Introduction to ALS
Sir Sandford Fleming
Outline
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Work Environment
Scope of Practice
Training
Equipment
Procedures
How PCP/ACP Combos work
What will be expected of you?
Work Environment
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Many services are up to 40% ALS
Presents different challenges
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Bags are different
Dispatched differently
Crew configuration different (>age)
Expectations for level of care higher
Closer scrutiny
Potentially more stress for the crew
Combined care (different attendant/driver roles)
Work
Environment
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Legislation
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Narcotics
Check sheets
Signatures
DMA
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Risk’s/benefit
Higher chance
something will go
much better or much
worse
Scope of Practice
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Lots more drugs
Lots more heavy things
Special airway equipment
Special features on monitor
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Manual defib
Cardioversion
Pacing (transcutaneous)
Scope of Practice
Manual Defibrillation, Pacing and Cardioversion
Advanced Airway
LMA’s , Lited Stylets
BTLS, ACLS ,PALS
IV Therapy
ALS Drugs plus Symptom Relief, Versed, Fentanyl
Activated Charcoal
CXR Interp
Pentaspan
Difficult Airway Algorithm
Need ETT
Attempt #1 -Without sedation(crash) or nasal ETT
Attempt #2- Midazolam 0.05 mg/kg
Fentanyl 1-1.5 mcg/kg
Attempt #3(or RSI Direct) Lidocaine, (atropine) with
midazolam and fentanyl (see above) and succinylcholine
1-1.5 mg/kg
Backup- Laryngeal Mask Airway, Lighted
Stylet, Surgical Airway
Training
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Time lines – roughly 1
year for ALS
Didactic –classroom time
Clinical –practice in a
controlled setting
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OR
ER
MOP/SOP
OBS/PEDS/ICU
Other (Burn Unit, HSC IV
Team)
Preceptorship/Consolidation
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Where it should all come together
With a designated preceptor
Gradual transition to full care
Equipment
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Airway–
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Basic airway
Laryngoscope plus ETT for Intubation
Rescue Devices –advanced airway
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Lighted stylet
LMA –
Surgical –Seldinger vs Quik Trach
Bougie
Procedures
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Cardioversion
Pacing
Sedation
Vagal and CSM
Manual Defibrillation
IV Bolus and IV
medication
Other routes
(PR,IN,IM,ETT,IO)
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Intubation
Advanced airway
Needle decompression
IO
Thrombolytics
VAD Central access
Airway
CONTROL THE AIRWAY
Airway Management Decision Process
(Judge how aggressive you need to be.)
-Time/Distance
-Personnel
-Equipment
-Other Considerations?
CONTROL THE AIRWAY
“Evaluate for signs of difficult intubation”
(this may help in your decision as well)
-Obesity
-Small body habitus
-Small jaw
-Large teeth
-Burns
-Trauma
-Anaphylaxis
-Stridor
CONTROL THE AIRWAY
The PCP vs. ACP airway
decision may not be based on
one single factor, but rather
based on an overall
assessment of many factors.
CONTROL THE AIRWAY
Pre-Intubation
-Prepare Equipment
-Hyper-oxygenate
CONTROL THE AIRWAY
Orotracheal Intubation Procedure
Sweep
Left and
Look
CONTROL THE AIRWAY
Find Your Landmarks
Backward, Upward, Right Pressure (B.U.R.P.)
CONTROL THE AIRWAY
Find Your Landmarks
CONTROL THE AIRWAY
Find Your Landmarks
It may not be perfect!
CONTROL THE AIRWAY
Find Your Landmarks
CONTROL THE AIRWAY
Readjusting with Cricoid Pressure
CONTROL THE AIRWAY
Common Provider Mistakes
*Making a difficult intubation more difficult
*Rushing
*Poor equipment preparation
*Suction (lack there of)
CONTROL THE AIRWAY
What is your back-up plan today?
prolonged BVM…
another provider…
a smaller tube…
better lighting…
additional suctioning…
CONTROL THE AIRWAY
Helpful Adjuncts
Gum
Elastic
Bougie
CONTROL THE AIRWAY
Helpful Adjuncts
Lighted Stylette
CONTROL THE AIRWAY
Nasotracheal Intubation
Indications:
“Patient still breathing but
in respiratory failure and
in whom oral intubation is
impossible or difficult.”
CONTROL THE AIRWAY
Nasotracheal Intubation
Contraindications:
-Apnea
-Resistance in the nares
-Blood clotting or
anticoagulation
problems
-Basilar Skull Fx (?)
STEP 4. CONTROL THE AIRWAY
Nasotracheal Intubation
Technique:
-Prepare patient and nostril
-Prepare tube
-Insert on inspiration
-Take your time
Complications:
-Bleeding
. CONFIRM THE AIRWAY
Intubation Confirmation
Good, Better, Best
Traditional
Technology Based
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Direct
Visualization
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ETCO2 (monitor)
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EDD (bulb)
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Lung Sounds
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Colormetric (cap)
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Tube
Condensation
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Pulse Ox change
SECURE THE AIRWAY
Secure Your Tube
Good, Better, Best
Tape
Improvised devices
Commercial devices
Immobilization (?)
