1 Intubation Obstacle Course February 2011 CE Condell Medical Center EMS System Site code #107200E - 1211 Prepared by: FF/PM Erich Castillo; Greater Round

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Intubation Obstacle Course

February 2011 CECondell Medical Center

EMS SystemSite code #107200E - 1211

Prepared by: FF/PM Erich Castillo; Greater Round Lake Fire Department

Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P

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ObjectivesUpon successful completion of this module, the EMS

provider will be able to:

1. Describe the airway anatomy in the adult, child and infant populations.

2. Explain the pathophysiology of airway compromise.

3. Review the use of oxygen therapy in cases of airway management in severe situations.

4. Describe the measurement, placement, and assessment of oropharyngeal and nasopharyngeal airways.

5. Explain the value of performing advanced airway procedures.

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Objectives cont’d6. List indications, contraindications, and

complications of ET intubation.7. List equipment required for oral intubation.8. Explain the rationale for having a suction unit

immediately available during intubation attempts.9. State the time limit for suctioning in the adult, child

and infant populations.10. Describe the methods of choosing the

appropriate sized endotracheal tube in an adult, child and infant populations.

11. Explain the rationale for using the stylet during intubation.

12. Describe the proper use of a stylet in orotracheal intubation.

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Objectives cont’d13. Describe the landmarks used with the Macintosh

and Miller blades for oral intubation.14. Describe the skill of orotracheal intubation in the

adult, child and infant populations.15. Describe the steps in confirming endotracheal tube

placement in the adult, child and infant patient.

16. Describe the use of the ETCO2 monitor.17. Describe the use of capnography to monitor

patient condition.18. State the consequence of and the need to

recognize unintentional esophageal intubation.19. Explain the rationale for securing the endotracheal

tube.

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Objectives cont’d

20. Describe the technique of securing the endotracheal tube in the adult, infant and child populations.

21. Review documentation components of the patient who has been intubated.

22. Demonstrate the skill of measuring and placing the oropharyngeal and nasopharyngeal airways in the adult patient.

23. Demonstrate the skill of orotracheal intubation in the adult patient.

24. Demonstrate confirmation of endotracheal tube placement in the adult patient.

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Objectives cont’d

25. Demonstrate the skill of securing the endotracheal tube in the adult patient.

26. Demonstrate the skill of intubation on the adult patient with multiple challenges and multiple obstacles confining the patient (in-line, face to face, in confined space, digital intubation, with a foreign body).

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Upper and Lower Airways

Upper airwaystructures

Lower airwaystructures

Nose

Mouth

Alveoli

/ Pharynx

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Pediatric Airway Funnel Shaped

Peds Airway Adult Airway

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Airway Compromise

Blockage Improper positioning Foreign bodies Improperly placed ETT

Swelling TraumaBlunt, crushing injuryBurnsImproper use of airway adjuncts

DiseaseAsthmaCroupEpiglottitis

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Oxygen Therapy

If the patient is in dire need and requires oxygen, the maximum amount is to be deliveredAirway compromise Shock Impending arrestArrest

Use best tool for the situationNon-rebreatherBVM

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Future Trend - Oxygen Therapy

New research = future practice

Hyperventilation pitfalls

intrathoracic pressure which CO

Compromises systemic blood flow

Hypocapnia (low CO2) may worsen global brain ischemia due to excessive cerebral vasoconstriction

100% O2 worsens short-term functional outcome compared to titrated O2 use to SaO2 of 94-96%

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New SOP’s Coming

Watch for revisions in oxygen administration

guidelines coming to you in the revised SOP 2011

More to follow!

