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The Unexpected Difficult Airway in Emergency Departments

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SMACC Conference
SMACC Conference

John Vassiliadis speaks at Bedside Critical Care Conference 4 about The Unexpected DIfficult Airway. He speaks from an ICU perspective about intubation - how and who should do it to help achieve better results.

Health & Medicine
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The Unexpected Difficult Airway A/Prof John Vassiliadis Senior Staff Specialist Emergency Medicine Deputy Director Sydney Clinical Skills & Simulation Centre, RNSH
I am NOT an anaesthetist!!!
Intubating In ED • Why it is a danger zone • Role of Checklists • Pre-oxygenation and Apnoeic Oxygenation • Laryngoscopy
Danger Zone
ED Patient Airways are Different • They are emergent – Usually for airway +/- breathing failure – Limited history – Limited opportunity to predict difficult airway or difficult laryngoscopy – They are sick… Really sick (ie high metabolic demands)
I have a bad feeling about this one!!! I LOVE it when I have a registrar!! Oh S!!! I knew I should have called in sick today!!
Our training and Skill Level
Our Training and Skill Level Adequate supervision and support Anaesthetics and ICU experience E-learning and simulation training to practice drills Credentialling process and guidelines on who should be allowed to intubate in ED and other critical care environments
Suggested parameters for predicting the difficult airway Long upper incisors and/or prominent overbite Inter-incisor distance <3 finger breaths Mandibular floor distance < 3 finger breaths Thyromental distance < 2 finger breaths Mallampati score > 2 High arched palate Large, thick tongue Short, thick neck Patient unable to touch the chin to the chest
Are they any good? In 2003 ASA Difficult Airway Task force after a review of literature found there was insufficient evidence to recommend any predictive tool, however some of these markers were associated with difficult airways!
So..What Do We Do?
Ron Walls and Difficult Airway Team
The JV Method ED Physician Gestalt Looks Bloody Hard!!
Have an Approach and A Plan ED appropriate assessment, checklist and difficult airway algorithm Meticulous preparation, pre-oxygeation, positioning, apnoeic oxygenation Excellent laryngoscopy Plan B and C and D....
Ramping and Positioning
Preoxygenation
Weingart & Levitan, Annals of EM Volume 59, No. 3, March 2012 pp 165175
C-MAC
C-MAC
Take Home Messages ED Intubations are Difficult Need Experience and Training Prepare and Plan Preoxygenate and Apnoeic Ventilation C-MAC and bougie
The Unexpected Difficult Airway in Emergency Departments

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The Unexpected Difficult Airway in Emergency Departments

  • 1. The Unexpected Difficult Airway A/Prof John Vassiliadis Senior Staff Specialist Emergency Medicine Deputy Director Sydney Clinical Skills & Simulation Centre, RNSH
  • 2.
  • 3. I am NOT an anaesthetist!!!
  • 4. Intubating In ED • Why it is a danger zone • Role of Checklists • Pre-oxygenation and Apnoeic Oxygenation • Laryngoscopy
  • 6. ED Patient Airways are Different • They are emergent – Usually for airway +/- breathing failure – Limited history – Limited opportunity to predict difficult airway or difficult laryngoscopy – They are sick… Really sick (ie high metabolic demands)
  • 7. I have a bad feeling about this one!!! I LOVE it when I have a registrar!! Oh S!!! I knew I should have called in sick today!!
  • 8. Our training and Skill Level
  • 9. Our Training and Skill Level Adequate supervision and support Anaesthetics and ICU experience E-learning and simulation training to practice drills Credentialling process and guidelines on who should be allowed to intubate in ED and other critical care environments
  • 10. Suggested parameters for predicting the difficult airway Long upper incisors and/or prominent overbite Inter-incisor distance <3 finger breaths Mandibular floor distance < 3 finger breaths Thyromental distance < 2 finger breaths Mallampati score > 2 High arched palate Large, thick tongue Short, thick neck Patient unable to touch the chin to the chest
  • 11. Are they any good? In 2003 ASA Difficult Airway Task force after a review of literature found there was insufficient evidence to recommend any predictive tool, however some of these markers were associated with difficult airways!
  • 12.
  • 14. Ron Walls and Difficult Airway Team
  • 15. The JV Method ED Physician Gestalt Looks Bloody Hard!!
  • 16. Have an Approach and A Plan ED appropriate assessment, checklist and difficult airway algorithm Meticulous preparation, pre-oxygeation, positioning, apnoeic oxygenation Excellent laryngoscopy Plan B and C and D....
  • 17.
  • 18.
  • 21. Weingart & Levitan, Annals of EM Volume 59, No. 3, March 2012 pp 165175
  • 22.
  • 23. C-MAC
  • 24. C-MAC
  • 25.
  • 26.
  • 27. Take Home Messages ED Intubations are Difficult Need Experience and Training Prepare and Plan Preoxygenate and Apnoeic Ventilation C-MAC and bougie