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Home The corporate EHS function, which oversees environmental, health and safety compliance began to merge at the management level around 1990. The first area is environmental management, which emerged as a profession in the 1970s, following the creation of the U.S. Environmental Protection Agency (EPA) and other state-level regulatory systems. As companies began limiting waste to prevent pollution, they needed engineers to adapt scrubbers, filters, and other process changes to existing manufacturing systems. Workplace safety and occupational health also grew in importance during this time, with the passage of legislation such as the Occupational Safety and Health Act of 1970.
Over time, companies developed systematic way of complying with environmental, health and safety regulations. Corporations began tracking key measures and looking for ways to improve their performance. Then, in the 1990s, improvements in data technology management made it easier for an organization to analyze its operations.
Around that time, corporations began to merge oversight for environmental, health and safety programs through a new management role called EHS. The newly appointed leaders, who began their careers in one of the three sub-disciplines, started to create systems to drive EHS progress across all operations. Today, with the advent of sustainability, EHS professionals are leading corporate efforts toward sustainability. Building on their decades of experience, EHS leaders are striving to meet this challenge, creating systems to reduce energy use, conserve water, and better communicate with stakeholders. Indeed, a 2009 survey found that two-thirds of the sustainability initiatives at member companies are being led or managed by the EHS. Capital Markets Banc Trade Like a Pro CMB is a leading provider of online trading services.
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Successful emergency airway intervention incorporates the anaesthetist’s basic skills in airway management with the knowledge of the special nature of the clinical problems that arise outside the operating room. While a thorough but rapid evaluation of the key anatomical and physiological factors of an individual patient may result in an obvious choice for optimal management, clinical problems often arise in which there is not an evident “best approach.” In these less clearcut situations, the anaesthetist may do well to employ those techniques with which she/he has the greatest skills and experience. At times, however, some degree of creative improvisation is required to care for an especially difficult problem. 0From the Department of Anesthesiology, University of Vir- ginia Health Sciences Center, Department of Anesthesiology, Box 238,Charlottesville, Virginia,USA 22908.
Accepted for publication lOth July, 1992Successful emergency airway intervention incorporates the anaesthetist's basic skills in airway management with the knowledge of the special nature of the clinical problems that arise outside the operating room. While a thorough but rapid evaluation of the key anatomical and physiological factors of a n individual patient may result in an obvious choice for optimal management, clinical problems often arise in which there is not an evident 'best approach. ' In these less clear-cut situations, the anaesthetist may do well to employ those techniques with which shehe has the greatest skills and experience. At times, however, some degree of creative improvisation is required to care for an especially difficult problem. En situation d'urgence, le contrdle efficace de l'intdgritd des voies respiratoires fait appel aux connaissanees fondamentales de l'anesthdsiste et exige en plus l'identification des problkmes particuliers qui ont prdc3dd l'entrde en salle d'op#ration. Bien qu 'une dvaluation rapide desfacteurs anatomiques etphysiologiques essemiels propres une condition spdciale puisse conduire d un choix dvident pour une prise en charge optimale, des problmes cliniques qui rendent ce choix moins certain se rdvlent souvent leur apparition.
Dans ces situations pour le moins douteuses, I 'anesthsiste serait real avisd de d' utiliser des techniques avec lesquelles il est moins familier. Cependant, occasionnellement, il devra faire usage de son imagination et improviser pour solutionner un problme particulirement difficile.Emergency management o f the airway outside the operating roomThe anaesthetist is called upon to manage the airway in avariety of different clinical environments unrelated to theperformance of general anaesthesia. Optimal managementof the airway in each o f these situations requires insightinto the disease processes which are present as well asan understanding of the implications o f the therapeuticinterventions. The acute management of the airway by theanaesthetist can be difficult a n d challenging because theclinical problems m a y differ considerably from those dealtwith in the controlled environment of the operating room.Emergencymanagementof the airwayGeneral considerationsThe performance of tracheal intubation in the emergencyroom is not always simple. The complication rate is highand is not necessarily reduced when more experiencedpersonnel are available) The underlying diagnosis andcondition of the patient on admission appear to be the mostimportant factors relating to ultimate outcome.A variety of clinical situations arises which necessitatesan airway consultation.
Assessment of the general level ofconsciousness, presence or absence of ventilatory drive,and patency of the airway are essential initial steps wellknown to the practicing anaesthetist. The results fromthese determinations will dictate the required urgency ofaction. It is important to note that intubation may notalways be required because simple and basic airwaymanoeuvres may not have been tried by other health careprofessionals.
Accordingly, initial intervention mayinclude basic airway manoeuvres to rule out the presence ofa foreign body or simple soft tissue upper airwayobstruction, as well as bag and mask ventilation to assure airwaypatency. These may be accompanied by attempts to arousethe unconscious patient in an effort to stimulateventilation. Failure of such manoeuvres should trigger anappropriate sequence to assure oxygenation, ventilation andairway protection. In the majority of these cases, trachealintubation will be necessary. A complete review of thegeneral approach to the airway is unnecessary. The wellknown principles of airway evaluation, compulsivepreparation, monitoring, and technical procedures mustbecarefully applied when outside the operating room.2The ability to manage the airway requires technicalskills but is also strongly based on anticipating thepotential consequences of the various manoeuvres on thecardiovascular system, intracranial pressure dynamics, andthe respiratory system, thereby minimizing any adversephysiological sequelae.