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“Securing” the Airway

Definition of a secured airwayWhatever it takes to have and maintain an open airway

Whatever it takes to ventilate the patient

Whatever it takes to maintain adequate oxygenation levels

New trend: oxyhemoglobin saturation > 94%

Includes use of positioning and airway adjunct tools – basic and advanced

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Open vs Blocked Airway

Tongue

Positioning of airway important for keeping airwayopen

Trachea

Esophagus

Vocal

cordsLarynx

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Airway Maneuvers

Head-tilt / chin liftManeuver used to open the airway to relieve obstruction by the tongueReliable, dependableOften under-utilized skillRecommended for all unconscious patients

If suspected cervical spine injury, perform modified jaw thrust with in-line stabilization of the cervical spine

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Airway AdjunctsMechanical airways

Helps lift base of tongue forward, away from posterior oropharynx

Does not replace good head positioning

Oropharyngeal airways NOT for patients with a gag reflex!!!

Nasopharyngeal airways Tolerated by patients with and without gag

reflex

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Oropharyngeal Airway

Noninvasive; follows curve of palate

Indicated in patients with NO gag reflex

Check for presence of blink reflex

Facilitates suctioning

Can be used as a bite block to protect an endotracheal tube

Does NOT protect from aspiration

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Oropharyngeal Airway

1 Measure

2 Place

3 Assess Check that the tongue was not

inadvertently pushed back blocking the airway

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Nasopharyngeal Airway

Uncuffed soft tube; follows curve of nasopharynx to just below base of tongueIndicated for soft tissue upper airway obstructionTolerated by patients with and without gag reflexNot recommended for facial or head trauma

Can cause more trauma during placement

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1 Measure

2 Place

3 Assess

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Inserted bevel side toward the septumLUBRICATE; LUBRICATE; LUBRICATERight nares slides inLeft nares, starts upside down (bevel to the septum) and rotated into position

TIP: pull up on tip of nose to straighten curve that may block ease of insertionDid we say LUBRICATE?!

Left nares

Rightnares

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Advanced Airway Techniques

Using an invasive device with additional equipment to secure the airway

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Indications for Intubation

Inadequate oxygenation

Inadequate ventilation

Need to control and remove pulmonary secretions

Need to provide airway protection in an unresponsive patient or a patient with a depressed gag reflex

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Intubation Contraindications

Awake patient

Airway can be managed less invasively

Severe airway trauma or obstruction that does not permit safe passage of an endotracheal tube

Cervical spine injury, in which the need for complete immobilization of the cervical spine makes endotracheal intubation difficult (relative contraindication)

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Potential Complications During Intubation

Inability to view vocal cordsBreaking teeth/dislodging bridgeworkDamage to gumsFaulty cuffUnrecognized esophageal intubationUnrecognized right main stem intubationLaryngospasmFailure to complete intubation

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Equipment Required

BVMLaryngoscope with curved and/or straight bladeET tube

(size of little finger for peds)

Extra ET tube – one size up and one size downStylet

Suction unitOral airways10 ml syringeLubricantGlovesEye ProtectionStethoscopeMethod to secure ET tube in place

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Opening the Airway & Creating A Seal

Proper positioning of patient essential to place airway in best plane possible

Proper seal essential when using the BVM

Use “EC” technique

BVM Assisted VentilationsHand-held device to provide positive ventilations to patients

Absent respirationsIneffective ventilations

Must have proper seal to prevent air leakageRate sufficient for situation

Risk of over inflation of lungs, gastric distention, vomitingTo support ventilations in presence of spontaneous heartbeat- once every 5 - 6 seconds in adults; once every 3 - 5 seconds in peds up to 8 years of ageTo ventilate via ET tube – once every 6 - 8 seconds in all peds and adults

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Suctioning

Removes secretions and oxygen!!!

May stimulate gagging and vomitingMost EMS patients not NPO!

Limit to 10 seconds for adultsLimit to 5 seconds in the pediatric population

Watch for hypoxia induced bradycardia

Suction on removal of catheter only

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Typical Sizing ETTGeneric guidelines

Use length based tape (ie: Broselow ) for pediatric sizing guidelines

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StyletUsed to give form to the ETT

Use is by personal preference

NEVER to extend past distal tip of ETT

Recess tip of stylet approximately 2cm (3/4″) from distal opening

Bend over excess stylet to prevent inadvertent trauma to tracheal wall

Place tip in “hockey stick” position

Could also reform ETT into a curve

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Straight Blade Miller

Blade lifts epiglottis

Vocal cords are exposed

Direct visualization allowed

30 second time limit to intubate!!!

