Scott Weingart - Emergent Intubation Resequenced

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SMACC Conference

Pretty much everything I learned as a resident in terms of the sequencing of airway management in ED has changed over the past 15 years. No longer is there simply RSI or stick a laryngoscope in with nothing and use pure brute force to intubate a patient; we have a host of different options and pathways when approaching airway management in the emergency department. This lecture discusses some of these updated ways of getting from a sick patient requiring airway management to a tube between the cords…with only minor technical mishaps.

Saúde e medicina

Re-
Sequencing
Intubation

43 Male
Sat 80% on NRB
Rales up to clavicles
In severe distress
Rips off the NRB and tries to get out of his
stretcher
Pt keeps shouting he can’t breathe

The
Laryngoscope as a
Murder Weapon

How to stop killing
our friggin’
patients when
intubating

DASH-1A
Bill Hinckley, MD

Definitive
Airway

Sine
Hypoxemia

1st
Attempt

Crash

Paradigm Shift

43 Male
Sat 80% on NRB
Rales up to clavicles
In severe distress
Rips off the NRB and tries to get out of his
stretcher
Pt keeps shouting he can’t breathe

Low Sat and the
Pt won’t tolerate the mask

RSI

Modified
RSI

Pulse Ox
Lag

From George Kovacs

DSI

Delayed
Sequence
Intubation

Denitrogenation
Preoxygenation
Positioning
Gastric Emptying
Team Briefing

Delayed Sequence Intubation
(DSI)

DSI is not
CPAP
Preoxygenation

DSI ApOx
Vent as
Bag
CPAP
Preox

How should we apply
CPAP for
PREOX?

CPAP Devices

Add a
Nasal Cannula
Journal of Clinical Anesthesia (2010) 22, 164–168

Mapleson

Nasal Cannula
+
BVM
+
PEEP Valve

Nasal Cannula (15)
+
BVM (15)
+
PEEP Valve (15)

Sometimes we
use it for other
reasons…

Where is the evidence
for DSI?

62 Patients

No complications
2 patients avoided
intubation

A Dirty
Little Secret
about DSI

Where is MORE
evidence?
Strayer RJ.Am J Emerg Med. 2008 Nov;26(9):985-1028.

What if something
goes wrong?

DSI
becomes
RSI

A Dirty
Little Secret
about DSI

Emesis

Altered
Mental
Status?

What if the pt is
hypertensive or
tachycardic?

Can’t I do this with
other meds?

Standard RSI
Induction Agents?

DSI is just procedural
sedation
The procedure is
preoxygenation

emcrit.org/preox
emcrit.org/dsi

To Review

Don’t be forced
into a
CRASH
Intubation

DSI
keeps you
in control

Most
Vulnerable
Moment

The
Laryngoscope as a
Murder Weapon

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Ellen O’Sullivan presents an outline of the Difficult Airway Society (DAS) Guidelines on airway management. Airway management is a fundamental responsibility and skill of all involved especially for emergency physicians, anaesthetists and critical care physicians. Ellen makes the point that mismanagement of airways leads to severe morbidity and mortality. She provides a few harrowing examples. The 2015 Difficult Airway Society guidelines, published in the British Journal of Anaesthesia in December 2015, provide a sequential series of plans (A to D) to implement when tracheal intubation fails. They promote patient safety by prioritising oxygenation and minimising trauma. Furthermore, they highlight the role of neuromuscular blockade in making airway management easier. The guidelines recognise the difficulties in decision making during an emergency and stress importance of human factor training. The guidelines include steps to assist the anaesthetic team by providing a common stem of options (a simple algorithm) for maintaining oxygenation, limiting the number of airway intervention attempts, encouraging declaration of failure by placing a Supraglottic Airway Device and overtly recommending a time for stopping and thinking. They emphasise the importance of considering discontinuing anaesthesia and waking the patient up (if appropriate) when tracheal intubation has failed. The guidelines recommend videolaryngoscopy and second generation Supraglottic Airway Devices. All anaesthetists, intensivists and emergency medicine physicians should be able to use these devices. There is limited evidence relating to the management of the ‘can’t intubate can’t oxygenate’ situation (CICO) PLAN D. However, all anaesthetists should be able to perform a surgical cricothyroidotomy (and trained accordingly). Join Ellen as she provides you with what you need to know for management of the difficult airway, in line with the DAS Guidelines. For more like this, head to our podcast page. #CodaPodcast

