Dr. Jay Mekwan
Tag Archives: airway
ADULT Rapid Sequence Intubation and Post-Intubation Analgesia and Sedation for Major Trauma Patients – NB Trauma
Consensus Statement:
ADULT Rapid Sequence Intubation and Post-Intubation
Analgesia and Sedation for Major Trauma Patients
NB Trauma Program – July 2018
Background:
- Major trauma patients frequently require advanced airway control.
- Endotracheal intubation is the preferred advanced airway intervention in major trauma patients.
- Intubated trauma patients also need significant post-intubation pharmacological support.
- Specifically, these patients require analgesia and sedation. This is particularly true when transfer to another facility is required, during which ICU level support is not available unless transfer occurs via Air Ambulance.
- In New Brunswick, there is significant variation in the approach to both advanced airway control and post-intubation analgesia and sedation practices for major trauma patients.
- Physicians in smaller centres in particular have asked for standardized, evidence-based guidance for both Rapid Sequence Intubation (RSI) and post-intubation pharmacological support in preparation for (and during) ground-based interfacility transfer.
- Rapid Sequence Intubation (RSI) is a method to achieve airway control that involves rapid administration of sedative and paralytic agents, followed by endotracheal intubation.
- The purpose of RSI is to affect a state of unconsciousness and neuromuscular blockade, allowing for increased first pass success of endotracheal intubation.
- Post-intubation analgesia and sedation is a method of controlling pain, agitation and medically induced amnesia for major trauma patients.
Consensus Statements:
- A provincially standardized, evidence-based guideline for Rapid Sequence Intubation should be available in all NB Trauma Centres (Appendix A).
- Similarly, a provincially standardized, evidence-based guideline for Post-Intubation Analgesia and Sedation should be available in the Emergency Department of all NB Trauma Centres (Appendix B).
- In addition to standardized, evidence-based guidelines, a provincially standardized equipment layout is recommended to optimize the preparation for RSI (Appendix C).
- Ambulance New Brunswick should ensure consistency with the provincially standardized guidelines for RSI and Post-Intubation Sedation and Analgesia in procedures for Ambulance New Brunswick’s Air Medical Crew.
- RSI should not be considered or applied for trauma patients who are in cardiac arrest or who are apneic.
- RSI should not be considered in patients with a predicted difficult airway.
- RSI should be considered for all trauma patients meeting the following:
- GCS < 8, quickly deteriorating GCS or loss of airway protection
- Facial trauma with poor airway control
- Burns with suspected inhalation injury
- Respiratory failure
- Hypoxia
- Persistent or uncompensated shock (reduction of respiratory efforts)
- Agitation with possible injury to self or others
- Potential for eventual respiratory compromise
- Possible respiratory and/or neurological deterioration during prolonged transport
- Transport in a confined space with limited resources
- In addition to the above, RSI Guidelines should include
- Assessment of the possibility of a difficult intubation
- Troubleshooting
- Immediate reference to post-intubation analgesia and sedation
- In addition to standardized, evidence-based guidelines, a provincially standardized pre-induction checklist is recommended to optimize the preparation for RSI (Appendix D)
Wired shut: cutting jaw wires in an emergency
Wired shut: cutting jaw wires in an emergency
Resident Clinical Pearl (RCP) – January 2018
Kavish Chandra R3 FMEM, Dalhousie University, Saint John, New Brunswick
Reviewed by Dr. Awdesh Chandra
It’s 0300 and you are on a solo night shift when a couple are rushed into the resuscitation bay by the triage nurse. The woman says that the man had his jaw “wired shut” three weeks ago and began retching an hour ago. Your suspicions are confirmed when you look at his mouth and see the image below:
Figure 1. Arch bars (green arrows) are used for mandibular fixation, adapted from Jones and Read (2006).
As your patient is being placed on cardiac and oxygen monitoring, you can see they are agitated and hypoxic. You ask yourself, how can I get access to their oropharynx and begin my resuscitation?
