5.30.19 Conference Summary

Airway Series: The Physiologically Difficult Airway Part 1: Dr. Stull

  • Review of anatomically difficult airway:

    • Use the LEMON law

    • “yoda” the pre-oxygenation (DO IT EVERY TIME)

    • Make your first attempt for best attempt

    • Paralytics are usually your friend

  • Physiologic Difficult Airway: An airway in which physiologic derangements place the patient at higher risk of cardiovascular collapse with intubation and conversion to PPV.

    • Hypoxia

    • Hypotension

    • Metabolic acidosis

    • Right heart failure

2323_Oxygen-hemoglobin_Dissociation-b.jpg

Hypoxia

  • Case 1 - 70 yo M previously healthy presented for sob + diarrhea after Europe trip

    • SpO2 85% 6L, RR 24, HDS, mild tachycardia, T 100.9

    • Comfortable-appearing

    • CXR with bilateral consolidations

    • Next steps: immediately place on NRB, consider NIPPV for preoxygenation while preparing to intubate (CPAP at 10), dissociate with 1.5mg/kg ketamine

  • Key points

    • Consider NIPPV to pre-oxygenate

    • Don’t neglect ap-ox

    • Use LMA early and often

    • Ketamine is your friend!

Hypotension

  • Case 2A - 23 yo M GSW to LLQ

    • HR 135, BP 86/72, RR 26, afebrile, 98% NRB

    • Diaphoretic, confused, thrashing

    • Next steps: Resuscitate with blood products prior to RSI

  • Case 2B - 65 yo F h.o arthritis on frequent NSAIDs c/o severe abd pain + fever, now with AMS

    • HR 121, BP 98/42, RR 28, SpO2 93%, T 101.4

    • Projectile vomiting, not protecting airway

    • Next steps: start abx, call surgery, resuscitate (fluids, push dose pressors — epi preferably — start preparing drip (norepi), consider ketamine) while preparing for RSI

  • Key points

    • Stop and think!

    • Don’t assume AMS/agitation = intoxication; may be sign of impending decompensation

    • Resuscitate before RSI (prioritize “C” in ABCs); positive pressure —> drop in preload

    • Start pressors early

    • Ketamine is your friend

***We are the masters of the airway!