Accessbt2019 04 airway v2
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This document outlines an airway management training session with 3 stations. The first station covers basic life support airway procedures like using NPA, OPA, Nu Mask, and BLS nebulizers. The second station demonstrates advanced techniques like surgical airways and using a bougie to assist with endotracheal intubation. The final station is a difficult airway scenario emphasizing teamwork between BLS and ALS providers, with a focus on briefing, pre-oxygenation, intubation, and post-intubation management. The goal is to successfully complete airway scenarios incorporating both basic and advanced life support components, including rapid sequence intubation.
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Accessbt2019 04 airway v2
- 1. Don’t Fear the Reaper… ACCESS – BT – 2019 04 Airway Management
- 2. Objectives Complete Successfully complete an airway management scenario with BLS and ALS components, including RSI. Demonstrate Demonstrate Surgical Airway procedures. Demonstrate Demonstrate use of the LMA and ETT Placement, with the assistance of a bougie. Demonstrate Demonstrate use of basic airway adjuncts including NPAs, OPAs, the Nu Mask, HF Nasal cannula’s and positioning, and BLS nebulizers Review and update Review and update basic airway management practices
- 3. Outline/Agenda Lecture – approx. 30 min 3 stations 1. Core BLS and AEMT Procedures 1. NPA, Nu Mask, OPA and BLS Nebulizer 2. Review LMA’s. 2. Advanced Airway Tools 1. Surgical Airways, Needle Airways 2. Suctioning Airway station. 3. RSI/Difficult Airway Scenario 1. Team based emphasis (BLS and ALS) 2. Crew Based briefing, Pre-oxygenation, Intubation, Post ETT management 4. (EMTs) EPI Check off
- 5. Administration of Oxygen • Reminder: Most cases the SPO2 of 94% is the guiding threshold for O2 administration. • Why? • Constricts coronary arteries! • Constricts cerebral arteries! • Decreased LV output = 11% reduction in systemic oxygen delivery despite increased O2 administration • Is there a good waveform? • Question? Are their exceptions? • Of course. What are they? • Obvious Dyspnea • Obvious shock • Life-threatening Bleeding • Suspected CO or Cyanide toxicity
- 6. Now forget what I just said…
- 7. KEY POINT • SPO2 >94 % WITHOUT Preoxygenation means NOTHING!
- 8. NO DESAT (15 + LPM via NC) • NC at “High flows” for unstable desaturating patients – Protocol: (greater than 6 LPM” – Ideal 15 LPM OR MORE for adults. – Turn the “Dead Air Space” into a reservoir – Passive oxygenation
- 10. Remember: •Good BVM use can save a life •Bad BVM use can take a life
- 11. TIP #1: Using the TE Method Use of the TE technique appears BETTER than the CE technique when used WITH a “JAW LIFT”
- 12. Tip #2: Ventilate to chest rise Minimal Volume = Minimal Damage
- 13. Tip #3: Slow your squeeze • I:E Ratio • I = Inspiratory • E= Expiratory • Longer I Times = More Aveolar Recruitment -> better gas exchange • Longer E times = Better exhalation and less air trapping
- 14. Tip #4: Use the Manometer • Keep Pressure < 20 cmH20 • Decreases vomiting!
- 15. Tip #5: Use PEEP • Almost all patients need about 2 cm of peep to improve aveolar recruitment • CHF, drawing, etc may need up to 10 cm H2O
- 16. Tip #6: Use the ETCO2 • Helps rate control • Remember: Do NOT CHASE the number. • Cardiac arrest: Slow, minimal breaths • DKA and metabolic Acidotic states? : Math the patients rate
- 17. Tip #7: Position, Position, Position
- 18. Tip #8: The “Super Plug”
- 19. Tip #9: Have a plan
- 20. Nebulizers
- 21. Nebulizers • Route for many medications • Albuterol, Atrovent, and Epinephrine are approved for the ACCESS system • What common conditions do we often nebulize patients? • What are the Doses for those Medications? • Albuterol: 2.5 mg • Atrovent: 0.5 mg, do not repeat • Epi: 3 mg 1:1,000 with 3 cc saline (6 cc total • Where are they kept on your rig/In your Bag?
