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Backup AirwaysBackup Airways
New HampshireNew Hampshire
Division of Fire Standards & Training andDivision of Fire Standards & Training andEmergency Medical ServicesEmergency Medical Services
Know Your Options!!!& Don’t hesitate to use them!
Purpose It is vital that the prehospital crew be
confident and comfortable with the rescue airways approved for their level of licensure.
During this module you will review and practice the back up airways for your level of licensure.
Purpose
Review Backup Airway Devices (Rescue Airways) BVM LMA King-LT-D Combitube Cricothyrotomy
The Basics
Position OPA BVM Suction
Most difficult airways will still be manageable using basic airway
maneuvers!
The Need for Oxygen
0 – 1 minute: cardiac irritability 0 – 4 minutes: brain damage not likely 4 – 6 minutes: brain damage possible 6 – 10 minutes: brain damage very likely > 10 minutes: irreversible brain damage
Oxygen and Carbon Dioxide Exchange
Oxygen-rich air is inhaled to alveoli
O2 exchanged at alveolocapillary level
Perfusion to capillary beds O2/CO2 exchange at
cellular level Perfusion from capillary
beds CO2 exhanged at
alveolocapillary level CO2 exhaled
Assessment of Respiration
Patients level of consciousness Respiration quality Pulse quality Respiratory rate Pulse rate SPO2 EtCO2 Blood pressure Glasgow coma score
Every TRUE life saving intervention performed by EMS reverses one or more failing components of respiration
BVM is the most essential intervention in RSI
Inadequate Breathing
Fast or slow rate Irregular rhythm Abnormal lung sounds Reduced tidal volume Use of accessory muscles Cool, pale, diaphoretic, cyanotic skin
Head Tilt-Chin Lift
One hand on the forehead Apply backward pressure
Tips of fingers under mandible Lift the chin
Jaw-Thrust Maneuver
Place fingers behind the angle of the jaw Use thumbs to open mouth
Look, Listen, and Feel
Assess that Airway!
Basic Airway Adjuncts
Oropharyngeals Keeps tongue from blocking oropharynx Eases suctioning Used with BVM Patients without gag reflex
Nasopharyngeals Maintains patency of oropharynx Patients with gag reflex Should not be used with head trauma
Oxygen
Nonrebreathing mask– Provides up to 90% oxygen– Used at 10 to 15 L/min
Nasal cannula– Provides 24% to 44% oxygen– Used at 1 to 6 L/min
Oxygen
Nasal cannula 24-40% at 1-6 liters
Non-rebreather mask Up to 90% at 15 liters
BVM 21% atmosphere Up to 100% at 15 liters with reservoir
Artificial Ventilation
Mouth to mask BVM – one person BVM – two person
Ventilation Rates
Adults: 8 - 10 breaths per minute Approximately one breath every 6 – 8 seconds
Pediatric: 12 – 20 breaths per minute Approximately one breath every 3 – 6 seconds
Bag Valve Mask
Delivers > 90% oxygen Requires practice and proficiency Use with airway adjuncts and/or advanced
airways
O2 ReservoirBag
Valve
Mask
BVM-Problems encountered
Inattentiveness Poor mask seal = poor ventilatory ability Varying ventilatory rates Varying expiration rates Varying tidal volumes Often excessive airway pressure Often hyper-ventilation
Mastering the BVM overcomes these obstacles!
BVM – One person
Insert an oral/nasal airway Seal mask by placing the apex over the bridge of
the nose and lower portion of the mask over the mouth and upper chin.
Make a “C” with your index finger and thumb around the mask.
Maintain the airway with your middle, ring and little finger, creating a “E”, under the jaw to maintain the chin lift.
Squeeze the bag with your other hand slowly at a rate of one breath every 6–8 seconds.
Monitoring SpO2
BVM – Two Person Insert oral/nasal airway First provider hold the bag portion of the BVM
with both hands. Second provider seals the mask with apex over
the bridge of the nose and base at the upper chin.
