Intubation Obstacle Course February 2011 CE Condell Medical Center EMS System Site code #107200E - 1211

1. Intubation Obstacle CourseFebruary 2011 CECondell Medical Center EMS SystemSite code #107200E - 1211 Prepared by: FF/PM Erich Castillo; Greater Round Lake Fire Department Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives Upon successful completion of this module, the EMS provider will be able to: 1. Describe the airway anatomy in the adult, child and infant populations. 2. Explain the pathophysiology of airway compromise. 3. Review the use of oxygen therapy in cases of airway management in severe situations. 4. Describe the measurement, placement, and assessment of oropharyngeal and nasopharyngeal airways. 5. Explain the value of performing advanced airway procedures.

3. Objectives cont’d 6. List indications, contraindications, and complications of ET intubation. 7. List equipment required for oral intubation. 8. Explain the rationale for having a suction unit immediately available during intubation attempts. 9. State the time limit for suctioning in the adult, child and infant populations. 10. Describe the methods of choosing the appropriate sized endotracheal tube in an adult, child and infant populations. 11. Explain the rationale for using the stylet during intubation. 12. Describe the proper use of a stylet in orotracheal intubation.

4. Objectives cont’d 13. Describe the landmarks used with the Macintosh and Miller blades for oral intubation. 14. Describe the skill of orotracheal intubation in the adult, child and infant populations. 15. Describe the steps in confirming endotracheal tube placement in the adult, child and infant patient. 16. Describe the use of the ETCO2 monitor. 17. Describe the use of capnography to monitor patient condition. 18. State the consequence of and the need to recognize unintentional esophageal intubation. 19. Explain the rationale for securing the endotracheal tube.

5. Objectives cont’d 20. Describe the technique of securing the endotracheal tube in the adult, infant and child populations. 21. Review documentation components of the patient who has been intubated. 22. Demonstrate the skill of measuring and placing the oropharyngeal and nasopharyngeal airways in the adult patient. 23. Demonstrate the skill of orotracheal intubation in the adult patient. 24. Demonstrate confirmation of endotracheal tube placement in the adult patient.

6. Objectives cont’d 25. Demonstrate the skill of securing the endotracheal tube in the adult patient. 26. Demonstrate the skill of intubation on the adult patient with multiple challenges and multiple obstacles confining the patient (in-line, face to face, in confined space, digital intubation, with a foreign body).

7. Upper and Lower Airways Upper airway structures Nose Mouth / Pharynx Lower airway structures Alveoli

8. Pediatric Airway Funnel Shaped Peds Airway Adult Airway

9. Airway Compromise • Blockage • Improper positioning • Foreign bodies • Improperly placed ETT • Swelling • Trauma • Blunt, crushing injury • Burns • Improper use of airway adjuncts • Disease • Asthma • Croup • Epiglottitis

10. Oxygen Therapy • If the patient is in dire need and requires oxygen, the maximum amount is to be delivered • Airway compromise • Shock • Impending arrest • Arrest • Use best tool for the situation • Non-rebreather • BVM

11. Future Trend - Oxygen Therapy • New research = future practice • Hyperventilation pitfalls •  intrathoracic pressure which  CO • Compromises systemic blood flow • Hypocapnia (low CO2) may worsen global brain ischemia due to excessive cerebral vasoconstriction • 100% O2 worsens short-term functional outcome compared to titrated O2 use to SaO2 of 94-96%

12. New SOP’s Coming Watch for revisions in oxygen administration guidelines coming to you in the revised SOP 2011 More to follow!