Background
Arch bars and intermaxillary fixation are placed after mandibular fractures. In Figure 1, the arch bars, horizontal bars indicated by the green arrow, are fixated by circumferential wires around the teeth.1 In order to fixate the mandible and maxilla, fixation wires (vertical wires indicated by the red arrow seen in Figure 2) bring together and upper and lower arch bars, effectively eliminating mouth opening.1
Figure 2. Intermaxillary fixation wires, vertical wires indicated by the red arrows. Adapted from Jones and Read (2006).
While it is standard procedure for dentists and oral surgeons to provide patients with wire cutters and instructions following intermaxillary fixation for emergencies, this may not be readily available in the emergency department when needed the most.
The materials required:
- A deep breath
- Wire cutters (or if not, heavy metal scissors)
- Hemostat or needle driver
The steps:
- Identify and cut the vertical fixation wire on one side of the twist as seen in Figure 2. This is similar to cutting a single interrupted suture.
- Pull on the twist with a hemostat or needle driver and pull the wire out. There are generally 2-4 fixation wires per each side that require cutting in order to open the mouth.
- In some instances, there may be heavy elastics vertically as well, pull and cut those as well.
- Proceed with the resuscitation as deemed necessary (airway access or allowing the patient to vomit)
- The dentist or oral surgeon can re-fixate the wires non-urgently after the emergency has passed
See the following links on how arch bars and intermaxillary fixating wires are placed (to get an understanding of where to cut to release the mandible)
- https://www.youtube.com/watch?v=RGp46yHoVag&feature=youtu.be (minute 14 and on for application of intermaxillary fixation wires)
- https://emcrit.org/racc/airway-decisions/
Pearl: consider having wire cutters as part of your difficult airway cart or kit
Bottom Line: intermaxillary fixation can pose a serious threat to a patient needing to vomit or one that requires emergency airway access. Be prepared to cut the right wires in order allow mouth opening.
References
(1) Jones TR, Read L. Emergent separation of arch bars. J Emerg Med 2006; 35(2):205-206.
This post was copyedited by Kavish Chandra @kavishpchandra
RSI Drugs
RSI Drugs Summary
Dr James French
- REDUCE THE DOSE OF INDUCTION AGENTS IN HYPOTENSION or when Pulse Rate is greater than Systolic Blood Pressure.
- INCREASE THE DOSE OF PARALYZING AGENTS IN HYPOTENSION.
Give the sedative first, followed by a flush, followed by the parlaying agent, followed by a small fluid bolus.
KETAMINE
Ketamine is a dissociating sedative that that can also be used in lower doses for procedural sedation ( i.v. 0.5 – 1.0mg/kg) and as a powerful analgesic (i.v. 0.3mg/Kg). When used for RSI the dose is 2.0 mg/Kg and is halved to 1.0 mg/kg in hypotension or a raised shock index (i.e. if the pulse is greater than the systolic blood pressure) . Ketamine causes hypertension, tachycardia and vomiting as its main side effects. When used for procedural sedation Ketamine causes less respiratory depression than other sedatives. Patients can misperceive stimuli during sedation and recovery and become agitated; this is called “emergence”.
Ketamine is available as 10mg/ml concentration for IV use and a 50 mg/ml concentration for IM use only – confusing the concentration being used can cause cardiac arrest. The 10mg/ml concentration is used neat for analgesia, sedation and RSI in adult patients.
ETOMIDATE
Etomidate is a sedative. It has no analgesic effect.
Etomidate’s chief side effect is hypotension, hypoventilation and adrenal suppression. When used for RSI iv the dose is 0.3. In hypotension or is the pulse rate us greater than the systolic blood pressure the dose of per Kg is halved from 0.3 to 0.15 mg/kg to prevent post induction hemodynamic instability.
Etomidate can cause a myoclonic jerk which are a single gross limb movements. It has a rapid onset of 45 seconds.
Etomidate is short acting – The sedation effect lasts about 5 minutes.
Etomidate is usually dispensed as a white liquid in a single 10ml ampoule, which has a concentration of 2mg/ml.
SUCCINYCHOLINE
Succinylcholine is a depolarizing muscle relaxant that acts on acetylcholine receptors. It works by binding non-competitively to the muscular acetylcholine receptor. This causes muscular relaxation by “burning out” the neuromuscular mechanism. This activation of the neuromuscular junction causes fasiculations.