- 22. Set up a neb Neb – Standard Set Up Respiratory Tubing T Piece and Neb “The Neb” (atomization Chamber) O2 Tubing (Run at 6-8 LPM) Mouth Piece
- 23. Can you neb with a NRB? (yes)
- 24. In Line Neb with an ETT
- 25. Identify the parts of an In Line Neb Kit Respiratory Tubing “The Neb” (atomization Chamber) O2 Tubing (Run at 6-8 LPM) No Mouth Piece 15/22 mm barrel connector Elbow Connector T Piece
- 26. Neb “in line” (ETT) Set up 15/22 mm barrel connector (Not Used) Respiratory Tubing (Increases Dead Space but allows flexibility) T Piece and Neb Elbow Connector
- 27. LMAs
- 28. LMA • Success rates are up again • 197 insertions last year(2018) • 92% success rate (first attempt)
- 29. LMA Procedure • Key Lessons: • Minimal Inflation (15-35 ml) • Overinflection causes leaks and displacements • Over inflation can compress the carotid arteries
- 31. The Vomitkin and You:
- 33. Divert the flow (Esophageal Diversion) • “Consider deliberate esophageal tube for purpose of regurg diversion if unable to rapidly tracheal intubate / airway decon otherwise .. The priority is O2ation/ventilation ... not plastic in the trachea ... here we are going for airway decontamination with an esophageal tube.” • - Dr. Yen Chow • ETT to occlude and diver the esophagus…
- 34. ETT as a suction catheter (Esophageal Diversion)
- 36. RSI/Difficult Airway • Team-based approach • Focus on BLS airway maintenance • RSI Procedure • Post ETT management
- 37. RSI • When you plan to make people stop breathing, you would be well advised to practice controlled ventilation. • Dan White, EMT-P
- 38. Don’t forget the Bougie
- 39. Resuscitate BEFORE you intubate • Consider a change From RSI to RAP (Resuscitation Airway Procedures) using the HEAVEN criteria. • H = Hypoxemia/Hypotension • E = Extremes of size • A = Anatomic disruption/obstruction • V = Vomit/blood/fluid • E = Exsanguination • N = Neck mobility
- 40. Better Planning
- 41. Surgical Airways
- 42. Medics: Involve your BLS personnel
- 45. Addition: “Brief team on care plan and contingency actions.” • Research shows that a 15 second pre-brief decreases errors and improves team performance.
- 46. Summary 3 stations 1- BLS Airway management, suction and trach suction Trach tube suctioning Nu Mask, NPA and OPA, LMAs, and BLS Nebs. 2- Advanced Airway Tools Surgical Airways, Bougie assisted ETT with CPR 3- RSI/Difficult Airway Scenario a. Team based emphasis (BLS and ALS) b. Crew Based briefing, Pre-oxygenation, Intubation, Post ETT management
- 47. Questions?
Editor's Notes
- NOTE: The inclusion of the Tracheostomy section
- Eur J Emerg Med. 2011 Feb;18(1):25-30. doi: 10.1097/MEJ.0b013e32833a295e. Effects of oxygen inhalation on cardiac output, coronary blood flow and oxygen delivery in healthy individuals, assessed with MRI.
- The whole point of this graphic is to drive home how quickly a patient can crash without preoxygenation, even if their SPO2 is good. Preoxygenation builds reserve!
