Airway management part 2

Airway Management:Airway Management: Part 2 Part 2

EMS ProfessionsEMS Professions

Temple CollegeTemple College

Risks/Protective MeasuresRisks/Protective Measures

Be prepared for:Be prepared for: CoughingCoughing SpittingSpitting VomitingVomiting BitingBiting

Body Substance IsolationBody Substance Isolation GlovesGloves Face, eye shieldsFace, eye shields Respirator, if concern for airborne diseaseRespirator, if concern for airborne disease

ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods

Gastric TubesGastric Tubes Nasogastric Nasogastric

Caution with esophageal disease or facial Caution with esophageal disease or facial traumatrauma

Tolerated by awake patients, but uncomfortableTolerated by awake patients, but uncomfortable Patient can speakPatient can speak Interferes with BVM sealInterferes with BVM seal

OrogastricOrogastric Usually used in unresponsive patientsUsually used in unresponsive patients Larger tube may be usedLarger tube may be used Safe in facial traumaSafe in facial trauma

Nasogastric Tube InsertionNasogastric Tube Insertion Select size (French)Select size (French) Measure length (nose to ear to xiphoid)Measure length (nose to ear to xiphoid) Lubricate end of tube (water soluble)Lubricate end of tube (water soluble) Maintain aseptic techniqueMaintain aseptic technique Position patient sitting up if possiblePosition patient sitting up if possible

Nasogastric Tube InsertionNasogastric Tube Insertion Insert into nare towards angle of jawInsert into nare towards angle of jaw Advance gradually to measured lengthAdvance gradually to measured length Have patient swallowHave patient swallow Assess placementAssess placement

Instill air, ausculateInstill air, ausculate aspirate gastric contentsaspirate gastric contents

SecureSecure May connect to low vacuum (80-100 May connect to low vacuum (80-100

mm Hg)mm Hg)

Orogastric Tube InsertionOrogastric Tube Insertion Select size (French)Select size (French) Measure lengthMeasure length Lubricate end of tubeLubricate end of tube Position patient (usually supine)Position patient (usually supine) Insert into mouthInsert into mouth Advance gradually but steadilyAdvance gradually but steadily Assess placement (instill air or aspirate)Assess placement (instill air or aspirate) SecureSecure Evacuate contents as neededEvacuate contents as needed

ET IntroductionET Introduction

Endotracheal IntubationEndotracheal Intubation Tube into trachea to provide ventilations Tube into trachea to provide ventilations

using BVM or ventilatorusing BVM or ventilator Sized based upon inside diameter (ID) in Sized based upon inside diameter (ID) in

mmmm Lengths increase with increased ID (cm Lengths increase with increased ID (cm

markings along length)markings along length) Cuffed vs. UncuffedCuffed vs. Uncuffed

Endotracheal IntubationEndotracheal Intubation

AdvantagesAdvantages Secures airwaySecures airway Route for a few medications (LANE)Route for a few medications (LANE) Optimizes ventilation, oxygenationOptimizes ventilation, oxygenation Allows suctioning of lower airwayAllows suctioning of lower airway

IndicationsIndications Present or impending respiratory Present or impending respiratory

failurefailure ApneaApnea Unable to protect own airwayUnable to protect own airway

These are These are NOTNOT Indications Indications Because I can intubateBecause I can intubate Because they are unresponsiveBecause they are unresponsive Because I can’t show up at the hospital Because I can’t show up at the hospital

without itwithout it

ComplicationsComplications Soft tissue trauma/bleedingSoft tissue trauma/bleeding Dental injuryDental injury Laryngeal edemaLaryngeal edema LaryngospasmLaryngospasm Vocal cord injuryVocal cord injury BarotraumaBarotrauma HypoxiaHypoxia AspirationAspiration Esophageal intubationEsophageal intubation Mainstem bronchus intubationMainstem bronchus intubation

Insertion TechniquesInsertion Techniques Orotracheal Intubation (Direct Orotracheal Intubation (Direct