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In the past two decades, airway management has been revolutionized by the development of video laryngoscopy, hyperangulated blade geometry, optical stylets, laryngeal masks, and a host of advances in airway pharmacology and technique. The core skill of airway management, however, remains laryngoscopy, whether or not the operator uses a blade with a camera at the end. In this presentation, we break down laryngoscopy into its discrete components and describe best practice technique at each step. We will start by describing common mistakes made in patient positioning; proposing a set of parameters the provider can use to guide positioning that is optimal for laryngoscopy, including the configuration of the patient in the bed, the bed height and head elevation, as well as provider stance. We then move into the effect of laryngoscope grip on operator catecholamine management and describe the optimal laryngoscope grip for emergency airway management. We next confront one of the core principles of RSI, the delay between medication administration and commencement of laryngoscopy, and propose an alternative approach that emphasizes early laryngoscopy with deliberate slowness. We turn our attention to the value of the jaw thrust–as performed by an assistant–during airway management, and then move into a step by step analysis of laryngoscopy as the blade moves into the mouth, down the tongue and ultimately to the glottis. We espouse suction as an underutilized device by emergency providers, and describe the two most important intra-laryngoscopy optimization maneuvers: optimization of the position of the head, and optimization of the position of the larynx. We discuss the value of using the gum elastic bougie for both difficult and routine intubations and describe pitfalls encountered when using the bougie (and how to manage them). We conclude by describing the 3-finger tracheal palpation method of endotracheal tube depth confirmation.

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The BONANZA Trial and PbTO2 Monitoring

SMACC Conference

R. Loch Macdonald, M.D., Ph.D. Community Neurosciences Institute Fresno, California, USA Angiographic vasospasm and more accurately, delayed cerebral ischemia, continue to contribute to morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). It is known that angiographic vasospasm is common after SAH, occurring in two-thirds of patients. Cerebral infarctions that developed days after the SAH have been attributed to angiographic vasospasm, occuring in about a third of patients, although this has always been controversial. Angiographic vasospasm theoretically can only damage the brain by restricting blood flow but there is no easy, accurate, widely available method to measure cerebral blood flow and this is not the measurement we need. Blood flow depends on metabolic demand so what we need to know to determine if angiographic vasospasm is causing ischemia is oxygen extraction fraction in the brain tissue supplied the the spastic artery. Without this measurement, the attribution of ischemia to vasospasm is subjective. Since angiographic vasospasm is essentially the only detectable delayed phenomenon after SAH, we focus on it and apply tremendous resources to preventing or reversing the vasospasm. Undoubtedly angiographic vasospasm can cause cerebral infarctions, but it has to be severe and flow limiting. But SAH is a complex disease. There are many other causes for cerebral infarctions after SAH, the most common being due to the aneurysm repair procedure. And a given degree of vasospasm may cause infarction in a volume-depleted patient with poor collateral blood supply but not in a patient without these things. There also are hypodense brain lesions after SAH that are due to intracerebral hemorrhages. There can be hypodensities in the brain directly under usually thick SAH where the brain dies. This observation in particular supports a role for cortical spreading depolarizations/ischemia as a cause of infarction after SAH. Other macromolecular processes that are hypothesized to cause brain damage after SAH include microthromboembolism, changes in the microcirculation, delayed brain cell apoptosis and capillary transit time heterogeneity. Determining the importance of these things is hindered by the lack of an easy way to detect them in patients. It is also known that poor grade patients, who presumably have more early brain injury and ischemia than good grade patients, are more prone to delayed cerebral ischemia, suggesting increased sensitivity to secondary insults of the already injured brain. We also assume delayed neurological deterioration when attributed to vasospasm or delayed cerebral ischemia, is purely due to ischemia. While knowledge about what happens pathophysiologically after SAH is increasing, management of delayed cerebral ischemia still focuses on detecting angiographic vasospasm and then augmenting the blood pressure to improve cerebral blood flow or dilating the spastic arteries with balloons or drugs.

Dilating the Dogma of Vasospasm

Dilating the Dogma of Vasospasm

Dilating the Dogma of Vasospasm

SMACC Conference

EVD Tips and Tricks

EVD Tips and Tricks

EVD Tips and Tricks

SMACC Conference

Part 2 of a debate over the classification of TBI. Andrew Udy then argues that this classification is fundamentally flawed. He discusses the issues with the Glasgow Coma Scale, and therefore the follow-on issues in TBI classification, including all the confounders to the GCS, the issues with timing of the score as well as GCS not taking baseline function or specifics subtypes of TBI into account. He makes teh argument that biomarkers may better categorise the diffuse entity we call TBI.

