POCUS for Emergency Airway Management

November 27, 2020

JournalFeed | SAEM – AEUS

JournalFeed is excited to announce a new partnership with SAEM-AEUS (Academy of Emergency Ultrasound)! Now, EM POCUS experts will summarize an article or two a month on JournalFeed.

To kick us off, meet AEUS President-Elect, Lindsay Taylor.

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Written by Lindsay Taylor

Spoon Feed
Improve the safety of your next emergency airway with point-of-care ultrasound (POCUS).

Why does this matter?
Can’t oxygenate, can’t ventilate, can’t intubate is a nightmare for any provider caring for a patient in respiratory distress. Emergency airway management (EAM) has a high rate of morbidity and mortality due to the significant peri-procedural complications. In preparation for this high-risk procedure, the provider must have airway adjuncts to mitigate these obstacles. POCUS can help improve airway safety and mitigate complications. Here’s how.

POCUS so you don’t choke us
POCUS can help screen a patient for difficult direct laryngoscopy, assess for increased aspiration risk by measuring gastric volume and contents, identify the anatomical landmarks of the cricothyroid membrane, and confirm endotracheal tube positioning. Here are some key facts.

POCUS for EAM:

• Distance from skin to epiglottis > 27.5mm predicts a Cormack-Lehane view of 3 or 4.

• Identification of the cricothyroid membrane on ultrasound has been shown to be accurate 81% of the time, which is a 10-fold increase over palpation alone.

• Gastric antral cross-sectional area (ASCA) > 3.6 cm2 correlates with gastric volume at least 0.8 mL/kg, indicating risk for aspiration during induction and could be a great screening tool for procedural sedation in the emergency department as well.

• For ETT confirmation, a large meta-analysis showed 98.7% sensitivity, 97.1% specificity, and average time of 13 seconds to perform.

The authors propose a systems-based algorithm with a dedicated provider performing POCUS and the other provider using this information to guide airway management. The algorithm (see below) is divided into phases: a pre-intubation airway assessment and a post-intubation airway assessment/confirmation.

The study has some limitations. Most, if not all, of the research reviewed in this paper is based on non-emergent airways. This potentially limits utility in the ED. However, we have certainly been using and studying POCUS to view the cricothyroid membrane and to confirm ETT placement in the EM literature. They also use “handheld” in the title. Use of handheld devices is increasing, but most of the literature has been performed with traditional ultrasound equipment. The upside of this review is to stimulate use of POCUS technology as an adjunct to airway management, to improve patient safety, and to establish the need for future validation studies.

Source
Use of Handheld Point-of-Care Ultrasound in Emergency Airway Management. Chest. 2020 Sep 21;S0012-3692(20)34501-3. doi: 10.1016/j.chest.2020.09.083. Online ahead of print.

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