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Curved Blade - MacintoshBlade placed in vallecular space

Use left forearm to lift anatomy out of way to view vocal cords

Lifting motion moves epiglottis out of the way

30 second time limit to intubate!!!

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Choosing the Correct Pediatric Blade Size

Measure using space from tip of blade to notch

Measure from child’s upper incisor to angle of jaw within +/- 1/2″

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Difficult Airways – What Are You Going To Do?

Positioning

Peds

Obstructions

Anatomy

Swelling

Do you have adequate padding?

Evaluate the patient in the horizontal position

Draw an imaginary line from ear to shoulders

Patient will then be “in line”

Add to or subtract padding when cervical spine can be moved

Foreign BodyMagill forceps

Useful to pull out foreign bodies from the airway

Can be used to guide ET tube through vocal cords

If you always anticipate you need them,

Not a tool you have time to look for – when you need them, you need them NOW

Vocal cords

ET tube cuff

Magill forceps

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What else is out there?

What does the literature say?

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Mallampati Score

Tool to evaluate and gain estimate of difficulty of intubationEvaluation obtained while visualizing the anatomy

Fewer structures visible=greater difficulty in completing the intubation

Used in hospitals and some EMS areas

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Cricoid Pressure/ Sellick Maneuver

Helpful to stabilize anatomical structuresHelpful to reduce regurgitationHazardous if too much force applied and airway is actually compromised during ventilationsPalpate cricoid cartilage and press directly backwards

“BURP” – Visualizes CordsBackward, upward, right pressure

Placed on thyroid cartilage (not cricoid cartilage)Improves visualization of vocal cords during intubation attemptLarynx moved to the right as the tongue is swept to the left with the laryngoscope blade

NOT same maneuver as cricoid pressure; used for different results

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Blind Insertion Airway Devices

1. Combitube2. King LT-D airway3. LMA

Not as effective as ETT in preventing aspirationUseful in unsuccessful traditional ETT placementMore information coming related to this equipment with 2011 SOP updates

#1

#2

#3

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Medication Assisted Intubation

Region X is reviewing the use of medications used to assist in intubation in the non-arrested patient

Which drugs are most effective?

Which have the least amount of side effects?

Which drugs help to get the job done and improve patient outcome?

More to come with 2011 SOP updates

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Standard Oral Intubation

Use the curved or straight blade in left hand

Use right hand to place ET tube

DO NOT slide ET thru blade but along side blade – you still need to visualize your landmarks!

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View with a blade and good light.

Vocal cords and surrounding structures

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Insertion Techniques for ETT

Your positioning may be critical for successful insertion

Put the anatomy “in line” to improve visualization

Bring your body down to the airway level

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Confirming ET Tube Placement

Direct visualization of vocal cords

5 point auscultationListen over epigastric area first

Then listen upper lobes and midaxillary regions (farthest laterally in peds)

Watch for chest rise and fall

ETCO2 changing to & maintaining yellow coloring

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ETCO2

Measures the amount of CO2 exhaled at the end of each breath

Perfusion needs to be sufficient to circulate waste products (CO2) back to the lungs to be exhaled

Ventilation needs to be adequate to wash the CO2 out of the lungs to be measured

Yellow coloring indicates adequate CO2 levels

Indicator changes back and forth with the situation

Capnography

Measurement of exhaled CO2 levelsDevice displays a tracing and level of readings – similar to an EKGNormal reading is 35 – 45 mmHg

Watching wave shape can indicate hypoventilation, hyperventilation, return of spontaneous circulation during CPR

