advanced airway management - shenandoah county · 2011-10-13 · chapter 37 advanced airway limmer...
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CHAPTER 37
Advanced Airway
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Airway Management
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Airway AnatomyAirway Anatomyandand
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Physiology ReviewPhysiology Review
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RespiratoryRespiratorySystem: System: The Airway The Airway
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The Airway The Airway
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Respiratory System (Supine)Respiratory System (Supine)
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Functioning brainstem
Open airway
Physiology: Factors of Adequate Breathing
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Intact chest wall
Alveolar gas exchange
Changes in any of these may
result in inadequate breathing!
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Adequate Breathing:Normal Breath Rates
Adults 12-20/min
Children 15-30/min
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Children 15-30/min
Infants 25-50/min
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Adequate Breathing
Rhythm Usually regular
Quality Breath sounds audible with stethoscope
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Minimal effort
Depth Chest expands normally
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Signs of Inadequate Breathing
Rate Outside normal range (too fast or slow)
Rhythm Irregular pattern
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Rhythm Irregular pattern
Depth Chest expansion shallow
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Signs of Inadequate Breathing
Quality Abnormal breath sounds
(unequal, diminished, or
absent)
Chest expansion unequal
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Chest expansion unequal
Increased breathing effort
Use of accessory muscles
Inability to speak full
sentences
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Signs of Inadequate Breathing
Skin Pale, cyanotic, cool, or clammy
Retractions Above clavicles,
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Retractions Above clavicles, between/below ribs
Agonal Respirations
Just before respiratory arrest
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Airway Differences between Adults and Airway Differences between Adults and ChildrenChildren
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Differences between theAirways of Children & Adults
Mouth and nose smaller
Tongue is proportionally larger
Trachea is softer & narrow
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Trachea is softer & narrow
Cricoid cartilage is narrowest
opening
Diaphragm performs most work
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Slow heart rates
Weak/absent peripheral pulse
Signs of Inadequate BreathingIn Infants and Children
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Retractions
Nasal flaring
“Seesaw” breathing
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Suctioning
Always be prepared for the need
to suction the patient’s airway
as needed.
Have suction equipment ready
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Have suction equipment ready
for use!
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Advanced AirwayAdvanced AirwayManagementManagement
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ManagementManagement
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Orotracheal Intubation
Advantages Complete control of
the airway
Allows direct
ventilation of the lungs
Minimizes risk of
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Minimizes risk of
aspiration
Better oxygen delivery
Allows deep suctioning
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Orotracheal Intubation
Complications Stimulation of airway
can cause bradycardia
Trauma to lips, teeth,
tongue, gums, airway
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tongue, gums, airway
structures
Continued…
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Orotracheal Intubation
Hypoxia from
prolonged attempts
Right mainstem
intubation
Complications
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intubation
Continued…
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Orotracheal Intubation
Esophageal intubation
Vomiting
Complications
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Vomiting
Self-extubation
Movement of tube out of
trachea when patient
moves
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Equipment: Body Substance IsolationEquipment: Body Substance Isolation
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Orotracheal Intubation
Laryngoscope handle
Laryngoscope blades
Assorted sizes (0-4)
Curved or straight
Equipment
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Curved or straight
Straight preferred for
infants/children
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Laryngoscope BladesLaryngoscope Blades
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Assembly of Laryngoscope HandleAssembly of Laryngoscope Handleand Bladeand Blade
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Assembly of Assembly of Laryngoscope Laryngoscope HandleHandleand Bladeand Blade
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Straight blade brings vocal cords intoStraight blade brings vocal cords intoview by lifting the epiglottis.view by lifting the epiglottis.
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Curved blade brings vocal cords into viewCurved blade brings vocal cords into viewby lifting vallecula and indirectlyby lifting vallecula and indirectlylifting epiglottis.lifting epiglottis.
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Endotracheal Tubes
Range in size (inner diameter) from
2.0 (smallest) to 10.0 (largest)
Have a standard 15mm bag valve
connection
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connection
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Endotracheal Tubes
Adult Female: 7.0-8.0 mm
Adult Male: 8.0-8.5 mm
Average Sizes (inner diameter)
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Adult Male: 8.0-8.5 mm
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Endotracheal TubeEndotracheal Tube
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Endotracheal Tubes
Emergency Rule:
7.5 fits most adults.
Have available one size larger
and one size smaller.
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and one size smaller.
