Updates in the Management of the Difficult Airway

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1

2 Disclaimer The views in the presentation are the author's, and do not reflect the views of the Department of Defence I am a full time Australian Defence Force Procedural Specialist (Anaesthetist)

3 Updates in the Management of the Difficult Airway The extent of the problem Difficult Airway Algorithms Training Equipment What this means for the ADF.

4 Predicting the Difficult Airway Anticipated Vs Unanticipated Difficult Airway How predictive are airway assessments? In a trauma patient? In a combat environment? Tactical / space / time critical injuries? Frequency of events Civilian NAP 4 VS Military

5

6 NAP4- Summary Analysis of the cases has identified repeated gaps in care that include: poor identification of at-risk patients (Obesity); poor or incomplete planning (Plan A, B,C,D); inadequate provision of skilled staff and equipment to manage these events successfully (ICU/ ED); delayed recognition of events; and failed rescue because of lack of interpretation or lack use of capnography. British Journal of Anaesthesia 106 (5): (2011) Advance Access publication 29 March doi: /bja/aer059

7 Civilian data NAP events in 12 months- Anaesthesia, ICU and DEM 1 event per 22,000 anaesthetics 58 events - 4 died (2 failure surgical airway) Induction 52%, maintenance 18%, emergence 16%, recovery 14% Surgical Tracheostomies 29 cases 11 in CICO, all tracheostomies successful (2 deaths) Needle cricothyroidotomy technique success range 36-57%

8 NAP4- Outcome of Rescue Techniques Anaesthetist 9 of 25 attempts successful airway rescue (36% success rate ) 11 rescued by surgeon performed tracheostomy 1 by 2 nd anaesthetist - percutaneous tracheostomy 3 by intubation 1 died

9 Military Experience Leading Preventable Causes of death Haemorrhage Tension Pneumothorax Airway obstruction- 6% Tactical Combat Casualty Care TTTC Treat the casualty, prevent further casualties and complete the mission Limited published data of overall difficult airway or Can t Intubate Can t Oxygenate incidence on operations pre hospital gap

10 Military Aetiology of Threatened Airway Military Factors- Injury IED / Bomb Gunshot Rocket / Grenade Blast injury Burns Inhalation Shrapnel Protective Equipment Individual and transport SOP s Patient factors Pre-existing Anatomical causes (Civilian Vs Military) Airway Management Training and competency (procedures and protocols) Equipment + Drugs Environment (Threat / confined space)

11 Retrospective analysis of 3yr period OEF - surgical cricothryoidotomies battlefield/ aid station 72 attempts at surgical airway in 20,066 casualties (WIA/ KIA) - 26% Unsuccessful Too high/ low Parallel/ false tracts Oesophageal Specific Training to address deficiencies

12

13 Combat Casualty Care Working Group: Supra-glottic Airway not suitable facial injuries or the un-obtunded pt Surgical cricothyrotomy recommended as the definitive airway Migration of cuffed ETT down Right Main Bronchus x2 hypoxia/ misdiagnosis of Tension Pneumothorax commercial Surgical airway kit to prevent this

14

15

16 Guidelines American Society of Anesthesiologists Difficult Airway Society ADF Health Manual 7 Vortex Combat Anaesthesia- First 24 hours ATLS/ EMST? PCCM? ADF Airway Guidelines for MA, NO s, Nurse Practitioners and MO s

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18 Difficult Airway Algorithm Assessment of Difficult mask ventilation Difficult supraglottic airway placement Difficult laryngoscopy Difficult Intubation Difficult surgical airway access Strategies AWAKE Vs Asleep Intubation Non-Invasive Vs Invasive technique for intubation Video-assisted Laryngoscopy as an initial approach to intubation Preservation Vs Ablation of Spontaneous Ventilation

19

20 Difficult Airway Society Airway evaluation is imperfect in predicting problems and an airway strategy (combination of plans) should be drawn up for each patient to cover the entire period of anaesthetic care, particular at the start and end of anaesthesia.

