The woman arrived hypoxic and confused, her face, neck, and chest covered in skin grafts. She'd recently been discharged from the hospital's burn center, but now she was back, with a probable aspiration. A metal device protruded from the corners of her mouth, and rows of blue hoses were curled around her neck.
“I had no idea what this was,” said Robert Vissers, MD, the director of emergency services and the associate chief medical officer at Legacy Emanuel Medical Center in Portland, OR. A social worker soon found the patient's record: That blue tubing was put there to prevent the skin from further contracture. So, blue hoses and all, with the patient's oral airway restricted and her neck flexed and immobile, members of the ED staff set about trying to intubate the woman.
They did just that, using a two-person awake-video laryngoscope, sedating her with ketamine, and with a cricothyrotomy kit standing by, just in case. But it wasn't necessary. The technique saved the day.
Or did it? Not in the opinion of Dr. Vissers, also an adjunct associate professor at Oregon Health Sciences University and an author of a recent state-of-the-art article, “The High-Risk Airway.” (Emerg Med Clin North Am 2010;28:203.) “It was the approach agreed upon by the team that saved her, not the technique,” he said. A team approach for airway management is essential to error-free success, he stressed.
That road to success for emergency intubation has been paved with good intentions but strewn with mixed results. The largest surveillance report on the subject, conducted eight years ago at the University of California, Davis, showed — unsurprisingly — that most rescue intubation is performed by emergency physicians and that it is generally done by rapid sequence intubation undertaken because oral intubation with sedation has failed. In fact, intubation failed in nearly three percent of cases. (J Emerg Med 2002; 23:131.) All EDs want to succeed with difficult airway management, but these incidents are relative rarities, so rare, in fact, that surgical societies once considered them the domain of that specialty, despite the fact that emergency medicine began airway intubation at the birth of urgent care, on the battlefields of the Civil War.
“There is a saying that goes, ‘A bad airway is on a conveyor belt headed your way,’ and that is true,” cautioned Darren Braude, MD, MPH, the author of Rapid Sequence Intubation and Rapid Sequence Airway. (2nd edition. Albuquerque: University of New Mexico; 2009.) “So it is essential to have a clear plan in your head for that,” he said.
Just how to achieve such a successful plan has been discussed in the medical literature over the past decade, roughly dividing the issue into a two-pronged debate: technique versus technology. One 10-year report from a trauma registry shows that those two Ts seem important determinants in outcome, but so are a well practiced staff and a reliable algorithm. (Anesth Analg 2009;109:866.)
When the Canadian Association of Emergency Physicians attempted to recommend emergency intubation for rural physicians 10 years ago, they did so by way of an algorithm, but they also included the rather dire-sounding warning that the physicians should be confident about using a paralytic, about the ramifications of drug-related complications, about how to ventilate the patient safely if the intubation fails, and to keep in mind that guidelines for performing the procedure were not a “recipe” for anyone not knowledgeable. (CJRM 1999;4:87.) Add to that mix the critical factor of planning and the idea of difficult airway management in an ED where it is rarely experienced, and good preparation can seem like quite a task, particularly in a small or rural setting.
A good plan is one that makes practice realistic, according to some emergency physicians. “It is interesting to me that some [physicians] seem to think that it is important to know many different devices,” said Michael Gibbs, MD, an author with Dr. Vissers on “The High-Risk Airway.” “Do you need a dozen?” he asked. “No. You need to know what you will reach for, and that may be three or four that you can become proficient with,” said Dr. Gibbs, the chief of the department of emergency medicine at Maine Medical Center in Portland. “Then your homework will drop from a dozen to less than half that,” he concluded.
By following the three Ps: preparation, planning, and practice, it is not improbable for even a small emergency department to develop high skill levels, concurred Dr. Braude, also an associate professor of emergency medicine at the University of New Mexico School of Medicine in Albuquerque. And there is one “P” to avoid: persistence, Dr. Braude warned.
“Humility is critical in this. You have to be able to know when to call for help,” Dr. Vissers agreed.
“You have tried three times, and are failing? This is really no place for bravado; stick with your management plan and know when to bag, when to rescue, when to back off,” Dr. Vissers added. The ability to change strategies quickly is key. “For me, getting the tube in is less important than knowing I can successfully bag the patient.”
“The most critical check for me is the assurance that nurses, respiratory therapists, and other providers understand the management plan before pushing the paralytic,” Dr. Vissers said. Fortunately, there are few incidents of failed airways in most EDs, but when they happen, they can be very difficult to manage. Trauma, like a gunshot wound, can make anatomy unrecognizable, and blood can obscure good visualization, he noted. At his center, there are annual training days using both mannequins and porcine tracheas, he said.
When British researchers tracked the experience of a lone physician in accident and emergency medicine, they found that this health care provider had eight complications in 100 attempts over a five-year period. It was the pattern of failures that may have proved most illuminating, however. In the beginning, the doctor misplaced the tube a few times, but by the end of the study, it was the lack of adequate visualization that was attributed to failures. These findings seem to indicate that experience pays off significantly, and though the learning curve may be somewhat perilous initially, appropriate devices are helpful in the right hands. (Emerg Med J 2007;24:654.)
Though experience is credited with developing expertise in assessing and managing the difficult airway, “it isn't just experience,” Dr. Braude cautioned. Rote experiences may be valuable, but preparation for the rare situations is invaluable, he said. “Would you rather fly with a complacent pilot who has done 5,000 uneventful landings and no other practice? Or one that has done 500 landings but diligently practices emergency procedures in a simulator every month?” he asked.
Like a cockpit checklist, Dr. Vissers recommends a rundown of verbal queries at the bedside to staff before proceeding with RSI: Are you satisfied with the intravenous line? Have the medications been drawn up? Are oxygen and suction working? Do we have the right rescue device ready to use? The latter can include a bag, an intubating stylet, a supraglottic rescue device, a cricothyrotomy kit, and if available, videolaryngoscopy or flexible fiberoptics.
In the ED, there really is no such thing as an airway management specialist, he pointed out. “A huge part of this is acknowledging when you are in a difficult or failed airway situation so you can make the appropriate adjustment,” Dr. Braude said. Two kinds of “dress rehearsals” are good preparation, he stressed: an actual one in which simulators are used in training to help keep skills on par and a mental one in which a difficult airway is visualized from time to time to help keep that in mind.
Most bad outcomes occur not because of technical error, Dr. Vissers said, but due to lack of preparation for initial failure, inadequate patient assessment, or poor communication. The emergency department is, in effect, the “difficult airway clinic” for patients in urgent need. That is precisely the reason that a system of cautionary steps, from a verbal checklist to a backup plan, is a necessity in every case.”Nothing can replace good decision-making,” he said.
Courses, Web Sites, and Books on Difficult Airways
A few years ago, anesthesiologists grappling with defining the term “difficult airway” concluded there just wasn't one. That didn't stop guidelines from being written, studies from being conducted, or resources being developed for dealing with troublesome airways.
The result: Courses with and by emergency physicians that delve into topics ranging from cutting-edge devices to hands-on skill enhancement. Easy-to-read web sites and books also now provide flowcharts for fast decision-making and tips for quickly predicting the degree of difficulty in an airway. “The Difficult Airway Course,” which includes Michael Gibbs, MD, and Robert Vissers, MD, as faculty, will be coming soon to a city near you, with stops in Washington, D.C., St. Louis, Atlanta, and Las Vegas. (www.theairwaysite.com)
Also debuting is the book “Rapid Sequence Intubation & Rapid Sequence Airway” by Darren Braude, MD, which include declarative advice in simple-to-read text and via colorful decision trees. (www.airway911.com)