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Endotracheal IntubationUseful Dimensions
Teeth to vocal cords: 15 cm
Teeth to suprasternal notch: 20 cm
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Teeth to carina: 25 cm
Teeth to tip: 22 cm
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Endotracheal Intubation
Provides stiffness/shape.
Lubricant may ease removal.
Use to shape tube like hockey
stick.
Stylet
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stick.
Do not let stylet go past the
proximal end of the Murphy eye.
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Stylet Stylet
Stylet in PlaceStylet in Place
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Water-soluble lubricant
10 cc syringe
Securing devices
Other
Equipment
Endotracheal Intubation
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Suction unit
Towels
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Endotracheal Intubation
Inability to ventilate
apneic patient
Protect airway when
no cough or gag
reflex
Indications
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reflex
Protect airway of
patient unresponsive
to painful stimuli
Cardiac arrest
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Ensure proper ventilation of the patient.Ensure proper ventilation of the patient.
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Assemble, prepare, and test equipment.Assemble, prepare, and test equipment.
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Position patient’s head.Position patient’s head.
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If trauma is suspected, have a rescuer
hold the head in a neutral position.
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Insert laryngoscope blade into mouth,Insert laryngoscope blade into mouth,avoiding contact with teeth.avoiding contact with teeth.
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Lift tongue up Lift tongue up and sweep to and sweep to the left.the left.
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Lift mandible; do not use a fulcrum motion.Lift mandible; do not use a fulcrum motion.
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Have rescuer apply Sellick’s maneuverHave rescuer apply Sellick’s maneuver(bring vocal cords into view).
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Visualize glottic opening between vocal Visualize glottic opening between vocal cords.cords.
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Gently insert ET tube Gently insert ET tube (with stylet in place)until cuff passes between vocal cords.until cuff passes between vocal cords.
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Make sure airway structures are aligned.Make sure airway structures are aligned.
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Remove laryngoscope and stylet withoutRemove laryngoscope and stylet withoutmoving tube. Inflate cuff with 5moving tube. Inflate cuff with 5--10 cc of air.10 cc of air.
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Attach bagAttach bag--valve resuscitator and ventilate. valve resuscitator and ventilate. Observe rise of chest.Observe rise of chest.
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Confirm placement by auscultatingConfirm placement by auscultatingepigastrium and lungs.epigastrium and lungs.
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Visualize tube passing through
vocal cords.
Observe chest rise and fall.
Confirm Correct Tube Placement
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Observe chest rise and fall.
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Observe for signs of deterioration,
such as cyanosis.
As protocols direct, use pulse
Confirm Correct Tube Placement
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
As protocols direct, use pulse
oximeter or CO2 detector.
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If correct placement is confirmed, secure tube and continue to ventilate.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Incorrect Tube Placement
If breath sounds present only on right:
Deflate cuff.
Ventilate, and while auscultating
over lungs,
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
over lungs,
Withdraw tube slightly until breath
sounds are equal.
Secure tube and ventilate.
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If sounds present only in epigastrium:
Deflate cuff.
Remove tube.
Incorrect Tube Placement
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilate for at least 1 minute.
Reattempt intubation.
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Tube Placement
Reassess breath sounds after every
major move:
From scene to ambulance
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
From ambulance to hospital
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Sellick’s ManeuverSellick’s Maneuver(Cricoid Pressure)
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
(Cricoid Pressure)
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Sellick’s Maneuver
Purpose
To help prevent regurgitation and
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
To help prevent regurgitation and
aspiration during endotracheal
intubation
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Cricoid Cartilage
Key Term
Surrounds entire trachea; it is
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Surrounds entire trachea; it is
inferior to cricothyroid membrane
(depression below thyroid
cartilage or Adam’s apple).
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Location of Location of Cricoid Cricoid CartilageCartilage
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Perform Sellick’s maneuver by exertingPerform Sellick’s maneuver by exertingposterior pressure on cricoid cartilage.posterior pressure on cricoid cartilage.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Sellick’s Maneuver
Verify correct position to avoid
damaging other structures.
Cricoid more difficult to find in
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
infants/children.
