“airway, airway – who’s got the airway?” issues and techniques in ems airway management...
TRANSCRIPT
“Airway, Airway –Who’s got the Airway?”
Issues and Techniques in EMS Airway Management
Silver Cross EMS SystemJanuary 2012 1st Trimester CME
Our Agenda Today
• Review airway anatomy and physiology• Review issues and techniques in airway
management• Review use of CPAP in CHF and pulmonary
edema for both ALS and BLS providers• EKG strip o’ the month: AV blocks/pacing
A & P Review
The abbreviated version!
Anatomy of the Upper Airway
Internal Anatomy of the Upper Airway
Anatomy of the Lower Airway
Anatomy of the Pediatric Airway
Three Cardinal Sins of Airway Management
1 - Failure to Ventilate
• Intubation still be considered the gold standard in prehospital airway security.
• But if you can’t intubate you must still ventilate.• Proper equipment size, good mask seal and proper
tidal volume is essential.
2 - Failure to Recognize an Esophageal Intubation and Correct It
• Always use multiple methods of confirming tube placement– Reconfirm each and every time you move the patient. – Document each confirmation on your PCR. – With as many confirmation devices we have, patients still delivered to
the ED with unrecognized esophageal tube placement.
3 - Being Unprepared for the Difficult Airway
• Have multiple back–up methods for establishing an airway and/or ventilating your patient.
– Reposition airway and re-bag– King Airway– Needle Cric
• Practice those methods, individually and in sequence.
Rule of Two’s
Rule of Twos
2 people One to ventilate, one to hold the mask
2 airways NPA + OPA
2 inches Head elevation to sniffing position
2 seconds Slow, gentle ventilation
2 PSI Minimal pressures
2
2
22
22
2
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2 People• Hardest part of BVM
ventilation is achieving adequate seal between the mask and the patient’s face.
• Much easier to achieve and maintaining seal using two person technique.
– One to ventilate, and one to hold the mask.
2 Airways
• Nasal and oral airways often forgotten in chaotic scene.• But these simple techniques can make a lifesaving difference. • An OPA and an NPA may be used together.
– Two NPAs can be used along with an OPA, if necessary.
• Imperative to make sure these devices are properly sized to each individual patient and inserted correctly.
Two inches • Sniffing position best way
to minimize airway resistance during BVM ventilation
• Also happens to be the best position to visualize larynx during intubation.
• Combination of forward flexion and extension of the neck achieved by elevating head at least two inches.
• Can assist with difficult intubations.
• Can be increased with additional padding, if needed.
• Obviously contraindicated in patient with suspected cervical spine injury.
Two seconds
• Deliver a slow, gentle ventilation over two seconds.
• Slower ventilations result in more air going into lungs than stomach.
• Also important to allow for sufficient time for exhalation.
2 PSI
• Two PSI not the actual pressure, but a useful reminder to minimize ventilation pressures.
• Assess for adequate ventilation by observing chest rise or appropriate lung sounds.
• In some patients, using one hand to squeeze the bag rather than two will help avoid over-pressured ventilations.
Basic Airway Maneuvers
Basic Airway Maneuvers
Head Tilt/Chin Lift
Head Tilt-Chin Lift
• Without suspected spinal injury• Unresponsive patient that can not protect
their own airway• Simple, safe and non-invasive• Does not protect from aspiration
Head Tilt -Chin Lift
• Method– Tilt head back with hand on patient’s forehead– Fingers of other hand under bony part of lower
jaw and lift chin forward– AHA standard for non-injury patient
Head-tilt chin-lift maneuver.
Jaw Thrust
Jaw-thrust Maneuver
• Used in the absence of suspected spinal injury– Provides additional forward displacement of the mandible
– Method• Grasp angle of lower jaw• Lift with both hands and displace mandible forward while tilting
the head back
Jaw-thrust maneuver.
Mechanical Adjuncts in Airway Management
ALWAYS BLS BEFORE ALS!
Oropharyngeal Airway
Oral Airway
• Hold tongue away from the posterior wall of the pharynx
• Unconscious, semi-conscious without a gag• Infant to adult sizes
• Measuring for placement– Place next to patient’s face so flange is a central incisors
and the bite block segment parallel to the hard palate
Oral Airway
• Insertion– Clear airway– Upside-down OR at 90-degree angle– Rotate until against posterior wall of oropharynx– Confirm placement: observe chest wall expansion with
ventilation and breath sounds auscultated
Too Long: airway obstruction by pressing on epiglottisToo Short: does not pull tongue away from the back of the
pharynx
Oral Airway
• Complications– Does not protect lower airway from aspiration– May stimulate vomiting and laryngospasm if gag
present– If not inserted properly, pushes tongue back and
causes airway obstruction
Measuring an oral airway.
