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Chapter Advanced  Airway Management Twenty-Nine
Chapter <ul><li>Purpose and procedure for    nasogastric tubes and orotracheal   intubation </li></ul><ul><li>How to perfo...
Anatomy of the Respiratory System
Bronchioles and Alveoli
Shallow chest expansion <ul><li>Depth: </li></ul>Outside normal range <ul><li>Rate: </li></ul>(fast or slow) Regular or ir...
Abnormal breath sounds <ul><li>Quality: </li></ul>(noisy, diminished, or absent) Unequal chest expansion Increased breathi...
Just before death <ul><li>Agonal   Respirations: </li></ul>Pale, cyanotic, cool,  or clammy <ul><li>Skin: </li></ul>Above ...
<ul><li>Nasal flaring </li></ul><ul><li>“ See-saw” breathing </li></ul>Inadequate Breathing in Infants and Children
Airway Differences between  Adults and Children
<ul><li>Mouth and nose </li></ul><ul><li>Pharynx </li></ul><ul><li>Trachea </li></ul><ul><li>Cricoid cartilage </li></ul><...
A IRWAY ADJUNCTS
Orotracheal Intubation Purpose <ul><li>Most effective way to </li></ul>control airway. <ul><li>Use in apneic patients: </l...
Complications <ul><li>Stimulation of airway  </li></ul>can cause bradycardia. <ul><li>Trauma can occur to </li></ul>lips, ...
<ul><li>Hypoxia may result </li></ul>from prolonged attempts. <ul><li>No oxygen to left lung </li></ul>because tube is in ...
<ul><li>Esophageal intubation </li></ul><ul><li>Vomiting </li></ul><ul><li>Self-extubation </li></ul><ul><li>Movement of t...
<ul><li>Laryngoscope handle </li></ul><ul><li>Laryngoscope blades </li></ul>Equipment <ul><li>Assorted sizes  (0–4) </li><...
Straight blade brings vocal cords into view by lifting epiglottis.
Curved blade brings vocal cords into  view by lifting vallecula and indirectly lifting epiglottis.
Assembly of Laryngoscope Handle and Blade Align identification with bar, press-forward to lock Press To lock
<ul><li>Adult female: </li></ul><ul><li>Adult male: </li></ul>7.0–8.0 mm 8.0–8.5 mm Endotracheal Tubes: Average Sizes   (I...
Endotracheal Tubes <ul><li>Emergency rule: </li></ul><ul><li>Have available one size larger </li></ul><ul><li>7.5 fits mos...
Endotracheal Tube
<ul><li>Teeth to cords: </li></ul><ul><li>Teeth to suprasternal notch: </li></ul><ul><li>Teeth to carina: </li></ul><ul><l...
<ul><li>Provides stiffness/shape. </li></ul><ul><li>Lubricant may ease removal. </li></ul><ul><li>Used to shape tube like ...
Stylet  Stylet  in Place
<ul><li>Water-soluble lubricant </li></ul><ul><li>10 cc syringe </li></ul><ul><li>Securing devices </li></ul><ul><li>Sucti...
Endotracheal Intubation <ul><li>Inability to ventilate </li></ul>Indications apneic patient <ul><li>Unresponsiveness to  <...
Use in unresponsive patient who lacks a cough or gag reflex to help prevent regurgitation and aspiration during endotrache...
Cricoid Cartilage Surrounds entire trachea,  inferior to cricothyroid membrane  (depression below thyroid cartilage  or Ad...
Location of Cricoid Cartilage
Perform Sellick’s maneuver by exerting posterior pressure on cricoid cartilage.
Sellick’s Maneuver <ul><li>Verify correct position to avoid </li></ul>damaging other structures. <ul><li>Cricoid is more d...
<ul><li>Have third rescuer </li></ul>perform maneuver. <ul><li>Maintain maneuver until </li></ul>patient is intubated. Sel...
Ensure proper ventilation of patient.
Assemble, prepare, and test equipment.
If trauma is suspected, have rescuer  hold head in neutral position. Position patient’s head.
Make sure airway structures are aligned.
Insert laryngoscope blade into mouth, avoiding contact with teeth.
Lift tongue up and to left.
Insert blade and lift mandible.
Have rescuer apply Sellick’s maneuver. (Bring vocal cords into view.)
Visualize glottic opening between vocal cords.
Gently insert endotracheal tube (with stylet in place) until cuff passes between vocal cords.
Remove laryngoscope and stylet without moving tube.  Inflate cuff with 5–10 cc of air.
Attach bag-valve resuscitator and ventilate.  Observe rise of chest.
Confirm placement by auscultating epigastrium and lungs.
<ul><li>Observe chest rise and fall. </li></ul><ul><li>Auscultate epigastrium for </li></ul>absence of sounds. <ul><li>Aus...
<ul><li>Observe for signs such </li></ul>as cyanosis. <ul><li>As protocols direct, use end-tidal </li></ul>CO 2  detector ...
Colorimetric end-tidal CO 2  detector
Esophageal detector device
Combined devices check pulse oximetry, ETCO 2  blood pressure, pulse, respiratory rate, and temperature.
Tube Placement If correct placement is confirmed, secure  tube and continue to ventilate.
Tube Placement <ul><li>If breath sounds are present only </li></ul>on right, deflate cuff and withdraw tube slightly until...