A variety of technical andpharmacological approaches must be considered rapidly in thetreatment of each patient.The philosophy of the approach to the airway outsidethe operating room is highly dependent on the localhospital situation. In our teaching hospital, residentsanswer emergency consultations and are stronglyencouraged to manage the airway with local anaesthesia, minimalamounts of sedation and very infrequently, musclerelaxants. They are also encouraged to call for more senior helpif the situation is extremely difficult and/or relaxantsappear to be indicated. A second pair of educated handsmay be beneficial in these situations. On the other hand,experienced clinicians may prefer to employ the classicrapid sequence approach to intubation in this setting. As inthe operating room, it must be kept in mind that one maybe left with a patient whose lungs cannot be ventilated bymask and whose trachea cannot be intubated afterrelaxants have been given.3Unlike the operating room, neitherthe people nor the equipment needed to manage thissituation may be available.
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Overall, we believe that aconservative approach which spares the ability of thepatient to breathe spontaneously is safest.LOCALANAESTHESIAAlthough airway anaesthesia may not be required inextremely obtunded patients, the ability to block sensationfrom the oropharynx and larynx is a skill which may besufficient to permit intubation. Simple topical anaesthesiais applied effectively with a 10% lidocaine spray.Blockade of noxious sensory stimuli can blunt the hypertensiveresponse and increase intracranial pressure oftenassociated with laryngoscopy and intubation. A shortcoming oftopical anaesthesia is the failure to anaesthetize themechanoreceptors at the base of the tongue which areresponsible for much of the gagging and discomfort duringlaryngoscopy.
Bilateral glossopharyngeal blocks arehelpful as they serve to interrupt both innervation of thesemechanoreceptors as well as sensation over the tongue andpharyngeal mucosa.4 This block is performed bilaterallyby injection of 2 ml lidocaine 2%, 0.5 cm lateral to theedge of the tongue where it forms the palatoglossal arch(Figure 1). With practice, this block can be performedrapidly and adapted for use in such emergency settings toprovide blockade of deep pressure sensation in the tonguenot provided by other glossopharyngeal block techniques.Laryngotracheal spray or translaryngeal anaesthesia iseffective, rapid and easy to perform. The use of nebulizedlidocaine may be effective if secretions are absent orhave been controlled with antisialagogues.5 However,nebulization requires extra time and special equipmentwhich may not be available. Other techniques of topicalanaesthesia with slurries and gels require a high level ofpatient cooperation.SEDATIONIntravenous sedation is often utilized as an adjunct forairway management, particularly in awake patients.Sedatives may blunt discomfort, airway reactivity andhaemodynamic effects. No single medication is ideal forall situations.Narcotics are a useful group of drugs for'out ofoperating room' airway management.They serve well toalleviate some of the pain associated with manipulation of theupper airway and larynx and also block cough reflexeselicited by intubation. The introduction of a short-actingagent, alfentanil, as well as the availability of antagonistssuch as naloxone, provide an element of safety not presentwith other drugs. Fentanyl is often used carefully in 25-50Ixg increments with meticulous observation for possibleadverse responses.
However, it is important to recognizethat narcotics may predispose the patient to the risks ofpulmonary aspiration by means of their ability to blunt thelaryngeal closure reflex.6Benzodiazepines are effective anxiolyticdrugs and havebeen used extensively for conscious tracheal intubation inthe operating room. The introduction of a specificantagonist, flumazenil, may allow for more liberal use of thesedrugs in other situations. Anxiolysis and amnesia are lessimportant in the urgent or emergency situation and thesedrugs are less effective and predictable at producing rapidsedation when compared with other drugs. It should alsobe noted that when benzodiazepines are combined withnarcotics, dangerous degrees of sedation may be achieved.Although the combination does not result in any additionaldepression of ventilatory response to carbon dioxide thanthe opioid alone, more apnoea and hypoxia may occur thanwith either drug alone.7The hypnotic drugs commonly used for anaestheticinduction are in a class of drugs whose use in a rapidsequence scenario is obvious. However, in small dosesthey may be useful in other settings. The careful titrationof sedative doses further enhances their relative safetybecause of the rapid redistribution which characterizes theelimination of these drugs from the central nervoussystem.
One must always balance the respiratorydepression with the benefit from the anticipated sedative effects.Thiopentone, methohexitone, etomidate and propofol areall equally useful. Individual differences between thesedrugs are undetectable when used in small sedative doses.Ketamine also deserves some consideration because ofits profound analgesic effects, maintenance of respiratorydrive, and relative sparing of airway protective reflexeswhen used in small doses. I)roperidol, though commonlyused in the operating room environment for its ataracticeffects, is rarely helpful and suffers from a lack ofreversibility, long half-life, and high incidence of dysphoricreactions.The use of any sedative demands attention to thepossibilities of vomiting with subsequent pulmonaryaspiration, Use of cricoid pressure may be considered butonly with caution to avoid gagging as a result of excessivepressure on the larynx.Confirmation of intubationConfirmation of tube placement within the trachea isimportant immediately following intubation.
Thenumerous reports of undetected oesophageal intubation in theoperating room under ideal conditions underscores the factthat correct tube placement is not trivial,s The lack ofreliability of the physical examination has led to thegradual acceptance of capnography as the 'gold standard'for confirmation of tube placement. Such devices areusually not available in the emergency ward or in criticalcare units and thus one must rely on physical examination.Direct visualization of the tube as it passes through thevocal cords is one of the best methods available but is lessreliable if movement of the tube occurs before it issecured. Chest movement may be a helpful sign but itsobservation is hindered in the obese patient or in womenwith large breasts. Similarly, the barrel chest of chronicobstructive pulmonary disease obscures most of the chestexpansion associated with ventilation of these patients.Indeed, there are reports of chest movement beingobserved when the oesophagus is intubated.9 Auscultationof breath sounds over the chest and the lack of sounds overthe epigaslrium are the most commonly employedtechniques.