ALTERNATIVES TO ETI
Laryngeal Mask Airway
Developed in 1981 at the Royal London
Hospital By Dr Archie Brain
STEP 7. ALTERNATIVES TO ETI
Laryngeal Mask Airway
Indications:
-When definitive airway management
cannot be obtained. (ETT)
Not a substitute for definitive airway
management
ALTERNATIVES TO ETI
Laryngeal Mask Airway
Contraindication/Limitations:
-Obesity
-Non-secure
-Size based
-Not a med route
ALTERNATIVES TO ETI
Laryngeal Mask Airway
Weight Based Sizing
<5kg = Size 1
5-10 kg = Size 2
20-30 kg = Size 2.5
Small Adult= Size 3
Average Adult = Size 4
Large Adult = Size 5
ALTERNATIVES TO ETI
Laryngeal Mask Airway
Average Adult Woman = 4
Average Adult Male = 5
*If in doubt, check the LMA
ALTERNATIVES TO ETI
Laryngeal Mask Airway
Procedure:
-Hyper oxygenate
-Check cuff
-Lubricate posterior cuff
-Head in neutral or slightly flexed position
-Insert following hard palate (use index finger to guide)
-Stop when met with resistance
-Let go and inflate cuff (visualize “pop”)
-Confirm and secure
ALTERNATIVES TO ETI
Laryngeal Mask Airway
Air volume is variable depending on cuff size
and individual patient anatomy
General Guideline:
Size 1 = 4 ml
Size 2 = 10 ml
Size 2.5 = 14 ml
Size 3 = 20 ml
Size 4 = 30 ml
Size 5 = 40 ml
ALTERNATIVES TO ETI
Laryngeal Mask Airway
Common Provider Problems:
-Failure to seat properly
-Sizing difficulties
-Aspiration
King Airway
King Airway
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Why
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Unconscious / unresponsive patients without gag reflex
Blind insertion technique
Alternative to E.T.T.
Known Issues
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Obtaining proper seal / placement
Is NOT a medication route for Endotracheal drugs
Multiple sizes, based on height, also multiple cuff volumes
Contraindications
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Responsive patients with an intact gag reflex.
Patients with known esophageal disease.
Patients who have ingested caustic substances.
User Tip
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The key to insertion is to get the distal tip of King Airway around
the corner in the posterior pharynx, under the base of the
tongue.
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Experience has indicated that the lateral approach, in
conjunction with a chin lift, facilitates the placement of the King
Airway.
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Alternatively, a laryngoscope or tongue depressor can be used
to lift the tongue anteriorly to allow easy advancement of the
airway into place.
Insertion #1
Insertion #2
Insertion #3
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As the King Airway is advanced around the corner
in the posterior pharynx, it is important that the tip of the device
be maintained at the midline.
If the tip is placed or deflected laterally, it may enter into the
piriform fossa and the tube will appear to bounce back upon full
insertion and release.
Keeping the tip at the midline assures that the distal tip is
properly placed in the upper esophagus.
Insertion #4
Insertion #5
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Air Volume Required for Cuff Inflation:
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Size #3: 55 ml
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Size #4: 70 ml
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Size #5: 80 ml
Insertion #6
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Attach Bag
While gently bagging, simultaneously
withdraw the King Airway until ventilation is
easy and free-flowing.
Can the King tube device be used for PPV?
Yes, in unresponsive non breathing pts
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Is there an optimal head position for insertion?
– Sniffing position, but the head can be in neutral position.
– For obese patient’s, elevation of the shoulders & upper back should be
considered.
How long can the King tube be left in place?
– Up to 8 hours. For longer procedures it is important to monitor& limit cuff
pressure to 60 cm H20 or less.
If my patient needs to be on a mechanical ventilator, do I need to replace the
tube?
– Due to the King tube’s improved ventilatory seal, it is less frequent that the
tube needs to be exchanged compared to other supraglottic airways.
Can a laryngoscope be used?
– Yes, but it is not routinely used. It may be used by the inexperienced user,
or difficult airway.
What volume of pressure is needed to properly inflate the cuffs?
– The least amount needed to create a seal at the desired ventilatory
pressures. Each tube size is different
What reference point for the centimeter depth markings on the tubes?
– The cm markings indicate the distance from the distal ventilatory opening.
The markings serve as a visual reference after placement and can be used
to document insertion depth.
SURGICAL AIRWAYS
Indications
-Obstruction
-Facial Trauma
-Intubation or other
alternatives impossible
-Trismus (clenching)
->8 years old (for open
procedures)
LAST RESORT!
SURGICAL AIRWAYS
-Vertical Incision
over membrane
-Pierce membrane
in horizontal plane
-Open and spread
to insert 4.0 or 5.0
tube
-Secure tube in
place and ventilate
SURGICAL AIRWAYS
Needle
Cricothyrotomy
Needle Procedure:
-Identify Cricothyroid membrane
-Pierce at 45° angle
-Place catheter or styllette
-Advance dilator per
manufacturer’s recommendation
SURGICAL AIRWAYS
Commercial Needle
Cricothyrotomy Devices
Quick Trach
Pertrach
WHY AN ALGORITHM?
