Airway Tips and Tricks Your Patient Cant Live Without!

Eastern OR EMS Conference 2015

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!

BETTER POSITIONING

Tip #1:

Better Positioning

Elevate the trunk 20-30 degrees!

KEY POINT: Still put towels under shoulders for infants!

BETTER OXYGENATION

Tip #1:

What does Preoxygenation mean to you?

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

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%)

KEY POINT

• SPO2 >94 % WITHOUT Preoxygenation means NOTHING!

Why its important: “Safe Apnea”

What is Desaturation?

• Desaturation is defined as saturation below 88%

• Safe Apnea period

– Time to 90% AFTER preoxygenation

How quick can desaturation occur?

Between IMMEDIATELY and 8 minutes.

Who is at risk?

Introducing NO DESAT

NO DESAT (15 + LPM via NC)

+LPM

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 ChirScand. 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..

Can you not bag at all?

• Answer: “Depends”

• Considerations: – Obesity

– Shunt Physiology

– Shock

• What should you do?– Cautious Bagging

– CPAP?

– Bagging with PEEP Valve?

KEY POINT:

• This works best when you have excellent airway positioning!

BETTER FACE MASK SEAL

Tip # 3:

Better Face Mask Seal ?

At least 8 good full tidal volume breaths is “Ideal”

E-C Techniques

The “T-E” Technique

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

Nu MASK

• BLS difficult airway Device

• Cheap and easy

Using a Pedi Mask

Weyland-Yutani Face Mask

BETTER VENTILATION

Tip # 4

OPA + NPA x2

• Less Turbulant Flow

• Better Tidal Volume

• Estimated time to placement is 9-10 seconds.

The “Super Plug”

Monitor your airway pressures

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

BETTER NASAL INTUBATION

Tip # 4:

Nasal ETT

Tennessee Technique

Close up view

BETTER ORAL INTUBATION

Tip # 5:

Medics: Involve your BLS personnel

KIWI GRIP

Pistol Grip

• https://www.youtube.com/watch?v=O2OI7Yx7rHE

BETTER PLANNING

Tip #6:

Better Planning

Better Planning

EMCRIT.org CRICON

Better Planning

Checklists!

Checklists and CRM save lives

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

Closing

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