“Airway, Airway –
Who’s got the Airway?”
Issues and Techniques in
EMS Airway Management
Silver Cross EMS System
January 2012 1st Trimester CME
Our Agenda Today
• Review airway anatomy and physiology
• Review issues and techniques in airway
management
• Review use of CPAP in CHF and pulmonary
edema for both ALS and BLS providers
• EKG strip o’ the month: AV blocks/pacing
A & P Review
The abbreviated version!
Anatomy of the Upper
Airway
Internal Anatomy of the Upper Airway
Anatomy of the Lower Airway
Anatomy of the Pediatric Airway
Three Cardinal Sins of Airway
Management
1 - Failure to Ventilate
•
•
•
Intubation still be considered the gold standard in
prehospital airway security.
But if you can’t intubate you must still ventilate.
Proper equipment size, good mask seal and proper
tidal volume is essential.
2 - Failure to Recognize an Esophageal
Intubation and Correct It
•
Always use multiple methods of confirming tube placement
–
–
–
Reconfirm each and every time you move the patient.
Document each confirmation on your PCR.
With as many confirmation devices we have, patients still delivered to
the ED with unrecognized esophageal tube placement.
3 - Being Unprepared for the Difficult
Airway
•
Have multiple back–up methods for establishing an
airway and/or ventilating your patient.
–
–
–
•
Reposition airway and re-bag
King Airway
Needle Cric
Practice those methods, individually and in
sequence.
2
2
2
Rule of Two’s
Rule of Twos
2
2
2 people
One to ventilate, one to hold the mask
2 airways
NPA + OPA
2 inches
Head elevation to sniffing position
2 seconds
Slow, gentle ventilation
2 PSI
Minimal pressures
2
2
2
2 People
• Hardest part of BVM ventilation
is achieving adequate seal
between the mask and the
patient’s face.
• Much easier to achieve and
maintaining seal using two
person technique.
– One to ventilate, and one to hold the
mask.
2 Airways
• Nasal and oral airways often forgotten in chaotic scene.
• But these simple techniques can make a lifesaving difference.
• An OPA and an NPA may be used together.
– Two NPAs can be used along with an OPA, if necessary.
• Imperative to make sure these devices are properly sized to each
individual patient and inserted correctly.
Two inches
• Sniffing position best way to
minimize airway resistance
during BVM ventilation
•
Also happens to be the best
position to visualize larynx
during intubation.
• Combination of forward
flexion and extension of the
neck achieved by elevating
head at least two inches.
• Can assist with difficult
intubations.
•
Can be increased with
additional padding, if needed.
• Obviously contraindicated in
patient with suspected
cervical spine injury.
Two seconds
• Deliver a slow, gentle ventilation over
two seconds.
• Slower ventilations result in more air
going into lungs than stomach.
• Also important to allow for sufficient
time for exhalation.
2 PSI
•
•
•
Two PSI not the actual pressure, but a
useful reminder to minimize ventilation
pressures.
Assess for adequate ventilation by
observing chest rise or appropriate lung
sounds.
In some patients, using one hand to
squeeze the bag rather than two will help
avoid over-pressured ventilations.
Basic Airway Maneuvers
Basic Airway Maneuvers
Head Tilt/Chin Lift
Head Tilt-Chin Lift
• Without suspected spinal injury
• Unresponsive patient that can not protect
their own airway
• Simple, safe and non-invasive
• Does not protect from aspiration
Head Tilt -Chin Lift
• Method
– Tilt head back with hand on patient’s forehead
– Fingers of other hand under bony part of lower
jaw and lift chin forward
– AHA standard for non-injury patient
Head-tilt chin-lift maneuver.
Jaw Thrust
Jaw-thrust Maneuver
• Used in the absence of suspected spinal injury
– Provides additional forward displacement of the mandible
– Method
• Grasp angle of lower jaw
• Lift with both hands and displace mandible forward while tilting
the head back
Jaw-thrust maneuver.
Mechanical Adjuncts in Airway
Management
ALWAYS BLS BEFORE ALS!
Oropharyngeal Airway
Oral Airway
• Hold tongue away from the posterior wall of the
pharynx
• Unconscious, semi-conscious without a gag
• Infant to adult sizes
• Measuring for placement
– Place next to patient’s face so flange is a central incisors
and the bite block segment parallel to the hard palate
Oral Airway
• Insertion
–
–
–
–
Clear airway
Upside-down OR at 90-degree angle
Rotate until against posterior wall of oropharynx
Confirm placement: observe chest wall expansion with
ventilation and breath sounds auscultated
Too Long: airway obstruction by pressing on epiglottis
Too Short: does not pull tongue away from the back of the
pharynx
Oral Airway
• Complications
– Does not protect lower airway from aspiration
– May stimulate vomiting and laryngospasm if gag
present
– If not inserted properly, pushes tongue back and
causes airway obstruction
Measuring an oral airway.