Succinylcholine also acts on the acetylcholine receptors on the heart causing bradycardia as its primary side effect, particularly when giving a second dose. 5 mcg/kg of Atropine is therefor given before the second dose of Succinylcholine and in children under one year of age (who are more prone to bradycardia).
Succinylcholine works rapidly, with optimal relaxation in the jaw produced 10 seconds after fasciculations finish in the face.
The paralyzing effect wears off after about 6 – 9 minutes.
Succinylcholine provides no analgesic or sedative effect so it is essential that analgesia and sedation are given after anesthesia.
Succinylcholine is given neat. is a clear liquid and is supplied in one concentration of 20 mg/ml in a glass ampoule containing 100mg.
Succinylcholine dose in adults is 1.5 mg kg. The dose can be increased in severe shock to 2.0 mg/kg and in children. Do not “underdose” the paralyzing drugs so round up when doing drug calculations. Especially do not practice “ampoule based medicine” when using paralyzing agents in emergency situations.
Succinylcholine cannot be given to anybody with acute or chronic neuromuscular disease.
ROCURONIUM
Rocuronium is a non-depolarizing muscle relaxant. It does not activate the acetylcholine receptor but blocks the bodies own neurotransmitter. It therefore does not cause fasciculations.
Rocuronium also blocks the action of acetylcholine on the heart causing tachycardia as its primary side effect.
Rocuronium is fast onset proving intubating conditions in 60 seconds when given in the correct dose – it is essential that this period is timed after administration.
Rocuronium is long acting providing muscular parlays for about 45 minutes. It provides no analgesic or sedative effect so it is essential that analgesia and sedation are given after anesthesia.
Rocuronium is given as 1.5mg/kg, which is a dose increase, so does not need to be adjusted in severe hypotension.
Rocuronium is given neat and is supplied as a colourless liquid of 10 mg/ml concentration.
Lessons from Case Review and the Literature.
- REDUCE THE DOSE OF INDUCTION AGENTS IN HYPOTENSION.
- INCREASE THE DOSE OF PARALYZING AGENTS IN HYPOTENSION.
- Give the sedative first, followed by a flush, followed by the parlaying agent, followed by a small fluid bolus.
- Time from the moment the drugs are given to prevent the intubator from making the first attempt too early.
- When pushing the drugs make sure the IV line is blocked off to prevent the drugs from being pushed back into the giving set.
- Use IV access on the opposite side of the blood pressure cuff.
- Always follow RSI drugs with analgesia first after the tube is secured.
- Give the RSI drugs rapidly, fast IV push, sedative first, then the paralysing agent followed by a large flush or fluid bolus.
- Do not paralyze the hypoxic patient until every attempt to restore hypoxia has been corrected.
- Resuscitate the circulation with haemorrhage control and blood products, or fluid and vasopressors prior to RSI.
ED Rounds – September 2016
Report by Kraig Worrall
DMNB Clinical Clerk Med3
Pre-oxygenation for Intubation – Dr Jay Mekwan
Oxygenation is essential in the management of critically ill patients. Intubation in the emergency department is a critical skill in improving patient outcomes. When indicated, intubation should be performed by skilled personnel to minimize hypoxia. Desaturation in the peri-intubation period can happen quickly – particularly in pediatric, bariatric and critically ill patients. Today in rounds, Dr. Mekwan reviewed recent evidence in the realm of pre-oxygenation. Bag Valve Mask (BVM) pre-oxygenation alone outperforms: (1) BMV with concurrent nasal cannula, (2) non-rebreather mask, and (3) non-rebreather mask with concurrent nasal cannula. Using a nasal cannula together with BMV compromises the mask seal, which leads to inferior pre-oxygenation performance. A nasal cannula should be applied after BMV and before intubation and remain in place during the intubation process. Discussion in rounds centered around strategies to improve peri-intubation O2 saturations, and ultimately improve outcomes in the Saint John Emergency Department. Finally, the use of ketamine in rapid sequence intubation was also discussed.
