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#1Essential Emergency Airway Care-

Airway Preparation

Andrew Brainard, MD, MPH, FACEM, FACEMwww.thesharpend.org

abrainard01@gmail.com

#1 Pre-arrival preparation of Team, Plan, Room,and Equipment

• Learning Objectives:– Prepare TEAM

• Assign team leader (jacket, roles, plan)• Primary airway operator • Backup airway operator • Airway assistant• Drug provider

– Basic Pre-Arrival PLAN• Possible A, B, C, and D• Likely Medications• Ensure team members understand and

are skilled in their roles– Prepare ROOM

• Move bed, Resus tower, and Airway cart– Prepare EQUIPMENT

• Monitor• BVM, Adjuncts, Oxygen, Suction • Laryngoscopes, ETT, Bougie • Backups (SGA/Video/Cric)• Drugs

• R40: 50y/o F found down and unresponsive at home. – No signs of trauma, OSA – GCS 5, RR 6, SaO2 88%, pulse 100, BP 100/60.

• Team should prepare for critical patient– Team– Plan– Room– Equipment

• Conduct a Detailed Tour of ED resus area– 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

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Managing the Airway Team

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Airway Assista

ntPrimary Airway

Operator

Medications

Team Leader

Backup Airway

Operator

Intensive Care

Drugs

• Team Leader• Primary Airway Operator– Backup Airway Operator

• Airway Assistant• Manual In-line Stabilization

• Drug Provider• Runner/Scribe/Other• Intensive Care

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Preparing the room and equipment• Locate your personnel

– 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

TowerSuction TestedUnder Pt’s R shoulder

Oxygen MaskNasalBVM

BVM O2 onReservoir bagPEEP

Monitoring1st monitor onSaO2Not on BP arm

ETCo2 TestedOn BVM

2nd monitor on

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Airway Cart

Adjuncts

Laryngoscope x2

ETT x2

Bougie/Stylet

Lube/syringe/tie

LMA/Cric

Sucti

on

Preparing the Airway Cart

• Cart Location– Pt’s right– Orientation (able to open drawer)

• Top– Set up as needed

• Side– 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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Resus Tower/Gantry

Airway Cart

Adjuncts

Laryngoscope x2

ETT x2

Bougie/Stylet

Lube/syringe/tie

LMA/Cric

CirculationIVFluidsA-lines

VentilatorOxygenPower

Monitor

SaO2

ETCo2

BP/ECG

2nd M

onitor

MedicationsRSI meds

Tower/GantrySuction

TestedUnder R shoulder

Oxygen MaskBVMNasal

BVM O2Reservoir bagPEEP

CartTop

Adjuncts (OPA/NPA)Laryngoscope Lights tested2 sizesETTLubedStylet shapedSmaller size readySyringe/tie

DrawersLMA/AirQ sizedCric kit located

Monitoring1st monitor onSaO2

Not on BP armETCo2

TestedOn BVM

2nd monitor on

Sucti

on

Important Equipment Checks:

VideoscopeETTStyletOn

Resus Tower/GantrySuctionOxygenMask/BMV/Nasal

RoomBed

PositionHeightLocked

TowerPositionHeight

Videoscope

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*Airway Assistant*Prep airway table

Suction, Adjuncts, Laryngoscopy, ETT, Bougie, LMA, Cric Kit, Place nasal O2External laryngeal

manipulationHandles tube/bougieAssists with securing tube

*Primary Airway Operator*Assure oxygenationFormal airway assessmentVocalize plan A, B, C, DPrimary airway procedure

MedicationsPrep RSI medsPrep IV fluidPrep maintenance meds

Team LeaderPrepare room/staffLeads resuscitation

MonitoringPrep RoomMonitoring

SaO2, ETCo2, BP, ECG

*Backup Airway Operator*Examine patientPosition patientExternal laryngeal manipulationBackup airway proceduresPerform cricothyroidotomy

Intensive CareContinuity of CareTransport

*Drugs*IV/IO x2 Administer RSI meds

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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)– 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)– R: restricted mouth– O: obstruction– D: disrupted or distorted– S: stiff lungs or c-spine

• SHORT (Surgical Airway)– S: surgery– H: haematoma– O: obesity– R: radiation– T: tumor

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Airway Assistant Primary Airway Operator

DrugsTeam

Leader

Primary Airway Operator

Airway Assistant

Team 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

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

Drugs• Access• Drugs• Dose

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AirQ 3.5

Direct laryngoscopy bougie+7.5 tube

Video laryngoscopy stylet+7.5 tube

The Pre-arrival briefing• 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.

• The team will be: –Me as team leader– Fred as primary airway operator – Linda as backup airway operator – Viola as airway assistant– I will also push the drugs

• 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 tubeB- Video laryngoscopy with stylet+7.5 tubeC- AirQ size #3.5D- Cric for Sats <80% and dropping

• We will use all our “best practice” techniques.

• Everyone understand their roles?

• Questions or suggestions?

• Let’s make sure everything is ready for this patient’s arrival.

Airway Assistant•External Laryngeal

Manipulation•Bougie/tube

procedure•Equipment names

& sizes

Primary•Formal Airway

Assessment**•Plan A, B, C, D•Pullout Criteria

Backup•Backup Criteria•Cric plan

Drugs•Access•Drugs•Dose

*Confirm that people understand their roles*

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Tips for managing the team

• Knowledge• Experience• Respect• Seniority• Mannerisms• Age• Gender

• 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-D3T3-1430-Contemporary-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)

• 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 predictors- http://academiclifeinem.com/mnemonics-for-difficult-airway-predictors/ (accessed on 15/6/2014)