There is no such thing as mild, moderate and severe TBI - by Andrew Udy

There is no such thing as mild, moderate and severe TBI - by Andrew Udy

There is no such thing as mild, moderate and severe TBI - by Andrew Udy

SMACC Conference

Andrew Chow, Intensivist with a neurosurgical background, argues that the current categorisation system for traumatic brain injury (TBI) works, and makes sense! He tackles us through the history of this system, and why it’s important to differentiate different types of TBI. The arguments in favour of this categorisation include the consistency and benefits of a universal language, the implications for triage and management, and the fact that this system has been endorsed by all major organisations

TBI Debate - Mild, moderate and severe categories work

TBI Debate - Mild, moderate and severe categories work

TBI Debate - Mild, moderate and severe categories work

SMACC Conference

Dr Nick Little is an experienced Neurosurgeon who's looked after patients with traumatic brain injury for his whole career. Here he discusses the difficulties of prognostication following traumatic brain injury (TBI). He talks about the statistics of outcomes following mild, moderate and severe TBI and then goes on to tackle the harder topic of how we try to work out what an individual would want if they knew the spectrum of outcomes that they may face. The issues with the clinical examination findings we use to prognosticate are covered, as well as which imaging findings he finds most helpful. He also mentions the difficulties with current prognostic calculators.

TBI: when to stop and when to give time

TBI: when to stop and when to give time

TBI: when to stop and when to give time

SMACC Conference

Historically, when it came to brain injury, ketamine had a bad rap. Much of that dogma was dispelled in the last decade, and ketamine is now frequently used as an induction agent in acute brain injury, especially traumatic brain injury, due to it’s favorable effects on haemodynamics. However a new application of ketamine is now being explored - whether ketamine may be able to reduce secondary brain injury.

Ketamine in Brain Injury by Toby Jeffcote

Ketamine in Brain Injury by Toby Jeffcote

Ketamine in Brain Injury by Toby Jeffcote

SMACC Conference

20 million people around the world are living with a spinal cord injury (SCI). The medical issues they develop over the years differ to any other patient cohort. These complications include autonomic dysreflexia, management of pressure areas, specific infections, nuanced peri-operative care and highly specific issues such as baclofen pump management and syringomyelia Do look at the NeuroResus section on this and listen to Spinal Rehab Specialist Bonne Lee talk about this side of SCI care. Keywords SCI, spinal, spinal cord injury, autonomic dysreflexia, pressure areas, infection, peri-operative care, baclofen pump, syringomyelia, chronic SCI, spinal trauma, spinal rehab, incomplete SCI

Managing Complications of Chronic SCI by Bonne Lee

Managing Complications of Chronic SCI by Bonne Lee

Managing Complications of Chronic SCI by Bonne Lee

SMACC Conference

Tania is a neurologist and epileptologist with expertise in continuous EEG (cEEG) and status epilepticus (SE). This talk covers what a seizure is, what status is, including focal and generalised status epilepticus. So why do we do cEEGs for patients with suspected SE? To confirm the diagnosis To see if patient just post ictal or still seizing To establish that the clinical and electric seizures have stopped To see if burst suppression is achieved To exclude other differential diagnoses She makes a good argument for why cEEG is such an important tool in managing SE. In the questions after the talk, the issue of availability of cEEG in the Australian setting was discussed. Limited montage EEGs are discussed including their pros and cons.

EEG and Status Eplilepticus by Tania Farrar

EEG and Status Eplilepticus by Tania Farrar

EEG and Status Eplilepticus by Tania Farrar

SMACC Conference

Stuart Browne is a Neuro Rehab specialist from Sydney. These slides accompany a talk he gave at the Brian Symposium in 2023. He discusses what "severe disability" really means. Severe disability is more common than many realise - about 6% of the Australian population. Stuart discusses how health is more than simply physical recovery and how it is a multidimensional construct. He covers how permanent disability doesn't necessarily equate to a poor quality of life. He also discusses the long timespan of recovery, which is often much longer than appreciated. He specifically discusses "Locked-in Syndrome" and how the survivors have surprisingly positive self-reported health-related quality of life and well-being. Stuart also covers how severely disabled people face various forms of discrimination.