Reference:
http://www.sciencedirect.com/science/article/pii/S0196064411016672
Blunt chest trauma – Dr. Andrew Lohoar
Although blunt chest traumas can present to the emergency department from a variety of etiologies, motor vehicle collisions and falls account for the majority of cases. This statistic holds true in Saint John, for which Dr. Lohoar presented some recent data (see slides). Several important conditions arising from blunt chest trauma were discussed, including lung contusion, hemothorax (HTX), cardiac tamponade and pneumothorax (PTX). In particular, discussion was centered around decisions surrounding chest tube placement for PTX and HTX. Emergency chest tube insertion is the definitive initial management for either of these potentially deadly presentations. The decision to place a chest tube in a hemodynamically stable patient with radiological evidence of PTX following blunt trauma is influenced by a number of factors. Today in rounds, we discussed how experience is paramount to successful chest tube placement. The balance between practitioner experience and patient’s need for urgent decompression must be considered. Complications from improperly placed chest tube can contribute significant morbidity. Initial observation of an otherwise stable patient can certainly be the right choice for emergency room staff with limited chest tube experience. The same can be true for patients requiring hospital transfer.
Additional teaching points included: the use of POCUS as part of the primary survey, the role of CT and CT-decision rules, the disposition of blunt chest trauma patients, and, finally, strategies to reduce complications when placing chest tubes.
Managing violent patients – Dr. Jo-Ann Talbot
For many patients, emergency departments are the gateway into medical care. This includes violent patients, who, despite their behaviour, are sick and in need of care. This presentation, by Dr. Talbot, described strategies for managing violent patients. Strategies when faced with a violent patient include; (1) Calling for help, (2) controlling the scene, (3) de-escalating the situation. Fundamental to de-escalation is recognizing signs of an impending crisis. As with other aspects of medicine, prevention is better than reaction. Recognizing a patient’s needs can prevent a violent episode, for example, a simple gesture of food, nicotine replacement, or medication can calm a tense situation, develop a therapeutic trust with the patient, and prevent physical violence.
When a situation moves beyond prevention, physical and chemical restraints become viable options to reduce harm to the patient, staff, and assets. When physical restraints are used, it requires a team of 5 trained individuals. If possible, the treating physician should not participate in restraining the patient, as this can be deleterious to the therapeutic relationship. Agents, dosing, and strategies for chemical restraint are reviewed in the attached presentation.
Finally, Dr. Talbot emphasized the need for a centre/region-wide protocol for violence in the ED that is understood and implemented by all staff.
News from the Difficult Airway Course
Thanks to Dr Jay Mekwan for this update from the Difficult Airway Course
- The airway manual is being re-written with the paper copy available from Spring 2017. However the content that is currently being taught has all been updated. The App will be updated shortly.One of the big things from this is that the dosing of Roc is now suggested as Total body weight whereas before it was ideal body weight. This obviously makes dosing easier.
- Cricothyrotomy is still reducing in freq. Results from NEAR III, suggest a rate of about 0.3%. This is thought to be due to the increasing use of video laryngoscopy reducing the number of failed airways.
- CMAC is thought to be the best tool for education. While glidescope offers a similar platform, the feel of the CMAC is closer to DL and thus teaching residents is better.
- When positioning a child for intubation remember to align the external auditory canal with the anterior shoulder in a single horizontal line
- Sick/compromised patients require RSI drug modification, if still proceeding down the RSI route.Even the most cardio stable drugs (like Etomidate and Ketamine) can cause hypotension. Hence 1/2 dose (or lower) sedative and double dose paralytic are ideal
- When performing an “awake look”, ensure that time is taken to adequately topicalize the airway/oral or nasal passages. You should use glycopyrolate, Otrivin (Xylometazoline), atomized lidocaine & lidocaine paste. Sedation is not mandatory but may improve success.
Dr Jay Mekwan reminds us all to complete the Airway Audit Forms. Also please remember to record intubations using the C-MAC record button. Personally I have just got the hang of recording, after capturing a few selfies by mistake. I will post a how to record using C-MAC soon.
PoCUS for ETT Placement Confirmation
ETT Placement Confirmation During Cardiac Arrest: US for the Win!
