Intubation Obstacle Course
February 2011 CE
Condell Medical Center
EMS System
Site code #107200E - 1211
Prepared by: FF/PM Erich Castillo;
Greater Round Lake Fire Department
Reviewed/revised by: Sharon Hopkins, RN,
BSN, EMT-P
1
Objectives
Upon 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.
2
Objectives cont’d
6. 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.
3
Objectives cont’d
13. 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.
4
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.
5
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 (inline, face to face, in confined space, digital
intubation, with a foreign body).
6
Upper and Lower Airways
Upper airway
structures
Nose
Mouth
/ Pharynx
Lower airway
structures
Alveoli
7
Pediatric Airway Funnel Shaped
Peds Airway
Adult Airway
8
Airway Compromise
Blockage
 Improper positioning
 Foreign bodies
 Improperly placed ETT
Swelling
Trauma
 Blunt, crushing injury
 Burns
 Improper use of airway adjuncts
Disease
 Asthma
 Croup
 Epiglottitis
9
Oxygen Therapy
If the patient is in dire need and
requires oxygen, the maximum
amount is to be delivered
 Airway
compromise
 Shock
 Impending
arrest
 Arrest
Use best tool for the situation
 Non-rebreather
 BVM
10
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%
11
New SOP’s Coming
Watch for revisions in
oxygen administration
guidelines coming to you
in the revised SOP 2011
More to follow!
12
“Securing” the Airway
Definition of a secured airway
Whatever 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
13
Open vs Blocked Airway
Vocal
Larynx cords
Tongue
Trachea
Esophagus
Positioning of
airway important
for keeping airway
open
14
Airway Maneuvers
Head-tilt / chin lift
Maneuver used to open the airway to
relieve obstruction by the tongue
Reliable, dependable
Often under-utilized skill
Recommended for all unconscious
patients
If suspected cervical spine injury,
perform modified jaw thrust with
in-line stabilization of the cervical spine
15
Airway Adjuncts
Mechanical airways
Helps lift base of tongue forward, away from
posterior oropharynx
Does not replace good head positioning
 Oropharyngeal
 NOT
airways
for patients with a gag reflex!!!
 Nasopharyngeal
 Tolerated
airways
by patients with and without gag
reflex
16
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
17
Oropharyngeal
Airway
1 Measure
2 Place
3 Assess
Check that the tongue was not
inadvertently pushed back blocking the
airway
18
Nasopharyngeal Airway
Uncuffed soft tube; follows curve
of nasopharynx to just below base
of tongue
Indicated for soft tissue upper airway
obstruction
Tolerated by patients with and without gag
reflex
Not recommended for facial or head
trauma
Can cause more trauma during
placement
19
Nasopharyngeal
Airway
1 Measure
2 Place
3 Assess
20
Nasopharyngeal Airway
Inserted bevel side toward the septum
LUBRICATE; LUBRICATE;
LUBRICATE
Right
nares
Right nares slides in
Left 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 insertion
Did we say LUBRICATE?!
Left
nares
21
Advanced Airway Techniques
Using an invasive device with
additional equipment to secure the
airway
22
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
23
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)
24
Potential Complications During
Intubation
Inability to view vocal cords
Breaking teeth/dislodging bridgework
Damage to gums
Faulty cuff
Unrecognized esophageal intubation
Unrecognized right main stem
intubation
Laryngospasm
Failure to complete intubation
25
Equipment Required
BVM
Laryngoscope with
curved and/or
straight blade
ET tube
(size of little finger
for peds)
Extra ET tube – one
size up and one size
down
Stylet
Suction unit
Oral airways
10 ml syringe
Lubricant
Gloves
Eye Protection
Stethoscope
Method to secure
ET tube in place
26
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
27
BVM Assisted Ventilations
Hand-held device to provide positive
ventilations to patients
Absent respirations
Ineffective ventilations
Must have proper seal to prevent air
leakage
Rate sufficient for situation
Risk of over inflation of lungs, gastric distention,
vomiting
To 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 age
To ventilate via ET tube – once every 6 - 8
seconds in all peds and adults
Suctioning
Removes secretions and oxygen!!!
May stimulate gagging and vomiting
Most EMS patients not NPO!
Limit to 10 seconds for adults
Limit to 5 seconds in the pediatric
population
Watch for hypoxia induced bradycardia
Suction on removal of catheter only
29
Typical Sizing ETT
Generic guidelines
Use length based tape (ie: Broselow )
for pediatric sizing guidelines
30
Stylet
Used 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
31
Straight Blade
Miller
Blade lifts epiglottis
Vocal cords are exposed
Direct visualization allowed
30 second time limit to intubate!!!