<ul><li>If sounds are present only in </li></ul>epigastrium, deflate cuff,  remove tube, and hyperventilate  for at least ...
Tube Placement <ul><li>Reassess breath sounds after </li></ul>every major move:  <ul><li>From scene to ambulance </li></ul...
It cannot be overemphasized that inadvertent esophageal intubation will likely result in death.  Because of the magnitude ...
I NFANT AND CHILD INTUBATION
<ul><li>Mouth and nose  (smaller) </li></ul><ul><li>Pharynx  (tongue proportionally larger) </li></ul><ul><li>Epiglottis  ...
<ul><li>Vocal cords  (harder to see) </li></ul><ul><li>Trachea  (narrower) </li></ul><ul><li>Cricoid cartilage  (less rigi...
Cricoid Cartilage Child and Adult Airways
<ul><li>Since cricoid ring is narrowest </li></ul>part of child’s airway, <ul><li>Pediatric tube has no cuff. </li></ul><u...
<ul><li>Most effective means of </li></ul>controlling airway. <ul><li>In apneic patients, also allows </li></ul>deeper suc...
Orotracheal Intubation Complications <ul><li>Stimulation of airway  </li></ul>can cause bradycardia. <ul><li>Trauma can oc...
<ul><li>Hypoxia can result from </li></ul>prolonged attempts. <ul><li>No oxygen to left lung </li></ul>because tube is in ...
<ul><li>Esophageal intubation </li></ul><ul><li>Vomiting </li></ul><ul><li>Self-extubation </li></ul><ul><li>Movement of t...
<ul><li>Prolonged artificial </li></ul>Indications Infant and Child Intubation ventilation required <ul><li>Inability to v...
Indications <ul><li>Apnea </li></ul><ul><li>Unresponsiveness </li></ul>without cough or gag reflex Infant and Child Intuba...
<ul><li>Prevents gastric distention </li></ul><ul><li>Minimizes risk of aspiration </li></ul><ul><li>Permits suctioning of...
Equipment: BSI
<ul><li>Bag-valve mask with mask </li></ul>of correct size Equipment <ul><li>Laryngoscope handle </li></ul>Infant and Chil...
<ul><li>Straight blade allows: </li></ul><ul><li>Greater displacement of tongue </li></ul><ul><li>Better visualization of ...
<ul><li>Curved blade inserted into    vallecula allows: </li></ul><ul><li>Visualization of glottis, cords </li></ul>(prefe...
<ul><li>Consult chart or tape. </li></ul><ul><li>In general, use: </li></ul>Endotracheal Tube Size <ul><li>3.0–3.5 for new...
Formula for Endotracheal Tube Size 16 + age  (years) 4 = Tube size  (mm) (Continued) Infant and Child Intubation
<ul><li>Alternative: </li></ul><ul><li>Have tubes one size larger and </li></ul><ul><li>Use tube same size as patient’s li...
<ul><li>Use UNCUFFED tubes for   children up to 8 years old. </li></ul>ET Tubes (Narrowing of cricoid acts as a cuff.) Inf...
<ul><li>Use CUFFED tubes for   children older than 8 years. </li></ul>ET Tubes (Tube should have marker for vocal cords, t...
(Measured from teeth to midtrachea) Pediatric ET Tube Distances
Endotracheal Intubation <ul><li>Provides stiffness/shape. </li></ul><ul><li>Lubricant may ease removal. </li></ul><ul><li>...
<ul><li>Water-soluble lubricant </li></ul><ul><li>10 cc syringe </li></ul><ul><li>Securing devices </li></ul><ul><li>Sucti...
Tell new EMT-Bs that ideally a chart should be placed in the airway kit to help them determine what size tube is generally...
<ul><li>Ventilate appropriately. </li></ul><ul><li>Assemble and test equipment. </li></ul><ul><li>Take BSI precautions. </...
<ul><li>Monitor heart rate throughout. </li></ul>(Mechanically stimulating airway may  slow heart rate.  If this happens, ...
If trauma is suspected, have rescuer  hold head in neutral position. Place head in “sniffing” position.
<ul><li>Using little force, insert </li></ul>laryngoscope blade into right corner of mouth. <ul><li>Sweep tongue out of wa...
<ul><li>Insert end of blade into position:  </li></ul><ul><li>Lift mandible:  </li></ul><ul><li>Straight lift–epiglottis <...
<ul><li>Have rescuer apply  </li></ul>Sellick’s maneuver. <ul><li>Visualize glottic opening and </li></ul>vocal cords. Inf...
<ul><li>Gently insert tube until glottic </li></ul>marker  (if present)   is at level of vocal cords. <ul><li>If using cuf...
<ul><li>Holding tube, remove  </li></ul>laryngoscope blade and stylet. <ul><li>Have partner attach bag-valve </li></ul>and...
<ul><li>Observe chest rise and fall. </li></ul><ul><li>Auscultate epigastrium for </li></ul>absence of sounds. Infant and ...
<ul><li>Auscultate apex and base of </li></ul>each lung. <ul><li>Assess for improvement in </li></ul>heart rate and skin c...
<ul><li>If correct placement is confirmed </li></ul>(no sounds over epigastrium and bilaterally  equal breath sounds) ,   ...
