What s New in Airway Management

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1 What s New in Airway Management Monday, Sept. 28th, 2015 Andreas Grabinsky, MD! Associate Professor, Department of Anesthesiology! Program Director and Section Head, Emergency & Trauma Anesthesia! Associate Medical Director King County Medic One

2 Learning Objectives Importance of Airway Management! Trauma Airway Scenarios! Airway tools! Other things to consider!

3 Harborview Medical Center Level I Trauma Center (Washington State, Alaska, Idaho, Montana)! 25 Operating rooms - 14,000 surgeries/year! 69,000 ED visits - 18,000 admissions! 4120 Trauma admissions 697 patients directly to OR!

4 Harborview Medical Center University of Washington

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7 Prehospital Airway Management

8 Learning Objectives Importance of Airway Management! Trauma Airway Scenarios! Airway tools! Other things to consider!

9 Miraflor E. et al. Timing is Everything: Delayed Intubation is Associated with Increased Mortality in Initially Stable Trauma Patients. J surg. research 2011.

10 Miraflor E. et al. Timing is Everything: Delayed Intubation is Associated with Increased Mortality in Initially Stable Trauma Patients. J surg. research 2011.

11 Bernard SA et al. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury. Annals of Surgery 2010; 252(6):

12 Victoria, Australia Results: A total of 312 patients with severe TBI were randomly assigned to paramedic rapid sequence intubation or hospital intubation. The success rate for paramedic intubation was 97%....The proportion of patients with favorable outcome... was 80 of 157 patients (51%) in the paramedic intubation group compared with 56 of 142 patients (39%) Bernard SA et al. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury. Annals of Surgery 2010; 252(6):

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14 The overall [intubation] success rate was 100%; in 87.4% the first attempt was successful. Helm M, Hossfeld B, Schafer S, Hoitz J, Lampl L. Factors influencing emergency intubation in the pre-hospital setting. A multicenter study in German Helicopter Emergency Medical Service. Br J Anaesth 2006;96:67 71

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16 Non-anaesthetists performed 4394 intubations and failed to intubate in 41 cases (0.9%); anaesthetists performed 2587 intubations and failed in 11 (0.4%) Lockey D, Crewdson K, Weaver A, Davies G. Observational study of the success rate of intubation and failed intubations of trauma patients by pre-hospital physicians. British Journal of Anaesthesia 2014; 113(2):220-5

17 RSI with direct Laryngoscopy 99.2% to 99.7% success rate.! Remaining patients underwent cricothyrotomy. Sollid SJ, Lossius HM, Søreide E. Pre-hospital intubation by anaesthesiologists in patients with severe trauma: an audit of a Norwegian helicopter emergency medical service. Scand J Trauma Resusc Emerg Med 2010;18:30!! Stephens CT, Kahntroff S, Dutton RP. The success of emergency endotracheal intubation in trauma patients: a 10-year experience at a major adult trauma referral center. Anesth Analg 2009;109:866 72!! Lockey D, Crewdson K, Weaver A, Davies G. Observational study of the success rate of intubation and failed intubations of trauma patients by pre-hospital physicians. British Journal of Anaesthesia 2014; 113(2):220-5!!

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20 Emergency Airway Management Who is managing the airway?

21 The person, with the highest level of training and the most experience available should supervise or perform a medical procedure. Dr. M. Copass

22 Learning Objectives! Importance of Airway Management! Trauma Airway Scenarios! Airway tools! Other things to consider!

23 Video Assisted Laryngoscopy

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25 Cricothyrotomy

26 Supraglottic Devices

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31 Gum Elastic Bougie Eschmann!

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33 Eschmann

34 Bag-Mask Ventilation

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39 Learning Objectives! Importance of Airway Management! Trauma Airway Scenarios! Airway tools! Other things to consider!

40 Injury to neck / face / airway

41 Difficult Airway Access

42 Cervical Spine Trauma!

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44 Neerja B, Kajal J, Madhusudan R, Arup KM. Assessment of cervical spine movement during laryngoscopy with Macintosh and Truview laryngoscopes. J of Anesth Clin Pharmacology 2013;29(3):308-12

45 Learning Objectives Importance of Airway Management! Airway tools! Other things to consider!

46 Summary - Early Intubation and controlled ventilation! - Cervical Spine Protection! - Decompress stomach after intubation! - Low pressure/volume ventilation

47 Basic Considerations - Trauma patients are not NPO! - Always Pre-Oxygenate! - Hypotension is more dangerous than recall

48 System Change! - Manage (difficult) trauma intubations by/with Anesthesia! - Help with training of prehospital provider and Emergency physicians

49 What s New in Airway Management Andreas Grabinsky, MD! Associate Professor, Department of Anesthesiology! Program Director and Section Head, Emergency & Trauma Anesthesia! Associate Medical Director King County Medic One

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