Improper ET Tube Placement

Huge risk not to identify this complication and immediately take the appropriate intervention

Right main stem bronchusBreath sounds absent on left; more chest rise and fall on rightWhile listening over left chest, reposition ET tube until breath sounds are heard

Esophageal intubationEpigastric sounds, no breath sounds, no rise and fall of chestImmediately remove ET tube, ventilate/oxygenate patient, reattempt intubation

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Securing ET Tube NEVER let go of the tube until securedTape Commercial tube holder

ETT easily displaced so requires ongoing assessment

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Documentation ET Tube Placement

On patient care report:

ET (size)___depth___cm Post ET lung sounds ET Attempt (x___) Capnography Checked Suction

Boxes used to indicate crew member activity

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Documentation ETT Placement

Do your times indicate the patient received ventilations via BVM prior to intubation?

Did you document assessment used to confirm tube placement?

Do you indicate a ventilation rate of once every 6-8 seconds (8-10 breaths per minute) post intubation?

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Alternate Techniques for ETT Placement

In-line Intubation

Used in patients with suspected cervical spine injuriesHead and neck maintained in-line without manipulationBest accomplished with 2 persons

1 person at head of patient intubating

If sitting, may have to use legs to hold head

1 person to the side holding head and neck

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Face to Face

Helpful for seated patient

Use the curved blade in RIGHT hand

Use LEFT hand to place ET tube

Note: Not hard to do, just needs practice!

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Digital IntubationUseful if positioning is difficultRescuer does not have full view of airwayPatient may have spinal cord injuryFacial injuries distort anatomyHazardous to rescuer if patient clamps down on fingers

Always have sturdy material between teeth

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Digital Intubation Procedure

Place mouth prod to protect fingers from being bittenStand to patient’s left sideInsert left index and middle fingers into patient’s mouthElevate epiglottis with left middle finger

Feels like tragus of ear (area next to canal opening & next to cheek)

Insert tube with right hand and guide tube forward into glottic opening with left index and middle fingers

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Becoming an Expert Intubator

Like any psychomotor skill, it takes instruction and practice to perfect ETI. There are five phases in the process of mastering a psychomotor skill

Imitation: The student repeats what is

done by the instructor. In medicine, this is often referred to as, "See one, do one."

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Manipulation: The student will use guidelines for skill development, and rely less on the instructor. The student may make mistakes, but correcting mistakes promotes learning. This also allows the student to develop their own style.

Precision: The student has practiced to the point where they don't make mistakes. However, they often can't perform the skill as well in a different setting.

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Articulation: The student is able to integrate both cognition and affect into skill performance. They understand why the skill is necessary and when it's indicated. They perform it proficiently and with style. They can perform the skill in multiple settings. This is the phase that students should reach before graduating an initial educational program.

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Naturalization: Eventually, the skill is performed without thought. The process has been ingrained into the operator's mind. For example, prior to mastering ETI, a student will reflexively pick up a laryngoscope in their dominant hand (usually right). After mastery, they reflexively pick it up with their left hand regardless of hand dominance.

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Case Studies

Read the accompanying scenarios.

What do you think?

How would you approach the situation?

Is there anything you would do different?

Remember to check the notes section for details on the scenarios

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Case Scenario #1

You are preparing to intubate your patient.If you are using the Miller (straight) blade, where does the tip go?

Under the epiglottis to lift it

If you are using the Macintosh (curved) blade, where does the tip go?

Into the valecullar space

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Case Scenario #2How do you secure this airway?

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Case Scenario #2You have arrived on the scene of a MVC (auto versus tree)Patient is pinned in the carRespirations are laboredHow are you going to secure the airway?

Need C-spine manual immobilizationIntubation possibly face to face

May have to lay across hood of car reaching over steering wheelMay need to do digital intubation

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Case Scenario #3 - DocumentationCall for low blood sugar - what do you think?