Using two hands the second provider places his/her thumbs over the top half of the mask; index and middle finger over bottom half; ring and little finger under jaw.
Second provider also maintains chin-lift First provider squeezes bag every 6–8 seconds Monitoring SpO2.
Adequate Ventilation
Equal chest rise and fall Appropriate rate Heart rate returns to normal
Inadequate Ventilation
Minimal or no chest rise Ventilating too fast or too slow Heart rate does not return to normal
Asthma and COPD
These patients complicate the traditional RSI approach due to the difficulty encountered when mask ventilating
Alveolar hyperinflation secondary to underlying pathophysiology must be considered and adequate passive ventilation time must be ensured
Tidal volumes should be reduced, initially, to reduce likelihood of barotrauma and air trapping
Gastric Distention
Air fills the stomach from too forceful or too frequent ventilations
Airway may be blocked and ventilations are re-routed to stomach
Decreases lung capacity May cause patient to vomit
Airway Obstructions
Tongue Vomit Blood, clots, traumatized tissue Swelling Foreign objects
Recognizing an Obstruction
Partial or complete? Can patient speak? Cough? If unconscious, deliver artificial ventilation Does air go in? Does the chest rise?
Removing an Obstruction
Heimlich maneuver Suction Magills (paramedics)
Suctioning
Turn on unit and ensure proper suctioning pressure (300 mmHg)
Select proper tip and measure Insert with suction off Suction on the way out Suction for no more than 15 seconds
Continuous Positive Airway Pressure (CPAP)
Is the patient a candidate for CPAP?
CPAP Indications
Any patient in respiratory distress associated with CHF with any of the below obvious signs and symptoms or a history of CHF: Bibasilar or diffuse rales Respiratory rate greater than 25 Pulse oximetry below 92% Retractions or accessory muscle use Abnormal capnography (rate, waveform, CO2 levels)
RSI Indication
Immediate severe airway compromise in the context of trauma, drug overdose, status epilepticus, etc. where respiratory arrest in imminent.
Always have a back-up plan.
Plans “A”, “B”, and “C” Know the answers before you begin
Plan “A”: (ALTERNATIVES) Different:
Size of blade Type of blade
Miller Macintosh Specialty
Position (patient & provider) Hockey stick bend in ETT or Directional tip ETT Remove the stylette as you pass through the cords “BURP” (aka “ELM”) Gum Elastic Bougie 2-person technique
“cowboy” or “skyhook” Have someone else try
Viewmax Scope
Easy of use Can be used like a Mac or Miller Should improve your view by one grade
“BURP” – a.k.a. “External Laryngeal Manipulation”
Backward, Upward, Rightward Pressure: manipulation of the trachea
90% of the time the best view will be obtained by pressing over the thyroid cartilage
Differs from the Sellick Differs from the Sellick ManeuverManeuver
Plan “B”: (BVM and BACK UP Airways)
Can you ventilate with a BVM?
(Consider two NPA’s and an OPA, +
Cricoid pressure w/ gentle ventilation)
KING–LT-D
Combitube
LMA
King-LT-D
King LT-D
Combitube
CombiTube
Insertion Technique
• Tongue-Jaw Lift• Anatomical
Insertion• Black rings will lie
between teeth or alveolar ridges
• Bending the tip prior to use may ease insertion
CombiTube• Inflate Blue
Balloon• Inflate White
Balloon• The
CombiTube may reposition as the oropharyngeal is inflated.
Esophageal Placement
• Ventilate Blue Tube
• Visualize• Auscultate• EtCO2
Tracheal Placement
• Ventilate Clear Tube
• Visualize• Auscultate• EtCO2
Laryngeal Mask AirLMA
LMA
The LMA was invented by Dr. Archie Brain at the London Hospital in Whitechapel in 1981
The LMA consists of two parts: The mask The tube
The LMA has proven to be a very effective management tool for the airway
Introduction continued
The LMA design: Provides an “oval seal around
the laryngeal inlet” once the
LMA is inserted and the cuff
inflated.