Inserting an airway upside down.
Oropharyngeal Airway
Improper placement of oropharyngeal airway
Alternative method of inserting an oral airway.
Nasal airways.
Nasopharyngeal Airway
• Semiconscious or patient unable to maintain own airway
• Unconscious where oropharyngeal airway not used
• Seizures• C-spine Injury• Before nasotracheal intubation• Guide for inserting a nasogastric tube
Nasopharyngeal Airway
Measuring a nasal airway.
Nasal Airway
• Insertion– Lubricate with water-soluble lubricant– Bevel tip toward nasal septum (change position
for left vs right)– Use natural curvature of nasal passage– Should rest in posterior pharynx– Displace mandible
Insertion of a nasal airway.
Nasal Airway
• Disadvantages– Longer length may enter esophagus– Laryngospasm and vomiting– Injury to nasal mucosa, bleeding or obstruction– Small diameters can become obstructed with vomit, mucus– Does not protect lower airway from aspiration– Can’t suction through
• Advantages– Well tolerated in those with a gag reflex– Inserted rapidly– Used when oropharyngeal is contraindicated/facial trauma
Bag-Valve Mask DevicesBag-Valve Mask Devices
BVM Devices
• Self inflating and non-rebreathing valve• Used with BLS or ALS airway maintenance device• Use with apenic patient or diminished respiratory
effort• Provides blood/body fluid barrier• Assist patient’s with shallow respirations• Room air (21%) to 100% concentration• Sense of lung compliance
BVM Devices
• Difficult to master – tidal volume dependent on mask seal
• Complications– Inadequate tidal volume from poor technique, poor mask
seal, and gastric distention
BVM Devices
• Method– Rescuer at patient’s head– Clear airway– Head tilt- chin lift– BLS or ALS airway – Tight seal on mouth with E-C positioning– One and two rescuer options
BVM Devices
• Method/Technique– Observe for gastric distension, changes in bag
compliance, color changes, improvement in level of consciousness, air leak around mask
– Trauma patients require in-line BVM
Pediatric bag-valve-mask device.
Airway Obstruction
Most common airway obstruction is tongue and epiglottis.
• When unconscious patient lies on back, muscles in
jaw relax and jaw falls posteriorly. – Epiglottis flops over the glottic opening.
• You can move tongue and epiglottis out of airway with head tilt chin lift maneuver– Lifts hyoid bone and epiglottis.
The Tongue as an Airway Obstruction
Other Causes of Obstruction
• Anaphylaxis– Medications– Food– Bugs
Methods to Clear the Airway
Finger Sweep
Be careful when placing your fingers in someone’s mouth
Think about your safety first
A finger sweep is okay … as long as there is no chance the patient can close their mouth on your finger!
Visualization
Attempt to visualize an obstruction and remove
Magill Forceps
Using the Magills
Endotracheal Intubation
So, you think you may want to intubate..
Why Do We Do This?• Paramedics have been intubating since the 70’s.• We’ve been taught that maintaining an airway and ensuring adequate
oxygenation supersedes everything other than scene safety. • Currently some critics are revisit why we do this procedure
– In some instances it’s actually harming patients, and we know above all that our goal is “to do no harm”.
• Let’s look further at some of the issues.
The Problems
• Some questioning if paramedics can safely intubate• Some programs have data which shows successful
intubations as low as 50%– In Silver Cross, intubation success widely variable, ranges
between 25-100 percent in any given month.
• Data shows intubation may be harmful in head-injured patients (rise in ICP during procedure)
• Some children seem to do better with BLS airway interventions
The Cause Analysis
1. Poor initial training2. No or minimal OR experience3. “Fred the Head” training only4. Not enough field tubes to go around5. Inadequate continuing education
requirements
Intubation - The Last Word
• Paramedics must continue to intubate and can do it well
• Complacency can set in; don’t let it• Training, practice and medical control issues;
get involved• If we lose expertise in advanced airway
management, ALS can lose significant value
Consider….Endotracheal Intubation Indicators
• Respiratory or cardiac arrest.• Unconsciousness, absent gag reflex (“GCS <8, intubate”)• Risk of aspiration.• Obstruction due to foreign bodies, trauma,
burns, or anaphylaxis.• Respiratory arrest• Pneumothorax, hemothorax,
hemopneumothorax with respiratory difficulty.• Need for mechanical ventilation
Know….Complications of Endotracheal Intubation
• Equipment malfunction• Teeth breakage and soft tissue lacerations• Hypoxia• Esophageal intubation• Endobronchial intubation (right mainstem)• Tension pneumothorax
Recognize…Advantages of Endotracheal Intubation
• Isolates trachea and permits complete control of airway.