Laryngoscopy)Laryngoscopy) Blind Nasotracheal IntubationBlind Nasotracheal Intubation Digital IntubationDigital Intubation Retrograde IntubationRetrograde Intubation TransilluminationTransillumination

Orotracheal IntubationOrotracheal Intubation

TechniqueTechnique Position, ventilate patientPosition, ventilate patient Monitor patientMonitor patient

ECGECG Pulse oximeterPulse oximeter

Assess patient’s airway for difficultyAssess patient’s airway for difficulty Assemble, check equipment (suction)Assemble, check equipment (suction) Hyperventilate patient (30-120 sec)Hyperventilate patient (30-120 sec)

Orotracheal IntubationOrotracheal Intubation Position patientPosition patient Open mouthOpen mouth Insert laryngoscope blade on right sideInsert laryngoscope blade on right side Sweep tongue to leftSweep tongue to left Identify anatomical landmarksIdentify anatomical landmarks Advance laryngoscope bladeAdvance laryngoscope blade

Vallecula for curved (Miller) bladeVallecula for curved (Miller) blade Under epiglottis for straight (Miller) bladeUnder epiglottis for straight (Miller) blade

Orotracheal IntubationOrotracheal Intubation Elevate epiglottisElevate epiglottis Directly with straight (Miller) bladeDirectly with straight (Miller) blade Indirectly with curved (Macintosh) bladeIndirectly with curved (Macintosh) blade Visualize vocal cords, glottic openingVisualize vocal cords, glottic opening Enter mouth with tube from corner of Enter mouth with tube from corner of

mouthmouth

Orotracheal IntubationOrotracheal Intubation Advance tube into glottic opening about Advance tube into glottic opening about

1/2 inch past vocal cords1/2 inch past vocal cords Continue to hold tube, note locationContinue to hold tube, note location Ventilate, ausculateVentilate, ausculate

EpigastriumEpigastrium Left and right chestLeft and right chest

Inflate cuff until air leak around cuff Inflate cuff until air leak around cuff stopsstops

Reassess tube placement Reassess tube placement

Orotracheal IntubationOrotracheal Intubation Secure tubeSecure tube Reassess tube placement, ventilation Reassess tube placement, ventilation

effectivenesseffectiveness

IntubationIntubation

Total time between ventilations

should not exceed

30 seconds!

IntubationIntubation

Death occurs from Death occurs from failure to failure to VentilateVentilate, ,

not failure to Intubatenot failure to Intubate

ALS EquipmentALS Equipment

EquipmentEquipment Laryngoscope Handle Laryngoscope Handle

(lighted) & Blades(lighted) & Blades StyletStylet SyringeSyringe MagillsMagills LubricantLubricant SuctionSuction BVMBVM BAAM (Blind Nasal)BAAM (Blind Nasal)

SelectionSelection Typical Adult ET Typical Adult ET

Tube SizesTube Sizes Male - 8.0, 8.5Male - 8.0, 8.5 Female - 7.0, 7.5, 8.0Female - 7.0, 7.5, 8.0

BladeBlade Mac - 3 or 4Mac - 3 or 4 Miller - 3Miller - 3

Tube DepthTube Depth Usually 20 - 22 cm at Usually 20 - 22 cm at

the teeththe teeth

From AHA PALS

Pediatric ET IntubationPediatric ET Intubation

Pediatric Equipment Pediatric Equipment DifferencesDifferences Uncuffed tube < 8 Uncuffed tube < 8

yoayoa Miller blade Miller blade

preferredpreferred Tube SizeTube Size

Premie: 2.0, 2.5Premie: 2.0, 2.5 Newborn: 3.0, 3.5Newborn: 3.0, 3.5 1 year: 41 year: 4 Then: (age/4)+4Then: (age/4)+4

Pediatric Pediatric DifferencesDifferences Anatomic Anatomic

DifferencesDifferences Depth (cm)Depth (cm)