<ul><li>Ventilate patient at a rate </li></ul>appropriate for age. <ul><li>Note tube’s depth of insertion.  </li></ul><ul>...
<ul><li>If breath sounds are present </li></ul>only on right, withdraw tube slightly until breath  sounds are equal. <ul><...
Infant and Child Intubation Techniques (Continued) <ul><li>If  sounds present only in </li></ul><ul><li>epigastrium: </li>...
<ul><li>Once tube is secured, secure head </li></ul>to prevent movement that  can dislodge tube. Infant and Child Intubati...
<ul><li>Reassess breath sounds after </li></ul>every major move: <ul><li>Scene to ambulance </li></ul><ul><li>Ambulance to...
<ul><li>If tube is in proper place, but  </li></ul>lung expansion is inadequate: <ul><li>Tube too small/large air leak. </...
<ul><li>Pop-off valve on bag-valve </li></ul>device activated. <ul><li>Leak in bag-valve device. </li></ul><ul><li>If tube...
<ul><li>Inadequate compression of bag </li></ul><ul><li>Tube blocked with secretions </li></ul>SUCTION ENDOTRACHEALLY;  RE...
<ul><li>Stimulation of airway can </li></ul>cause bradycardia. <ul><li>Trauma can occur to lips, teeth,  </li></ul>tongue,...
<ul><li>Hypoxia may result from </li></ul>prolonged attempts. <ul><li>No oxygen to left lung because </li></ul>tube is in ...
<ul><li>Esophageal intubation </li></ul><ul><li>Vomiting </li></ul><ul><li>Self-extubation </li></ul><ul><li>Tube dislodge...
Reasons for Use <ul><li>Decompress stomach </li></ul><ul><li>Gastric lavage </li></ul><ul><li>Administration of </li></ul>...
Indications <ul><li>Inability to ventilate  </li></ul>infant/child because of  gastric distention <ul><li>Unresponsive inf...
Contraindications <ul><li>Presence of major face, head, or </li></ul>spine trauma  (use orogastric technique instead) Naso...
Complications <ul><li>Tracheal intubation </li></ul><ul><li>Nasal trauma </li></ul><ul><li>Emesis </li></ul><ul><li>Passag...
<ul><li>Newborn/Infant   8.0 French </li></ul><ul><li>Toddler/Preschool   10.0 French </li></ul><ul><li>School age     12....
Equipment <ul><li>20 cc syringe </li></ul><ul><li>Water-soluble lubricant </li></ul><ul><li>Emesis basin </li></ul><ul><li...
Nasogastric Intubation  Infant/Child: Oxygenate patient; prepare and  assemble equipment.
Measure tube from tip of nose, around  ear, to below  xiphoid process. Pass lubricated tube downward along nasal floor int...
Confirm placement as you inject 10–20 cc  air.  Listen for bubbling.
Aspirate for  stomach contents. Secure tube in place.
Indications <ul><li>Obvious secretions </li></ul><ul><li>Poor compliance when  </li></ul>using bag-valve mask Orotracheal ...
Complications Orotracheal Suctioning <ul><li>Arrhythmias </li></ul><ul><li>Hypoxia </li></ul><ul><li>Coughing </li></ul><u...
Take BSI precautions! Preoxygenate and ventilate patient.
Carefully check equipment. Insert catheter  without suction. Use sterile technique.
Advance catheter no farther than carina.
Apply suction and withdraw catheter in twisting motion.
Resume ventilation.  (Suctioning should not interrupt ventilation longer than  15 seconds.) Orotracheal Suctioning
Nothing is more embarrassing for the EMT-B, or harmful for the patient, than fumbling around to get a suction unit working...
Combitubes ®
A Dual Lumen Airway
Indication Combitubes ® <ul><li>Unconscious patient   in need of airway   management </li></ul>
Contraindications: <ul><li>Conscious patient </li></ul><ul><li>Patient with gag reflex </li></ul><ul><li>Under 5 feet tall...
<ul><li>Take BSI precautions. </li></ul><ul><li>Ventilate with bag-valve mask. </li></ul><ul><li>Prepare and check equipme...
Lubricate the Combitube ®
<ul><li>Insert device blindly along center of the mouth. </li></ul><ul><li>Advance device until  the teeth are  centered b...
Insert the Combitube ® .
<ul><li>Inflate valve #1 cuff with 100 cc of air. </li></ul><ul><li>Inflate valve #2 cuff with 15 cc of air. </li></ul>Com...
Combitube ®  in place with cuffs inflated.
Ventilate through tube #1 (blue tube).
<ul><li>Auscultate for lung sounds and the absence of epigastric sounds. </li></ul><ul><li>If lung sounds are present and ...
If no lung sounds are present and epigastric sounds are heard, ventilate through the shorter tube (tube #2).
Laryngeal Mask Airway (LMA)
A Laryngeal  Mask Airway
<ul><li>Take BSI precautions. </li></ul><ul><li>Ventilate with bag-valve mask. </li></ul><ul><li>Prepare and check equipme...
<ul><li>Lubricate the posterior side of cuff. </li></ul><ul><li>Insert tube with open side facing anteriorly. </li></ul><u...
Inserting the LMA
<ul><li>Inflate cuff with air based on size of LMA. </li></ul><ul><li>Ventilate through the tube. </li></ul><ul><li>Auscul...