• Impedes gastric distention.• Eliminates need to maintain a mask seal.• Offers direct route for suctioning.• Permits administration of some medications.
– No longer give ETT meds in Region 8
Remember…Disadvantages of Endotracheal Intubation
• Requires training and experience.• Requires specialized equipment.• Requires direct visualization of vocal cords.• Bypasses upper airway’s functions
of warming, filtering, and humidifying the inhaled air.
So, you’re still determined to intubate, what next?
Conscious Sedation
Consider conscious sedation with an initial 2mg dose of versed.
Documentation should reflect individual doses of versed, NOT total dose.
Pre-ventilate patient.
Position Patient
*In most supine patients, sniffing position achieved by extension of head and elevation of the occiput. *Elevate the head until the ear is at the level of the sternum
Assemble and check equipment
What blade do you use?
Macintosh or Curved blade
The tip of the curved blade should be placed in the vallecula
Miller or Straight blade
The tip of the straight blade is designed to lift the epiglottis.
Special Needs Tip
*Soft tissue airway obstruction a threat for all patients, but bigger problem for obese patients. *Obesity increases the volume of upper airway soft tissue and subcutaneous fat. *It lacks the rigidity and turgor of other tissue and threatens the airway.
Documentation Tip
• Completely assess and document condition of mouth, lips, and teeth before and after all airway management procedures.
• Trauma to teeth and soft tissues often caused by rough airway technique– But they also may be present before you treat the patient. – If a patient has damaged teeth or soft tissue injuries
before treatment begins, be sure it is documented.
Insert laryngoscope.
Visualize larynx and insert the ETT.
Tip of blade is inserted into vallecula.
Use blade to lift epiglottis, directly Use blade to lift epiglottis, directly exposing vocal cords.exposing vocal cords.
View of vocal cords.
ET tube passing through vocal cords.
Positube may also be used to confirm placement
PosiTubePosiTube
Bulb-Syringe Detectors
• Operate under the principle that esophagus is collapsible tube
• Vacuum created in bulb after compressed (negative pressure) to syringe = ET tube in esophagus
• Bulb device easily refills with air = ET tube in trachea
Confirm placement with an ETCO2 detector.
Purple “poopy” = no CO2 detected (no perfusion)
Yellow “yay” = CO2 detected (good perfusion)
Secure tube.
When placement is confirmed and the cuff has been inflated, release cricoid pressure.
Secure ETT and apply a cervical collar.
Reconfirm ETT placement.
Recheck placement “often” and every time the patient is moved.
Documentation Tips
*Document number of attempts needed to complete the procedure.
*Document tube size and depth of insertion at the patient’s teeth or lip line.
*Also document how the tube was secured in place (for example, by tape or device).
Paramedic Safety Tip
*Accidental extubation can occur if BVM device pulls on the tube.
Pediatric Intubation
• Anatomical considerations– Upper airway small– Tongue disproportionately large– Large tongue makes procedure more difficult– Epiglottis narrower and longer, more difficult to control– Larynx more anterior and elevated making visualization
more difficult– Trachea more flexible and shorter– Tracheal rings less developed and collapse more easily
Complications from Intubation Procedures
• Vomiting and aspiration• Release of epinephrine/norepinephrine
– Hypertension– Cardiac rhythm disturbances
• Traumatic injury– Laceration to lips, tongue– Dental trauma– Tearing of tissue– Vocal cord injury
Complications in Intubation Procedures
• Vagal stimulation in children causing hypotension, bradycardia
• Increase in ICP• Intubation of esophagus (most common
error/problem)• Equipment malfunction
Colorimetric end-tidal COColorimetric end-tidal CO22 detector. detector.
Cricothyroidotomy
CricothyroidotomyIndications
• Upper airway obstruction which cannot be dislodged by back blows or direct larygoscopy and Magill forceps.