Tube ID x 3Tube ID x 3 12 + (age/2)12 + (age/2) easily dislodgedeasily dislodged

Intubation vs BVMIntubation vs BVM

PositioningPositioning

Patient PositioningPatient Positioning GoalGoal

Align 3 planes of view, so Align 3 planes of view, so Vocal cords are most visibleVocal cords are most visible

T - tracheaT - trachea P - PharynxP - Pharynx O - OropharynxO - Oropharynx

Airway AssessmentAirway Assessment

Cervical SpineCervical Spine Temporal Mandibular JointTemporal Mandibular Joint A/O JointA/O Joint Neck length, size and muscularityNeck length, size and muscularity Mandibular size in relation to faceMandibular size in relation to face Over biteOver bite Tongue sizeTongue size

Assessment AcronymAssessment Acronym

M MandibleM Mandible O OpeningO Opening U UvulaU Uvula T TeethT Teeth H HeadH Head S SilhouetteS Silhouette

The Lemon LawThe Lemon Law

LL Look externallyLook externally EE Evaluate the 3-3-2 ruleEvaluate the 3-3-2 rule MM Mallampati scoreMallampati score OO Obstruction?Obstruction? NN Neck MobilityNeck Mobility

Look Look

Morbidly obeseMorbidly obese Facial hairFacial hair Narrow faceNarrow face OverbiteOverbite TraumaTrauma

Evaluate Evaluate 33--33--22

Temporal Mandibular JointTemporal Mandibular Joint Should allow 3 fingers between incisorsShould allow 3 fingers between incisors 3-4 cm3-4 cm

MandibleMandible 3 fingers between mentum & hyoid bone3 fingers between mentum & hyoid bone Less than three fingersLess than three fingers

Proportionately large tongue Proportionately large tongue Obstructs visualization of glottic openingObstructs visualization of glottic opening

Greater than three fingersGreater than three fingers Elongates oral axisElongates oral axis More difficult to align the three axisMore difficult to align the three axis

LarynxLarynx Adult located C5,6Adult located C5,6 If higher, obstructive view of glottic If higher, obstructive view of glottic

openingopening Two fingers from floor of mouth to Two fingers from floor of mouth to

thyroid cartilagethyroid cartilage

Mallampati ScoreMallampati Score

Evaluates ability to visualize glottic Evaluates ability to visualize glottic openingopening Patient seated with neck extendedPatient seated with neck extended Open mouth as wide as possibleOpen mouth as wide as possible Protrude tongue as far as possibleProtrude tongue as far as possible Look at posterior pharynxLook at posterior pharynx Grade based on visual fieldGrade based on visual field

Grades 1,2 have low intubation failure ratesGrades 1,2 have low intubation failure rates Grades 3,4 have higher intubation failure Grades 3,4 have higher intubation failure

ratesrates

Mallampati ScoreMallampati Score

Not useful in emergent situationsNot useful in emergent situations Informal versionInformal version

Use tongue blade to visualize pharynxUse tongue blade to visualize pharynx

Mallampati GradesMallampati Grades

Difficulty

Class I Class II Class III Class IV

ObstructionObstruction

Know or suspectedKnow or suspected Foreign bodiesForeign bodies TumorsTumors AbscessAbscess EpiglottitisEpiglottitis HematomaHematoma TraumaTrauma

Neck MobilityNeck Mobility

Align axis to facilitate Align axis to facilitate orotracheal intubationorotracheal intubation

Decreased mobility Decreased mobility fromfrom C-Spine immobilizationC-Spine immobilization Rheumatoid arthritisRheumatoid arthritis

Quick TestQuick Test Put chin on chest then Put chin on chest then

move toward ceilingmove toward ceiling

Curved Blade (Macintosh)Curved Blade (Macintosh)

Insert from right to Insert from right to leftleft

Visualize anatomy Visualize anatomy Blade in valleculaBlade in vallecula Lift up and away Lift up and away

DO NOT PRY ON DO NOT PRY ON TEETHTEETH

Lift epiglottis Lift epiglottis indirectlyindirectly

From AHA ACLS

Straight Blade (Miller)Straight Blade (Miller)