Automatic Transport  Ventilators (ATVs)
An Automatic Transport Ventilator
<ul><li>Protocols may allow use in place of bag-valve mask. </li></ul><ul><li>Controls set rate of ventilations and weight...
1. Explain the procedure of nasogastric tube insertion. 2. Discuss the indications for orotracheal intubation. 3. How and ...
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Advanced Airway Management

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Transcript of "Advanced Airway Management"

  1. 1. Chapter Advanced Airway Management Twenty-Nine
  2. 2. Chapter <ul><li>Purpose and procedure for nasogastric tubes and orotracheal intubation </li></ul><ul><li>How to perform Sellick’s maneuver </li></ul><ul><li>How to use the Combitube® airway and the LMA </li></ul><ul><li>Usefulness of an ATV </li></ul>Twenty-Nine CORE CONCEPTS
  3. 3. Anatomy of the Respiratory System
  4. 4. Bronchioles and Alveoli
  5. 5. Shallow chest expansion <ul><li>Depth: </li></ul>Outside normal range <ul><li>Rate: </li></ul>(fast or slow) Regular or irregular <ul><li>Rhythm: </li></ul>(Continued) Inadequate Breathing
  6. 6. Abnormal breath sounds <ul><li>Quality: </li></ul>(noisy, diminished, or absent) Unequal chest expansion Increased breathing effort (Continued) Inadequate Breathing
  7. 7. Just before death <ul><li>Agonal Respirations: </li></ul>Pale, cyanotic, cool, or clammy <ul><li>Skin: </li></ul>Above clavicles, between/below ribs <ul><li>Retractions: </li></ul>Inadequate Breathing
  8. 8. <ul><li>Nasal flaring </li></ul><ul><li>“ See-saw” breathing </li></ul>Inadequate Breathing in Infants and Children
  9. 9. Airway Differences between Adults and Children
  10. 10. <ul><li>Mouth and nose </li></ul><ul><li>Pharynx </li></ul><ul><li>Trachea </li></ul><ul><li>Cricoid cartilage </li></ul><ul><li>Diaphragm </li></ul>Differences between the Airways of Children and Adults
  11. 11. A IRWAY ADJUNCTS
  12. 12. Orotracheal Intubation Purpose <ul><li>Most effective way to </li></ul>control airway. <ul><li>Use in apneic patients: </li></ul><ul><li>Minimizes risk of aspiration. </li></ul><ul><li>Allows more oxygen </li></ul>delivery. <ul><li>Allows deeper suctioning. </li></ul>
  13. 13. Complications <ul><li>Stimulation of airway </li></ul>can cause bradycardia. <ul><li>Trauma can occur to </li></ul>lips, teeth, tongue, gums, airway structures. Orotracheal Intubation (Continued)
  14. 14. <ul><li>Hypoxia may result </li></ul>from prolonged attempts. <ul><li>No oxygen to left lung </li></ul>because tube is in right mainstem bronchus. Complications Orotracheal Intubation (Continued)
  15. 15. <ul><li>Esophageal intubation </li></ul><ul><li>Vomiting </li></ul><ul><li>Self-extubation </li></ul><ul><li>Movement of tube out </li></ul>of trachea when patient moved Complications Orotracheal Intubation
  16. 16. <ul><li>Laryngoscope handle </li></ul><ul><li>Laryngoscope blades </li></ul>Equipment <ul><li>Assorted sizes (0–4) </li></ul><ul><li>Curved or straight </li></ul>(straight preferred for infants/children) Orotracheal Intubation (Continued)
  17. 17. Straight blade brings vocal cords into view by lifting epiglottis.
  18. 18. Curved blade brings vocal cords into view by lifting vallecula and indirectly lifting epiglottis.
  19. 19. Assembly of Laryngoscope Handle and Blade Align identification with bar, press-forward to lock Press To lock
  20. 20. <ul><li>Adult female: </li></ul><ul><li>Adult male: </li></ul>7.0–8.0 mm 8.0–8.5 mm Endotracheal Tubes: Average Sizes (Inner diameter) (Continued)
  21. 21. Endotracheal Tubes <ul><li>Emergency rule: </li></ul><ul><li>Have available one size larger </li></ul><ul><li>7.5 fits most adults. </li></ul>and one size smaller.
  22. 22. Endotracheal Tube
  23. 23. <ul><li>Teeth to cords: </li></ul><ul><li>Teeth to suprasternal notch: </li></ul><ul><li>Teeth to carina: </li></ul><ul><li>Teeth to tip: </li></ul>15 cm 20 cm 25 cm 22 cm Endotracheal Intubation Useful Dimensions
  24. 24. <ul><li>Provides stiffness/shape. </li></ul><ul><li>Lubricant may ease removal. </li></ul><ul><li>Used to shape tube like </li></ul>Stylet hockey stick. <ul><li>Do not let stylet get closer </li></ul>than 1/4 inch to end of tube. Endotracheal Intubation
  25. 25. Stylet Stylet in Place
  26. 26. <ul><li>Water-soluble lubricant </li></ul><ul><li>10 cc syringe </li></ul><ul><li>Securing devices </li></ul><ul><li>Suction unit </li></ul><ul><li>Towels </li></ul>Equipment Endotracheal Intubation
  27. 27. Endotracheal Intubation <ul><li>Inability to ventilate </li></ul>Indications apneic patient <ul><li>Unresponsiveness to </li></ul>painful stimuli <ul><li>No cough or gag reflex </li></ul><ul><li>Inability of patient to </li></ul>protect airway
  28. 28. Use in unresponsive patient who lacks a cough or gag reflex to help prevent regurgitation and aspiration during endotracheal intubation. Sellick’s Maneuver
  29. 29. Cricoid Cartilage Surrounds entire trachea, inferior to cricothyroid membrane (depression below thyroid cartilage or Adam’s apple) K EY TERM
  30. 30. Location of Cricoid Cartilage
  31. 31. Perform Sellick’s maneuver by exerting posterior pressure on cricoid cartilage.