• Inability to insert an ETT past edema• Destructive facial injury precluding the use of
ALS upper airway adjuncts.
Anatomical Landmarksfor Cricothyroidotomy
Thyroid CartilageCricothyroid
Membrane
Cricoid Cartilage
Needle Cricothyrotomy
• Procedure– BSI– Ventilate– Check equipment
• 12-14 ga. Cannula• syringe• 3.0 mm pediatric ET tube adapter
– Locate cricothyroid membrane – Hyperextend head and neck
Needle Cricothryotomy
• Procedure– Prep area of insertion– Insert catheter at 45 degree angle into membrane (pop)– Aspirate with syringe (should get air if in trachea)– Withdraw needle– Attach 3.0 mm ET adapter– Ventilate and assess chest rise/lung sounds– Secure placement
Stabilize larynx and identify Stabilize larynx and identify cricothyroid membrane.cricothyroid membrane.
Locate/palpate Locate/palpate cricothyroid membranecricothyroid membrane.
Insert catheter & syringe downward Insert catheter & syringe downward through membrane toward carina.through membrane toward carina.
Insert large-bore catheter through Insert large-bore catheter through cricothyroid membrane.cricothyroid membrane.
Apply negative pressure to syringe; Apply negative pressure to syringe; air in syringe indicates air in syringe indicates needle is in trachea.needle is in trachea.
Cannula properly placedin trachea
Slide catheter off stylet into Slide catheter off stylet into larynx.larynx.
Remove syringe, stabilize catheter, connect Remove syringe, stabilize catheter, connect oxygen tubing to oxygen regulator.oxygen tubing to oxygen regulator.
Quicktrach
• More expensive than needle crichs, but really easy to use!
• Silver Cross EMS only allows the 4mm size, no pediatric Quicktrachs in this system.
Quicktrach
neck strap
syringe
stopper
hub of catheter
Picture courtesy Christ Medical Center
Quicktrach Procedure
• Patient supine with head slightly extended if no cervical spine trauma suspected
• Locate the cricothyroid membrane• Cleanse the overlying skin
Quicktrach Procedure cont’d• Puncture cricothyroid membrane at 90 degree angle• Aspirate air through syringe• Change the angle of insertion to 60 degrees• Slide catheter sheath forward to level of stopper• Remove stopper – may be a bit tight.• Advance plastic cannula while removing needle and
syringe
Quicktrach Procedure cont’d
• Ventilate the patient• Secure catheter in place using the strap provided• Confirm placement
– Auscultation, bilateral chest rise and fall
Chest Needle Decompression
• Used to decrease intrathoracic pressure caused by pneumothorax/hemothorax
• Increased pressure causes inadequate venous return and impaired cardiac output
• Definitive care is thoracostomy (chest tube)• Air is trapped in the pleural space
Needle Decompression
• Signs/symptoms– Agitation, diminishing level of consciousness (early)– Pale, ashen, cyanotic skin color (early)– Diminished/absent breath sounds on affected side– Difficulty in breathing– Tachycardia– Narrowing pulse pressures– Tracheal deviation (late)– Subcutaneous emphysema
Needle Decompression
• Life Threatening Emergency– Affected side lung compressed resulting in tidal
volume decrease– Trapped air compresses on unaffected lung and
mediastinum– Internal blood loss can occur– Pressure increases venous return
Needle Decompression
• Procedure– BSI– Ventilate – Check equipment
• 10-16 ga. Catheter need for decompression
Needle Decompression
• Identify and cleanse landmark– 2nd intercostal space, mid clavicular line– 4th intercostal space, mix axillary line
• Insert on the top of rib• Nerves, arteries and veins at bottom of rib
Needle Decompression
• Reassess patients respiratory status• Secure catheter
EMT-B Corner!CPAP
• Both BLS and ALS providers in Silver Cross EMSS now allowed to use CPAP– CHF/Pulmonary Edema per SMO.– Asthma and other respiratory issues with medical
control approval.
And now an Oscar-winning training film!
• Starring Erika Ball, RN, the newest member of our EMS office!
• She will show the most common disposable CPAP in the system.– New info for EMT-B’s, a refresher for
EMT-P’s.
• Turn up your computer speakers… film audio will come from speakers, not phone.
Now is your chance…
• Use the text box on the right to ask your CPAP questions.
• If you are watching the recording, or reading this Powerpoint online, contact the EMS office or your EMS coordinator with questions!
• If you wish to watch the film separately, a link will be posted to the website.