Inserting an airway upside down.
Oropharyngeal Airway
Improper placement of oropharyngeal
airway
Alternative method of inserting an oral
airway.
Nasal airways.
Nasopharyngeal Airway
• Semiconscious or patient unable to maintain
own airway
• Unconscious where oropharyngeal airway not
used
• Seizures
• C-spine Injury
• Before nasotracheal intubation
• Guide for inserting a nasogastric tube
Nasopharyngeal Airway
Measuring a nasal airway.
Nasal Airway
• Insertion
– Lubricate with water-soluble lubricant
– Bevel tip toward nasal septum (change position
for left vs right)
– Use natural curvature of nasal passage
– Should rest in posterior pharynx
– Displace mandible
Insertion of a nasal airway.
Nasal Airway
• Disadvantages
–
–
–
–
–
–
Longer length may enter esophagus
Laryngospasm and vomiting
Injury to nasal mucosa, bleeding or obstruction
Small diameters can become obstructed with vomit, mucus
Does not protect lower airway from aspiration
Can’t suction through
• Advantages
– Well tolerated in those with a gag reflex
– Inserted rapidly
– Used when oropharyngeal is contraindicated/facial trauma
Bag-Valve Mask Devices
BVM Devices
• Self inflating and non-rebreathing valve
• Used with BLS or ALS airway maintenance device
• Use with apenic patient or diminished respiratory
effort
• Provides blood/body fluid barrier
• Assist patient’s with shallow respirations
• Room air (21%) to 100% concentration
• Sense of lung compliance
BVM Devices
• Difficult to master – tidal volume dependent on mask
seal
• Complications
– Inadequate tidal volume from poor technique, poor mask
seal, and gastric distention
BVM Devices
• Method
– Rescuer at patient’s head
– Clear airway
– Head tilt- chin lift
– BLS or ALS airway
– Tight seal on mouth with E-C positioning
– One and two rescuer options
BVM Devices
• Method/Technique
– Observe for gastric distension, changes in bag
compliance, color changes, improvement in level
of consciousness, air leak around mask
– Trauma patients require in-line BVM
Pediatric bag-valve-mask device.
Airway Obstruction
Most common airway obstruction is tongue and
epiglottis.
• When unconscious patient lies on back, muscles in
jaw relax and jaw falls posteriorly.
– Epiglottis flops over the glottic opening.
• You can move tongue and epiglottis out of airway
with head tilt chin lift maneuver
– Lifts hyoid bone and epiglottis.
The Tongue as an Airway Obstruction
Other Causes of Obstruction
• Anaphylaxis
– Medications
– Food
– Bugs
Methods to Clear the Airway
Finger Sweep
Be careful when placing your fingers in
someone’s mouth
Think about your safety first
A finger sweep is okay … as long as there is no chance
the patient can close their mouth on your finger!
Visualization
Attempt to visualize an obstruction and remove
Magill Forceps
Using the Magills
Endotracheal Intubation
So, you think you may want to
intubate..
Why Do We Do This?
• Paramedics have been intubating since the 70’s.
• We’ve been taught that maintaining an airway and ensuring adequate
oxygenation supersedes everything other than scene safety.
• Currently some critics are revisit why we do this procedure
– In some instances it’s actually harming patients, and we know above all that our goal is
“to do no harm”.
• Let’s look further at some of the issues.
The Problems
• Some questioning if paramedics can safely intubate
• Some programs have data which shows successful
intubations as low as 50%
– In Silver Cross, intubation success widely variable, ranges
between 25-100 percent in any given month.
• Data shows intubation may be harmful in headinjured patients (rise in ICP during procedure)
• Some children seem to do better with BLS airway
interventions
The Cause Analysis
1.
2.
3.
4.
5.
Poor initial training
No or minimal OR experience
“Fred the Head” training only
Not enough field tubes to go around
Inadequate continuing education
requirements
Intubation - The Last Word
•
•
•
•
Paramedics must continue to intubate and
can do it well
Complacency can set in; don’t let it
Training, practice and medical control issues;
get involved
If we lose expertise in advanced airway
management, ALS can lose significant value
Consider….Endotracheal Intubation
Indicators
•
•
•
•
•
•
•
Respiratory or cardiac arrest.
Unconsciousness, absent gag reflex (“GCS <8, intubate”)
Risk of aspiration.
Obstruction due to foreign bodies, trauma,
burns, or anaphylaxis.
Respiratory arrest
Pneumothorax, hemothorax,
hemopneumothorax with respiratory difficulty.
