This document provides airway tips and tricks for EMS providers. It discusses better positioning by elevating the trunk 20-30 degrees, even for infants. It emphasizes the importance of preoxygenation to achieve an SpO2 above 94% before intubation through various techniques. It also discusses maintaining oxygenation through apneic oxygenation techniques using high-flow nasal cannula for over 100 minutes. Other tips include using a two-handed mask seal technique, inserting an OPA and NPA to improve ventilation, and utilizing checklists to plan intubations and improve team performance. Resources for continuing education like blogs and podcasts are recommended.
Dr. Noureldin lecture at ICEM Egypt 2012.
ICEM Egypt 2012 is the leading medical conference and exhibition for Intensive Care and Emergency Medicine in Egypt
Airway management in the Emergency Department for TraineesBishan Rajapakse
This is a power point presentation on Airway Management given by our deputy director in Emergency Medicine Training at the Wollongong Hospital, Paul Labana (consultant Emergency Physician) that presents a case illustrating difficulties in airway management and gives an overview of airway management in the emergency department. (Nb another video to do with airway management, and "airway exchange" can be found on this link http://youtu.be/6vaWNknIDQg) - thanks to Paul for sharing his educational material in the name of free open access meducation (#FOAMed)
Dr. Noureldin lecture at ICEM Egypt 2012.
ICEM Egypt 2012 is the leading medical conference and exhibition for Intensive Care and Emergency Medicine in Egypt
Airway management in the Emergency Department for TraineesBishan Rajapakse
This is a power point presentation on Airway Management given by our deputy director in Emergency Medicine Training at the Wollongong Hospital, Paul Labana (consultant Emergency Physician) that presents a case illustrating difficulties in airway management and gives an overview of airway management in the emergency department. (Nb another video to do with airway management, and "airway exchange" can be found on this link http://youtu.be/6vaWNknIDQg) - thanks to Paul for sharing his educational material in the name of free open access meducation (#FOAMed)
Brief description on how to assess airway and manage difficult intubation. There is alot of detail about airway management but this will get you through
Airway management in polytrauma scenario is highly challenging and requiring special challenges. This presentation covers basic, advanced skills, airway assessment in trauma scenario, special challenges, and management pearls.
2018 advanced concepts n basic airway mangementRobert Cole
Updated version of previous airway lecture, focused primarily at EMTs and AEMTs, but good for medics too. This lecture given at the GRaingeville EMS Conference in 2018
Brief description on how to assess airway and manage difficult intubation. There is alot of detail about airway management but this will get you through
Airway management in polytrauma scenario is highly challenging and requiring special challenges. This presentation covers basic, advanced skills, airway assessment in trauma scenario, special challenges, and management pearls.
2018 advanced concepts n basic airway mangementRobert Cole
Updated version of previous airway lecture, focused primarily at EMTs and AEMTs, but good for medics too. This lecture given at the GRaingeville EMS Conference in 2018
2024 03 Monumental Mistakes in EMS BAD EMS v0.2.pdfRobert Cole
(note: This presentation contained videos not included in this slide deck)
Describe the elements of Negligence
Describe the concept of vicarious liability
Describe the role of anchor bias, fatigue, anger and fear in EMS decision making
Review the case of Kyle Vess
Review the case of Paul Tarashuk
Review the case of Crystal Galloway
Introductory/onboarding training for Video Laryngeoscopy, specifically for the MacGrath VL.
NOTE: This is meant to be part of a larger educational endeavor including online, hands on, and team based training.
2018 Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiop...Robert Cole
Bag-mask ventilation (BMV) is a less complex technique than endotracheal
intubation (ETI) for airway management during the advanced cardiac life support phase of
cardiopulmonary resuscitation of patients with out-of-hospital cardiorespiratory arrest.
It has been reported as superior in terms of survival.
1963 COWLEY Clinical Shock: A study of the Biochemical Response in Man.pdfRobert Cole
Accession Number: AD0427998
Title: CLINICAL SHOCK; A STUDY OF THE BIOCHEMICAL RESPONSE TO INJURY IN MAN
Descriptive Note: Annual progress rept. 1 Jan-31 Dec 1963
Corporate Author: MARYLAND UNIV BALTIMORE SCHOOL OF MEDICINE
Personal Author(s): Crowley, R. A.
Report Date: 1963-12-31
Pagination or Media Count: 226.0
Abstract: Traumatic shock is associated usually with severe injury and characterized principally by inability to maintain an adequate circulation. This study focuses on the total problem - the reaction of the body to injury, maintenance of life, and repair of injury. Studies currently in progress and those proposed are aimed primarily to understanding the biochemical response to injury in man. Provisions have been made for careful metabolic studies in the shocked patient without interfering with obvious life saving measures. Such extensive studies have required the assembly of a considerable staff - professional and technical - to support a C.S.U. on a 24-hour basis. Experimental problems relevant to establishment of such a unit evolved from two major factors 1 original nature of the study a scientific study of shock in man and 2 an unprecedented design of this study. Solutions to these problems are described. Since inception of the contract January, 1962, some 200 patients have been studied as they have undergone resuscitation measures. Final organization of the unit now permits more complex studies into the physio-biochemical response to injury in man.