EKG Strip O’ the Month
• AV Blocks
Review - AV Junction
124
• AV Junction = AV Node and Bundle of His• Pacemaker cells located throughout AV
Junction
Review - Functions of AV Node
125
• Backup pacemaker for SA Node• Creates delay between atrial and ventricular
depolarizations• Physiologic block for rapid supraventricular
rhythms
Degrees of AV Blocks
126
• First Degree - Delay in conduction• Second Degree - Some impulses blocked• Third Degree - All impulses blocked
First Degree AV Block
127
• An abnormal slowing of AV Junction conduction
First Degree AV Block ECG Criteria
128
• Rate - Dependent on underlying rhythm– Interpretation must include underlying rhythm
• Rhythm - Dependent on underlying rhythm• P-Waves - Normal morphology with one P-
Wave for each QRS• PRI - > .20 seconds and constant• QRS - Dependent on underlying rhythm
First Degree AV Block Clinical Significance
129
• Not usually detrimental and often resolves when ischemia corrected
• Must consider entire patient
Second Degree AV Blocks
130
• Type I– Also called “Wenckebach”– Also called Mobitz I
• Type II– Also called Mobitz II
Second Degree AV Block, Type I
131
• Intermittent block in which AV conduction gradually slows until an impulse is blocked
• “Long, longer, longer, drop! Long, longer, longer, drop!”
Second Degree AV Block, Type I ECG Criteria
132
Rate - Atrial rate unaffected but ventricular rate is less than atrial rate
Rhythm - Atrial rhythm usually regular. Ventricular rhythm is irregular with more P-Waves than QRS Complexes.
P-Waves - Unaffected with more P-Waves than QRS Complexes
PRI - Progressively increases for consecutively conducted P-Waves until QRS Complex is dropped
QRS - Unaffected
Second Degree AV Block, Type I Etiology
133
• Often caused by increased parasympathetic tone or drug effect
• Can be caused by MI
Second Degree AV Block, Type I Clinical Significance
134
• Usually transient with good prognosis• Can reduce cardiac output due to bradycardia
Second Degree AV Block, Type II
135
• Intermittent block in which not all P-Waves are conducted to ventricles but there is no progressive prolongation of PRI
• “Extra” p-waves.
Second Degree AV Block, Type II Etiology
136
• Usually due to MI or other organic heart disease
• Rarely the result of increased parasympathetic tone or drug effect
Second Degree AV Block, Type II Clinical Significance
137
• Poorer prognosis than Type I• Usually requires pacemaker• Frequently develops into Complete Block
Second Degree AV Block, Type II ECG Criteria
138
Rate - Atrial rate is unaffected but ventricular rate is less than atrial
Rhythm - Atrial rhythm regular, Ventricular irregular with more P-waves than QRS Complexes
P-Waves - Normal morphology with more P-Waves than QRS Complexes
PRI - Constant for consecutively conducted P-Waves
QRS - Usually wide but may be narrow if block is at His level or above
Second Degree AV Block, Type II Example
139
Third Degree AV Block
140
• Complete blockage of impulse conduction through AV Junction
• Results in “AV dissociation” (very very bad thing)
• P’s and QRS’s “march to their own drummer”
AV Dissociation
141
• No relationship between P-waves and QRS complexes
Third Degree AV Block Etiology
142
• MI• Increased parasympathetic tone• Drug toxicity
Third Degree AV Block ECG Criteria
143
• Rate - Atrial > 60, Ventricular based on escape• Rhythm - Atrial and ventricular regular• P-Waves - Normal• PRI - No association between P-Waves and
QRS complexes (P’s and QRS’s are divorced and do their own thing)
• QRS - Narrow if intranodal, Wide if infranodal
Transcutaneous Pacing (TCP)
144
• Non-invasive electrical therapy for symptomatic bradycardias/complete heart blocks
• Fast to set up• Reasonably reliable
TCP Equipment
145
• Give the patient Versed if they are awake, per SMO
• Set milliamps (adjustable 0-200mA typical)– Start low if they are awake, and high if they are
out.
• Set rate to 70.• Similar controls across brands
• Be familiar with your equipment!
Typical TCP Controls
146
Assess Electrical and Mechanical Capture
147
• Electrical– Displayed on monitor
• Mechanical– Pulse
Questions?
• Recording of this session will be sent out shortly.
• Please feel free to type questions in the text box to the right before we sign off.
• Or email questions to [email protected]• Thank you!