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Infant and ChildInfant and ChildIntubationIntubation
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
IntubationIntubation
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Smaller mouth and nose
Tongue larger proportionally
Anatomic and PhysiologicConsiderations
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Tongue larger proportionally
Floppier epiglottis
Smaller glottic opening
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Anatomic and PhysiologicConsiderations
Harder to see vocal cords
Narrower trachea
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Less rigid cricoid cartilage
Increased reliance on diaphragm
for breathing
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Child and Adult AirwaysChild and Adult Airways
Cricoid Cartilage
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Infant and Child IntubationSpecial Considerations
Since cricoid ring narrowest part of
child’s airway:
Pediatric tube has no cuff
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Pediatric tube has no cuff
Tube size depends on size of cricoid
ring
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Most effective means of controlling
airway.
In apneic patients, it also allows
Infant and Child IntubationPurpose
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
In apneic patients, it also allows
deeper suctioning.
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Prolonged artificial
ventilation required
Inability to ventilate
by other means
Indications
Infant and Child Intubation
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
by other means
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Indications
Infant and Child Intubation
Apnea
Cardiac arrest
Unresponsive with
no cough or gag
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
no cough or gag
reflex
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Prevents gastric distention
Minimizes risk of aspiration
Advantages
Infant and Child Intubation
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Minimizes risk of aspiration
Permits suctioning of airway
secretions
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Infant and Child Intubation
Bag-valve mask with mask of
correct size
Equipment
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
correct size
Laryngoscope handle &
blades
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Infant and Child IntubationEquipment – Laryngoscope Blades
Straight blade allows:
Greater displacement of
tongue
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
tongue
Better visualization of glottis
(preferred in infants)
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Curved blade
Inserted into vallecula to allow
visualization of glottis, cords
Infant and Child IntubationEquipment – Laryngoscope Blades
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
visualization of glottis, cords
Preferred in older children
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Consult chart or tape.
In general, use:
3.0-3.5 for newborns,
Tube Size
Infant and Child Intubation
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
3.0-3.5 for newborns,
small infants
4.0 up to 1 year old
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Infant and Child Intubation
TUBE SIZE FORMULA
16 + Age (years)
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
16 + Age (years)
4
= Tube Size (mm)
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Infant and Child Intubation
Alternative tube size selection
Use tube same size as little finger
or that will fit nostril.
Have tubes one size larger and
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Have tubes one size larger and
smaller available.
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Use UNCUFFED tubes for
children up to 8 years old
(narrowing of cricoid acts as
a cuff).
ET Tubes
Infant and Child Intubation
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
a cuff).
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Uncuffed ET Tube for Child UnderUncuffed ET Tube for Child Under8 Years Old8 Years Old
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Infant and Child Intubation
Use CUFFED tubes for
children older than 8 years.
Tube should have marker
for vocal cords, to assure
ET Tubes
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
for vocal cords, to assure
proper insertion depth.
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Pediatric ET Tube Distances
Age Depth
0.5-1 year 12 cm
2 years 14 cm
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Measured from teeth to mid-trachea
4-6 years 16 cm
6-10 years 18 cm
10-12 years 20 cm
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Pediatric stylet
Water-soluble lubricant
10 cc syringe
Equipment
Endotracheal Intubation
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
10 cc syringe
Securing devices
Suction unit
Towels
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Infant and Child IntubationTechniques
Ventilate appropriately.
Assemble and test
equipment.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
equipment.
Take BSI precautions.
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Monitor heart rate throughout.
Stimulating airway may slow heart
rate. If this happens, stop and
Infant and Child IntubationTechniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
rate. If this happens, stop and
ventilate.
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Place head in “sniffing” position.Place head in “sniffing” position.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
If trauma is suspected, have rescuer
hold head in neutral position.
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Insert laryngoscope blade into
right corner of mouth.
Infant and Child IntubationTechniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Sweep tongue out of way.
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Insert end of blade into
position.
Infant and Child IntubationTechniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Lift mandible.
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Consider using Sellick’s maneuver.
Visualize glottic opening and vocal
cords.
Infant and Child IntubationTechniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
cords.
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Gently insert tube until glottic
marker (if present) is at level of
vocal cords.
Infant and Child IntubationTechniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
vocal cords.
If using cuffed tube, insert cuff
beyond vocal cords.
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Holding tube, remove
laryngoscope blade and stylet.
Infant and Child IntubationTechniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Attach bag-valve and ventilate.
Confirm correct placement.
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Observe chest rise and fall.
Auscultate lung sounds.
Infant and Child IntubationConfirming Placement
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Auscultate epigastrium for
absence of sounds.
Assess for improving skin color &
heart rate.
