1	Airway Management: Part 2 Medic 1 Paramedic Education Program
2	Risks/Protective Measures Be prepared for: Coughing Spitting Vomiting Biting Body Substance Isolation Gloves Face, eye shields Respirator, if concern for airborne disease
3	ET Introduction Endotracheal Intubation Tube into trachea to provide ventilations using BVM or ventilator Sized based upon inside diameter (ID) in mm Lengths increase with increased ID (cm markings along length) Cuffed vs. Uncuffed
4	Endotracheal Intubation Advantages Secures airway Route for a few medications (LANE) Optimizes ventilation, oxygenation Allows suctioning of lower airway
5	Endotracheal Intubation Indications Present or impending respiratory failure Apnea Unable to protect own airway
6	Endotracheal Intubation These are NOT Indications Because I can intubate Because they are unresponsive Because I can’t show up at the hospital without it
7	Endotracheal Intubation Complications Soft tissue trauma/bleeding Dental injury Laryngeal edema Laryngospasm Vocal cord injury Barotrauma Hypoxia Aspiration Esophageal intubation Mainstem bronchus intubation
8	Endotracheal Intubation Insertion Techniques Orotracheal Intubation (Direct Laryngoscopy) Blind Nasotracheal Intubation Digital Intubation Retrograde Intubation Transillumination
9	Orotracheal Intubation Technique Position, ventilate patient Monitor patient ECG Pulse oximeter Assess patient’s airway for difficulty Assemble, check equipment (suction) Hyperventilate patient (30-120 sec)
10	ALS Airway/Ventilation Methods Orotracheal Intubation Position patient Open mouth Insert laryngoscope blade on right side Sweep tongue to left Identify anatomical landmarks Advance laryngoscope blade Vallecula for curved (Miller) blade Under epiglottis for straight (Miller) blade
11	ALS Airway/Ventilation Methods Orotracheal Intubation Elevate epiglottis Directly with straight (Miller) blade Indirectly with curved (Macintosh) blade Visualize vocal cords, glottic opening Enter mouth with tube from corner of mouth
12	ALS Airway/Ventilation Methods Orotracheal Intubation Advance tube into glottic opening about 1/2 inch past vocal cords Continue to hold tube, note location Ventilate, ausculate Epigastrium Left and right chest Inflate cuff until air leak around cuff stops Reassess tube placement
13	ALS Airway/Ventilation Methods Orotracheal Intubation Secure tube Reassess tube placement, ventilation effectiveness
14	Intubation
15	Intubation Death occurs from failure to Ventilate, not failure to Intubate
16	ALS Equipment Equipment Laryngoscope Handle (lighted) & Blades Stylet Syringe Magills Lubricant Suction BVM BAAM (Blind Nasal) Selection Typical Adult ET Tube Sizes Male - 8.0, 8.5 Female - 7.0, 7.5, 8.0 Blade Mac - 3 or 4 Miller - 3 Tube Depth Usually 20 - 22 cm at the teeth
17	ALS Equipment
18	ALS Equipment
19	ALS Equipment
20	Pediatric ET Intubation Pediatric Equipment Differences Uncuffed tube < 8 yoa Miller blade preferred Tube Size Premie: 2.0, 2.5 Newborn: 3.0, 3.5 1 year: 4 Then: (age/4)+4 Pediatric Differences Anatomic Differences Depth (cm) Tube ID x 3 12 + (age/2) easily dislodged Intubation vs BVM
21	Positioning Patient Positioning Goal Align 3 planes of view, so Vocal cords are most visible T - trachea P - Pharynx O - Oropharynx
22
23	Airway Assessment Cervical Spine Temporal Mandibular Joint A/O Joint Neck length, size and muscularity Mandibular size in relation to face Over bite Tongue size
24	Assessment Acronym M Mandible O Opening U Uvula T Teeth H Head S Silhouette
25	The Lemon Law L Look externally E Evaluate the 3-3-2 rule M Mallampati score O Obstruction? N Neck Mobility
26	Look Morbidly obese Facial hair Narrow face Overbite Trauma
27	Evaluate 3-3-2 Temporal Mandibular Joint Should allow 3 fingers between incisors 3-4 cm
28	Evaluate 3-3-2 Mandible 3 fingers between mentum & hyoid bone Less than three fingers Proportionately large tongue Obstructs visualization of glottic opening Greater than three fingers Elongates oral axis More difficult to align the three axis
29	Evaluate 3-3-2 Larynx Adult located C5,6 If higher, obstructive view of glottic opening Two fingers from floor of mouth to thyroid cartilage
30	Mallampati Score Evaluates ability to visualize glottic opening Patient seated with neck extended Open mouth as wide as possible Protrude tongue as far as possible Look at posterior pharynx Grade based on visual field Grades 1,2 have low intubation failure rates Grades 3,4 have higher intubation failure rates
31	Mallampati Score Not useful in emergent situations Informal version Use tongue blade to visualize pharynx
32
33	Mallampati Grades
34	Obstruction Know or suspected Foreign bodies Tumors Abscess Epiglottitis Hematoma Trauma
35	Neck Mobility Align axis to facilitate orotracheal intubation Decreased mobility from C-Spine immobilization Rheumatoid arthritis Quick Test Put chin on chest then move toward ceiling
36	Curved Blade (Macintosh) Insert from right to left Visualize anatomy Blade in vallecula Lift up and away DO NOT PRY ON TEETH Lift epiglottis indirectly
37	Straight Blade (Miller) Insert from right to left Visualize anatomy Blade past vallecula and over epiglottis Lift up and away DO NOT PRY ON TEETH Lift epiglottis directly
38	Glottic Opening
39	Tube Placement
40	Confirmation of Placement
41	"Placement of the ETT within..." Placement of the ETT within the esophagus is an accepted complication. However, failure to recognize and correct is not!