Insert from right to Insert from right to leftleft

Visualize anatomyVisualize anatomy Blade past vallecula Blade past vallecula

and over epiglottisand over epiglottis Lift up and away Lift up and away

DO NOT PRY ON DO NOT PRY ON TEETHTEETH

Lift epiglottis directlyLift epiglottis directlyFrom AHA ACLS

Glottic OpeningGlottic Opening

Cormack-Lehane Cormack-Lehane laryngoscopy grading laryngoscopy grading system system Grade 1 & 2 low Grade 1 & 2 low failure ratesfailure ratesGrade 3 & 4 high Grade 3 & 4 high failure ratesfailure rates

Tube PlacementTube Placement

From TRIPP, CPEM

Confirmation of Confirmation of PlacementPlacement

Placement of the ETT within Placement of the ETT within the esophagus is an the esophagus is an

accepted complication.accepted complication.

However, failure to However, failure to recognize and correct is recognize and correct is

not!not!

Traditional MethodsTraditional Methods

Observation of ETT passing Observation of ETT passing through vocal cords.through vocal cords.

Presence of breath soundsPresence of breath sounds Absence of epigastric soundsAbsence of epigastric sounds Symmetric rise and fall of chestSymmetric rise and fall of chest Condensation in ETTCondensation in ETT Chest RadiographChest Radiograph

All of these methods All of these methods havehave failed in the clinical settingfailed in the clinical setting

Additional MethodsAdditional Methods

Pulse OximetryPulse Oximetry Aspiration TechniquesAspiration Techniques End Tidal COEnd Tidal CO22

Confirming ETT Location Confirming ETT Location

Fail SafeFail Safe Near Fail SafeNear Fail Safe Non-Fail SafeNon-Fail Safe

Fail SafeFail Safe

Improvement in Clinical SignsImprovement in Clinical Signs ETT visualized between vocal cordsETT visualized between vocal cords Fiberoptic visualization of Fiberoptic visualization of

Cartilaginous ringsCartilaginous rings CarinaCarina

Near FailsafeNear Failsafe

CO2 detectionCO2 detection Rapid inflation of EDDRapid inflation of EDD

Non-FailsafeNon-Failsafe

Presence of breath soundsPresence of breath sounds Absence of epigastric soundsAbsence of epigastric sounds Absence of gastric distentionAbsence of gastric distention Chest Rise and FallChest Rise and Fall Large Spontaneous Exhaled Tidal Large Spontaneous Exhaled Tidal

VolumesVolumes

Non FailsafeNon Failsafe

Condensation in tube disappearing Condensation in tube disappearing and reappearing with respirationand reappearing with respiration

Air exiting tube with chest Air exiting tube with chest compressioncompression

Bag Valve Mask having the Bag Valve Mask having the appropriate complianceappropriate compliance

Pressure on suprasternal notch Pressure on suprasternal notch associated with pilot balloon pressureassociated with pilot balloon pressure

Blind Nasotracheal IntubationBlind Nasotracheal Intubation Position, oxygenate patientPosition, oxygenate patient Monitor patientMonitor patient

ECG monitorECG monitor Pulse oximeterPulse oximeter

Blind Nasotracheal IntubationBlind Nasotracheal Intubation Assess for difficulty or contraindicationAssess for difficulty or contraindication

Mid-face fracturesMid-face fractures Possible basilar skull fracturePossible basilar skull fracture Evidence of nasal obstruction, septal Evidence of nasal obstruction, septal

deviationdeviation Assemble, check equipmentAssemble, check equipment

Lubricate end of tube; do not warmLubricate end of tube; do not warm Attach BAAM (if available)Attach BAAM (if available)

Blind Nasotracheal IntubationBlind Nasotracheal Intubation Position patient (preferably sitting upright)Position patient (preferably sitting upright) Insert tube into largest nareInsert tube into largest nare Advance slowly, but steadilyAdvance slowly, but steadily Listen for sound of air movement in tube or Listen for sound of air movement in tube or

whistle via BAAMwhistle via BAAM Advance tubeAdvance tube Assess placementAssess placement Inflate cuff, reassess placementInflate cuff, reassess placement Secure, reassess placementSecure, reassess placement