Descriptors: *ENDOTOXIC SHOCK BACTERIA ENZYMES METABOLISM AMMONIA THERAPY HYPOXIA PHYSIOLOGY WOUNDS AND INJURIES IMMUNOLOGY CARDIOVASCULAR SYSTEM HYPOTHERMIA TOXINS AND ANTITOXINS HEMORRHAGE BLOOD COAGULATION
Subject Categories: Stress Physiology
Distribution Statement: APPROVED FOR PUBLIC RELEASE
Proposal to establish a new training center for Multi Agency EMS Training v1....Robert Cole
Vision
The Joint Emergency Medical Services training Center (JEMSTC) is a multi-use campus
and facilities dedicated to the provision of EMS and public safety education in the Ada
County-City Emergency Medical Services System. It would serve as a locus of collaboration and
effort in EMS education, providing not simply classroom space, but a relevant, dynamic,
realistic, and effective learning capacity, ultimately affecting the provision of all EMS services in
a positive way.
The JEMSTC would provide facilities for 24 /7 EMS education, vehicle operation, skills
practice, and credentialing. The facilities would be able to accommodate both EMS and Fire
apparatus in all climates for a diverse array of educational activities. This JEMSTC would meet
all the EMS (and related operational) training for the ACCESS system.
This document from • The Centers for Medicare & Medicaid Services shows that refusing to accept reports or parking EMS patients on the wall may be an EMTALA violation.
Hospitals and administrators do not want line EMS providers to know this, but this is ammo against abuse of EMS systems by ER Staff.
Improving Drug Calculation Performance in Paramedics Practicing in an Emergen...Robert Cole
This literature review will examine the scope of the problem and challenges with mathematical proficiency in out-of-hospital care. It will also explore interventions targeted at improving performance in the out-of-hospital environment, and how they may be applied in initial and continuing education models. The author hopes that improvement in drug calculations will result in fewer medical errors and improved patient care.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Under Pressure : Kenneth Kruk's StrategyKenneth Kruk
Kenneth Kruk's story of transforming challenges into opportunities by leading successful medical record transitions and bridging scientific knowledge gaps during COVID-19.
International Cancer Survivors Day is celebrated during June, placing the spotlight not only on cancer survivors, but also their caregivers.
CANSA has compiled a list of tips and guidelines of support:
https://cansa.org.za/who-cares-for-cancer-patients-caregivers/
This document is designed as an introductory to medical students,nursing students,midwives or other healthcare trainees to improve their understanding about how health system in Sri Lanka cares children health.
PET CT beginners Guide covers some of the underrepresented topics in PET CTMiadAlsulami
This lecture briefly covers some of the underrepresented topics in Molecular imaging with cases , such as:
- Primary pleural tumors and pleural metastases.
- Distinguishing between MPM and Talc Pleurodesis.
- Urological tumors.
- The role of FDG PET in NET.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Letter to MREC - application to conduct studyAzreen Aj
Application to conduct study on research title 'Awareness and knowledge of oral cancer and precancer among dental outpatient in Klinik Pergigian Merlimau, Melaka'
The global radiation oncology market size reached US$ 8.1 Billion in 2023. Looking forward, IMARC Group expects the market to reach US$ 14.5 Billion by 2032, exhibiting a growth rate (CAGR) of 6.5% during 2024-2032.
More Info:- https://www.imarcgroup.com/radiation-oncology-market
PrudentRx's Function in the Management of Chronic Illnesses
2015 airway tips and tricks v.02
1. Airway Tips and Tricks Your
Patient Cant Live Without!
Eastern OR EMS Conference 2015
2.
3. What we are going to talk about…
• Better….
– Positioning
– Oxygenation
– Facemask Seal
– Ventilation
– Nasal ETT
– Oral ETT
– Planning
• Better resources
– 5 blogs and podcasts that will change what you do!
14. What the anesthesia world thinks of it
• SPO2 > 94% before apnea WITH
preoxygenation efforts.
– Min of 3 minutes on well fitted NRB at flow rates >
15 LPM
OR
– 8-10 full inhalation/exhaltion breaths on 100%
Oxygen
– Nitrogen Washout
15. Nitrogen Washout and the Oxygen
Resovoir
• Normal FIO2 approx. .21-.24 (21-24%)
– Remainder is Nitrogen, CO2, and other gasses
• Tidal Volume is 600-800 cc
– “Dead Air Space” is approx. 150 cc
• If we replace that inert gas in the dead air
space with 100% Oxygen, what happens?