Comments: Found 37 y/o female unconscious, lying on floor. Pt’s husband states this happens frequently and she must not have eaten after taking her insulin. Glucose level 30. IV started and Dextrose given. Pt became A&O x3 with blood sugar of 57. Refused further treatment and transport. Release signed.Only information documented under drugs:

0505 – 50% Dextrose - 50ml - IV

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Case Scenario #4 - Documentation

Call for lift assist – what do you think?Comments: responded to residence for male subject who needed assistance to stand. AOx3 sitting on floor. Stated low back pain. Denied LOC, head or neck trauma. Assisted to standing position. Risks and benefits explained. Wife signed refusal.


Call for unresponsive person – what do you think?

Upon arrival found 87 y/o male lying on couch unresponsive. GCS 3. Respirations 6/minute. Log rolled to backboard. Pt cyanotic. Airway opened. Pt moved to ambulance. Put on monitor. NRB mask applied. Medication given for sinus brady. Report to medical control and further orders obtained. Pt transported.

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Call for MVC – what do you think?Dispatched to MVC. UA found 17 y/o pt ambulatory A&Ox3. 4 cars involved. Denies head, neck, back pain but complains of headache. Denied LOC. Refuses transport. Mother contacted and advised to have patient sign the release.

Area under “vital signs” marked as DNA

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Called to the scene for a seizure – what do you think?

Upon arrival found pt on the floor in an active seizure. Bystanders assisted patient to ground when seizure started. NRB mask applied at 15 L/min. IV established after 2 attempts. Valium administered and seizure activity stopped. Patient remains post ictal. Transported laying on left side.

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Call for low blood sugar – what do you think?

Upon arrival found 58 y/o female conscious, alert sitting in bed. Slow to respond. Glucose 27. Husband trying to give glucagon but forgot to reconstitute. Husband also gave oral glucose prior to our arrival. Pt A&Ox3 after dextrose. Pt voiced no complaints. Did not want transport. IV D/C’d. Catheter intact. No infiltration at site. Advised to follow-up with MD, informed of risks and benefits. Pt signed refusal.Check boxes: Alert, cooperative, GCS 4/4/6; 4/5/6; blood glucose levels 27/57/251


Call for possible overdose – what do you think?

UOA found 18 y/o pt with shallow respirations at 4/minute. Bystanders state took unknown drugs about 3 hours ago and has been drinking heavily. Immediately began bagging patient once every 6 seconds. Adequate chest rise and fall. SaO2 increased to 99%.Color improved. No response to Narcan x2. After above meds administered, patient intubated with #8 ET tube. Placement confirmed with bilateral breath sounds, no epigastric sounds, chest rise and fall. ETCO2 yellow.

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Practical SkillsEMT-Basic

Measure and place oro and nasopharyngeal airwaysPractice effective bagging

Once every 5-6 seconds with BVMOnce every 6-8 seconds via ETT

EMT-Paramedic Measure and place oro and nasopharyngeal airwaysIntubate a manikin

Work with manikin in a variety of positionsTry regular, in-line, face-to-face, and digital

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Questions?

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BibliographyAmerican Heart Association. 2010 Guidelines for Cardiopulmonary Resuscitation.Bledsoe, B., Porter, R., Cherry, R.. Essentials of Paramedic Care 2nd Edition. Brady. 2011.Campbell, J.E., International Trauma Life Support 6th Edition. Brady. 2008Journal of Emergency Primary Health Care. Article #990101. Vol 3 Issue 1-2. 2005Suprun, S. C. New Airway Models in the Fast Lane. Fire Engineering. May 1, 2005.www.cic.ahajournals.org/cgi/content/full/122/18_suppl_3/S640www.Fireengineering.comwww.4um.com/tutorial/icm/intubate.htmhttp://images.pennet.com/articles/ems/thm/th_132305.jpg

Documents

1 Intubation Obstacle Course February 2011 CE Condell Medical Center EMS System Site code #107200E - 1211 Prepared by: FF/PM Erich Castillo; Greater Round