21 Difficult Airway Society 2004 Guidelines Unanticipated difficult intubation

22

23 ADF- Health Manual 7 Difficult HLTHMAN, volume Airway Checklist Annexes: A. Endotracheal intubation B. Cricothyroidotomy Figure 6 4: Difficult airway checklist 1

24 Can t Intubate Can t oxygenate - CICO Replaces can t intubate can t ventilate is an airway emergency : failure to establish oxygenation = death Response to a CICO situation is a Individual TEAM- system responsibility Ownership of Preventable Death Service, Commanders and health providers

25 The Airway Vortex

26

27 Vortex Optimisation strategies

28 Combat Anaesthesia- First 24 hours - Penetrating injuries Limited anaesthetic papers on military cases- case reports Facial Injuries Keep Pt in position that maintains airway Assess the zones of injury Don t panic - take the few seconds to plan and communicate If airway not compromised- role of CT

29 Neck injuries - the airway zones Zones: Zone 1- Area between clavicles and criocoid cartilage Zone 2- Area between Cricoid cartilage and angle of Mandible Zone 3 Area between angle of mandible and base of Skull Injury to airway lumen, airway wall or external to wall Chapter 6:Combat Anaesthesia first 24 hours

30

31 Zone 1 Injury- Suggested Guidelines penetrating airway trauma Direct intubation through a large defect Surgical Cricothyroidotomy Thoracotomy in complete tracheal transection

32 Zone 2 Injury- Suggested Guidelines penetrating airway trauma CT Scan to Exclude distal airways injury (provided no immediate impending airway obstruction) Oral intubation by RSI for injuires proximal to the larynx Fibreoptic intubation for injuries distal to Larynx Surgical Airway for injuries distal to the larynx

33 Zone 3 Injury - Suggested Guidelines penetrating airway trauma Oral Intubation by RSI for small defects Surgical airway for gross disruption For all Zones Where Distal Airway has not been excludedconsider primary surgical airway For any large defect- direct intubation through defect

34 CICO: Airway Goal and Team Oxygenation and establish ventilation Emergency Front of Neck Access (New DRAFT DAS guidelines ) Surgical Cricothyroidotomy Cannula cricothyroidotomy [only if skilled] Airway Providers Medics, Nurses, Doctors S is for Surgeon Assistant(s): get equipment ready

35 Training Train Hard Fight easy General Aleksandr Vasil Evich Suvorvo ( )

36 Too high/ low Parallel/ false tracts Oesophageal Specific Training to address deficiencies

37 US Medic Airway Training NPAs Supra glottic airways Surgical Cricothyroidotomy Simulation / airway models Cadavers Cadavers at night / tactical simulation Mannequin Intubation with NVG s Does the skill set increase incidence of unnecessary intervention?

38 ADF Training Medical Assistants Joint ADF Medic Course Initial Training- at Army Logistics Training Centre conducted by Army School of Health Unit Training / service specific Refresher and skills maintenance Clinical Placement Simulation Capability to meet lessons learnt from operational deployments

39 Medical Assistants Health Manual Volume 8 Primary Clinical Care Manual (QLD, RFDS, ADF) Replaces the Advanced Medical Assistance Emergency Manual PCCM Limited treatment guidelines Non specific regarding airway/ drugs Single Service Individual scopes of practice, and Define scope of training Clinical Placement Deeds

40 Medical Officers Health Manual Volume 7- Military Anaesthesia EMST- every 4 years MiLAN course- Military Anaesthesia Definitive Surgical Trauma Course College Requirements CPD ML2- ML4 Clinical Placements (Clinical Placement Deeds)

41 Training Challenges Who What Where When and Why Initial Training Maintenance perishable skills Individual/ Team Training Certification Predeployment? Maintenance on deployment when low activity

42 Equipment- Challenges ANZCA Guidelines Difficult Airway Equipment Health Manual 7 / PCCM Sterilization- reusable Vs Disposable Different equipment in civilian institutions Training Liability Updating equipment Packs

43 Airway Devices Oropharyngeal and Nasopharyngeal Airways Endotracheal Tubes Supraglottic Airways Laryngoscope handles and blades Video Laryngoscopes (VL) Flexible fibreoptic laryngoscopes / bronchoscopes Needle and Surgical cricothyroidotomy kits

44 Current ADF VL AirTraq Prism Screen Channel Device- ETT preloaded in a channel and is guided on a fixed path Adult and Paediatric sizes

45 C-MAC VL

46 King Vision VL, McGrath Mac

47 Drugs Thomas pack, AME, MCAT, Role 1/2/3 Training and certification Ongoing skills maintenance Can abolish ventilation- Health providers need top be able to Manage this Role of Rocuronium in Rapid Sequence Induction, Suggamadex

48 What does this mean for ADF? Where do the airway interventions need to occur during the TCCC and CASEVAC/ MEDEVAC process Who performs airway interventions Protocols Equipment Training Skills Maintenance and Team training/ CRM Data and Closed loop

49 Questions The Walker Dip recurrent historical cycles whereby medical care improves during conflicts, but the lessons are forgotten afterward and have to be relearned again during the next war, thus repeating the cycle.. Surgeon Commodore Alasdair Walker, UK Military Health Services Medical Director, 2013

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