placement of EGDs
  

• 95% success with 1st method of airway management
  
• 98% overall success of intubation
  
• 4% of ED airways are difficult
  

DIAGNOSIS

• Predictors of difficult to bag-mask ventilate (MOANS)
  
  • M – Mask seal (beards/structural abnormality)
    
  • O – Obese or obstructed
    
  • A – Advanced age (>55 yr)
    
  • N – No teeth
    
  • S – Stiff
    
• Predictors of difficult laryngoscopy and intubation (LEMON)
  
  • L – Look externally
    
    • Micrognathia
      
    • Buck teeth
      
    • Large tongue
      
    • Short neck
      
  • E – Evaluate 3-3-2
    
    • Mouth opens <3 fingerbreadths
      
    • Horizontal length of mandible <3 fingerbreadths
      
    • Thyromental distance <2 fingerbreadths
      
  • M – Mallampati score (increasing difficulty)
    
    • Class I: Soft palate, uvula, fauces, pillars visible
      
    • Class II: Soft palate, uvula, fauces visible
      
    • Class III: Soft palate visible
      
    • Class IV: Hard palate only visible
      
  • O – Obstruction
    
    • Vocal changes/muffled voice
      
    • Difficulty managing secretions
      
    • Stridor
      
  • N – Neck mobility (limited)
    
• Predictors of difficult cricothyrotomy (SHORT)
  
  • S – Surgery or disrupted airway
    
  • H – Hematoma or infection
    
  • O – Obese (access problem)
    
  • R – Radiation
    
  • T – Tumor
    
• Predictors of difficult EGD (RODS)
  
  • R – Restricted mouth opening
    
  • O – Obstruction
    
  • D – Disrupted or distorted airway anatomy
    
  • S – Stiff lungs or cervical spine
    

• Pulse oximetry should rise or remain at high level with successful airway management
  
• Confirming correct placement:
  
• Fiberoptic bronchoscopy (gold standard)
  
• End tidal capnometry/capnography (>99% reliable)
  
• Physical exam (common but unreliable)
  
• Chest rise/fall
  
• Auscultation of breath sounds with absence of sound over epigastrium
  
• Condensation inside the ETT
  
• Arterial blood gas is used to guide ventilator settings once airway established.
  

CXR: Useful only in patients following endotracheal intubation to exclude mainstem bronchus intubation or pneumothorax and to adjust the position of the tube

TREATMENT

• Options for patients requiring prehospital airway management vary by region and include:
  
  • Bag-valve-mask ventilation ± OPA or NPA
    
  • Orotracheal intubation (±RSI)
    
  • Nasotracheal intubation
    
  • EGD placement
    
  • Surgical airway
    

• Maintain in-line cervical spine immobilization in trauma patients
  
• Oxygen (high flow via nonrebreather or BVM)
  
• Vascular access (for resuscitation and medication administration) IV or IO
  

• Rapid sequence intubation
  
• Prepare
  
  • Suction, BVM, ETT, primary airway management modality, rescue airway management modality, medications
    
• Preoxygenate
  
  • NRB or BVM with 100% FiO
    ₂
    for 3 min
    
• Pretreatment
  
  • Minimize adverse responses to airway management
    
  • Suspected elevated ICP
    
  • Ischemic heart disease or major vessel dissection/rupture
    
  • Adults with significant reactive airways disease
    
  • Children up to 10 yr of age
    
• Paralysis with induction
  
  • Administration of induction agent
    
  • Rapid sequential administration of paralytic agent
    

• Induction
  
  • Etomidate: 0.3 mg/kg IV
    
  • Ketamine: 1--2 mg/kg IV or 4–7 mg/kg IM
    
  • Midazolam: 0.07–0.3 mg/kg IV
    
  • Propofol: 2–2.5 mg/kg IV
    
  • Thiopental: 3 mg/kg IV
    
• Paralysis
  
  • Succinylcholine: 1–1.5 mg/kg (peds: 2 mg/kg) IV, 2.5 mg/kg IM/SC
    
  • Rocuronium: 1 mg/kg IV (paralyzing dose); 0.1 mg/kg IV (defasciculating dose)
    
  • Pancuronium: 0.1 mg/kg IV (paralyzing dose); 0.01 mg/kg IV (defasciculating dose)
    
  • Vecuronium: 0.1 mg/kg IV (paralyzing dose); 0.01 mg/kg IV (defasciculating dose)
    

FOLLOW-UP

Almost all intubated patients should be admitted to an ICU or OR

Rarely, ED patients who have been intubated may be extubated in the ED and discharged after a period of observation.