  32. 32. Sellick’s Maneuver <ul><li>Verify correct position to avoid </li></ul>damaging other structures. <ul><li>Cricoid is more difficult to find </li></ul>in infants/children. (Continued)
  33. 33. <ul><li>Have third rescuer </li></ul>perform maneuver. <ul><li>Maintain maneuver until </li></ul>patient is intubated. Sellick’s Maneuver
  34. 34. Ensure proper ventilation of patient.
  35. 35. Assemble, prepare, and test equipment.
  36. 36. If trauma is suspected, have rescuer hold head in neutral position. Position patient’s head.
  37. 37. Make sure airway structures are aligned.
  38. 38. Insert laryngoscope blade into mouth, avoiding contact with teeth.
  39. 39. Lift tongue up and to left.
  40. 40. Insert blade and lift mandible.
  41. 41. Have rescuer apply Sellick’s maneuver. (Bring vocal cords into view.)
  42. 42. Visualize glottic opening between vocal cords.
  43. 43. Gently insert endotracheal tube (with stylet in place) until cuff passes between vocal cords.
  44. 44. Remove laryngoscope and stylet without moving tube. Inflate cuff with 5–10 cc of air.
  45. 45. Attach bag-valve resuscitator and ventilate. Observe rise of chest.
  46. 46. Confirm placement by auscultating epigastrium and lungs.
  47. 47. <ul><li>Observe chest rise and fall. </li></ul><ul><li>Auscultate epigastrium for </li></ul>absence of sounds. <ul><li>Auscultate apex and base of </li></ul>each lung. Confirm Correct Tube Placement (Continued)
  48. 48. <ul><li>Observe for signs such </li></ul>as cyanosis. <ul><li>As protocols direct, use end-tidal </li></ul>CO 2 detector and “tube-check.” (Continued) Confirm Correct Tube Placement
  49. 49. Colorimetric end-tidal CO 2 detector
  50. 50. Esophageal detector device
  51. 51. Combined devices check pulse oximetry, ETCO 2 blood pressure, pulse, respiratory rate, and temperature.
  52. 52. Tube Placement If correct placement is confirmed, secure tube and continue to ventilate.
  53. 53. Tube Placement <ul><li>If breath sounds are present only </li></ul>on right, deflate cuff and withdraw tube slightly until breath sounds are equal. <ul><li>Secure tube with a commercial device and ventilate. </li></ul>(Continued)
  54. 54. <ul><li>If sounds are present only in </li></ul>epigastrium, deflate cuff, remove tube, and hyperventilate for at least 2 minutes before reattempting intubation. Tube Placement (Continued)
  55. 55. Tube Placement <ul><li>Reassess breath sounds after </li></ul>every major move: <ul><li>From scene to ambulance </li></ul><ul><li>From ambulance to hospital </li></ul>
  56. 56. It cannot be overemphasized that inadvertent esophageal intubation will likely result in death. Because of the magnitude of this complication, tell new EMT-Bs that if at any time, despite the best efforts to properly assess tube placement, they are in doubt of proper tube placement, they should immediately withdraw the tube and manage the airway with basic airway adjuncts. P RECEPTOR P EARL
  57. 57. I NFANT AND CHILD INTUBATION
  58. 58. <ul><li>Mouth and nose (smaller) </li></ul><ul><li>Pharynx (tongue proportionally larger) </li></ul><ul><li>Epiglottis (floppier) </li></ul><ul><li>Glottic opening (smaller) </li></ul>Anatomic and Physiologic Considerations (Continued)
  59. 59. <ul><li>Vocal cords (harder to see) </li></ul><ul><li>Trachea (narrower) </li></ul><ul><li>Cricoid cartilage (less rigid; </li></ul>part of child’s airway) <ul><li>Diaphragm (children rely more on </li></ul>diaphragm for breathing) narrowest Anatomic and Physiologic Considerations
  60. 60. Cricoid Cartilage Child and Adult Airways
  61. 61. <ul><li>Since cricoid ring is narrowest </li></ul>part of child’s airway, <ul><li>Pediatric tube has no cuff. </li></ul><ul><li>Tube size depends on size of </li></ul>cricoid ring. Infant and Child Intubation Special Considerations
  62. 62. <ul><li>Most effective means of </li></ul>controlling airway. <ul><li>In apneic patients, also allows </li></ul>deeper suctioning. Infant and Child Intubation Purpose
