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Airway Management in STEMI, Stroke, and Trauma Patients:

Interventions, Timing, and Outcomes

Joshua Stilley, MD FACEP FAAEM

Assistant Professor of Clinical Emergency Medicine

Chief, Division of EMS

Medical Director, Prehospital Services

University of Missouri

Conflicts of Interest & Disclosures

• None

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Objectives

If

Why

When

How

• STEMI

• Stroke

• Trauma

• Cardiac Arrest

• Sepsis

• Opioid Overdose

• Pediatrics

• Vascular catastrophe

• Gonadal torsion

• Ocular emergency

TCD +

TCD+

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http://c1.thejournal.ie/media/2013/06/passed-out-752x501.jpg

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"Controlled Airway"

Intubation Complications

• Inability to intubate

• Multiple attempts

• Mainstem

• Hypoxia

• Dental Trauma

• Damage to airway

• Aspiration

• Bronchospasm

• De-recruitment

https://litfl.com/adverse-effects-of-endotracheal-intubation/

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Physiologic effect of Intubation/PPV

• Pulmonary Changes– Decreased surfactant production– Unequal alveoli inflation– Stress and shear forces

• Decreased Cardiac Output– Decreased venous return– Reduced right ventricular output– Reduced left ventricular output

• Neuro Effects– Decreased venous return -> Increases Intracranial Pressure– Hippocampal Apoptosis

• Induced inflammation• Disordered sleep

N. Soni, P. Williams, Positive pressure ventilation: what is the real cost?, BJA: British Journal of Anaesthesia, Volume 101, Issue 4, October 2008, Pages 446–457, https://doi.org/10.1093/bja/aen240

https://www.uptodate.com/contents/physiologic-and-pathophysiologic-consequences-of-mechanical-ventilation

Clinical Outcomes - TBI

• Worse outcomes if:– Hypoxemia during intubation

– Hypotension during intubation

– Hypocapnia after intubation

• Post-injury apnea requiring ventilation support does not necessarily predict poor outcome.

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Predictors of Peri-Intubation Arrest

• SBP < 90 mm Hg prior to intubation

• Hypoxemia prior to intubation

• Absence of Preoxygenation

• BMI > 25 kg/m2

• Age > 75

De Jong et al. Cardiac Arrest and Mortality Related to Intubation Procedure in Critically Ill Adult Patients: A Multicenter Cohort Study. Critical Care Medicine. Issue: Volume 46(4), April 2018, p 532-539.

Predictors of Peri-Intubation Arrest

De Jong et al. Cardiac Arrest and Mortality Related to Intubation Procedure in Critically Ill Adult Patients: A Multicenter Cohort Study. Critical Care Medicine. Issue: Volume 46(4), April 2018, p 532-539.

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Trauma – Post-Intubation Hypotension

• Post-Intubation Hypotension Prevalence = 36.3%

• ED Mortality AOR 3.45

• In-hospital Mortality AOR, 1.83

Green, Robert S. MD; Butler, Michael B. MD; Erdogan, Mete PhD. Increased mortality in trauma patients who develop postintubation hypotension Journal of Trauma and Acute Care Surgery. October 2017 - Volume 83 - Issue 4 - p 569–574.

https://journals.lww.com/jtrauma/fulltext/2017/10000/Increased_mortality_in_trauma_patients_who_develop.1.aspx

Hyperoxia

• Supratherapeutic levels = >Increased mortality– Stroke, TBI, Cardiac Arrest

Elisa Damiani, Erica Adrario, Massimo Girardis, Rocco Romano, Paolo Pelaia, Mervyn Singer and Abele Donati. Arterial hyperoxia and mortality in critically ill patients: a systematic review and meta-analysis. Critical Care. 2014. 18:711. Elmer J, Scutella M, Pullalarevu R, et al. The association between hyperoxia and patient outcomes after cardiac arrest: analysis of a high-resolution database. Intensive Care Med. 2014;41(1):49-57.

Girardis M, Busani S, Damiani E, et al. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. JAMA. 2016;316(15):1583–1589. doi:10.1001/jama.2016.11993

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Airway Management in OOCHA

PART Airways-2 CAAMSettingComparisonPractitionersSample SizeRandomization

Primary Outcome

BVM-Only RatePrimary FindingImportant SecondaryFinding

Airway Management in OOCHA

PART Airways-2 CAAMSetting USAComparison LT v ETIPractitioners PM and EMTSample Size 3,000Randomization Cluster Randomized

by EMS AgencyPrimary Outcome 72-hour Survival

BVM-Only Rate ~12%Primary Finding LT > ETIImportant SecondaryFinding

LT fasterLow ETI Success Rate

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Airway Management in OOCHA

PART Airways-2 CAAMSetting USA UKComparison LT v ETI i-gel v ETIPractitioners PM and EMT PMSample Size 3,000 9296Randomization Cluster Randomized

by EMS AgencyCluster Randomized by Medic

Primary Outcome 72-hour Survival Hospital Survival with Fav Neuro Status

BVM-Only Rate ~12% ~18%Primary Finding LT > ETI No differenceImportant SecondaryFinding

