Airway COurse - Basics: Dr. Gibbs (Airway Master)

Core Concepts

• First Do NO Harm!
• ED intubations are High-Risk
• Assessment = Anatomy & Physiology
• Hypotension is a significant cause of increased mortality
• Use "sophisticated Pre-oxygenation" - good positioning, Bag-valve mask oxygenation and continuous apneic oxygenation are essential
  

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The stakes are high!

• Risk of Adverse Events (aspiration, desaturations, esophageal intubation, hypotension, dysrhthmia, arrest) increases significantly with each attempt.
• One study showed: 1st attempt - 14%; 2nd - 47.2%; 3rd - 63.6%; 4th - 70.6%

Stepwise Assessment Goals

1. Is Intubation Required?
   
   • Failure to protect airway
   • Traumatic Brain Injury with a GCS </= 8
   • Inadequate oxygenation
   • Inadequate ventilation
   • Uncontrollable agitation
   • Anticipated course
2. Will it be Difficult?
   
   • Difficult Bag-valve mask?
     MOANS - Mask Seal, Obesity, Aged, No Teeth, Stiff Lungs
   • Difficult supraglottic adjunct insertion?
     RODS - Restricted, Obstruction/Obese, Distorted, Stiff Lungs
     
   • Difficult Laryngoscopy?
     LEMON - Look externally, Examine (3-3-2), Mallampati, Obstruction, Neck mobility
     3-3-2 rule - Mouth opening <3 = DL difficult; Mandible <3 = Tongue in your way; Thyromental distance < 2 = Anterior Airway.
     Criteria most associated with difficult intubation = Large teeth, small mouth, and short neck!
     
   • Difficult Surgical Airway?
     SHORT - Surgery previously, Mass (ex, goiter), Access/Anatomy, Radiation, Tumor
3. Best Technique?
   
   • Neuromuscular blockade (Y/N)?
   • Laryngoscopy vs adjunct?
   • DL vs VL?
   • Double Set-up (with cric ready)?
   
   
4. Will Physiology Suffer?
   
   • Hypotension?
   • Desaturation?
   • Aspiration
   • Dysrhythmia
   • Increased Cardiac Demand
   • Increased ICP
   • Increased IOP
   • Drug Effects - hyperkalmia, myoclonus, rigid chest, adrenal suppression
   
   
5. Best Rescue Strategy?
   
   • Must contemplate BEFORE you start!
   • Mastery of 3-4 airway rescue devices will get you out of a jam 99.9999% of the time...

Anticipate Trouble!!

Always ask yourself:

1. Do I need more help?
2. Do I need more equipment?
3. Do I need a different plan?
4. Does the patient need additional resuscitation before proceeding!