32
Curved Blade - Macintosh
Blade 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!!!
33
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″
34
Difficult Airways – What Are You
Going To Do?
Positioning
Peds
Anatomy
Swelling
Obstructions
35
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 Body
Magill forceps
Useful to pull out foreign bodies from the
airway
Vocal cords
Can be used to guide ET
tube through vocal cords
ET tube cuff
Magill
forceps
If you always anticipate you need them,
Not a tool you have time to look for –
when you need them, you need them
NOW
What else is out there?
What does the
literature say?
38
Mallampati Score
Tool to evaluate and gain
estimate of difficulty of
intubation
Evaluation obtained while
visualizing the anatomy
Fewer structures
visible=greater difficulty in
completing the intubation
Used in hospitals and
some EMS areas
39
Cricoid Pressure/ Sellick Maneuver
Helpful to stabilize
anatomical structures
Helpful to reduce
regurgitation
Hazardous if too much force
applied and airway is
actually compromised during
ventilations
Palpate cricoid cartilage and
press directly backwards
40
“BURP” – Visualizes Cords
Backward, upward, right pressure
Placed on thyroid cartilage (not cricoid
cartilage)
Improves visualization of vocal cords
during intubation attempt
Larynx 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
Blind Insertion Airway Devices
#1
1. Combitube
2. King LT-D airway
3. LMA
#2
Not as effective as ETT in
preventing aspiration
Useful in unsuccessful traditional #3
ETT placement
More information coming related
to this equipment with 2011 SOP
updates
42
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
43
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!
44
View with a blade and good light.
Vocal cords and surrounding structures
45
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
46
Confirming ET Tube
Placement
Direct visualization of
vocal cords
5 point auscultation
Listen 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
47
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
48
Capnography
Measurement of exhaled CO2 levels
Device displays a tracing and level of
readings – similar to an EKG
Normal 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 bronchus
Breath sounds absent on left; more chest rise
and fall on right
While listening over left chest, reposition ET
tube until breath sounds are heard
Esophageal intubation
Epigastric sounds, no breath sounds, no rise
and fall of chest
Immediately remove ET tube,
ventilate/oxygenate patient, reattempt
intubation
Securing ET Tube
NEVER let go of the tube until secured
 Tape
 Commercial
tube holder
ETT easily displaced so requires
ongoing assessment
51
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
52
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?
53
Alternate Techniques
for ETT Placement
54
In-line Intubation
Used in patients with suspected
cervical spine injuries
Head and neck maintained in-line
without manipulation
Best 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
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!
56
Digital Intubation
Useful if positioning is difficult
Rescuer does not have full view of
airway
Patient may have spinal cord injury
Facial injuries distort anatomy
Hazardous to rescuer if patient
clamps down on fingers
Always have sturdy material between
teeth
57
Digital Intubation
Procedure
Place mouth prod to protect
fingers from being bitten
Stand to patient’s left side
Insert left index and middle
fingers into patient’s mouth
Elevate 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
58
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."
59
Becoming an Expert Intubator
 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.
60
Becoming an Expert Intubator
 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.
61
Becoming an Expert Intubator
 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.
62
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
63
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
64
Case Scenario #2
How do you secure this airway?
65
Case Scenario #2
You have arrived on the scene of a
MVC (auto versus tree)
Patient is pinned in the car
Respirations are labored
How are you going to secure the
airway?
Need C-spine manual immobilization
Intubation possibly face to face
May have to lay across hood of car
reaching over steering wheel
May need to do digital intubation
66
Case Scenario #3 - Documentation
Call 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
67
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.
68
Case Scenario #5 - Documentation
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.
Case Scenario #6 - Documentation
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
70
Case Scenario #7 - Documentation
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.
71
Case Scenario #8 - Documentation
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
72
Case Scenario #9 - Documentation
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.
Practical Skills
EMT-Basic
Measure and place oro and
nasopharyngeal airways
Practice effective bagging
Once every 5-6 seconds with BVM
Once every 6-8 seconds via ETT
EMT-Paramedic
Measure and place oro and
nasopharyngeal airways
Intubate a manikin
Work with manikin in a variety of positions
Try regular, in-line, face-to-face, and digital
74
Questions?
75
Bibliography
American 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. 2008
Journal of Emergency Primary Health Care. Article
#990101. Vol 3 Issue 1-2. 2005
Suprun, S. C. New Airway Models in the Fast
Lane. Fire Engineering. May 1, 2005.
www.cic.ahajournals.org/cgi/content/full/122/18_su
ppl_3/S640
www.Fireengineering.com
www.4um.com/tutorial/icm/intubate.htm
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