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If correct placement confirmed,
secure tube and continue to
ventilate.
Infant and Child IntubationConfirming Placement
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
ventilate.
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Ventilate patient at a rate
appropriate for age.
Note tube's depth of insertion.
Infant and Child IntubationTechniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Note tube's depth of insertion.
May insert oral airway as a bite
block.
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Incorrect Tube Placement
If breath sounds present only on right:
Deflate cuff (if used).
Ventilate, and while auscultating
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
over lung, withdraw tube slightly
until breath sounds are equal.
Secure tube and ventilate.
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Incorrect Tube Placement
If sounds present only in epigastrium:
Deflate cuff (if used).
Remove tube.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilate for at least 1 minute.
Reattempt intubation.
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Once tube is secured, secure head
to prevent movement that can
dislodge tube.
Infant and Child IntubationTechniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
dislodge tube.
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Reassess breath sounds after every
major move:
Scene to ambulance
Infant and Child IntubationTechniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Scene to ambulance
Ambulance to hospital
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If tube in proper place, but inadequate
lung expansion:
Tube may be too small.
Infant and Child IntubationComplications
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Tube may be too small.
Auscultate neck.
Replace with larger tube.
Consider cuffed tube if child is older
than 8 years old.
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If tube is in proper place, but
inadequate lung expansion:
Check if pop-off valve on bag-valve
Infant and Child IntubationComplications
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Check if pop-off valve on bag-valve
device is activated.
Check for a leak in bag-valve device.
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If tube in proper place, but inadequate
lung expansion:
Possible inadequate compression
Infant and Child IntubationComplications
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Possible inadequate compression
of bag.
Check for tube blocked with
secretions.
Continued…
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Suction endotracheally;
Replace tube.
Infant and Child IntubationComplications
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Replace tube.
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Nasogastric TubesNasogastric Tubes
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Nasogastric Tubes
Indications Inability to ventilate
infant/child because
of gastric distention
Unresponsive infant/
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Unresponsive infant/
child with gastric
distention
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Reasons for
Use:
Nasogastric Tubes
Decompress stomach
Gastric lavage
Administration of
medications/nutrition
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
medications/nutrition
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Contraindications
Nasogastric Tubes
Presence of major
face, head, or
spine trauma.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
spine trauma.
Use orogastric
technique instead.
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Complications
Nasogastric Tubes
Tracheal intubation
Nasal trauma
Emesis
Passage into cranium
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Passage into cranium
through basilar skull
fracture
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Newborn/Infant 8.0 French
Toddler/Preschool 10.0 French
Tube Sizes
Nasogastric Tubes
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Toddler/Preschool 10.0 French
School-age 12.0 French
Adolescent 14-16 French
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Equipment
Nasogastric Tubes
20 cc syringe
Water-soluble lubricant
Emesis basin
Tape, stethoscope
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Tape, stethoscope
Suction unit and catheters
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Nasogastric Intubation Nasogastric Intubation –– Infant/Child:Infant/Child:
Use BSI; oxygenate patient; prepare and assemble equipment.
Limmer et al., Emergency Care Update, 10th Edition
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Measure tube from tip of nose, around Measure tube from tip of nose, around ear, to below xiphoid process.ear, to below xiphoid process.
Limmer et al., Emergency Care Update, 10th Edition
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Pass lubricated tube downward alongPass lubricated tube downward alongnasal floor into stomach.nasal floor into stomach.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Confirm placement as you inject 10Confirm placement as you inject 10--20 cc 20 cc air. Listen for bubbling.air. Listen for bubbling.
Limmer et al., Emergency Care Update, 10th Edition
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Aspirate stomach contents.Aspirate stomach contents.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Secure tube in place.Secure tube in place.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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OrotrachealOrotrachealSuctioningSuctioning
“Deep Tracheal“Deep Tracheal
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“Deep Tracheal“Deep Tracheal
Suctioning”Suctioning”
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Indications:
Orotracheal Suctioning
Obvious secretions
in endotracheal tube
Poor compliance
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Poor compliance
with bag valve
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Complications
Orotracheal Suctioning
Hypoxia
Cardiac dysrhythmias
Trauma to airway
Bronchospasm
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Bronchospasm
Laryngospasm
Coughing
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Preoxygenate and hyperventilate patient.Preoxygenate and hyperventilate patient.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Carefully checkCarefully checkequipment. Use BSI.equipment. Use BSI.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Approximate depth of insertion by Approximate depth of insertion by
measuring the suction catheter measuring the suction catheter
from lips, to the ear, to the nipple from lips, to the ear, to the nipple
line.line.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
line.line.