Digital IntubationDigital Intubation Blind technique Blind technique Variable probability of successVariable probability of success Using middle finger to locate epiglottisUsing middle finger to locate epiglottis Lift epiglottisLift epiglottis Slide lubricated tube along index fingerSlide lubricated tube along index finger Assess tube placement/depth as with Assess tube placement/depth as with

orotracheal intubationorotracheal intubation

Digital Intubation

From AMLS, NAEMT

ALS Airway Ventilation MethodsALS Airway Ventilation Methods

Surgical CricothyrotomySurgical Cricothyrotomy IndicationsIndications

Absolute need for definitive airway, ANDAbsolute need for definitive airway, AND unable to perform ETT due for structural or anatomic unable to perform ETT due for structural or anatomic

reasons, ANDreasons, AND risk of not securing airway is > than surgical airway riskrisk of not securing airway is > than surgical airway risk

OROR Absolute need for definitive airway ANDAbsolute need for definitive airway AND

unable to clear an upper airway obstruction, ANDunable to clear an upper airway obstruction, AND multiple unsuccessful attempts at ETT, ANDmultiple unsuccessful attempts at ETT, AND other methods of ventilation do not allow for effective other methods of ventilation do not allow for effective

ventilation, respirationventilation, respiration

Surgical CricothyrotomySurgical Cricothyrotomy Contraindications (relative)Contraindications (relative)

No real demonstrated indicationNo real demonstrated indication Risks > BenefitsRisks > Benefits Age < 8 years (some say 10, some say 12)Age < 8 years (some say 10, some say 12) Evidence of fractured larynx or cricoid Evidence of fractured larynx or cricoid

cartilagecartilage Evidence of tracheal transectionEvidence of tracheal transection

Surgical CricothyrotomySurgical Cricothyrotomy TipsTips

Know anatomyKnow anatomy Short incision, avoid inferior tracheaShort incision, avoid inferior trachea Incise, do not sawIncise, do not saw Work quickly Work quickly Nothing comes out until something else is in Nothing comes out until something else is in Have a planHave a plan Be prepared with backup planBe prepared with backup plan

Needle Cricothyrotomy/Transtracheal Needle Cricothyrotomy/Transtracheal Jet VentilationJet Ventilation IndicationsIndications

Same as surgical cricothyrotomy withSame as surgical cricothyrotomy with Contraindication for surgical cricothyrotomyContraindication for surgical cricothyrotomy

ContraindicationsContraindications None when demonstrated needNone when demonstrated need Caution with tracheal transectionCaution with tracheal transection

Jet VentilationJet Ventilation Usually requires high-Usually requires high-

pressure equipmentpressure equipment Ventilate 1 sec then Ventilate 1 sec then

allow 3-5 sec pauseallow 3-5 sec pause Hypercarbia likelyHypercarbia likely TemporaryTemporary: 20-30 : 20-30

minsmins High risk for High risk for

barotraumabarotrauma

ALS Airway/ Ventilation MethodsALS Airway/ Ventilation Methods

Alternative AirwaysAlternative Airways Multi-Lumen Devices (CombiTube, PTLA)Multi-Lumen Devices (CombiTube, PTLA) Laryngeal Mask Airway (LMA)Laryngeal Mask Airway (LMA) Esophageal Obturator Airways (EOA, Esophageal Obturator Airways (EOA,

EGTA)EGTA) Lighted StyletsLighted Stylets

Pharyngeal Tracheal Lumen Airway

(PTLA)

From AMLS, NAEMT

100 ml

No. 1100 ml

Combitube®

From AMLS, NAEMT

CombitubeCombitube®®

IndicationsIndications ContraindicationsContraindications

HeightHeight Gag reflexGag reflex Ingestion of corrosive or volatile substancesIngestion of corrosive or volatile substances Hx of esophageal diseaseHx of esophageal disease