– “Nitrogen Washout”
– Dead Air Space (95%)
– Plasma (5%)
25. How long can this be done?
• At least 100 min
– Nielsen ND, Kjaergaard B, Koefoed-Nielsen J, et al. Apneic oxygenation
combined with extracorporeal arteriovenous carbon dioxide removal
provides sufficient gas exchange in experimental lung injury. ASAIO J.
2008;54:401-405
– Enghoff H, Holmdahl MH, Risholm L. Oxygen uptake in human lungs
without spontaneous or artificial pulmonary ventilation. Acta Chir
Scand. 1952;103:293-301.
– Holmdahl MH. Pulmonary uptake of oxygen, acid-base metabolism,
and circulation during prolonged apnoea. Acta Chir Scand Suppl.
1956;212:1-128..
26. Can you not bag at all?
• Answer: “Depends”
• Considerations:
– Obesity
– Shunt Physiology
– Shock
• What should you do?
– Cautious Bagging
– CPAP?
– Bagging with PEEP Valve?
27. KEY POINT:
• This works best when
you have excellent
airway positioning!
33. Which is better?
• In every study: 2 handed techniques out
performed 1 handed techniques.
• The T-E technique marginally delivered better
airway pressures and tidal volumes over the E-
C technique.
• TE produced less failed breaths
34. Nu MASK
• BLS difficult airway
Device
• Cheap and easy
42. Key Point!!!
• Airway pressures > 25 cmH2O can cause gastric
Distention
• Gastric Distention can cause vomiting
• Vomiting can cause aspiration
• Aspiration causes aspiration pneumonia in most
patients
• Aspiration Pneumonia kills 40-70% of its patients
• Don’t give ventilations at pressures > 25 cmH20
61. www.projectcheck.org
• Checklist are NOT
– A protocol
– A procedural checklist
– An algorithm
– A teaching tool
– Not an credentialing tool (NREMT)
• Checklist do:
– Red Label items
– Have Pause Points
– Have “Challenge and response”
– Are TEAM DRIVEN
– Are REALITY BASED
68. Important blogs and web series to
start following now!
• www.emcrit.org (Emergency Medicine Critical
Care)
• www.litfl.com (Life in the fast lane)
• www.rescusme.com (Resuscitate me)
• www.emupdates.com (Emergency medicine
Updates)
• www.rougemedic.com
Editor's Notes
Grrimm tv show reference
Im going to fill your toolbox/armory with tools for every occasion….
Preoxygenation for 3 – 5 minutes in a 20° head up position vs supine position:386 seconds vs 283 seconds to desaturate from 100% to 95% O2 saturation (Lane et al. 2005)*
452 seconds vs 364 seconds to desaturate to 93% (Ramkumar, Umesh, and Philip 2011)*
214 seconds vs 162 seconds to desaturate to 92% in patients with BMI > 40 kg/m2 (Benjamin J Dixon et al. 2005)*
Also consider reverse Trendelenburg position (head of bed 30º higher than foot) in trauma patients
Standard nonrebreather at 15L/minute will deliver 60 – 70% FiO2
The FiO2 can be increased to ≥90% by increasing the flow rate to 30 – 60L/min
Oxygen consumption is about 250 mL/minute or 3mL/kg/minute
A healthy person on room air can have a period of “safe apnea” of ≈ 1 minute
A healthy person on high FiO2 can have a period of “safe apnea” of ≈ 8 minutes
One study showed time to desaturation of < 90% O2 saturation after succinylcholine administration was 8 minutes (healthy patients), 5 minutes (moderately ill adults), and 2.7 minutes (obese adults) which is shown in the image to the right. (J L Benumof, Dagg, and R Benumof 1997)*
Conclusion: It is difficult to predict the time to desaturation after preoxygenation in the ED, but it is important to remember that critically ill and obese patients can desaturate quickly.
Oxygen consumption is about 250 mL/minute or 3mL/kg/minute The lungs hold 450 mL of oxygen when breathing room air but can increase to 3000 mL when breathing 100% O2 and replacing alveolar nitrogen
Study 1: In the operating room at the time of apnea, 5 L/min O2 via nasal cannula vs no O2 was tested to show time to desaturation of 95% and showed no desaturation out to 6 minutes in nasal cannula group vs 3.65 minutes in the no O2 group (Taha et al. 2006)*
Study 2: Obese patients in the operating room at the time of apnea, 5L/min O2 via nasal cannula vs no O2 was tested to show time to desaturation of ≥95% and showed a time of 5.29 minutes vs 3.49 minutes respectively (Ramachandran et al. 2010)*
Nasal cannula is the device of choice to provide apneic oxygenation and can be left on during pre oxygenation, bag valve mask ventilation, and during attempts for tracheal intubation.
