HEAVEN criteria

[VentMonkey]

This is a screening tool that one of the regional HEMS programs in the SoCal/ Nevada area apparently came up with. It's geared more towards the out of hospital providers difficult airway predictors.

http://www.airmedicaljournal.com/article/S1067-991X(16)30357-1/abstract

Obviously the Cormack-Lehane method can be a bit tricky and impractical in the prehospital setting, though I am curious to know how frequently the CRNA's on this forum are going through the difficult airway predictors pre-op.

Thoughts?...

 

[MonkeyArrow]

This seems a bit redundant. I don't think this acronym provides any new information about the potential for a difficult airway, and to be quite honest, yet another acronym adds to the meaningless fluff that most acronyms have become.

 

[VFlutter]

It was developed in Air Methods and is our standard pre-intubation assessment. I like it. Quick, straight forward, and incorporates both actual anatomical and physiological difficulties. Helps you pre-plan and consider resuscitation before intubation.

 

[E tank]

Not sure how hypoxemia or anemia/ exsanguinations affect difficulty of DL/incubation. Not sure what to think of " extremes of size" means either.

Seems pretty arbitrary. Anesthesia pre-op airway assessment most often involves an awake cooperative patient, but not always. After a while it becomes an "eyeball test" as to predicting a difficult intubation.

If I had to skim it down, the three biggies are fat neck, no chin/over bite and a stiff neck (poor to no extension.) You can assess these in an unconscious/unable to cooperate patient. Poor mouth opening is in there too, but the first three, IMO, are the most important.

 

[EpiEMS]

Not sure what to think of " extremes of size" means either.

Obese patients & small patients (quick desat, hard to seal, etc. for the former, worries about overinflating the lungs of the latter)?

 

[E tank]

Obese patients & small patients (quick desat, hard to seal, etc. for the former, worries about overinflating the lungs of the latter)?

Yes, those are things associated with those patients, but not necessarily with a good view on DL and tube placement.

 

[VentMonkey]

Not sure how hypoxemia or anemia/ exsanguinations affect difficulty of DL/incubation.

Lack of adequate RBC's would in theory induce the likelihood of a quicker desaturation/ hypoxic event, or so they say //shrug//

If I had to skim it down, the three biggies are fat neck, no chin/over bite and a stiff neck (poor to no extension.) You can assess these in an unconscious/unable to cooperate patient. Poor mouth opening is in there too, but the first three, IMO, are the most important.

Good stuff, thanks.

I can't say I disagree that it is yet one of many airway, let alone EMS, acronyms that do seem to flood this industry. Just figured I'd throw it out to the masses and see what kind of bites it got.

@Chase, yes Mercy Air/ Air Methods were apparently the ones who came up with the study, and acronym. I know Olvera is a frequent FlightBridgeEd/ FOAM-ed guy, but didn't know he was a Mercy affiliate. Quick off thread question for you:

Do you guys share medical directors, or does each region have their own directors respectively?

 

[VFlutter]

@Chase, yes Mercy Air/ Air Methods were apparently the ones who came up with the study, and acronym. I know Olvera is a frequent FlightBridgeEd/ FOAM-ed guy, but didn't know he was a Mercy affiliate. Quick off thread question for you:

Do you guys share medical directors, or does each region have their own directors respectively?

Each Region has it's own or multiple medical directors. Dr. Dan Davis, co-author of the paper, is the "Scientific Advisor" for Air Methods so kind of the overall medical director and then David Olvera is the Clinical Education Manager.

Not sure how hypoxemia or anemia/ exsanguinations affect difficulty of DL/incubation. Not sure what to think of " extremes of size" means either.
.

It is supposed to make you think about difficult intubations beyond just difficult visualization. A patient with perfect anatomy but with refractory hypoxia, anemia, exsanguination, etc may be physiologically difficult resulting in reduced safe apneic time and greater risk of peri-inbuation arrest.

 

[E tank]

Each Region has it's own or multiple medical directors. Dr. Dan Davis, co-author of the paper, is the "Scientific Advisor" for Air Methods so kind of the overall medical director and then David Olvera is the Clinical Education Manager.


It is supposed to make you think about difficult intubations beyond just difficult visualization. A patient with perfect anatomy but with refractory hypoxia, anemia, exsanguination, etc may be physiologically difficult resulting in reduced safe apneic time and greater risk of peri-inbuation arrest.

OK.... can't read the whole thing but from the abstract and the rest, seemed like it was solely a novel way of predicting a technically difficult airway. That said, sounds like different specialties are using the same terms but give them different meanings/definitions based on the context in which they operate...I'd look at those things as independent of a technically difficult airway. Those are issues with any tube, not just a difficult one.

 

[Carlos Danger]

Without understanding how the assessment is meant to be used or how it has been validated (doesn't sound as though it has been validated from the abstract), it's hard to make any sort of judgement about how useful it might be.

If it is just meant to be used as a cognitive aid to remember what factors to consider while planning for an intubation, it makes sense. Although for that purpose, I think a little more formal and comprehensive checklist is probably a better idea.

I don't think it's likely that a tool like this will ever be useful as an actual predictor of intubation difficulty. The specificity of the factors listed is not nearly great enough to build a reliable tool on. It's a safe bet that someone with a mouthful of vomit will be a challenging intubation (we don't need a formal assessment tool to tell us that), but someone who is very large or very small won't necessarily be. Poor neck mobility can make an intubation more difficult, but not necessarily.

When I'm doing a pre-op, I always ask the patient to demonstrate Mallampati and neck mobility, and as they do that I visually estimate inter-incisor distance (mouth opening) and thyromental distance. Things like a huge neck will be apparent too. If all those factors agree (either all favorable or all unfavorable) then you have a pretty reliable indication of whether the intubation will be technically easy or technically difficult. Quite often they don't all agree, of course, in which case you just sort of go by your overall impression. Like E tank said, it's really more of an eyeball test than a formal assessment.

I think of and approach physiologic factors separate from anatomic ones. Someone who is septic or has a really bad heart needs to be approached differently than someone who is perfectly healthy of course, but that really just comes down to your choice of pharmacology and has nothing to do with the technical difficulty of the intubation.

No matter what predictors you use, you will be surprised at times.

In the field where things are inherently more challenging, I think the most important assessment question to be answered is really "does this patient actually have to be intubated now?" If the answer is yes, then everything else becomes secondary and all you have to focus on is the basic steps to optimize your chances of success. If the answer is "no, probably not, but we're going to do it anyway" (which I think is the majority of prehospital intubations), that's when it becomes really important to have your ducks in a row and get as good a handle as possible on what you might be getting yourself into. In a true emergency, the priorities are clear and there's little blame to be placed if things don't go well because it was just a really challenging situation and you had no choice but to make an attempt. It's the "elective" ones where you really own it when you makes that choice and things don't go well. I think that's the assessment that we should be focusing more on in EMS airway management. I think for all the focus on airway management education in EMS, we don't see nearly enough emphasis on learning how to judge when to pull the trigger and when to hold off.

 

[climberslacker]

When I was working for MBA in SoCal, I remember there being a big stink when the Medical Director for Mercy Air suggested to High Desert's ED staff that they "should just call our crews whenever you're going to intubate. They're better".

 

[TXmed]

I think the criteria is pretty good, although i mainly use the acronyms for charting reasons (LEMON,MOANS etc) to explain difficulties or thought process.