- Simply put, it is a Nasal Cannula used in an atypical way and role to improve oxygenation during airway procedures. So the purpose of NO DESAT is to convert apnea periods into oxygenation periods even though no ventilation is occurring. The easiest way to think of this is not pre-oxygenation, but ongoing oxygenation, even though there may be no respiratory effort. NOTE: The airflow from the nares is superior to the airflow from the oral pharynx, but even this is improved further with anterior displacement of the mandible and good airway positioning. Q: How long can this be done? A: At least 100 min. 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. 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.. Q: Will it work everytime? A: No, though it will still improve oxygenation over traditional “apnea”. Those with “Shunt Physiology” will still require some positive pressure. The exact type (C-PAP, Bi_PAP, NIPPV) will depend on what you have available and situation. Pulmonary shunting is (in simple terms) impaired or altered pulmonary blood flow causing impaired gas exchange. Examples are: Pulmonary Emboli CHF/Pulmonary Edema prohibiting gas exchange Q: What are the uses in EMS? A: Preoxygenation leading up to a “apniec period “ (intubation) Possible tool to avoid the CI/CV situation Buy time to better manage the problem Pre-oxygenate during RSI and avoid problems to begin with! Final Point: NO DESAT is just ONE method to provide better oxygenation to the patient. It should be used with multiple approaches NO DESAT effectiveness depends on multiple physiologic factors “PREOXYGENATION EXTENDS THE SAFE APNEA PERIOD. IT SHOULD BE DONE FOR EVERY INTUBATION”
- Inspiratory:Expiratory ratio refers to the ratio of inspiratory time:expiratory time. In normal spontaneous breathing, the expiratory time is about twice as long as the inspiratory time. ... This ratio is typically changed in asthmatics due to the prolonged time of expiration. They might have an I:E ratio of 1:3 or 1:4
- Route for many medications: Albuterol, Atrovent, and Epinephrine are most common in the ACCESS system. In addition to albuterol, Atrovent, and Epi, Mag, Lidocaine, Xopenex, fentanyl and even Ethanol Alcohol have all been nebulized in the past for different conditions. What common conditions do we often nebulize patients in our system? What are the Doses for those Medications? ALBUTEROL: Adults: • Nebulizer—2.5 mg via nebulizer, O2 flow @ 8 L per min, normally takes 8-12 minutes to administer. May repeat as needed. • Hyperkalemia (Intubated): 4 unit doses (10 mg) directly down ETT followed by hyperventilation. Pediatrics: • Nebulizer—Local respiratory experts have seen no reason to specify a different dosage for pediatrics. ATROVENT Adults: • Nebulizer—0.5 mg via nebulizer, O2 flow @ 8 L per min, normally takes 8-12 minutes to administer. Do not repeat. Subsequent nebulizers are with albuterol only. Pediatrics: • Identical dosage. EPI Epinephrine Neb (for laryngeal edema only) 5 mg (5 cc) epinephrine 1:1,000 nebulized undiluted NOTE This is in addition to ANY other epi for anaphylaxis, etc. Where are they kept on your rig/In your Bag?
- A standard neb kit KEY POINT: The NEB IS (almost) ALWAYS PLACED CLOSEST TO THE PATIENT”S AIRWAY Describe or question the students about the purpose of each piece. The “respiratory tubing” acts as a resovoir O2 tubing provides the oxygen flow to make the mist. The higher the flow, the smaller the participles. To low flow, and the medication collects in the upper airway. This may be desirable in certain situations (i.e. Epi for epiglottitis). The T-Piece allows airflow/medication flow to the patient and the the rousovoir (respiratory tubing) during both inhalationand ehalation The mouth piece gives the patient A means to hold in their mouth and “smoke it like a piece pipe” KEY POINT: The longer you can have a patient take a “deep breath” and hold the medication in the deep spaces of the lungs, the more medication will work.
- Questions to ask: What is an “in line suction” Why would we do this in the field?
- The ACCESS “In Line Neb” Kit Ask the question: WHERE IS IT IN YOUR KIT/RIG? Describe or question the students about the purpose of each piece. The “respiratory tubing” acts as a resovoir O2 tubing provides the oxygen flow to make the mist. The higher the flow, the smaller the participles. To low flow, and the medication collects in the upper airway. This may be desirable in certain situations (i.e. Epi for epiglottitis). The T-Piece allows airflow/medication flow to the patient and the the rousovoir (respiratory tubing) during both inhalationand ehalation The mouth piece is not used, therefore is not in the “in line kit” The 15/22 mm barrel connector allows connection to a wide variety of respiraotyr situations, like Trachs, etc. The 90 degree elbow allows connection from the T piece to the ETT.
