Intubation and Advanced Airway CCTC 2007

Intubation & Advanced Airway Management : 

Intubation & Advanced Airway Management Captain Marc West, CCEMT-P, AAS January, 2007

Mission Statement of the United States Coast Guard : 

Mission Statement of the United States Coast Guard We protect life and property at sea, enforce federal laws and treaties, preserve marine natural resources, and promote national security interests.

Mission Statement of the Critical Care Paramedic : 

Mission Statement of the Critical Care Paramedic We protect the airway and ensure adequate respirations, maintain hemodynamic stability and body systems homeostasis, to ensure adequate pain management to all patients we transport and we are patient advocates during their time in our charge.

Slide 6: 

Where’s our video….?

Slide 7: 

The ability to breathe and the ability to protect the airway are not always the same. Important point to understand:

Slide 8: 

Protecting the patients airway is the single most important objective and treatment skill set a paramedic should be proficient at. For without it, any other medical interventions are worthless and a waste of time.

DEFINITIONS : 

DEFINITIONS Hypoxemia Reduction of O2 in arterial blood Hypoxia Insufficient O2 available to meet O2 requirements Hypercarbia Increased level of CO@ in blood

Objectives for Airway Assessment : 

Objectives for Airway Assessment Rapidly assess the patients need for intubation and the urgency of the situation Determine the best method of airway management, given the circumstances Deciding on which pharmacological agents to use Managing the airway in the context of the patients overall condition Airway devices to achieve definitive airway and minimize hypoxia and hypercarbia Having a “PLAN B” and being ready to use it

AHA 2005 recommendations : 

AHA 2005 recommendations Lower tidal volume (6-7ml/Kg or 500-600 ml over 1 second) 8 to 10 breaths per minute MAX No pauses for breaths during CPR ETT only by skilled, no > 10sec Confirmation of ETT placement 6-18% misplaced ETT prehospital 0

Corollary Number One : 

Corollary Number One The paramedic is responsibly for airway management in the field and during transport.

ASSESSMENT : 

ASSESSMENT BSI/ scene safety General impression Identify and correct any life threatening conditions: Responsiveness/ c-spine Airway Breathing Circulation

ASSESSMENT : 

ASSESSMENT Primary Survey- quick crude Airway Breathing Circulation Secondary Survey- slower & refined

Assessment : 

Assessment POSITION Tripod Bolt upright COPD CHF Able to speak in sentences

ASSESSMENT : 

ASSESSMENT Adequacy of breathing Expose the chest Patients demeanor Blockages Mild Severe or complete Concerns that set off our alarms

ASSESSMENT : 

ASSESSMENT Adequacy of breathing Expose the chest Patients demeanor Blockages Mild Severe or complete Concerns that set off our alarms

AIRWAY : 

AIRWAY Is it patent? Snoring, gurgling or stridor may indicate potential problems Secretions, objects, blood, vomitus present Neck JVD (jugular vein distention) TD (tracheal deviation, tugging)

Corollary Number Two : 

Corollary Number Two Any patient that requires the establishment of an airway also requires protection of that airway.

BREATHING : 

BREATHING Adequacy? Rate and quality? Spontaneous & regular effortless Chest rise Equal and present: excursion Deformity/ crepitus Ecchymosis Subcutaneous emphysema Paradoxical (asymmetric) Flail chest

BREATHING EFFORT : 

BREATHING EFFORT Normal Labored/ dyspnic Tachypnic/ bradypnea Accessory muscle use Intercostal retractions Suprasternal Abdominal muscle use Pediatrics Grunting Nostril flaring

BREATH SOUNDS : 

BREATH SOUNDS CTA bilat Diminished Rhonci Rales Wheezing

Modified Forms of Respiration : 

Modified Forms of Respiration Reflexes which act to protect the respiratory system: Cough- forceful, spasmodic exhalation of a large volume of air Sneeze- sudden forceful exhalation from the nose Hiccough- sudden inspiration caused by spasmodic contraction of the diaphragm & glottic closure Gag reflex- spastic pharyngeal & esophageal reflex caused by stimulation of posterior pharynx Sighing- hyperinflation of lungs, opens atelectic alveoli

RESPIRATORY PATTERNS : 

RESPIRATORY PATTERNS Cheyne –Stokes Regular pattern of increasing rate & volume followed by gradual decrease and a short period of apnea Brain stem insult Kussmaul’s Deep, gasping regular respirations Diabetic coma

Slide 25: 

Biot’s Irregular rate & volume with intermittent periods of apnea Increased ICP Central Neurogenic Hyperventilation Regular, deep and rapid Increased ICP Agonal Slow, shallow, irregular Brain hypoxia RESPIRATORY PATTERNS

PULSUS PARADOXUS : 

PULSUS PARADOXUS Decrease in systolic BP > 10 mm HG during inspiration Caused by increase in intrathoracic pressure COPD Interference with ventricular filling Results in decreased BP

Corollary Number Three : 

Corollary Number Three The “gag reflex” does not correlate well with airway protection and is of NO CLINICAL VALUE when assessing the need for intubation.

Corollary Number Three : 

Corollary Number Three The “gag reflex” does not correlate well with airway protection and is of NO CLINICAL VALUE when assessing the need for intubation.

Advanced Airway Management : 

Advanced Airway Management Manual airway control Ventilation Oxygenation …Proceed to advanced management Allows for correction of: Profound hypoxia hypercarbia

Cortisol : 

Cortisol The principal glucocorticoid secreted by the adrenal cortex, in response to adrenocorticotropic hormone (ACTH). Sometimes referred to as the “stress hormone”. Marker of the extent of stress placed on the human body.

