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.
Right heart failure
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
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
Consider NIPPV to pre-oxygenate
Don’t neglect ap-ox
Use LMA early and often
Ketamine is your friend!
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
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!