Once inserted, it lies at the
crossroads of the digestive
and respiratory tracts.
Indications
Situations involving a difficult mask (BVM) fit.
May be used as a back-up device where endotracheal
intubation is not successful.
May be used as a “second-last-ditch” airway where a
surgical airway is the only remaining option.
Contraindications
Greater than 14 to 16 weeks pregnant
Patients with multiple or massive injury
Massive thoracic injury
Massive maxillofacial trauma
Patients at risk of aspiration
NOTE: Not all contraindications are absolute
Complications
Throat soreness
Dryness of the throat and/or mucosa
Complications due to improper placement vary based on
the nature of the placement
Equipment for LMA Insertion
Body Substance Isolation equipment Appropriate size LMA Syringe with appropriate volume for LMA cuff
inflation Water soluble lubricant Ventilation equipment Stethoscope Tape or other device(s) to secure LMA
Preparation
Step 1: Size selection
Step 2: Examination of the LMA
Step 3: Check deflation and inflation of
the cuff
Step 4: Lubrication of the LMA
Step 5: Position the Airway
Step 1: Size Selection
Verify that the size of the LMA is correct for the patient
Recommended Size guidelines: Size 1: under 5 kg Size 1.5: 5 to 10 kg Size 2: 10 to 20 kg Size 2.5: 20 to 30 kg Size 3: 30 kg to small adult Size 4: adult Size 5: Large adult/poor seal with size 4
Step 2: Examine the LMA
Visually inspect the LMA cuff for tears or other
abnormalities Inspect the tube to ensure that it is free of blockage
or loose particles Deflate the cuff to ensure that it will maintain a
vacuum Inflate the cuff to ensure that it does not leak
Step 3: Deflation & Inflation Slowly deflate the cuff to form a smooth flat
wedge shape which will pass easily around the back of the tongue and behind the epiglottis.
During inflation the maximum air in cuff should not exceed: Size 1: 4 ml Size 1.5: 7 ml Size 2: 10 ml Size 2.5: 14 ml Size 3: 20 ml Size 4: 30 ml Size 5: 40 ml
Step 4: Lubrication
Use a water soluble lubricant to lubricate the LMA Only lubricate the LMA just prior to insertion Lubricate the back of the mask thoroughly Important Notice: Avoid excessive amounts of lubricant
on the anterior surface of the cuff or in the bowl of the mask.
Inhalation of the lubricant following placement may result in coughing or obstruction.
Step 5: Positioning of the Airway Extend the head and flex the
neck
Avoid LMA fold over: Assistant pulls the lower
jaw downwards. Visualize the posterior oral
airway. Ensure that the LMA is not
folding over in the oral cavity as it is inserted.
LMALMAInsertionInsertionTechniqueTechnique
Step 1
Step 5
Step 4
Step 2
Step 3
LMA Insertion Step 1
Grasp the LMA by the
tube, holding it like a pen
as near as possible to the
mask end
Place the tip of the LMA
against the inner surface
of the patient’s upper
teeth
LMA Insertion Step 2
Under direct vision: Press the mask tip upwards
against the hard palate to flatten it out.
Using the index finger, keep pressing upwards as you advance the mask into the pharynx to ensure the tip remains flattened and avoids the tongue.
LMA Insertion Step 3
Keep the neck flexed and head extended:
Press the mask into the posterior pharyngeal wall using the index finger.
LMA Insertion Step 4
Continue pushing with your index finger.
Guide the mask downward into position.
LMA Insertion Step 5
Grasp the tube firmly with the other hand
Then withdraw your index finger from the pharynx.
Press gently downward with your other hand to ensure the mask is fully inserted.
LMA Insertion Step 6
Inflate the mask with the
recommended volume of air. Do not over-inflate the LMA. Do not touch the LMA tube while it
is being inflated unless the position
is obviously unstable. Normally the mask should be
allowed to rise up slightly out of the
hypopharynx as it is inflated to find
its correct position.
