Video Laryngoscopy in Cardiac Arrest Colby J Rowe

Video Laryngoscopy in Cardiac Arrest Colby J. Rowe MS, NRP, FP-C Stony Brook Medicine Stony Brook, New York

Introductions • Colby Rowe, MS, NRP, FP-C • Clinical Instructor of Emergency Medicine • Clinical Simulation Coordinator, SOM • BLS, ACLS, PALS TC Faculty • The Difficult Airway Course: EMS™ – Northeast Regional Director – Italy, South Korea, Canada

Presenter Disclosure Information Video Laryngoscopy in Cardiac Arrest Colby Rowe FINANCIAL DISCLOSURE: § none UNLABELED/UNAPPROVED USES DISCLOSURE: § none

Objectives • Discuss the evolution of advanced airway management techniques. • Discuss how the 2015 AHA Guidelines for CPR & ECC apply to advanced airway management. • Understand importance of First Pass Success in advanced airway management. • Learn techniques of video laryngoscopy to achieve First Pass Success!

Today Two Days Ago in History • December 7, 1963 • Army-Navy football game

Airway, Beating…and Circulation?

History of Cardiac Arrest Airway Management • Egyptians & Romans – Tracheotomies? • William Macewaen (Scotland, 1880) – ETI for obstruction • Joseph O’Dwyer (USA) – ETI for obstruction – Blind passage

History of Cardiac Arrest Airway Management • Benjamin Guy Babbington – Glottiscope • Philipp von Bozinni & Garignard de la Tour – “Mouth Mirrors” • Manual Garcia (1854) – Vocal teacher used sunlight and mirrors – First direct visualization of human glottic opening

History of Cardiac Arrest Airway Management • Chevalier Jackson (1913) – “Father of endoscopy” – Introduced light source on distal end of blade • Henry H. Janeway (1913) – Anesthesiologist – Introduced battery operated laryngoscope • Sir Robert Reynolds Macintosh (1943)

Direct Laryngoscopy • Conventional laryngoscope – Technique utilized to facilitate direct visualization of the glottic opening when performing endotracheal intubation.

History of Cardiac Arrest Airway Management • Pioneers – Dr. Peter Safar – Dr. James Elam • Manual maneuvers • Mouth-to-mouth • A, B, C’s of Resuscitation • The Breath of Life

The Late Dr. John Hinds • Modern day resuscitation guidelines. – ABC’s as Safar wrote. – “Gold Standards” – Poor outcomes in OHCA (out of hospital cardiac arrest). – Challenges

Challenges • Delivery of Oxygen (DO 2) in Cardiac Arrest – Methods of ventilation • Basic v. Advanced strategies – Manual maneuvers – Devices and adjuncts – Early v. Delayed ETI • Control • Protection • Carbon dioxide – Less invasive techniques – Experienced clinician

Challenges • • • Endotracheal Intubation Success rates of 75 -90% TTI (time-to-intubation) Interruptions in CPR Difficult intubations Unrecognized esophageal or dislodged ETT

2015 Guidelines for CPR & ECC • BVM or ETI? • SGD or ETI? • What does the science say? – “Low quality evidence” – “The type of airway used may depend on the skills and training of the healthcare provider. ”

So…Why Are We Here?

John C. Sakles, M. D. • University Arizona Medical Center Emergency Department – 61 beds – 70, 000 ED visits • July 2007 -June 2013 • Approximately 3000 intubations – Half DL & half VL – 100% capture

The Data

The Sakles Conversation

First Pass Success • Sakles et al. , International Journal of Emergency Medicine (2013)

First Pass Success

The Sakles Conversation

Evidence • • Assessed GVL, Pentax AWS, and DL 15 -30° lateral left tilt with LUCAS TTI and success rate TTV and TTI

Evidence

Evidence • Assessed GVL in simulated CPR • GVL v. DL with and without compressions • “Extremely high success rates”

Evidence • EMJ-Tandon et al (October 2014) – 20 EM physicians – DL, GVL, and GVL-Bougie – TTI with compressions – Results • DL (27 s) • GVL (20 s) • GVL-B (60. 1)

Evidence • Journal of Emergency Medicine-Sakles et al (December 2014) – 460 unsuccessful first attempt adult OTI’s (2009 -2014) – CMAC v. DL for rescue attempt after failed – Results • CMAC: 116/141 (82. 3%) • DL: 58/94 (61. 7%)

Evidence • Resuscitation- Park et al (December 2014) – 305 OHCA (May 2011 -April 2013) • Compared first pass success • 83 intubated by novice emergency physicians in the field – Results • VL (n=49) 91. 8% successful – 0 interruptions in compressions – 0 esophageal intubations • DL (n=34) 55. 9% successful – Median of CCI was 7 seconds – 1 esophageal intubation

Video (Indirect) Laryngoscopy • Use of a micro-video camera along a laryngoscope blade transmitting image to an external monitor. • Facilitates indirect visualization of the glottic opening when performing endotracheal intubation.

Tips for Success • • • Keep it similar! Look for blade! Go midline. Keep your distance. Compress tongue directly into submandibular space. • Go 3: 00 -12: 00 (back in time that is). • Alternate practice.

The Devices • Outline – Video Laryngoscopy • • Glidescope C-MAC Mc. Grath King Vision – Optical Laryngoscopy • Air. Traq

Optical Laryngoscopy § Placed midline § Lift in the vertical plane § Align vocal cords center § Slowly advance ETT through cords § Disengage ETT and remove device

Wrap-Up • We need to minimize hands off time • VL can minimize interruptions in chest compressions and increases compression fraction • VL improves First Pass Success! • “Practice doesn’t make perfect; perfect practice makes perfect”

Thank You!