Laryngeal Mask Laryngeal Mask Airway (LMA)Airway (LMA) use in ORuse in OR Gaining use out-of-Gaining use out-of-

hospitalhospital Not useful with high Not useful with high

airway pressureairway pressure Not replacement for Not replacement for

endotracheal tubeendotracheal tube Multiple models, Multiple models,

sizessizes

LMALMA

BLS & ALS Airway/ Ventilation BLS & ALS Airway/ Ventilation MethodsMethods

Esophageal Obturator Airway, Esophageal Obturator Airway, Esophageal Gastric Tube AirwayEsophageal Gastric Tube Airway Used less frequently todayUsed less frequently today Increased complication rateIncreased complication rate Significant contraindicationsSignificant contraindications

Patient heightPatient height Caustic ingestionCaustic ingestion Esophageal/liver diseaseEsophageal/liver disease

Better alternative airways are now availableBetter alternative airways are now available

Esophageal Gastric Tube Airway Esophageal Gastric Tube Airway (EGTA)(EGTA)

From AHA ACLS

Lighted StyletteLighted Stylette Not yet widely usedNot yet widely used ExpensiveExpensive Another method of visual feedback Another method of visual feedback

about placement in tracheaabout placement in trachea

Lighted SlyestLighted Slyest

Pharmacologic Assisted Intubation Pharmacologic Assisted Intubation “RSI”“RSI”

SedationSedation Reduce anxietyReduce anxiety Induce amnesiaInduce amnesia Depress gag reflex, spontaneous breathingDepress gag reflex, spontaneous breathing Used forUsed for

inductioninduction anxious, agitated patientanxious, agitated patient

ContraindicationsContraindications hypersensitivityhypersensitivity hypotensionhypotension

Pharmacologic Assisted Intubation Pharmacologic Assisted Intubation “RSI”“RSI”

Common Medications for SedationCommon Medications for Sedation Benzodiazepines (diazepam, Benzodiazepines (diazepam,

midazolam)midazolam) Narcotics (fentanyl) Narcotics (fentanyl) Anesthesia Induction AgentsAnesthesia Induction Agents

EtomidateEtomidate KetamineKetamine Propofol (Diprivan®)Propofol (Diprivan®)

Pharmacologic Assisted IntubationPharmacologic Assisted Intubation

Neuromuscular Blockade Neuromuscular Blockade Temporary skeletal muscle paralysisTemporary skeletal muscle paralysis IndicationsIndications

When intubation required in patient who:When intubation required in patient who: is awake,is awake, has gag reflex, orhas gag reflex, or is agitated, combativeis agitated, combative

Neuromuscular Blockade Neuromuscular Blockade ContraindicationsContraindications

Most are specific to medicationMost are specific to medication Inability to ventilate once paralysis inducedInability to ventilate once paralysis induced

AdvantagesAdvantages Enables provider to intubate patients who Enables provider to intubate patients who

otherwise would be difficult, impossible to otherwise would be difficult, impossible to intubateintubate

Minimizes patient resistance to intubationMinimizes patient resistance to intubation Reduces risk of laryngospasmReduces risk of laryngospasm

NMB Agent Mechanism of ActionNMB Agent Mechanism of Action Acts at neuromuscular junction where ACh Acts at neuromuscular junction where ACh

normally allows nerve impulse transmissionnormally allows nerve impulse transmission Binds to nicotinic receptor sites on skeletal Binds to nicotinic receptor sites on skeletal

musclemuscle Depolarizing or non-depolarizingDepolarizing or non-depolarizing Blocks further action by ACh at receptor sitesBlocks further action by ACh at receptor sites Blocks further depolarization resulting in Blocks further depolarization resulting in

muscular paralysismuscular paralysis

Disadvantages/Potential Disadvantages/Potential ComplicationsComplications Does not provide sedation, amnesiaDoes not provide sedation, amnesia Provider unable to intubate, ventilate Provider unable to intubate, ventilate

after NMBafter NMB Aspiration during procedureAspiration during procedure Difficult to detect motor seizure activityDifficult to detect motor seizure activity Side effects, adverse effects of specific Side effects, adverse effects of specific

drugsdrugs

Common Used NMB AgentsCommon Used NMB Agents Depolarizing NMB agentsDepolarizing NMB agents

succinylcholine (Anectine®)succinylcholine (Anectine®) Non-depolarizing NMB agentsNon-depolarizing NMB agents

vecuronium (Norcuron®)vecuronium (Norcuron®) rocuronium (Zemuron®)rocuronium (Zemuron®) pancuronium (Pavulon®)pancuronium (Pavulon®)