LT fasterLow ETI Success Rate

i-gel > ETI

Airway Management in OOCHA

PART Airways-2 CAAMSetting USA UK France, BelgiumComparison LT v ETI i-gel v ETI BVM v ETIPractitioners PM and EMT PM PhysiciansSample Size 3,000 9296 2,043Randomization Cluster Randomized

by EMS AgencyCluster Randomized by Medic

Per Patient (Envelope)

Primary Outcome 72-hour Survival Hospital Survival with Fav Neuro Status

28-day survival with Fav Neuro Status

BVM-Only Rate ~12% ~18% N/APrimary Finding LT > ETI No difference InconclusiveImportant SecondaryFinding

LT fasterLow ETI Success Rate

i-gel > ETI BVM -> Poorer Ventilation,Higher Aspiration

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OOHCA: BVM v SGA v ETI

• BVM v ETI: Equivalent

• BVM v ETI: BVM

• BVM v SGA: BVM

Jabre P, Penaloza A, Pinero D, et al. Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial. JAMA. 2018;319(8):779-787. https://www.ncbi.nlm.nih.gov/pubmed/29486039

Hasegawa K, Hiraide A, Chang Y, Brown DFM. Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest. JAMA.2013;309(3):257–266. doi:10.1001/jama.2012.187612

OOHCA

• BVM v Advanced Airway– 649,359 patients

• 57% BVM

• 6% ETI

• 37% SGA

• Favors Intubation

Hasegawa K, Hiraide A, Chang Y, Brown DFM. Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest. JAMA. 2013;309(3):257–266. doi:10.1001/jama.2012.187612

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OOHCA

• BVM v Advanced Airway– 649,359 patients

• 57% BVM

• 6% ETI

• 37% SGA

– Multivariable logistic regression, • AAM OR 0.38 (95% CI, 0.37-0.40)

– Adjusting for age, sex, etiology of arrest, first documented rhythm, witnessed status, type of bystander cardiopulmonary resuscitation, use of public access automated external defibrillator, epinephrine administration, and time intervals.

• Favors Advanced Airway

Hasegawa K, Hiraide A, Chang Y, Brown DFM. Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest. JAMA. 2013;309(3):257–266. doi:10.1001/jama.2012.187612

OOHCA

• ETI v SGA (Meta-Analysis)– Favors ETI

– ROSC, survive to hospital admission, and survive neurologically intact

Justin L. Benoit, Ryan B. Gerecht, Michael T. Steuerwald, Jason T. McMullan. Endotracheal intubation versus supraglottic airway placement in out-of-hospital cardiac arrest: A meta-analysis. Resuscitation. Volume 93. 2015. Pages 20-26. https://www.ncbi.nlm.nih.gov/pubmed/26006743

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OOHCA

• SGA v ETI: Favors SGA

Wang HE, Schmicker RH, Daya MR, et al. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018;320(8):769–778. doi:10.1001/jama.2018.7044 https://www.ncbi.nlm.nih.gov/pubmed/30167699

OOHCA

• ETI v LMA RCT

Wang HE, Schmicker RH, Daya MR, et al. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018;320(8):769–778. doi:10.1001/jama.2018.7044 https://www.ncbi.nlm.nih.gov/pubmed/30167699

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OOHCA

• ETI v LMA RCT

Wang HE, Schmicker RH, Daya MR, et al. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018;320(8):769–778. doi:10.1001/jama.2018.7044 https://www.ncbi.nlm.nih.gov/pubmed/30167699

IHCA

• Intubation within 8.8 minutes favorable

Wang, Chih-Hung et al. The association between timing of tracheal intubation and outcomes of adult in-hospital cardiac arrest: A retrospective cohort study. Resuscitation. Volume 105:59-65 https://www.resuscitationjournal.com/article/S0300-9572(16)30075-2/abstract

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IHCA

• Intubation within 15 minutes associated with decreased survival.

Andersen LW, Granfeldt A, Callaway CW, et al. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA.2017;317(5):494–506. doi:10.1001/jama.2016.20165 https://jamanetwork.com/journals/jama/fullarticle/2598717

Goal => Airway/Ventilation/Oxygenation

http://clccharter.org/mk/MKMedSchool/medschool/systems/system%20research/respiratory/respfacts.htm

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Alternatives

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Robert Matthew Bramante, M.D., and Masha Rand, M.D.