13. “Securing” the Airway • Definition of a secured airway • Whatever it takes to have and maintain an open airway • Whatever it takes to ventilate the patient • Whatever it takes to maintain adequate oxygenation levels • New trend: oxyhemoglobin saturation > 94% • Includes use of positioning and airway adjunct tools – basic and advanced

14. Open vs Blocked Airway Vocal cords Larynx Tongue Trachea Esophagus Positioning of airway important for keeping airway open

15. Airway Maneuvers • Head-tilt / chin lift • Maneuver used to open the airway to relieve obstruction by the tongue • Reliable, dependable • Often under-utilized skill • Recommended for all unconscious patients • If suspected cervical spine injury, perform modified jaw thrust with in-line stabilization of the cervical spine

16. Airway Adjuncts • Mechanical airways • Helps lift base of tongue forward, away from posterior oropharynx • Does not replace good head positioning • Oropharyngeal airways • NOT for patients with a gag reflex!!! • Nasopharyngeal airways • Tolerated by patients with and without gag reflex

17. Oropharyngeal Airway • Noninvasive; follows curve of palate • Indicated in patients with NO gag reflex • Check for presence of blink reflex • Facilitates suctioning • Can be used as a bite block to protect an endotracheal tube • Does NOT protect from aspiration

18. Oropharyngeal Airway 1 Measure 2 Place 3 Assess Check that the tongue was not inadvertently pushed back blocking the airway

19. Nasopharyngeal Airway • Uncuffed soft tube; follows curve of nasopharynx to just below base of tongue • Indicated for soft tissue upper airway obstruction • Tolerated by patients with and without gag reflex • Not recommended for facial or head trauma • Can cause more trauma during placement

20. Nasopharyngeal Airway 1 Measure 2 Place 3 Assess

21. Nasopharyngeal Airway • Inserted bevel side toward the septum • LUBRICATE; LUBRICATE; LUBRICATE • Right nares slides in • Left nares, starts upside down (bevel to the septum) and rotated into position • TIP: pull up on tip of nose to straighten curve that may block ease of insertion • Did we say LUBRICATE?! Right nares Left nares

22. Advanced Airway Techniques • Using an invasive device with additional equipment to secure the airway

23. Indications for Intubation • Inadequate oxygenation • Inadequate ventilation • Need to control and remove pulmonary secretions • Need to provide airway protection in an unresponsive patient or a patient with a depressed gag reflex

24. Intubation Contraindications • Awake patient • Airway can be managed less invasively • Severe airway trauma or obstruction that does not permit safe passage of an endotracheal tube • Cervical spine injury, in which the need for complete immobilization of the cervical spine makes endotracheal intubation difficult (relative contraindication)

25. Potential Complications During Intubation • Inability to view vocal cords • Breaking teeth/dislodging bridgework • Damage to gums • Faulty cuff • Unrecognized esophageal intubation • Unrecognized right main stem intubation • Laryngospasm • Failure to complete intubation

26. BVM Laryngoscope with curved and/or straight blade ET tube (size of little finger for peds) Extra ET tube – one size up and one size down Stylet Suction unit Oral airways 10 ml syringe Lubricant Gloves Eye Protection Stethoscope Method to secure ET tube in place Equipment Required

27. Opening the Airway & Creating A Seal • Proper positioning of patient essential to place airway in best plane possible • Proper seal essential when using the BVM • Use “EC” technique

28. BVM Assisted Ventilations • Hand-held device to provide positive ventilations to patients • Absent respirations • Ineffective ventilations • Must have proper seal to prevent air leakage • Rate sufficient for situation • Risk of over inflation of lungs, gastric distention, vomiting • To support ventilations in presence of spontaneous heartbeat- once every 5 - 6 seconds in adults; once every 3 - 5 seconds in peds up to 8 years of age • To ventilate via ET tube – once every 6 - 8 seconds in all peds and adults

29. Suctioning • Removes secretions and oxygen!!! • May stimulate gagging and vomiting • Most EMS patients not NPO! • Limit to 10 seconds for adults • Limit to 5 seconds in the pediatric population • Watch for hypoxia induced bradycardia • Suction on removal of catheter only

30. Typical Sizing ETT • Generic guidelines • Use length based tape (ie: Broselow ) for pediatric sizing guidelines

31. Stylet • Used to give form to the ETT • Use is by personal preference • NEVER to extend past distal tip of ETT • Recess tip of stylet approximately 2cm (3/4″) from distal opening • Bend over excess stylet to prevent inadvertent trauma to tracheal wall • Place tip in “hockey stick” position • Could also reform ETT into a curve

32. Straight Blade Miller • Blade lifts epiglottis • Vocal cords are exposed • Direct visualization allowed • 30 second time limit to intubate!!!