Summarized ProcedureSummarized Procedure Prepare all equipment, medications while Prepare all equipment, medications while

ventilating patientventilating patient HyperventilateHyperventilate Administer induction/sedation agents and Administer induction/sedation agents and

pretreatment meds (e.g. lidocaine or pretreatment meds (e.g. lidocaine or atropine)atropine)

Administer NMB agentAdminister NMB agent Sellick maneuverSellick maneuver Intubate per usualIntubate per usual Continue NMB and sedation/analgesia prnContinue NMB and sedation/analgesia prn

Pharmacologic Assisted Pharmacologic Assisted IntubationIntubation

Failure is not an option!Failure is not an option!

Needle ThoracostomyNeedle Thoracostomy IndicationsIndications

Positive signs/symptoms of Positive signs/symptoms of tensiontension pneumothoraxpneumothorax

Cardiac arrest with PEA or asystole with Cardiac arrest with PEA or asystole with possible tension pneumothoraxpossible tension pneumothorax

ContraindicationsContraindications Absence of indicationsAbsence of indications

Tension Pneumothorax Signs/SymptomsTension Pneumothorax Signs/Symptoms Severe respiratory distressSevere respiratory distress or absent lung sounds (usually unilateral)or absent lung sounds (usually unilateral) resistance to manual ventilationresistance to manual ventilation Cardiovascular collapse (shock)Cardiovascular collapse (shock) Asymmetric chest expansionAsymmetric chest expansion Anxiety, restlessness or cyanosis (late)Anxiety, restlessness or cyanosis (late) JVD or tracheal deviation (late)JVD or tracheal deviation (late)

Needle ThoracostomyNeedle Thoracostomy Prepare equipmentPrepare equipment

Large bore angiocathLarge bore angiocath Locate landmarks: 2nd intercostal space at Locate landmarks: 2nd intercostal space at

midclavicular linemidclavicular line Insert catheter through chest wall into pleural Insert catheter through chest wall into pleural

space over space over toptop of 3rd rib (blood vessels, of 3rd rib (blood vessels, nerves follow inferior rib margin)nerves follow inferior rib margin)

Withdraw needle, secure catheter like impaled Withdraw needle, secure catheter like impaled objectobject

Chest EscharotomyChest Escharotomy IndicationsIndications

Presence of severe edema to soft tissue of Presence of severe edema to soft tissue of thorax as with circumferential burnsthorax as with circumferential burns

inability to maintain adequate tidal volume, inability to maintain adequate tidal volume, chest expansion even with assisted chest expansion even with assisted ventilationventilation

ConsiderationsConsiderations Must rule out upper airway obstructionMust rule out upper airway obstruction RarelyRarely needed needed

Chest EscharotomyChest Escharotomy ProcedureProcedure

Intubate if not already doneIntubate if not already done Prepare site, equipmentPrepare site, equipment Vertical incision to anterior axillary lineVertical incision to anterior axillary line Horizontal incision only if necessaryHorizontal incision only if necessary Cover, protectCover, protect

Airway & Ventilation MethodsAirway & Ventilation Methods

Saturday’s classSaturday’s class Practice using Practice using

equipmentequipment orotracheal intubationorotracheal intubation nasotracheal nasotracheal

intubationintubation gastric tube insertiongastric tube insertion surgical airwayssurgical airways needle thoracostomyneedle thoracostomy combitubecombitube retrograde intubationretrograde intubation

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