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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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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)
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
Endotracheal IntubationEndotracheal Intubation
IndicationsIndications Present or impending respiratory Present or impending respiratory
failurefailure ApneaApnea Unable to protect own airwayUnable to protect own airway
Endotracheal IntubationEndotracheal Intubation
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
Endotracheal IntubationEndotracheal Intubation
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
Endotracheal IntubationEndotracheal 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)
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
ALS EquipmentALS Equipment
ALS EquipmentALS Equipment
From AHA PALS
ALS EquipmentALS Equipment
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
Evaluate Evaluate 33--33--22
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
Evaluate Evaluate 33--33--22
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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
Blind Nasotracheal IntubationBlind Nasotracheal Intubation Position, oxygenate patientPosition, oxygenate patient Monitor patientMonitor patient
ECG monitorECG monitor Pulse oximeterPulse oximeter
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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)
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
ALS Airway/ Ventilation MethodsALS Airway/ Ventilation Methods
Pharyngeal Tracheal Lumen Airway
(PTLA)
From AMLS, NAEMT
ALS Airway/ Ventilation MethodsALS Airway/ Ventilation Methods
No. 1
100 ml
No. 1100 ml
Combitube®
From AMLS, NAEMT
ALS Airway/ Ventilation MethodsALS Airway/ Ventilation Methods
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
ALS Airway/ Ventilation MethodsALS Airway/ Ventilation Methods
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
ALS Airway/ Ventilation MethodsALS Airway/ Ventilation Methods
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
ALS Airway/ Ventilation MethodsALS Airway/ Ventilation Methods
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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
Pharmacologic Assisted IntubationPharmacologic Assisted Intubation
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
Pharmacologic Assisted IntubationPharmacologic Assisted Intubation
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
Pharmacologic Assisted IntubationPharmacologic Assisted Intubation
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
Pharmacologic Assisted IntubationPharmacologic Assisted Intubation
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®)
Pharmacologic Assisted IntubationPharmacologic Assisted Intubation
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!
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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)
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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
ALS Airway/Ventilation MethodsALS Airway/Ventilation Methods
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