- KEY POINT: The NEB IS ALWAYS PLACED CLOSEST TO THE PATIENT”S AIRWAY
- Stats according to ESO Jan 1, 2017 – Dec 31, 2017 Remember, moist airways are most complicated. Suction as needed, secure airway before inflation, use care with insertion that you don’t damage balloon, don’t over-inflate.
- Go over the anatomy of the LMA
- The central tenant of the SALAD technique is to make the rigid suction catheter the “tent-pole” of airway management–the suction catheter is utilized in all phases of laryngoscopy to facilitate the quick and proper placement of the laryngoscope blade on the first pass attempt, in lieu of older methods such as opening the patient’s mouth with a scissor-type gesture of the right forefinger and thumb. The result is speed and efficiency coupled with the ability to decontaminate the airway during routine and emergency airway management. In this same manner, the SALAD method can facilitate the insertion of Supraglottic Airways as well, including the Laryngeal Tube. Modern suction catheters beyond standard hospital-issued Yankauer suctions are discussed and demonstrated as well as portable suction systems are demonstrated.
- You have a patient with decreased level of consciousness from a closed head injury. They are not protecting their airway and present with active vomiting and gurgling sounds in their airway. You try your best with c-spine precautions and try to position the patient’s head and neck to keep the spine immobilized in alignment (perhaps turned on a backboard). You know that you have to intubate this patient as they are not maintaining their airway and are at high risk of aspiration. Gastric regurgitation continues despite continuous suctioning. Having extra suctions are always good in this situation to clear the fluids adequately and also as backup in case one suction gets plugged up by particulate matter/fails. If the yankauer plugs up too much consider taking the suction tubing off and sinking the end of it into the airway to suction out the bits. Here is a tip on using the tubing for high volume suction.
- https://www.youtube.com/watch?v=U4ubvush_4s
- Changes to RSI in the SWOs: - Removal of Lidocaine from pre-medications Changes to sedatives prior to intubation Emphasis on Ketamine and no other sedative prior to Succs Review of the use of narcotics with sedation post intubation (reduce level of sedatives, trauma considerations) Rocuronium is new to the protocol for prolonged paralysis (with Medical Direction) Review the need for Team coordination and having help when taking an airway Last year: 49 RSI attempts with an 80% first-pass success rate
- Process includes: Team coordination Pre-planning Staging equipment Having help Patient airway and ventilation is of the highest priority – Pre-oxygenate patient well prior to procedure Pre-medication considerations Medication selection and dose considerations Sedation (Ketamine) Induction agent (Succs) Intubation attempt ETT placement assessment Securing ETT and properly monitored ventilation (ETCo2) Post ETT medication (sedatives and long-term paralytic considerations) Regular assessment of airwaypatency, ETT placement and ventilation success Adequate and accurate documentation (BLS Captains doing intubations)
- H = Hypoxemia—Good BLS airway maneuvers are key. We tend to forget how important airway adjuncts are. If patients can take one NPA, they can take two. If they can take an OPA, they can take an NPA. Using these adjuncts helps provide more flow when we ventilate. Don’t forget about patient positioning! E = Extremes of size—Does the patient need to be ramped? Elevate the head of the bed so gravity doesn't work against you. Which equipment do you use, video or direct? What blade choice? A = Anatomic disruption/obstruction—What do you notice from your assessment? Has there been blunt or penetrating trauma? Previous intubations or surgeries with scar tissue? Radiation or tumors? Have a plan to mitigate these factors prior to pushing induction agents or paralytics. V = Vomit/blood/fluid—Employ SALAD (suction-aided laryngoscopy and decontamination). Have the right equipment on hand (such as a DuCanto suction catheter) and make sure it functions appropriately prior to use. E = Exsanguination—Do we need to control bleeding? Fluid-resuscitate? Increase blood pressure before giving medications that take away compensatory measures? Literature suggests the combination of a low EtC02 (less than 24 mmHg) and systolic BP of less than 80 mmHg means CPR will be needed within eight minutes. N = Neck mobility—Do you need to keep c-spine in line, or is there room for manipulation? Will being inline restrict your view, requiring a modified technique?
- 7 minutes from Failure to airway