Browne Neuro symposium.pptx

Browne Neuro symposium.pptx

Browne Neuro symposium.pptx

SMACC Conference

Paediatric Stroke by Shree Basu

Paediatric Stroke by Shree Basu

Paediatric Stroke by Shree Basu

SMACC Conference

After spinal cord injury (SCI), there aren’t many interventions we have available that actually make a difference. Augmenting blood pressure to increase spinal cord perfusion pressure is an attractive concept that may improve neurological outcomes following SCI. We know that hypotension can make SCI worse. Clinical studies looking at blood pressure augmentation are mostly old, retrospective and flawed in various ways. Aiming for a MAP of > 85 for 5-7 days is recommended by guidelines but why this pressure and duration are good questions. Hypertensive therapy is relatively safe and easy to implement but not without risk. Tessa discusses the pros and cons, how this is managed practically and what the future may hold in this area.

Hypertensing Spinal Cord Injury - gold standard or wacky?

Hypertensing Spinal Cord Injury - gold standard or wacky?

Hypertensing Spinal Cord Injury - gold standard or wacky?

SMACC Conference

Mark Weedon takes us through the increasingly utilised concept of an optimal cerebral perfusion pressure (CPPopt) for each unique patient. He discusses the background to CPPopt, including intrcranial pressure (ICP), the Monroe Kelly hypothesis, neurovascular coupling, and cerebral autoregulation in health and following brain injury. He shows how intracranial pressure is affected by intracranial compliance and how this affects ICP waveforms. Cerebral perfusion pressure in relation to the Brain Trauma Foundation guidelines is covered including management of elevated ICP (EICP). The currently recommended tiered approach to managing cerebral perfusion pressure and EICP is mentioned citing recent guidelines. He uses a clinical case of a TBI to illustrate how the CPPopt can be ascertained and used to guide therapy, including the easy to perform “MAP Challenge”. Mark also describes the Pressure Reactivity Index (PRx) and how it can be used as a target for therapy. Finally, he covers the exciting results of the preliminary COGiTATE pilot study.

Optimal Cerebral Perfusion Pressure

Optimal Cerebral Perfusion Pressure

Optimal Cerebral Perfusion Pressure

SMACC Conference

The Power of Words - Death and Language.ppt

The Power of Words - Death and Language.ppt

The Power of Words - Death and Language.ppt

SMACC Conference

Appropriate use of antimicrobials is primarily a patient safety issue, and is the key aim of an effective antimicrobial stewardship program. We discuss the challenges in the management of a patient with sepsis, and how decision-making is usually done in the absence of effective diagnostics. Time dependent protocols and the knowledge that undertreatment of a patient with sepsis will lead to poor outcomes will lead to prescribing that may be driven by fear. Antimicrobial resistance is associated with over-use of antimicrobials but is usually not the immediate concern. Antimicrobial stewardship programs should work closely with sepsis teams to ensure that sepsis pathways are implemented across the whole hospital, and that key principles of judicious use are embedded within the clinical pathway.

Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin

Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin

Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin

SMACC Conference

Being able to prognosticate in the aftermath of a traumatic brain injury (TBI) is important as it assists with counselling patients and families. Moreover, it helps rationally allocate healthcare resources. However, due to the heterogenous nature of TBI and variable pre brain injury patient factors and post brain injury course, this has proven to be a difficult task. Large cohort studies have enabled improved accuracy in the prediction of 6 month mortality and unfavourable outcome. Furthermore, many of the factors that contribute to long-term outcome have also emerged. However, it is not yet possible to use them in prediction algorithms or mathematical models. There is emerging evidence that pre injury psychosocial and demographic factors may be of more relevance than injury severity. Moreover, that 'outcome' becomes increasingly subjective and complex as the post injury duration increases. We end with three brief vignettes which highlight the fraught nature of long term outcome prediction.

Brain injury outcomes and predictors

Brain injury outcomes and predictors

Brain injury outcomes and predictors

SMACC Conference

Mais de SMACC Conference (20)