42	Traditional Methods Observation of ETT passing through vocal cords. Presence of breath sounds Absence of epigastric sounds Symmetric rise and fall of chest Condensation in ETT Chest Radiograph
43	"All of these methods have..." All of these methods have failed in the clinical setting
44	Additional Methods Pulse Oximetry Aspiration Techniques End Tidal CO₂
45	Confirming ETT Location Fail Safe Near Fail Safe Non-Fail Safe
46	Fail Safe Improvement in Clinical Signs ETT visualized between vocal cords Fiberoptic visualization of Cartilaginous rings Carina
47	Near Failsafe CO2 detection Rapid inflation of EDD
48	Non-Failsafe Presence of breath sounds Absence of epigastric sounds Absence of gastric distention Chest Rise and Fall Large Spontaneous Exhaled Tidal Volumes
49	Non Failsafe Condensation in tube disappearing and reappearing with respiration Air exiting tube with chest compression Bag Valve Mask having the appropriate compliance Pressure on suprasternal notch associated with pilot balloon pressure
50	ALS Airway/Ventilation Methods Blind Nasotracheal Intubation Position, oxygenate patient Monitor patient ECG monitor Pulse oximeter
51	ALS Airway/Ventilation Methods Blind Nasotracheal Intubation Assess for difficulty or contraindication Mid-face fractures Possible basilar skull fracture Evidence of nasal obstruction, septal deviation Assemble, check equipment Lubricate end of tube; do not warm Attach BAAM (if available)
52	ALS Airway/Ventilation Methods Blind Nasotracheal Intubation Position patient (preferably sitting upright) Insert tube into largest nare Advance slowly, but steadily Listen for sound of air movement in tube or whistle via BAAM Advance tube Assess placement Inflate cuff, reassess placement Secure, reassess placement
53	ALS Airway/Ventilation Methods Digital Intubation Blind technique Variable probability of success Using middle finger to locate epiglottis Lift epiglottis Slide lubricated tube along index finger Assess tube placement/depth as with orotracheal intubation
54	ALS Airway/Ventilation Methods
55	ALS Airway Ventilation Methods Surgical Cricothyrotomy Indications Absolute need for definitive airway, AND unable to perform ETT due for structural or anatomic reasons, AND risk of not securing airway is > than surgical airway risk OR Absolute need for definitive airway AND unable to clear an upper airway obstruction, AND multiple unsuccessful attempts at ETT, AND other methods of ventilation do not allow for effective ventilation, respiration
56	ALS Airway/Ventilation Methods Surgical Cricothyrotomy Contraindications (relative) No real demonstrated indication Risks > Benefits Age < 8 years (some say 10, some say 12) Evidence of fractured larynx or cricoid cartilage Evidence of tracheal transection
57	ALS Airway/Ventilation Methods Surgical Cricothyrotomy Tips Know anatomy Short incision, avoid inferior trachea Incise, do not saw Work quickly Nothing comes out until something else is in Have a plan Be prepared with backup plan
58	ALS Airway/Ventilation Methods Needle Cricothyrotomy/Transtracheal Jet Ventilation Indications Same as surgical cricothyrotomy with Contraindication for surgical cricothyrotomy Contraindications None when demonstrated need Caution with tracheal transection
59	ALS Airway/Ventilation Methods Jet Ventilation Usually requires high-pressure equipment Ventilate 1 sec then allow 3-5 sec pause Hypercarbia likely Temporary: 20-30 mins High risk for barotrauma
60	ALS Airway/ Ventilation Methods Alternative Airways Multi-Lumen Devices (CombiTube, PTLA) Laryngeal Mask Airway (LMA) Esophageal Obturator Airways (EOA, EGTA) Lighted Stylets
61	ALS Airway/ Ventilation Methods
62	ALS Airway/ Ventilation Methods
63	ALS Airway/ Ventilation Methods Combitube^® Indications Contraindications Height Gag reflex Ingestion of corrosive or volatile substances Hx of esophageal disease
64	ALS Airway/ Ventilation Methods Laryngeal Mask Airway (LMA) é use in OR Gaining use out-of-hospital Not useful with high airway pressure Not replacement for endotracheal tube Multiple models, sizes
65	LMA
66	ALS Airway/ Ventilation Methods
