PREHOSPITAL AIRWAY MANAGEMENT

James Kempema MD FACEP

DISCLOSURES

• None

HISTORY

LITERATURE REVIEW

SUMMARY

• Worse outcomes in severe brain injured patients

• Worse outcomes in cardiac arrest

• Longer scene times

• Increased risk of aspiration

• Poor ventilatory management

• Exception:

• Higher trained providers (Air Medical) resulted in better outcomes

BARRIERS TO SUCCESS

• Which patients are getting intubated?

• How much experience do the providers have?

• Access to induction medications and paralytics?

• What tools do you have for the procedure?

• Post-intubation management and monitoring

TRAUMA INTUBATIONS

• Vast majority are severe head injuries

• Primary issues to AVOID in head injured patients:

• Hypoxia

• Hypotension

0

10

20

30

40

50

60

70

80

Mo

rtality

(%

)

Neither Hypoxia Hypotension Both

Any time

Arrival

FACTORS IN EMERGENT INTUBATION SUCCESS

• Ability to adequately pre-oxygenate / Delayed sequence intubation

• Prevention of desaturation / passive oxygenation

• Techniques and tools

• Continuous confirmation of endotracheal placement

• Prevention of post-intubation hypotension

• Post-intubation management • Vent settings • Avoiding hyper- and hypoventilation

CASE STUDY #1

• 72 yo female found obtunded

• Per family – PT feeling “ill” lately with elevated BS

• PMH: IDDM, HTN, CAD

• Exam: unresponsive, minimal movement to painful stimulus

• VS: P/112, 84/52, R/8, SpO2 84%, EtCO2 10, BS 442

• Does this patient need ventilatory support?

• What happens when she gets intubated?

SHOCK INDEX

• Shock index = SBP / HR

• Normal 0.5 -0.7

• Shock index > 0.9 associated with post-ETI cardiac arrest

CASE STUDY #2

• 23 yo female falls off cliff

• STAR Flight called for hoist rescue

• GCS 3, R/6

• How do you manage this patient’s ventilation while hoisting?

CASE STUDY #3

WHAT ABOUT ALTERNATIVE AIRWAYS?

• AKA: Blind insertion airways, supraglottic airways, extraglottic airway device

• Types: King LT, Combitube, I-Gel, LMA

• Most easy to place, reliable, some allow for gastric decompression

• Bottom Line: BIAD had worse outcomes compared to ETI or BVM

• Limitations:

• Primary vs secondary device

• # of intubation attempts prior to placement

• Is it the device or the technique?

CONCEPT OF RAPID SEQUENCE AIRWAY

• Use of sedation and / or paralytics to place an extraglottic airway as the primary airway

RSA

• Extraglottic airways have evolved significantly in the last 10-15 years

• Easier placement, better glottic seal, ability for gastric decompression

• In simulated study – lower time to airway placement, less predicted hypoxic time

WHERE DO WE GO FROM HERE?

• Indications for intubation:

• GCS < 8 = intubate!

• RR < 8 = intubate?

• Transport time / number and skill of providers

• Access to other options?

• Limit intubation to Advanced Providers

• Medications / tools / monitors to maximize success

Thank you! jkempema@seton.org