What is the cornerstone of emergency airway management?
Endotracheal intubation using rapid sequence intubation (RSI)
Indications for intubation?
- Inability to maintain airway
- Inability to protect airway against aspiration
- Ventilatory compromise
- Failure to adequately oxygenate pulm capillary blood
- Anticipation of deterioration that will eventually lead to inability to maintain airway
What is the preferred method of intubation in the ED and why?
RSI because it results in rapid unconsciousness (induction) and neuromuscular blockade (paralysis)
RSI is most important for which patients?
Those who have not fasted (i.e. ED pts) and are at much greater risk for vomiting/aspiration
Primary goal of RSI?
Intubate trachea w/o having to use bag-valve-mask (BVM) ventilation
*Often necessary when attempting to intubate w/sedative agents alone
Standard of care for RSI?
Administration of an induction agent (e.g. etomidate) followed by a paralytic (e.g. succinylcholine) to render pt unconscious and paralyzed within 1 minute
Related to emergent intubation, what is a/w significant decrease in complications?
Use of neuromuscular blocking agents (paralytics)
What are the competitive inhibitor neuromuscular blocking drugs used in intubation?
- Pancuronium
- Vecuronium
- Rocuronium
What are the non-competitive inhibitor neuromuscular blocking drugs used in intubation?
Succinylcholine
Contraindications to RSI
Unconscious and apneic patient (instead, immediate BVM ventilation and intubation w/o pretreatment)
For adequate visualization during intubation, how should a patient be positioned?
Sniffing position (flex neck, extend head)
What does the Sniffing position accomplish for intubation?
Helps align axes and facilitates visualization of glottic opening
What should be done before intubation?
Preoxygenate with 100% oxygen via a nonrebreather OR BVM
How to confirm tube placement of intubation?
- ET-CO2 monitor
- 5 point auscultation method
- CXR
What is the 5 point auscultation method?
- Confirms ET placement
- Listen over each lateral lung field, L axilla, and L supraclavicular region
- NO air should occur over stomach
What is an LMA?
- Laryngeal mask airway
- Supraglottic airway device
- Good alternative to BVM
Absolute contraindications to LMA
- Cannot open mouth
- Complete upper airway obstruction
Relative contraindications to LMA
- Increased risk of aspiration
- Prolonged BVM ventilation
- Morbid obesity
- 2nd or 3rd trimester preg
- Pts who have no fasted
- Upper GI bleed
- Suspected or known abnormalities in supraglottic anatomy
- Need for high airway pressures
What is a combitube?
- Twin lumen device used in emergency situations and difficult airways
- Can be inserted w/o need for visualization in oropharynx
Which airway is NOT available for use in children?
Combitube