  63. 63. Orotracheal Intubation Complications <ul><li>Stimulation of airway </li></ul>can cause bradycardia. <ul><li>Trauma can occur to lips, </li></ul>teeth, tongue, gums, airway structures. (Continued)
  64. 64. <ul><li>Hypoxia can result from </li></ul>prolonged attempts. <ul><li>No oxygen to left lung </li></ul>because tube is in right mainstem bronchus. Complications Orotracheal Intubation (Continued)
  65. 65. <ul><li>Esophageal intubation </li></ul><ul><li>Vomiting </li></ul><ul><li>Self-extubation </li></ul><ul><li>Movement of tube out </li></ul>of trachea when patient moved Complications Orotracheal Intubation
  66. 66. <ul><li>Prolonged artificial </li></ul>Indications Infant and Child Intubation ventilation required <ul><li>Inability to ventilate </li></ul>by other means (Continued)
  67. 67. Indications <ul><li>Apnea </li></ul><ul><li>Unresponsiveness </li></ul>without cough or gag reflex Infant and Child Intubation (Continued)
  68. 68. <ul><li>Prevents gastric distention </li></ul><ul><li>Minimizes risk of aspiration </li></ul><ul><li>Permits suctioning of </li></ul>airway secretions Advantages Infant and Child Intubation
  69. 69. Equipment: BSI
  70. 70. <ul><li>Bag-valve mask with mask </li></ul>of correct size Equipment <ul><li>Laryngoscope handle </li></ul>Infant and Child Intubation
  71. 71. <ul><li>Straight blade allows: </li></ul><ul><li>Greater displacement of tongue </li></ul><ul><li>Better visualization of glottis </li></ul>(preferred in infants) (Continued) Infant and Child Intubation Laryngoscope Blades
  72. 72. <ul><li>Curved blade inserted into vallecula allows: </li></ul><ul><li>Visualization of glottis, cords </li></ul>(preferred in older children) Infant and Child Intubation Laryngoscope Blades
  73. 73. <ul><li>Consult chart or tape. </li></ul><ul><li>In general, use: </li></ul>Endotracheal Tube Size <ul><li>3.0–3.5 for newborns, small infants </li></ul><ul><li>4.0 for up to 1 year old </li></ul>(Continued) Infant and Child Intubation
  74. 74. Formula for Endotracheal Tube Size 16 + age (years) 4 = Tube size (mm) (Continued) Infant and Child Intubation
  75. 75. <ul><li>Alternative: </li></ul><ul><li>Have tubes one size larger and </li></ul><ul><li>Use tube same size as patient’s little </li></ul>finger or that will fit nostril. smaller available. Infant and Child Intubation
  76. 76. <ul><li>Use UNCUFFED tubes for children up to 8 years old. </li></ul>ET Tubes (Narrowing of cricoid acts as a cuff.) Infant and Child Intubation (Continued)
  77. 77. <ul><li>Use CUFFED tubes for children older than 8 years. </li></ul>ET Tubes (Tube should have marker for vocal cords, to ensure proper insertion depth.) Infant and Child Intubation
  78. 78. (Measured from teeth to midtrachea) Pediatric ET Tube Distances
  79. 79. Endotracheal Intubation <ul><li>Provides stiffness/shape. </li></ul><ul><li>Lubricant may ease removal. </li></ul><ul><li>Used to shape tube like </li></ul>Stylet hockey stick. <ul><li>Do not let stylet get closer </li></ul>than 1/4 inch to end of tube.
  80. 80. <ul><li>Water-soluble lubricant </li></ul><ul><li>10 cc syringe </li></ul><ul><li>Securing devices </li></ul><ul><li>Suction unit </li></ul><ul><li>Towels </li></ul>Equipment Endotracheal Intubation
  81. 81. Tell new EMT-Bs that ideally a chart should be placed in the airway kit to help them determine what size tube is generally used for a certain age patient. As an alternative, there are commercially available measuring tapes that estimate tube size based on the length of the patient. P RECEPTOR P EARL
  82. 82. <ul><li>Ventilate appropriately. </li></ul><ul><li>Assemble and test equipment. </li></ul><ul><li>Take BSI precautions. </li></ul>(Continued) Infant and Child Intubation Techniques
  83. 83. <ul><li>Monitor heart rate throughout. </li></ul>(Mechanically stimulating airway may slow heart rate. If this happens, stop and ventilate.) Infant and Child Intubation Techniques
  84. 84. If trauma is suspected, have rescuer hold head in neutral position. Place head in “sniffing” position.