1. Step by step process in order
2. Start simple and work up
3. Alternatives
4. Be sure
5. Get it done
Procedure for Intubation
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Preoxygenate with 100% (may not need to bag)
Prepare equipment (SLOPES-M)
Hyperextend –Sniffing position
Insert larygoscope into R sweep tongue to left
Look for view
Insert ETT to 1-3 cm beyond cords
Withdraw largy
Remove stylet
inflate cuff with 5-8 cc air
Auscultate neck, chest x 4
Secure ETT
Document cm marking and reevaluate often
How you can help as PCP (PRN)
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Prepare equipment
Preoxygenate patient
BURP (backwards upwards and to the right
pressure-thyroid cartilege mvmt)
Cric pressure
Remove styet when asked
Inflate balloon
Secure ETT
Ventilate patient
Cricoid pressure
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Only when asked to
Know your landmarks
Burp –backwards upwards and to
the right (pressure)
Monitor/Defibrillator
LP 12/Zoll has
 pacing
 Cardioversion
 12 lead
 NIBP
 SpO2
 ETCo2 (mainstream) detection
 Manual defibrillation
Symptomatic Patients get treated
electrically
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Chest pain
Shortness of breath
Pulmonary edema
Hypotension
Diaphoresis
Decreased LOA
Vagal Manuvers/CSM
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For stable patients with signs of clinically
significant tachy rhythms
CSM “Fake” the baroreceptors into thinking
BP is too high so slows HR down
Vagal manuvers- increase ITP to see if can
stimulate a vagal response
Patients <70 or with no bruits in carotid
arteries
Synchronized Cardioversion
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Unstable tachydysrhythmias
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Pad placement
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Synchronize the monitor
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Sedation, anaelgisics, amnestics
Symptomatic Tachyarrhythmias
•Chest pain
•Hypotension
•Syncope
•Diaphoresis
•Shortness of breath
•Pulmonary edema
•Altered LOC
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Signs & symptoms
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Experience and judgment
What Does the “SYNC” Button
Do?
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Tags the R waves
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Timing – refractory periods
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Do NOT want to cardiovert at this time!
Iatrogenic R on T - Cardioversion
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Cardiac arrest
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Always double check
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Automatic ‘sync’ shutoff
Advanced Care Directive - VT with
Pulse
ATTEMPT PATCH IMMEDIATELY
O2 via NRB mask / Intubate PRN
IV access
Bolus 500 cc NS
Lidocaine 1.5 mg/Kg IV
Synchronized cardioversion Monophasic 100J
Synchronized cardioversion Monophasic 200J
Advanced Care Directive - VT with
Pulse
Patient Symptomatic?
Sedate PRN
ATTEMPT TO PATCH
Synchronized cardioversion Monophasic 200J or
Synchronized cardioversion Monophasic 360J
PATCH IF RETURN OF NORMAL RHYTHM
Atrial Flutter
Atrial Fibrillation
Synchronized cardioversion 50J
Synchronized cardioversion 100J
Synchronized cardioversion 100J
Synchronized cardioversion 200J
REATTEMPT TO PATCH
REATTEMPT TO PATCH
Synchronized cardioversion 200J
Synchronized cardioversion 300J
Synchronized cardioversion 300J
Synchronized cardioversion 360J
Synchronized cardioversion 360J
Considerations
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Inform bystanders
Skin irritation/burns
Arching of current
Adjust ECG size
EVERYONE CLEAR!
Transcutaneous Pacing
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Symptomatic bradycardias
Over-ride pacing
Quickly available
Standby pacing
Sedation, analgesics, amnestics
Contraindications
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Severe hypothermia
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Cardiac arrest > 20 minutes
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Open chest wounds
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Flail chest
Procedure for Pacing
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Explain to patient
O2 & IV therapy
Sedate – BHP
Pad placement
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Turn “pacer” on
Set HR between 6080
Increase mA capture
Add 10 mA - safe
zone
Defibrillation-Manual
ALS algorithm for Vfib/Vtach pulseless
CPR
Defibrillate Monophasic 200,300,360 J or
Biphasic
INTUBATE / IV ACCESS
1.0 mg Epi (1:10,000) IV or 2.0 mg Epi ETT
repeat q 3-5 minutes
Defibrillate Monophasic 360 J x3 or Biphasic
200J x3
1.5 mg/Kg LIDOCAINE IV or 3.0 mg/Kg ETT
Defibrillate Monophasic 360 J x3 or Biphasic
200J x3
Remember in manual mode, the machine will shock
regardless of what the rhythm on the monitor is!
Drugs Carried by ALS
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NTG
ASA
Ventolin (MDI,ETT,Neb)
Glucagon
Epinephrine 1:1000,1:10000
Atropine
Lidocaine (preload and spray
Lasix
Adenosine
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Dopamine
Midazolam
Diazepam
Fentanyl
Morphine
D50W
Na Bicarbonate
Otrivin
Gravol
Treating patients -Differences
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Can give NTG if no prior use
Increased selection of things to do
Also increased responsibility
Increased accountability
Increased $$$ too!