“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

22

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 afinkel@silvercross.org• Thank you!