Ep 110 Airway Pitfalls – Live from EMU 2018

This is EM Cases Episode 110 - Airway Pitfalls Live from EMU 2018. The last decade has seen a torrent of literature and expert opinion on emergency airway management. It is challenging to integrate all this new information into a seamless flow when faced with a challenging airway situation. In this live podcast recorded at North York General's Emergency Medicine Update Conference 2018, Scott Weingart and Anton Helman put together the latest in emergency airway management by outlining  6 common airway pitfalls: Failure to prepare for failure, failure to position the patient properly, failure to optimize oxygenation, failure to optimize hemodynamics, failure to consider an awake intubation and failure to prepare for a cricothyrotomy... Podcast production, sound design & editing by Anton Helman Written Summary and blog post Anton Helman May, 2018 Cite this podcast as: Weingart, S, Helman, A. Airway Pitfalls - Live from EMU 2018. Emergency Medicine Cases. May, 2018. https://emergencymedicinecases.com/airway-pitfalls-emu/. Accessed [date]. First, slow down. In the vast majority of airway management situations, you have time. Rushing towards endotracheal intubation without adequate preparation is a recipe for disaster. Beat The Stress Fool is a just-in-time stress management technique. It allows you to control your own physiology (heart rate, respiratory rate, stress response) when you anticipate a stressful situation. There are 4 techniques that you can choose one or more to do when a stressful situation arises. Adapted from Mike Lauria, Annals of EM 2017 Breath – tactical breathing - slow down your breathing by counting 4 seconds while you inhale, hold your breath, then count to 4 secs while you exhale, then hold your breath ("box breathing"). Talk – self talk – speak to yourself using positive cues such as “I got this”. See – visualize yourself doing the procedure or actions perfectly which augments your chances of success. Focus – use a trigger word such as “smooth” to slow and calm yourself down and focus on the task at hand. EMCrit podcast on Beat The Stress Fool Airway Pitfall #1: Failure to prepare for failure ABC plans: Have a plan A, plan B if plan A fails and plan C if plan B fails. Plan A is primary laryngoscopy – either VL or DL. A recent RCT suggests using VL with a Bougie to optimize first attempt success in anticipated difficult airways. After 3 attempts with a change in VL vs DL, position and/or intubators, move on to plan B. Plan B is rescue with a supraglottic device (e.g. i-gel, LMA, AirQ, King LT). If the supraglottic device does not result in rapid improvement in oxygenation and end tidal CO2, declare to your team that you are in a "can’t intubate, can’t oxygenate" situation and move on to plan C - cricothyrotomy. LMA description, insertion, contraindications and complications on LiTFL Minimal failed airway bedside gear list within arms reach: For plan A: VL, DL, ETT, Bougie, end tidal CO2 For plan B: supraglottic airway device For plan C: scalpel, Bougie, size 6 ETT