Page 567 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 45: Airway Management 387

EQUIPMENT with all of the equipment required to manage a difficult airway should
be available to airway managers, but need not be brought to the bedside
In spite of the vast array of available equipment, most tracheal intuba- of every patient in crisis. 7
tions can be accomplished using a very small subset of the equipment Ideally, bags or boxes containing the equipment on the basic list
and a very simple checklist (Table 45-6). A cart that is fully stocked for cardiac arrest are readily available to airway managers and can be
brought by them to any situation in which they may be asked to manage
an airway. The more complete equipment set for urgent and elective
intubation can be kept in a cart stocked specifically for this purpose.
TABLE 45-6 Equipment List for Intubation Equipment should be checked at least daily and should be stored so
Cardiac arrest that it is readily accessible. It is important that the equipment is checked
Two laryngoscopes with functioning lights (ideally one with a short handle) by the person who will use it. This procedure ensures that the airway
https://kat.cr/user/tahir99/
manager can focus on the patient during airway manipulation, and is
Macintosh no. 3 and 4 and Miller no. 3 blades
not distracted by equipment failures, equipment checks, or preparation.
Small, medium, and large face masks
Laryngeal airways (eg, laryngeal mask airway [LMA], cuffed oropharyngeal airway ■ PHARMACOLOGIC PREPARATION AND USE
[COPA], Proseal™, Combitube) The goals of pharmacologic preparation of the patient include creat-
Suction with Yankauer tip ing conditions that allow safe intubation, providing relief from the
6.5, 7.0, 7.5, 8.0, 8.5, and 9.0 mm endotracheal tubes with cuffs checked discomfort and hemodynamic consequences associated with airway
manipulation and tracheal intubation, and decreasing the hormonal
Malleable metal stylet
and neurologic consequences of the procedure. The spectrum of phar-
10-mL syringe for inflation of endotracheal tube cuff macologic preparation ranges from topical anesthesia to intravenous
Oxygen supply general anesthesia. In the hands of experienced operators, most airway
manipulations can be accomplished with topical anesthesia alone.
Ambubag or other circuit (eg, Mapleson D) to ventilate patient
Intravenous general anesthesia is indicated in the setting of elevated ICP
Stethoscope and favorable airway anatomy (Table 45-7). There are many institu-
Gloves and eye protection tions where an intravenous general anesthetic is routinely administered
Portable end-tidal CO monitoring device (eg, EZ-Cap™, capnograph) for all emergency tracheal intubations, but this practice is not without
2 significant risks. The majority of the literature suggests that the use of
Cricothyroidotomy kit
intravenous general anesthesia to facilitate airway management may be
Urgent and elective intubation associated with a higher rate of failure and need for emergency trache-
Functioning IV line ostomy/cricothyroidotomy, especially in less experienced hands. So the
risks of giving a general anesthetic based on the patient’s airway anatomy
Monitors: pulse oximeter, blood pressure, electrocardiograph and physical status and the experience of the airway manager must be
Resuscitation cart weighed against the advantages of potentially improved airway visual-
Drugs ization prior to proceeding with a general anesthetic.
Atropine Patients who require urgent intubation benefit from pharmacologic
preparation when circumstances allow. The administration of 0.2 mg IV
IV lidocaine
glycopyrrolate will dry the mouth and facilitate direct laryngoscopy or
Ephedrine fiberoptic laryngoscopy. The oropharynx can be anesthetized topically
Epinephrine with 4% lidocaine spray, followed by approximately 1 to 2 mL of 2% to
5% lidocaine jelly or ointment on an oral airway of appropriate size for
Glycopyrrolate the patient. The central channel of the oral airway can also be used to
Succinylcholine direct topical anesthetic at the vocal cords. The use of lidocaine for
Rocuronium topical anesthesia is preferable to benzocaine, as the latter can cause
Topical anesthetics (lidocaine jelly, benzocaine spray) methemoglobinemia. Care should be taken to avoid giving high doses
Topical phenylephrine spray
Controlled substances
Propofol
TABLE 45-7 Steps for Tracheal Intubation in the Presence of Elevated
Thiopental Intracranial Pressure and an Anatomically Favorable Airway
Etomidate 1. Administer 1 mg vecuronium or pancuronium (if available).
Midazolam 2. Preoxygenate for 3 minutes.
Fentanyl 3. Apply cricoid pressure.
Ketamine 4. Administer 0.03 mg/kg midazolam (if available).
Tape 5. Administer 1-2 μg/kg fentanyl (if available).
Magill forceps 6. Administer 100 mg lidocaine (optional, but generally desirable).
Size 7, 8, 9, and 10 oral airways 7. Administer 3-5 mg/kg thiopental or 2 mg/kg propofol.
28, 30, 32, and 34 French nasal trumpets 8. Administer 1.5 mg/kg succinylcholine or 0.2 mg/kg vecuronium or 1 mg/kg rocuronium.
Full variety of endotracheal tubes, including 7.0 and 8.0 mm 9. Hyperventilate for 45 seconds with Ambu bag/mask following succinylcholine admin-
Endotrol tubes, armored tubes istration, or for 2 minutes following vecuronium administration.
Fiberoptic bronchoscope 10. Perform laryngoscopy/intubation.
Videolaryngoscope 11. Confirm intubation with auscultation or capnography.
Jet ventilator 12. Elevate head of bed and ventilate to goals for patient.

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