Verify Placement of the LMA
Connect the LMA to a Bag-Valve Mask device or
low pressure ventilator
Ventilate the patient while confirming equal
breath sounds over both lungs in all fields and the
absence of ventilatory sounds over the
epigastrium
Securing the LMA
Insert a bite-block or roll of gauze to prevent
occlusion of the tube should the patient bite down.
Now the LMA can be secured utilizing the same
techniques as those employed in the securing of
an endotracheal tube.
Verify
During ventilation observe end-tidal CO2 monitor or
pulseoximetry to confirm oxygenation
Waveform Capnometry
Prerequisite Requirement
Becoming a standard of care
Easy to Use Good measure of
Pulmonary Perfusion
Relates well to PaCO2
Does have limitations
Problems with LMA Insertion
Failure to press the
deflated mask up against
the hard palate or
inadequate lubrication or
deflation can cause the
mask tip to fold back on
itself.
Problems with LMA Insertion
Once the mask tip has
started to fold over, this
may progress, pushing the
epiglottis into its down-
folded position causing
mechanical obstruction
Problems with LMA Insertion
If the mask tip is deflated forward
it can push down the epiglottis
causing obstruction
If the mask is inadequately
deflated it may either push down the epiglottis
penetrate the glottis
Plan C: Cricothyrotomy
Last resort!
Equipment Endotracheal or tracheostomy tube (or commercial device)
Scalpel
Curved hemostats
Suction apparatus
Oxygen Supply
BVM
Securing device
Bandaging materials
Procedure
Have all supplies (including suction) available and ready.
A commercially available device may be desirable.
Commercial Cricothyrotomy Kits
Must perform to recommendation of manufacturer and Medical Director’s satisfaction for proficiency.
Find the persons Adam's apple (thyroid cartilage)
Move your fingers about one inch down the neck until you find another bulge.
This is the cricoid cartilage. The indentation between the two is the cricothyroid membrane, where the incision will be made.
Procedure
Locate the cricothyroid membrane utilizing correct anatomical landmarks. Thyroid Cartilage
Cricothyroid Membrane
Cricoid Cartilage
Thyroid Gland
Tracheal Rings
Procedure
Prep the area with an antiseptic swap (e.g. Betadine).
Procedure
Using your non-dominant hand, stabilize the thyroid cartilage and secure the cricothyroid membrane.
Procedure
Make a 1-inch vertical incision through the skin and subcutaneous tissue using a scalpel.
Procedure
Using blunt dissection technique, expose the cricothyroid membrane.
This is a bloody procedure.
Procedure
Some protocols recommend stabilizing the cricothyroid membrane with a skin or trach hook.
Procedure
Make a horizontal, transverse incision approximately ½ inch long through the membrane.
Procedure
Using a dilator, hemostat, or gloved finger to maintain surgical opening, insert the cuffed tube into the trachea.
Cric tube from the kit of a 6.0 ETT is usually sufficient.
Procedure Using a dilator,
hemostat, or gloved finger to maintain surgical opening, insert the cuffed tube into the trachea.
Cric tube from the kit of a 6.0 ETT is usually sufficient.
Procedure
Inflate the cuff with 5-10cc of air and ventilate the patient while manually stabilizing the tube.
Procedure
All of the standard assessment techniques for ensuring tube placement should be performed (auscultation, chest rise and fall, end-tidal CO2 detector, etc..
Secure the tube.
Complications
Incorrect tube placement/ false passage
Thyroid gland damage
Severe bleeding
Subcutaneous emphysema
Laryngeal nerve damage
Always expect the unexpected!
RSI Procedure: The Seven P’s
1. Preparation2. Preoxygenate the patient3. Premedicate the patient4. Paralyze the patient5. Pass the tube6. Proof of placement7. Post intubation care
Recommended