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Insert catheter without suction.Insert catheter without suction.
Use sterile technique.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Advance catheter no farther than carina.Advance catheter no farther than carina.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Apply suction (no more than 15 seconds)Apply suction (no more than 15 seconds)and withdraw catheter in a twisting motion.and withdraw catheter in a twisting motion.Resume ventilations.Resume ventilations.
Limmer et al., Emergency Care Update, 10th Edition
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CombitubesCombitubes®®
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A Dual Lumen AirwayA Dual Lumen Airway
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Indication
Combitubes®
Unconscious patient
in need of airway
management
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Contraindications:
Conscious patient
Patient with gag reflex
Combitubes®
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Under 5 feet tall
Under 16 years old
Ingestion of caustic substance
Known esophageal disease
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Take BSI precautions.
Ventilate with bag-valve mask.
Combitubes®
Insertion Techniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Prepare and check equipment.
Have suction readily available.
If patient becomes conscious, at
any time, remove the tube!
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Lubricate the CombitubeLubricate the Combitube®
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Insert device blindly along center
of the mouth.
Advance device until the teeth are
Combitube®
Insertion Techniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Advance device until the teeth are
centered between the black rings
on the Combitube®.
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Insert the CombitubeInsert the Combitube®..
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Inflate valve #1 cuff with 100 cc of air.
Inflate valve #2 cuff with 15 cc of air.
Combitubes®
Insertion Techniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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CombitubeCombitube® in place with cuffs inflated.in place with cuffs inflated.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Ventilate through Ventilate through tube #1 (blue tube #1 (blue tube).tube).
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Auscultate for lung sounds and
the absence of epigastric
sounds.
Combitubes ®
Insertion Techniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
sounds.
If lung sounds are present and no
epigastric sounds are heard,
continue ventilating through the
blue tube (tube #1).
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If no lung sounds are present and epigastric sounds are heard, ventilate through the shorter tube (tube #2).
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Laryngeal Mask AirwayLaryngeal Mask Airway(LMA)(LMA)
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(LMA)(LMA)
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A Laryngeal A Laryngeal Mask AirwayMask Airway
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Take BSI precautions.
Ventilate with bag-valve mask.
Prepare and check equipment.
Laryngeal Mask AirwayInsertion Techniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Prepare and check equipment.
Have suction readily available.
Place patient in a sniffing
position.
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Lubricate the posterior side of
cuff.
Insert tube with open side
Laryngeal Mask AirwayInsertion Techniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Insert tube with open side
facing anteriorly.
Stop when resistance is felt.
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Inserting the LMAInserting the LMA
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Inflate cuff with air based on size of
LMA.
Ventilate through the tube.
Laryngeal Mask AirwayInsertion Techniques
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilate through the tube.
Auscultate for lung sounds and the
absence of epigastric sounds.
Insert an oral airway as a bite block.
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Automatic Transport Automatic Transport Ventilators (ATVs)Ventilators (ATVs)
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An Automatic Transport VentilatorAn Automatic Transport Ventilator
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Protocols may allow use in place of
bag-valve mask.
Controls set rate of ventilations and
Automatic TransportVentilators
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Controls set rate of ventilations and
weight-based tidal volume.
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1. Explain the differences between
orotracheal and oropharyngeal
suctioning.
2. Explain why nasogastric tubes are
Review Questions
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
2. Explain why nasogastric tubes are
used in an infant or child.
3. Explain the purpose of Sellick’s
maneuver.
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4. Explain the purpose of orotracheal
intubation and the complications
that can arise during intubation.
5. Explain the procedures for assuring
Review Questions
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
5. Explain the procedures for assuring
correct placement of an
endotracheal tube.
6. Describe the differences between
child and adult airways.
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What priority would you assign the
patient?
STREET SCENESSTREET SCENES
Limmer et al., Emergency Care Update, 10th Edition
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patient?
What definitive treatment do
pulseless patients require?
What alternatives for managing the
airway might you consider?
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What assessment procedures
STREET SCENESSTREET SCENES
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
What assessment procedures
should be performed at this time?
How often should this patient be
reassessed?
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Sample DocumentationSample Documentation
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