Precision Medicine in Acute Brain Injury

Precision Medicine in Acute Brain Injury

Precision Medicine in Acute Brain Injury

CSD by Jeffcote Coda 22.pdf

CSD by Jeffcote Coda 22.pdf

CSD by Jeffcote Coda 22.pdf

Subdural Haemorrhage and MMA embolisation

Subdural Haemorrhage and MMA embolisation

Subdural Haemorrhage and MMA embolisation

Andy Neill - More neuroanatomy pearls for neurocritical care

Andy Neill - More neuroanatomy pearls for neurocritical care

Andy Neill - More neuroanatomy pearls for neurocritical care

The BONANZA Trial and PbTO2 Monitoring

The BONANZA Trial and PbTO2 Monitoring

The BONANZA Trial and PbTO2 Monitoring

Dilating the Dogma of Vasospasm

Dilating the Dogma of Vasospasm

Dilating the Dogma of Vasospasm

EVD Tips and Tricks

EVD Tips and Tricks

EVD Tips and Tricks

There is no such thing as mild, moderate and severe TBI - by Andrew Udy

There is no such thing as mild, moderate and severe TBI - by Andrew Udy

There is no such thing as mild, moderate and severe TBI - by Andrew Udy

TBI Debate - Mild, moderate and severe categories work

TBI Debate - Mild, moderate and severe categories work

TBI Debate - Mild, moderate and severe categories work

TBI: when to stop and when to give time

TBI: when to stop and when to give time

TBI: when to stop and when to give time

Ketamine in Brain Injury by Toby Jeffcote

Ketamine in Brain Injury by Toby Jeffcote

Ketamine in Brain Injury by Toby Jeffcote

Managing Complications of Chronic SCI by Bonne Lee

Managing Complications of Chronic SCI by Bonne Lee

Managing Complications of Chronic SCI by Bonne Lee

EEG and Status Eplilepticus by Tania Farrar

EEG and Status Eplilepticus by Tania Farrar

EEG and Status Eplilepticus by Tania Farrar

Browne Neuro symposium.pptx

Browne Neuro symposium.pptx

Browne Neuro symposium.pptx

Paediatric Stroke by Shree Basu

Paediatric Stroke by Shree Basu

Paediatric Stroke by Shree Basu

Hypertensing Spinal Cord Injury - gold standard or wacky?

Hypertensing Spinal Cord Injury - gold standard or wacky?

Hypertensing Spinal Cord Injury - gold standard or wacky?

Optimal Cerebral Perfusion Pressure

Optimal Cerebral Perfusion Pressure

Optimal Cerebral Perfusion Pressure

The Power of Words - Death and Language.ppt

The Power of Words - Death and Language.ppt

The Power of Words - Death and Language.ppt

Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin

Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin

Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin

Brain injury outcomes and predictors

Brain injury outcomes and predictors

Brain injury outcomes and predictors

Último

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Scott Weingart - Emergent Intubation Resequenced

1. Re- Sequencing Intubation

2. 43 Male Sat 80% on NRB Rales up to clavicles In severe distress Rips off the NRB and tries to get out of his stretcher Pt keeps shouting he can’t breathe

3. The Laryngoscope as a Murder Weapon

4. How to stop killing our friggin’ patients when intubating

5. DASH-1A Bill Hinckley, MD

6. Definitive Airway

7. Sine Hypoxemia

10. Paradigm Shift

11.

12. 43 Male Sat 80% on NRB Rales up to clavicles In severe distress Rips off the NRB and tries to get out of his stretcher Pt keeps shouting he can’t breathe

13. Low Sat and the Pt won’t tolerate the mask

14.

15.

17. Modified RSI

18.

19. Pulse Ox Lag

20. From George Kovacs

22. Delayed Sequence Intubation

23. Denitrogenation Preoxygenation Positioning Gastric Emptying Team Briefing

24. Delayed Sequence Intubation (DSI)

25. DSI is not CPAP Preoxygenation

26. DSI ApOx Vent as Bag CPAP Preox

27. How should we apply CPAP for PREOX?

28. CPAP Devices

29. Add a Nasal Cannula Journal of Clinical Anesthesia (2010) 22, 164–168

31.

32.

33.

34. Nasal Cannula + BVM + PEEP Valve

35. Nasal Cannula (15) + BVM (15) + PEEP Valve (15)

36. Sometimes we use it for other reasons…

37. Where is the evidence for DSI?

38.

39. 62 Patients

40.

41.

42.

43.

44.

45.

46. No complications 2 patients avoided intubation

47. A Dirty Little Secret about DSI

48. Where is MORE evidence? Strayer RJ.Am J Emerg Med. 2008 Nov;26(9):985-1028.

49. What if something goes wrong?

50. DSI becomes RSI

51. A Dirty Little Secret about DSI

53. Altered Mental Status?

54. What if the pt is hypertensive or tachycardic?

55. Can’t I do this with other meds?

56. Standard RSI Induction Agents?

57.

58.

59. DSI is just procedural sedation The procedure is preoxygenation

60. emcrit.org/preox emcrit.org/dsi

62.

63. Don’t be forced into a CRASH Intubation

64. DSI keeps you in control

65. Most Vulnerable Moment

66. The Laryngoscope as a Murder Weapon