33. Curved Blade - Macintosh • Blade placed in vallecular space • Use left forearm to lift anatomy out of way to view vocal cords • Lifting motion moves epiglottis out of the way • 30 second time limit to intubate!!!

34. Choosing the Correct Pediatric Blade Size • Measure using space from tip of blade to notch • Measure from child’s upper incisor to angle of jaw within +/- 1/2″

35. Difficult Airways – What Are You Going To Do? Positioning Peds Anatomy Swelling Obstructions

36. Do you have adequate padding? • Evaluate the patient in the horizontal position • Draw an imaginary line from ear to shoulders • Patient will then be “in line” • Add to or subtract padding when cervical spine can be moved

37. Foreign Body • Magill forceps • Useful to pull out foreign bodies from the airway • Can be used to guide ET tube through vocal cords • If you always anticipate you need them, • Not a tool you have time to look for – when you need them, you need them NOW Vocal cords ET tube cuff Magill forceps

38. What else is out there? What does the literature say?

39. Mallampati Score • Tool to evaluate and gain estimate of difficulty of intubation • Evaluation obtained while visualizing the anatomy • Fewer structures visible=greater difficulty in completing the intubation • Used in hospitals and some EMS areas

40. Cricoid Pressure/ Sellick Maneuver • Helpful to stabilize anatomical structures • Helpful to reduce regurgitation • Hazardous if too much force applied and airway is actually compromised during ventilations • Palpate cricoid cartilage and press directly backwards

41. “BURP” – Visualizes Cords • Backward, upward, right pressure • Placed on thyroid cartilage (not cricoid cartilage) • Improves visualization of vocal cords during intubation attempt • Larynx moved to the right as the tongue is swept to the left with the laryngoscope blade • NOT same maneuver as cricoid pressure; used for different results

42. Blind Insertion Airway Devices #1 1. Combitube 2. King LT-D airway 3. LMA • Not as effective as ETT in preventing aspiration • Useful in unsuccessful traditional ETT placement • More information coming related to this equipment with 2011 SOP updates #2 #3

43. Medication Assisted Intubation • Region X is reviewing the use of medications used to assist in intubation in the non-arrested patient • Which drugs are most effective? • Which have the least amount of side effects? • Which drugs help to get the job done and improve patient outcome? • More to come with 2011 SOP updates

44. Standard Oral Intubation • Use the curved or straight blade inleft hand • Userighthand toplace ET tube • DO NOT slide ET thru blade but along side blade – you still need to visualize your landmarks!

45. View with a blade and good light. • Vocal cords and surrounding structures

46. Insertion Techniques for ETT • Your positioning may be critical for successful insertion • Put the anatomy “in line” to improve visualization • Bring your body down to the airway level

47. Confirming ET Tube Placement • Direct visualization of vocal cords • 5 point auscultation • Listen over epigastric area first • Then listen upper lobes and midaxillary regions (farthest laterally in peds) • Watch for chest rise and fall • ETCO2 changing to & maintaining yellow coloring

48. ETCO2 • Measures the amount of CO2 exhaled at the end of each breath • Perfusion needs to be sufficient to circulate waste products (CO2) back to the lungs to be exhaled • Ventilation needs to be adequate to wash the CO2 out of the lungs to be measured • Yellow coloring indicates adequate CO2 levels • Indicator changes back and forth with the situation

49. Capnography • Measurement of exhaled CO2 levels • Device displays a tracing and level of readings – similar to an EKG • Normal reading is 35 – 45 mmHg • Watching wave shape can indicate hypoventilation, hyperventilation, return of spontaneous circulation during CPR

50. Improper ET Tube Placement • Huge risk not to identify this complication and immediately take the appropriate intervention • Right main stem bronchus • Breath sounds absent on left; more chest rise and fall on right • While listening over left chest, reposition ET tube until breath sounds are heard • Esophageal intubation • Epigastric sounds, no breath sounds, no rise and fall of chest • Immediately remove ET tube, ventilate/oxygenate patient, reattempt intubation