  85. 85. <ul><li>Using little force, insert </li></ul>laryngoscope blade into right corner of mouth. <ul><li>Sweep tongue out of way. </li></ul>Infant and Child Intubation Techniques (Continued)
  86. 86. <ul><li>Insert end of blade into position: </li></ul><ul><li>Lift mandible: </li></ul><ul><li>Straight lift–epiglottis </li></ul><ul><li>Curved–vallecula </li></ul><ul><li>Use care not to contact teeth. </li></ul>Infant and Child Intubation Techniques (Continued)
  87. 87. <ul><li>Have rescuer apply </li></ul>Sellick’s maneuver. <ul><li>Visualize glottic opening and </li></ul>vocal cords. Infant and Child Intubation Techniques (Continued)
  88. 88. <ul><li>Gently insert tube until glottic </li></ul>marker (if present) is at level of vocal cords. <ul><li>If using cuffed tube, insert cuff </li></ul>beyond vocal cords. Infant and Child Intubation Techniques (Continued)
  89. 89. <ul><li>Holding tube, remove </li></ul>laryngoscope blade and stylet. <ul><li>Have partner attach bag-valve </li></ul>and ventilate. <ul><li>Confirm correct placement. </li></ul>Infant and Child Intubation Techniques (Continued)
  90. 90. <ul><li>Observe chest rise and fall. </li></ul><ul><li>Auscultate epigastrium for </li></ul>absence of sounds. Infant and Child Intubation Techniques (Continued)
  91. 91. <ul><li>Auscultate apex and base of </li></ul>each lung. <ul><li>Assess for improvement in </li></ul>heart rate and skin color. Infant and Child Intubation Techniques (Continued)
  92. 92. <ul><li>If correct placement is confirmed </li></ul>(no sounds over epigastrium and bilaterally equal breath sounds) , secure tube with commercial device and continue to ventilate. Infant and Child Intubation Techniques (Continued)
  93. 93. <ul><li>Ventilate patient at a rate </li></ul>appropriate for age. <ul><li>Note tube’s depth of insertion. </li></ul><ul><li>May insert oral airway/bite </li></ul>block. Infant and Child Intubation Techniques (Continued)
  94. 94. <ul><li>If breath sounds are present </li></ul>only on right, withdraw tube slightly until breath sounds are equal. <ul><li>Secure tube and ventilate. </li></ul>Infant and Child Intubation Techniques (Continued)
  95. 95. Infant and Child Intubation Techniques (Continued) <ul><li>If sounds present only in </li></ul><ul><li>epigastrium: </li></ul><ul><li>Remove tube. </li></ul><ul><li>Ventilate for at least 1 minute. </li></ul><ul><li>Reattempt intubation. </li></ul>
  96. 96. <ul><li>Once tube is secured, secure head </li></ul>to prevent movement that can dislodge tube. Infant and Child Intubation Techniques (Continued)
  97. 97. <ul><li>Reassess breath sounds after </li></ul>every major move: <ul><li>Scene to ambulance </li></ul><ul><li>Ambulance to hospital </li></ul>Infant and Child Intubation Techniques
  98. 98. <ul><li>If tube is in proper place, but </li></ul>lung expansion is inadequate: <ul><li>Tube too small/large air leak. </li></ul><ul><li>Auscultate neck </li></ul><ul><li>Replace with larger tube </li></ul><ul><li>Consider cuffed tube if child > 8 years old </li></ul>Infant and Child Intubation Techniques
  99. 99. <ul><li>Pop-off valve on bag-valve </li></ul>device activated. <ul><li>Leak in bag-valve device. </li></ul><ul><li>If tube is in proper place, but </li></ul>lung expansion is inadequate: Infant and Child Intubation Complications (Continued)
  100. 100. <ul><li>Inadequate compression of bag </li></ul><ul><li>Tube blocked with secretions </li></ul>SUCTION ENDOTRACHEALLY; REPLACE TUBE. <ul><li>If tube is in proper place, but </li></ul>lung expansion is inadequate: Infant and Child Intubation Complications (Continued)
  101. 101. <ul><li>Stimulation of airway can </li></ul>cause bradycardia. <ul><li>Trauma can occur to lips, teeth, </li></ul>tongue, gums, airway structures. Infant and Child Intubation Complications (Continued)
  102. 102. <ul><li>Hypoxia may result from </li></ul>prolonged attempts. <ul><li>No oxygen to left lung because </li></ul>tube is in right mainstem. Infant and Child Intubation Complications (Continued)
  103. 103. <ul><li>Esophageal intubation </li></ul><ul><li>Vomiting </li></ul><ul><li>Self-extubation </li></ul><ul><li>Tube dislodged by patient moving </li></ul><ul><li>Collapse of lung </li></ul>Infant and Child Intubation Complications (Continued)
  104. 104. Reasons for Use <ul><li>Decompress stomach </li></ul><ul><li>Gastric lavage </li></ul><ul><li>Administration of </li></ul>medications/nutrition Nasogastric Tubes
  105. 105. Indications <ul><li>Inability to ventilate </li></ul>infant/child because of gastric distention <ul><li>Unresponsive infant/child </li></ul>Nasogastric Tubes
  106. 106. Contraindications <ul><li>Presence of major face, head, or </li></ul>spine trauma (use orogastric technique instead) Nasogastric Tubes
  107. 107. Complications <ul><li>Tracheal intubation </li></ul><ul><li>Nasal trauma </li></ul><ul><li>Emesis </li></ul><ul><li>Passage into cranium </li></ul>through basilar skull fracture Nasogastric Tubes
  108. 108. <ul><li>Newborn/Infant 8.0 French </li></ul><ul><li>Toddler/Preschool 10.0 French </li></ul><ul><li>School age 12.0 French </li></ul><ul><li>Adolescent 14-16 French </li></ul>Tube Sizes Nasogastric Tubes
  109. 109. Equipment <ul><li>20 cc syringe </li></ul><ul><li>Water-soluble lubricant </li></ul><ul><li>Emesis basin </li></ul><ul><li>Tape, stethoscope </li></ul><ul><li>Suction unit and catheters </li></ul>Nasogastric Tubes
  110. 110. Nasogastric Intubation Infant/Child: Oxygenate patient; prepare and assemble equipment.