Cortisol : 

Cortisol Because one of our lower brain main functions is to protect our airway, the release of cortisol is a good marker for stress. (normal 7mcg – 28 mcg/dl) The only time cortisol levels exceed those during intubation is during a mid-sternotomy… think about it…..

Endotracheal Intubation : 

Endotracheal Intubation When ventilating an unresponsive patient through conventional methods cannot be achieved Protect the airway Prolonged artificial respiration required Patients with or likely to experience upper airway compromise Decreased tidal volume- bradypnea Airway obstruction

Advantages : 

Advantages Controls the airway Facilitates ventilation/ O2 pH issues (acidosis – alkalosis) Prevents gastric inflation Allows for direct suctioning Medication administration

Monitoring : 

Monitoring Pulse oximetry End tidal CO2 Quantitative capnography Qualitative Colormetric Purple to yellow

Disadvantages : 

Disadvantages Requires extensive and ongoing training for proficiency Requires specialized equipment Bypasses physiological function of upper airway Warm Filter Humidify

Complications with Intubated Patients : 

Complications with Intubated Patients Displacement Obstruction Pneumothorax Equipment failure Contraindicated in epiglottitis

Possible Occurring Complications : 

Possible Occurring Complications Bleeding Laryngeal swelling Laryngospasm Vocal cord damage Mucosal necrosis Barotrauma Dental trauma Laryngeal trauma Esophageal placement

Pathophysiology : 

Pathophysiology Increased interstitial fluid due to injury Pulmonary edema Destruction of alveoli ARDS Impaired gas exchange Hypoxemia Hypercarbia Increased mortality

Laryngoscope : 

Laryngoscope Move tongue and epiglottis Allows visualization of cords and glottis Miller- straight Lift epiglottis pediatrics Macintosh- curved Fits in valeculla More room for visualization Reduced trauma/ gag reflex

Endotracheal Tube : 

Endotracheal Tube 15mm universal adapter 2.5-9.0mm diameter 12-32cm length Male- 23cm 8.0-8.5mm (lets talk) Female- 21cm 7.5-8.0mm (lets talk) Balloon cuff Occludes tracheal lumen Pilot balloon magill forceps

Verify Placement : 

Verify Placement Esophageal intubation detector CO2 detector Auscultation EtCO2 Capnography 35-45mm Hg Hyperventilation in head injury with herniation 30-35mm HG

CAPNOGRAPHY- EtCO2 : 

CAPNOGRAPHY- EtCO2 Standard of care in hospital & during transport Immediate response to extubation Stand up in court to prove intubation Waveform indicative: Normal Obstructed airway- do you NEED a beta-2 agonist?

WAVEFORM : 

WAVEFORM Normal Acute upstroke- exhalation Acute down stroke- inhalation Straight across Shark fin- lower airway obstruction

ASPIRATION : 

ASPIRATION Partially dissolved food Protein dissolving enzymes Hydrochloric acid

Prevention : 

Prevention Cricoid pressure Suctioning Tonsil tip Whistle tip Positioning

Hazards of Suctioning : 

Hazards of Suctioning Cardiac dysrhythmias Increased BP/ HR Decreased BP/ HR Gag reflex “bucking on the tube” Cough Increased ICP Decreased CBF

Multilumen Airways : 

Multilumen Airways Combitube Pharyngotracheal Lumen Airway (COPA) King LT PAX GO2 Airway

Advantages : 

Advantages Blind insertion Facial seal is not necessary Can be placed in esophagus or trachea

Indications : 

Indications Over 4' tall. 4' - 5' 6" are considered small adult5' 6" + are considered adult B. Patients anatomy will accept CombiTube.C. If you are unsuccessful at TWO intubation attempts, use the CombiTube.

Contraindications : 

Contraindications Ingestion of caustic substances Esophageal disease Presence of gag reflex

Corollary Number Four : 

Corollary Number Four Acute, progressive anatomical airway distortion is a potential time bomb. Intubate early, before deterioration occurs.

Corollary Number Five : 

Corollary Number Five If the patient is leaving the relative safe confines of the ED, intubate early before deterioration and airway compromise occur

Corollary Number Six : 

Corollary Number Six Arterial blood gas values are rarely helpful in the decision to intubate and may lead to faulty decision making.

AHA 2005 recommendations : 

AHA 2005 recommendations Lower tidal volume (6-7ml/Kg or 500-600 ml over 1 second) 8 to 10 breaths per minute MAX No pauses for breaths during CPR ETT only by skilled, no > 10sec Confirmation of ETT placement 6-18% misplaced ETT prehospital 0

Special Airway Management Techniques : 

Special Airway Management Techniques BURP Digital Intubation NasoTracheal Intubation Sky-Hook Technique Lighted Stylet Retrograde Intubation Needle Cricothyroidomy Surgical Cricothyroidomy

Airway Pharmacology : 

Airway Pharmacology Opiates Morphine Fentanyl Neuromuscular Blocking Agents Succinylcholine (depolarizing, biphasic) Vecuronium Atracurium Pancuronium Rocuronium Benzodiazepines

Rapid Sequence Induction : 

Rapid Sequence Induction Preoxygenate Prepare Induce Sellick’s maneuver Consider premedication Paralyze Intubate ET confirmation Secure ETT Maintain paralysis / pain management

Triad of Death : 

Triad of Death Hypothermia Acidosis Coagulopathy

Slide 64: 

Followed by advanced adjunct placement ASAP Prevent gastric inflation Prevent aspiration Endotracheal tube Grandview blade Viewmax blade Gum Bougie CombiTube COPA PAX King LT PtL LMA LMA – FasTrach or LMA-I