Resident Clinical Pearl – November 2015
Kalen Leech-Porter, PGY 1, iFMEM, Saint John NB, Dalhousie University
Reviewed by: Dr Jay Mekwan and Dr David Lewis
The AHA has updated their guidelines for CPR and emergency cardiovascular care this year (2015)[i]. Previously, there were insufficient studies to warrant a recommendation for Point of Care Ultrasound (PoCUS) for ETT confirmation, however, a new study has emerged to suggest that PoCUS can be a useful adjunct for ETT placement confirmation. A 96 patient observational study done on patients during cardiac arrest, found that PoCUS had a sensitivity of 98.9% and a specificity of 100%[ii]. ETT placement was determined by placing the ultrasound transducer transversely above the suprasternal notch to identify endotracheal or esophageal intubation. It was determined during the study that in using this method ultrasound could be completed without interrupting chest compressions.
As the above study has yet to be replicated, end-tidal CO2 remains the gold standard for ETT placement confirmation (an observational, prospective study of 566 patients found colorimetric to be 95.6% sensitive, 99.8% specific[iii]) during cardiac arrest. However, AHA has added ultrasound as an additional method for confirmation of endotracheal tube placement, with the caveat that ultrasound should never interfere with the continuous conduction of high-quality CPR.
How to confirm ETT with PoCUS:
Video by Haney Mallemat
Video by Joseph Minardi
Abridged Instructions from ACEP Tips and Tricks [iv]
- Place the high frequency linear probe transversely just above the sternal notch (Image A); note normal airway anatomy (Image B), prior to ETT placement (if time permits)
Image A
From: Joseph Minardi’s Video [see above]
Image B
From: Halley Mallemat’s video [see above]
Trachea: Hyperechoic, curvilinear with comet-tail artifact
Esophagus: more distal, oval with heyperchoic wall and hypoechoic center
- PoCUS ETT confirmation can be done in real time, as ETT is placed, or done post placement. Successful ETT: there will be a slight increase in artifact/shadowing in trachea region only, known as the “Bullet Sign” (Image C) [v]. The operator should see reverberations in the trachea’s anterior lumen. To further confirm can slightly shake the ETT, this should only show trachea movement.
Image C
From: Mark Favot [v]
- Esophageal Intubation: will cause a second ‘trachea’ appear (Image D and E), referred to as the “double tract sign”
Image D
From: Halley Mallemat’s video [see above]
Image E
From ACEP Tips and Tricks [iv]
- Pitfalls: the esophagus may be located directly posterior to the trachea, therefore esophageal intubation may be missed if inadequate depth is used.
- Additionally, observing bilateral lung sliding while bagging a paralyzed patient also suggest ETT confirmation.
References
[i] Web-based Integrated 2010 & 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care; Part 7: Adult Advanced Cardiovascular Life Support. (Nov. 25, 2015) https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-7-adult-advanced-cardiovascular-life-support/
[ii] Sun, Jen-Tang, Sim, Shyh-Shyong, et al. “Ultrasonography for proper endotracheal tube placement confirmation in out-of-hospital cardiac arrest patients: two-center experience.” Critical Ultrasound Journal 6 (2014): A29 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4101346/
[iii] Hayden, SR., and Sciammerella, J., et al. “Colorimetric end-tidal CO2 detector for verification of endotracheal tube placement in out-of-hospital cardiac arrest.” Acad Emerg Med 6 (1995): 499-502 http://www.ncbi.nlm.nih.gov/pubmed/7497049
[iv] Chao, Alice and Ghrahbaghaian, Laleh. “Tips and Tricks: Airway Ultrasound.” American College of Emergency Physicians Emergency Ultrasound Section Newsletter (June, 2015). http://www.acep.org/Content.aspx?ID=102309
[v] Favot, Mark. “Ultrasound for Verification of Endotracheal Intubation.” FOAM EM (March, 2015). http://www.foamem.com/2015/03/02/ultrasound-for-verification-of-endotracheal-tube-location/
It’s Just Hot Air – Rounds May 2014
Here are the slides from Dr Mekwan’s thought provoking presentation on the use of high flow oxygen in ED.