  111. 111. Measure tube from tip of nose, around ear, to below xiphoid process. Pass lubricated tube downward along nasal floor into stomach.
  112. 112. Confirm placement as you inject 10–20 cc air. Listen for bubbling.
  113. 113. Aspirate for stomach contents. Secure tube in place.
  114. 114. Indications <ul><li>Obvious secretions </li></ul><ul><li>Poor compliance when </li></ul>using bag-valve mask Orotracheal Suctioning
  115. 115. Complications Orotracheal Suctioning <ul><li>Arrhythmias </li></ul><ul><li>Hypoxia </li></ul><ul><li>Coughing </li></ul><ul><li>Damage to mucosa </li></ul><ul><li>Bronchospasm </li></ul>
  116. 116. Take BSI precautions! Preoxygenate and ventilate patient.
  117. 117. Carefully check equipment. Insert catheter without suction. Use sterile technique.
  118. 118. Advance catheter no farther than carina.
  119. 119. Apply suction and withdraw catheter in twisting motion.
  120. 120. Resume ventilation. (Suctioning should not interrupt ventilation longer than 15 seconds.) Orotracheal Suctioning
  121. 121. Nothing is more embarrassing for the EMT-B, or harmful for the patient, than fumbling around to get a suction unit working when the airway is filled with vomit or blood. Remind new EMT-Bs that a working rigid-tip suction catheter is an essential piece of equipment for suctioning the mouth and pharynx, which must be done before orotracheal intubation. P RECEPTOR P EARL
  122. 122. Combitubes ®
  123. 123. A Dual Lumen Airway
  124. 124. Indication Combitubes ® <ul><li>Unconscious patient in need of airway management </li></ul>
  125. 125. Contraindications: <ul><li>Conscious patient </li></ul><ul><li>Patient with gag reflex </li></ul><ul><li>Under 5 feet tall </li></ul><ul><li>Under 16 years old </li></ul><ul><li>Ingestion of caustic substance </li></ul><ul><li>Known esophageal disease </li></ul>Combitubes ®
  126. 126. <ul><li>Take BSI precautions. </li></ul><ul><li>Ventilate with bag-valve mask. </li></ul><ul><li>Prepare and check equipment. </li></ul><ul><li>Have suction readily available. </li></ul><ul><li>If patient becomes conscious, at any time, remove the tube! </li></ul>Combitubes ® Insertion Techniques
  127. 127. Lubricate the Combitube ®
  128. 128. <ul><li>Insert device blindly along center of the mouth. </li></ul><ul><li>Advance device until the teeth are centered between the black rings on the Combitube ® . </li></ul>Combitube ® Insertion Techniques
  129. 129. Insert the Combitube ® .
  130. 130. <ul><li>Inflate valve #1 cuff with 100 cc of air. </li></ul><ul><li>Inflate valve #2 cuff with 15 cc of air. </li></ul>Combitubes ® Insertion Techniques
  131. 131. Combitube ® in place with cuffs inflated.
  132. 132. Ventilate through tube #1 (blue tube).
  133. 133. <ul><li>Auscultate for lung sounds and the absence of epigastric sounds. </li></ul><ul><li>If lung sounds are present and no epigastric sounds are heard, continue ventilating through the blue tube (tube #1). </li></ul>Combitubes ® Insertion Techniques
  134. 134. If no lung sounds are present and epigastric sounds are heard, ventilate through the shorter tube (tube #2).
  135. 135. Laryngeal Mask Airway (LMA)
  136. 136. A Laryngeal Mask Airway
  137. 137. <ul><li>Take BSI precautions. </li></ul><ul><li>Ventilate with bag-valve mask. </li></ul><ul><li>Prepare and check equipment. </li></ul><ul><li>Have suction readily available. </li></ul><ul><li>Place patient in a sniffing position. </li></ul>Laryngeal Mask Airway Insertion Techniques
  138. 138. <ul><li>Lubricate the posterior side of cuff. </li></ul><ul><li>Insert tube with open side facing anteriorly. </li></ul><ul><li>Stop when resistance is felt. </li></ul>Laryngeal Mask Airway Insertion Techniques
  139. 139. Inserting the LMA
  140. 140. <ul><li>Inflate cuff with air based on size of LMA. </li></ul><ul><li>Ventilate through the tube. </li></ul><ul><li>Auscultate for lung sounds and the absence of epigastric sounds. </li></ul><ul><li>Insert an oral airway as a bite block. </li></ul>Laryngeal Mask Airway Insertion Techniques
  141. 141. Automatic Transport Ventilators (ATVs)
  142. 142. An Automatic Transport Ventilator
  143. 143. <ul><li>Protocols may allow use in place of bag-valve mask. </li></ul><ul><li>Controls set rate of ventilations and weight-based tidal volume. </li></ul>Automatic Transport Ventilators
  144. 144. 1. Explain the procedure of nasogastric tube insertion. 2. Discuss the indications for orotracheal intubation. 3. How and when should the Sellick maneuver be performed? 4. When is an ETC appropriate to use? R EVIEW QUESTIONS
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