N Engl J Med 2011; 365:e4July 14, 2011DOI: 10.1056/NEJMicm1014034

Mohan S, Varghese G, Kumar S, Subramanian DP. Penetrating facial injury by a wooden log. Natl J Maxillofac Surg [serial online] 2014 [cited 2017 Nov 4];5:228-31. Available from: http://www.njms.in/text.asp?2014/5/2/228/154844

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Mohan S, Varghese G, Kumar S, Subramanian DP. Penetrating facial injury by a wooden log. Natl J Maxillofac Surg [serial online] 2014 [cited 2017 Nov 4];5:228-31. Available from: http://www.njms.in/text.asp?2014/5/2/228/154844

Mohan S, Varghese G, Kumar S, Subramanian DP. Penetrating facial injury by a wooden log. Natl J Maxillofac Surg [serial online] 2014 [cited 2017 Nov 4];5:228-31. Available from: http://www.njms.in/text.asp?2014/5/2/228/154844

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https://prod-images.static.radiopaedia.org/images/46858215/b7ff25d568a49d356be3b47d1beec0_jumbo.jpeg

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Agitated Patient

• Pre-existing or caused by condition

• TBI and Cerebral Hypoxia -> AMS including agitation

• Ketamine to facilitate airway management

George Kovacs MD, MHPE, FRCPC and Nicholas Sowers MD, FRCPC. Airway Management in Trauma. Emergency Medicine Clinics of North America, 2018-02-01, Volume 36, Issue 1, Pages 61-84. https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0733862717300755.

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Old RSI

• GCS < 8 => Intubate

• Stop breathing => Intubate

• Might Vomit => Intubate

• "Look Sick" => Intubate

• Dead-ish => Intubate

New RSI

• Resuscitation Sequence Intubation

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Correct Hypotension

• Access

• Trauma => Blood

• Sepsis => Fluid

• Cardiogenic => Inotrope and/or pump

• All => Pressors

https://litfl.com/intubation-hypotension-and-shock/

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Avoid Hypotension

• Drug dose– ½ Sedative Dose

• Ketamine most stable

– 2 x Paralytic dose• Consider Rocuronium

http://rebelem.com/critical-care-updates-resuscitation-sequence-intubation-hypotension-kills-part-1-of-3/

Avoid Hypotension

• Pressors– Peripheral pressor infusion

– Push dose pressors• Phenylephrine

• Epinephrine

http://rebelem.com/critical-care-updates-resuscitation-sequence-intubation-hypotension-kills-part-1-of-3/

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Avoid Hypoxia

• Positioning– BUHE (Back Up Head Elevated)

• Nasal Cannula– Preoxygenation

– Apneic Oxygenation

• PPV– BVM

– BiPAP

Avoid Hypotension

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Positioning

Positioning

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Positioning

Positioning

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Positioning

Positioning

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Preoxygenation

• NRB @15 + NC @ 15

• BVM @ 15 + PEEP @ 5 + NC @ 15

• NRB @ 40

• BiPAP + NC @ 15

http://rebelem.com/critical-care-updates-resuscitation-sequence-intubation-hypoxemia-kills-part-2-of-3/

BVM During Apneic Period

Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. N Engl J Med 2019; 380:811-821DOI: 10.1056/NEJMoa1812405 https://www.nejm.org/doi/full/10.1056/NEJMoa1812405?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed

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• https://twitter.com/i/status/1113140745613926402

BVM Technique

• Higher Tidal Volume with 2 handed technique

Aaron M. Joffe, D.O.; Scott Hetzel, M.S.; Elaine C. Liew, M.D. A Two-handed Jaw-thrust Technique Is Superior to the One-handed “EC-clamp” Technique for Mask Ventilation in the Apneic Unconscious Person. Anesthesiology 10 2010, Vol.113, 873-879. doi:10.1097/ALN.0b013e3181ec6414

http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1933275

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Alternative Preoxygenation/Preventilation

http://rebelem.com/critical-care-updates-resuscitation-sequence-intubation-ph-kills-part-3-of-3/

Suction

https://i.ytimg.com/vi/IPJFshx0i5I/maxresdefault.jpg

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End-Tidal CO2 Waveform Capnography

Bougie First

• Bougie = Higher 1st Pass Success (96% vs 82%) – Patients with difficult airway

Driver BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018;319(21):2179–2189. doi:10.1001/jama.2018.6496

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Video Laryngoscopy

McGrath

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Preparation improves outcomes

• Preoxygenation with noninvasive positive pressure ventilation

• Fluid loading and/or pressors

• Presence of two operators

• Rapid sequence induction

• Capnography

• Protective ventilation

• Preparation and early administration of sedation

• Vasopressor use if needed

Jaber et al. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Medicine. 2010. 36:2:248-255. https://link.springer.com/article/10.1007%2Fs00134-009-1717-8

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Summary

• Airway management = more than intubation

• Prevent and avoid expected complications

• Optimize technique

Thank You

stilleyjd@health.missouri.edu @joshuastilley

Credit Dan Berry