67	BLS & ALS Airway/ Ventilation Methods Esophageal Obturator Airway, Esophageal Gastric Tube Airway Used less frequently today Increased complication rate Significant contraindications Patient height Caustic ingestion Esophageal/liver disease Better alternative airways are now available
68	Esophageal Gastric Tube Airway (EGTA)
69	ALS Airway/ Ventilation Methods Lighted Stylette Not yet widely used Expensive Another method of visual feedback about placement in trachea
70	Lighted Slyest
71	ALS Airway/Ventilation Methods
72	Pharmacologic Assisted Intubation “RSI” Sedation Reduce anxiety Induce amnesia Depress gag reflex, spontaneous breathing Used for induction anxious, agitated patient Contraindications hypersensitivity hypotension
73	Pharmacologic Assisted Intubation “RSI” Common Medications for Sedation Benzodiazepines (diazepam, midazolam) Narcotics (fentanyl) Anesthesia Induction Agents Etomidate Ketamine Propofol (Diprivan®)
74	Pharmacologic Assisted Intubation Neuromuscular Blockade Temporary skeletal muscle paralysis Indications When intubation required in patient who: is awake, has gag reflex, or is agitated, combative
75	Pharmacologic Assisted Intubation Neuromuscular Blockade Contraindications Most are specific to medication Inability to ventilate once paralysis induced Advantages Enables provider to intubate patients who otherwise would be difficult, impossible to intubate Minimizes patient resistance to intubation Reduces risk of laryngospasm
76	Pharmacologic Assisted Intubation NMB Agent Mechanism of Action Acts at neuromuscular junction where ACh normally allows nerve impulse transmission Binds to nicotinic receptor sites on skeletal muscle Depolarizing or non-depolarizing Blocks further action by ACh at receptor sites Blocks further depolarization resulting in muscular paralysis
77	Pharmacologic Assisted Intubation Disadvantages/Potential Complications Does not provide sedation, amnesia Provider unable to intubate, ventilate after NMB Aspiration during procedure Difficult to detect motor seizure activity Side effects, adverse effects of specific drugs
78	Pharmacologic Assisted Intubation Common Used NMB Agents Depolarizing NMB agents succinylcholine (Anectine®) Non-depolarizing NMB agents vecuronium (Norcuron®) rocuronium (Zemuron®) pancuronium (Pavulon®)
79	Pharmacologic Assisted Intubation Summarized Procedure Prepare all equipment, medications while ventilating patient Hyperventilate Administer induction/sedation agents and pretreatment meds (e.g. lidocaine or atropine) Administer NMB agent Sellick maneuver Intubate per usual Continue NMB and sedation/analgesia prn
80	Pharmacologic Assisted Intubation Failure is not an option!
81	ALS Airway/Ventilation Methods Needle Thoracostomy Indications Positive signs/symptoms of tension pneumothorax Cardiac arrest with PEA or asystole with possible tension pneumothorax Contraindications Absence of indications
82	ALS Airway/Ventilation Methods Tension Pneumothorax Signs/Symptoms Severe respiratory distress ê or absent lung sounds (usually unilateral) é resistance to manual ventilation Cardiovascular collapse (shock) Asymmetric chest expansion Anxiety, restlessness or cyanosis (late) JVD or tracheal deviation (late)
83	ALS Airway/Ventilation Methods Needle Thoracostomy Prepare equipment Large bore angiocath Locate landmarks: 2nd intercostal space at midclavicular line Insert catheter through chest wall into pleural space over top of 3rd rib (blood vessels, nerves follow inferior rib margin) Withdraw needle, secure catheter like impaled object
84	ALS Airway/Ventilation Methods Chest Escharotomy Indications Presence of severe edema to soft tissue of thorax as with circumferential burns inability to maintain adequate tidal volume, chest expansion even with assisted ventilation Considerations Must rule out upper airway obstruction Rarely needed
85	ALS Airway/Ventilation Methods Chest Escharotomy Procedure Intubate if not already done Prepare site, equipment Vertical incision to anterior axillary line Horizontal incision only if necessary Cover, protect
86	Airway & Ventilation Methods LAB class Practice using equipment orotracheal intubation nasotracheal intubation gastric tube insertion surgical airways needle thoracostomy combitube retrograde intubation