Best Course Ever On Airway Management From First 10 EM

There are many awesome airway resources on the internet and I’ve linked to many of them in this blog. Just click on “Airway Management” in the Categories box.

But in this post I link to what I think is the best single course on airway management that I’ve seen.

The outstanding emergency medicine blog  First10EM by Dr. Justin Morgenstern has an excellent series of posts on airway management.

Dr. Morganstern’s posts are the best introduction to airway management that I’ve found.

I recommend these posts to anyone getting started in airway management. So I’ve listed and linked to all of his posts on airway management. These links are also an excellent review for experienced clinicians.

In addition I’ve linked to Dr. Weingart’s excellent article Managing Initial Mechanical Ventilation in the Emergency Department.

And finally, review Dr. Morganstern’s post Managing laryngospasm in the emergency department. His post has links to other excellent resources on laryngospasm.

Study carefully each link:

The Emergency Airway Series

Case
A 55 year old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. He is lying flat on the resuscitation stretcher and making some sonorous breath sounds. You resident grabs a laryngoscope and says, “ABCs… let’s get this guy intubated”…

My approach
Although many airway talks start at intubation, immediate intubation is rarely the first step in resuscitation. Basic airway maneuvers are essential. Many patients can be managed with simple maneuvers alone, preventing what seems like an otherwise necessary endotracheal tube. Even when the tube is ultimately necessary, starting with basic airway maneuvers stabilizes the patient, and gives you time to resuscitate, gather information, and effectively pre-oxygenate.

Case
A 55 year old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs on arrival are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. Although he was originally making sonorous noises, after elevating the head of the bed to 30 degrees, inserting a nasopharyngeal airway, and applying a jaw thrust, he is breathing quietly at 23 breaths a minutes, and his oxygen saturation has climbed to 92% with facemask oxygen…

My approach
Many airway discussions start from the moment that a laryngoscope is pulled out. In emergency medicine and critical care, we are rarely managing an airway in isolation. We manage the airway in the context of a critically ill patient. Therefore, it is essential to consider the physiology of the patient when deciding on the most appropriate time for advanced airway interventions like intubation.

For a number of reasons, the peri-intubation period is a time of high risk for cardiovascular collapse. Occasionally, rapidly evolving airway obstruction mandates immediate intervention. However, for the vast majority of critically ill patients, rushing to an advanced airway increases risk. When intubating critically ill patients, there are 4 risk factors for cardiovascular collapse that must be considered: hypoxemia, hypotension, severe metabolic acidosis, and right ventricular failure. (Mosier 2015)

Case
A 55 year old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs on arrival are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. After using basic airway maneuvers to temporarily stabilize his airway, you were able to take the time to appropriately resuscitate and pre-oxygenate him. His vital signs are now a heart rate of 105, a blood pressure of 122/77, a respiratory rate of 16, and an oxygen saturation of 100% with a non-rebreather set at flush rate and nasal prongs at 15 L/min. However, he remains unconscious and you think it is now time to proceed with intubation…

My approach
As was discussed in the last post, before starting with RSI it is important to consider if the patient is physiologically ready for intubation. After appropriate resuscitation and pre oxygenation, we can start with the procedure of intubation.

Case
A 55 year old man was found unconscious in the bathroom by his family. After appropriate resuscitation and pre-oxygenation, you determine that there are no major predictors of difficulty, and so proceed with RSI. On 2 attempts at laryngoscopy, both direct and video, you cannot visualize the cords. The LMA won’t sit properly, and now his oxygen saturation is 70% despite your best attempt at bag valve mask ventilation…

My approach
In the can’t intubate, can’t oxygenate scenario, I recommend a surgical approach to cricothyroidotomy. In the NAP4 audit, 60% of needle cricothyroidotomy attempts failed. In contrast, 100% of surgical cricothyroidotomy attempts were successful. (Cook 2011; Nolan 2011) Although there are a few studies indicating that guidewire techniques are equally fast to surgical techniques, such studies are not consistent. More importantly, such studies can never reproduce the stress and adrenaline of real can’t intubate can’t oxygenate scenarios. I simply cannot imagine trying to thread a guidewire in that situation. Furthermore, there are numerous significant complications reported with jet ventilation through a catheter. (Duggan 2016) The Difficult Airway Society guidelines recommend surgical front of neck access over catheter based approaches. Specifically, they recommend the scalpel-bougie technique described below. (Pracy 2016; Frerk 2015)

Case
A 55-year-old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs on arrival are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. After using basic airway maneuvers to temporarily stabilize his airway, you were able to take the time to appropriately resuscitate and pre-oxygenate him, prior to proceeding with intubation. You pass the tube easily on the first attempt. Looking around the room for someone to high-five, you realize your team is waiting for your instructions for the ongoing care of this sick patient…

My approach

Confirm ETT placement and secure the tube

Confirming tube placement is, in my mind, an essential step of the intubation procedure itself, but is important enough to be repeated here. Confirm placement with quantitative end-tidal capnography, and then leave the waveform capnography in place for monitoring purposes. . . .

Continue Resuscitation

In the emergency department we intubate critically ill patients. The plastic tubing of the endotracheal tube is very rarely the definitive treatment required. In fact, the transition to positive pressure ventilation is often detrimental to the patient’s hemodynamics. . . . [So be sure you or another clinician is aware of the patient’s total situation and is addressing the total situation.]

Start analgesia and (+/-) sedation

Immediately after my primary survey, I confirm that the patient has been given an analgesic. Ideally, post-intubation analgesia is ordered before intubation so that it can be given by a nurse while I perform my post-intubation primary survey.

Start with analgesia.

Get an opioid on board. This can be a fentanyl drip. It can be boluses of morphine or hydromorphone. (It is generally easier to start with boluses in the emergency department. Drips just seem to take too long to get setup. However, it is easy to get distracted as new patients come in, so transitioning to a drip as soon as possible also makes sense.)

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