The difference in oxygen and carbon dioxide movement across
the alveolar membrane is due to the significant differences in gas
solubility in the blood, as well as the affinity of hemoglobin for
oxygen. This causes the net pressure in the alveoli to become
slightly subatmospheric, generating a mass flow of gas from
pharynx to alveoli. This phenomenon, called apneic
oxygenation, permits maintenance of oxygenation without
spontaneous or administered ventilations. Under optimal
circumstances, a PaO2 can be maintained at greater than 100
mm Hg for up to 100 minutes without a single breath, although
the lack of ventilation will eventually cause marked hypercapnia
and significant acidosis.54
In patients who do not achieve an O2 saturation of >93 – 95% with 3 minutes of high FiO2 consider using positive pressure ventilation
These patients most likely have shunt physiology (i.e.alveoli are perfused but not ventilated), and require positive pressure ventilation and not more O2 to increase their oxygen saturation
This is extremely useful in obese patients: (Futier et al. 2011)*
66 patients with BMI of approximately 46 kg/m2
5 minutes of pre oxygenation with non-invasive positive pressure ventilation (NIPPV) vs spontaneous breathing of 100% FiO2
After preoxygenation, NIPPV group had a mean SpO2 of 98% vs spontaneous breathing group of 93%
During intubation NIPPV group only decreased SpO2 to 93% vs spontaneous breathing group of 81%
Positive pressure can be applied in one of three ways:
Walls RM, Murphy MF. Chapter 9: Bag-Mask Ventilation. Manual of Emergency Airway Management, 4th ed. Philadelphia: Lippincott, Williams & Wilkins, 2012.
Gerstein NS, Carey MC, Braude DA, et al. Efficacy of facemask ventilation techniques in novice providers. J Clin Anesth, 2013 May; 25(3): 193–7.
Walls RM, Murphy MF. Chapter 9: Bag-Mask Ventilation. Manual of Emergency Airway Management, 4th ed. Philadelphia: Lippincott, Williams & Wilkins, 2012.
Gerstein NS, Carey MC, Braude DA, et al. Efficacy of facemask ventilation techniques in novice providers. J Clin Anesth, 2013 May; 25(3): 193–7.
von Goedecke A, Wagner-Berger HG, Stadlbauer KH, et al. Effects of decreasing peak flow rate on stomach inflation during bag-valve-mask ventilation.Resuscitation, 2004; 63: 131–6.
t’s possible to limit the potential for high ventilation (inspiratory) pressures by placing a pressure manometer on your BVM each time one is used. High intrathoracic pressure is also a detriment to the critically ill patient, as it decreases venous return to the heart. Decreased venous return results in decreased preload. That in turn results in decreased stroke volume, decreased cardiac output and decreased blood pressure. So, overventilation in an already hemodynamically compromised patient can make them more hypotensive.
To avoid these complications, deliver ventilations slowly, over 1–2 seconds. Use as low of a tidal volume as needed to achieve normal chest rise and fall (typically about 5–7 mL/kg). Avoid unnecessarily high ventilation rates. If your patient has a pulse and pulse oximetry can be monitored, consider lowering your ventilation rate to one that achieves your goal of adequate oxygenation at as few breaths per minute as possible. In other words, if you can achieve acceptable oxygenation levels (94%–100% SpO2) at 8 breaths a minute, there is no reason to ventilate at 12.6 Monitoring the pulse oximetry in patients in cardiac arrest or extreme low-flow states is not an option. In such patients, relying on a predetermined ventilation rate—for example, 12 times a minute for an adult—is prudent.
Another adjunct that can be used to gauge the effectiveness of ventilation is EtCO2 monitoring. Use of a capnometer (a unit that gives a quantitative numerical readout) or capnograph (a unit that gives an EtCO2waveform) can be valuable in ventilated patients. Ventilation rate can be adjusted to maintain an EtCO2 of acceptable levels, most often 35–45 mmHg.
Kiwi Grip invented by Paul Baker (per airwaycam.com)
The aircraft was an Airbus A320-200, registered N106US, operating as a US Airways scheduled domestic commercial passenger flight from LaGuardia Airport in New York City to Seattle–Tacoma International Airport in SeaTac, Washington. About three minutes into the flight, at 3:27 p.m. EST, the plane struck a flock of Canada geese during its initial climb out from LaGuardia, just northeast of theGeorge Washington Bridge. The bird strike caused both jet engines to quickly lose power.
First Officer Skiles was at the controls of the flight when it took off to the northeast from Runway 4 at 3:25 pm, and was the first to notice a formation of birds approaching the aircraft about two minutes later, while passing through an altitude of about 2,700 feet (820 m)[4] on the initial climb out to 15,000 feet (4,600 m).
Descison, checklists, and successful ditching occurred injust over 3 minutes.