Need for mechanical ventilation
Know….Complications of Endotracheal
Intubation
•
•
•
•
•
•
Equipment malfunction
Teeth breakage and soft tissue lacerations
Hypoxia
Esophageal intubation
Endobronchial intubation (right mainstem)
Tension pneumothorax
Recognize…Advantages of Endotracheal
Intubation
•
•
•
•
•
Isolates trachea and permits complete control of
airway.
Impedes gastric distention.
Eliminates need to maintain a mask seal.
Offers direct route for suctioning.
Permits administration of some medications.
–
No longer give ETT meds in Region 8
Remember…Disadvantages of
Endotracheal Intubation
•
•
•
•
Requires training and experience.
Requires specialized equipment.
Requires direct visualization of vocal cords.
Bypasses upper airway’s functions
of warming, filtering, and humidifying the inhaled
air.
So, you’re still determined to
intubate, what next?
Conscious Sedation
Consider conscious sedation with an initial 2mg
dose of versed.
Documentation should reflect individual doses of
versed, NOT total dose.
Pre-ventilate patient.
Position Patient
*In most supine patients, sniffing position
achieved by extension of head and elevation
of the occiput.
*Elevate the head until the ear is at the level
of the sternum
Assemble and check equipment
What blade do you
use?
Macintosh or Curved blade
The tip of the curved blade
should be placed in the vallecula
Miller or Straight blade
The tip of the straight blade is
designed to lift the epiglottis.
Special Needs Tip
*Soft tissue airway obstruction a threat for all
patients, but bigger problem for obese
patients.
*Obesity increases the volume of upper
airway soft tissue and subcutaneous fat.
*It lacks the rigidity and turgor of other tissue
and threatens the airway.
Documentation Tip
• Completely assess and document condition of
mouth, lips, and teeth before and after all airway
management procedures.
• Trauma to teeth and soft tissues often caused by
rough airway technique
– But they also may be present before you treat the patient.
– If a patient has damaged teeth or soft tissue injuries
before treatment begins, be sure it is documented.
Insert laryngoscope.
Visualize larynx and insert the ETT.
Tip of blade is inserted into
vallecula.
Use blade to lift epiglottis, directly
exposing vocal cords.
View of vocal cords.
ET tube passing through vocal
cords.
Positube may also be used to confirm placement
PosiTube
Bulb-Syringe Detectors
• Operate under the principle that esophagus is
collapsible tube
• Vacuum created in bulb after compressed (negative
pressure) to syringe = ET tube in esophagus
• Bulb device easily refills with air = ET tube in trachea
Confirm placement with
an ETCO2 detector.
Purple “poopy” = no CO2 detected (no perfusion)
Yellow “yay” = CO2 detected (good perfusion)
Secure tube.
When placement is confirmed and the cuff has been inflated,
release cricoid pressure.
Secure ETT and apply a cervical collar.
Reconfirm ETT placement.
Recheck placement “often” and every time the patient is
moved.
Documentation Tips
*Document number of attempts needed to
complete the procedure.
*Document tube size and depth of insertion at
the patient’s teeth or lip line.
*Also document how the tube was secured in
place (for example, by tape or device).
Paramedic Safety Tip
*Accidental extubation
can occur if
BVM device pulls on the tube.
Pediatric Intubation
• Anatomical considerations
–
–
–
–
–
Upper airway small
Tongue disproportionately large
Large tongue makes procedure more difficult
Epiglottis narrower and longer, more difficult to control
Larynx more anterior and elevated making visualization
more difficult
– Trachea more flexible and shorter
– Tracheal rings less developed and collapse more easily
Complications from Intubation
Procedures
• Vomiting and aspiration
• Release of epinephrine/norepinephrine
– Hypertension
– Cardiac rhythm disturbances
• Traumatic injury
–
–
–
–
Laceration to lips, tongue
Dental trauma
Tearing of tissue
Vocal cord injury
Complications in Intubation
Procedures
• Vagal stimulation in children causing
hypotension, bradycardia
• Increase in ICP
• Intubation of esophagus (most common
error/problem)
• Equipment malfunction
Colorimetric end-tidal CO2 detector.
Cricothyroidotomy
Cricothyroidotomy
Indications
• Upper airway obstruction which cannot be
dislodged by back blows or direct larygoscopy
and Magill forceps.
• Inability to insert an ETT past edema
• Destructive facial injury precluding the use of
ALS upper airway adjuncts.
Anatomical Landmarks
for Cricothyroidotomy
Cricothyroid
Membrane
Thyroid
Cartilage
Cricoid
Cartilage
Needle Cricothyrotomy
• Procedure
– BSI
– Ventilate
– Check equipment
• 12-14 ga. Cannula
• syringe
• 3.0 mm pediatric ET tube adapter
– Locate cricothyroid membrane
– Hyperextend head and neck
Needle Cricothryotomy
• Procedure
–
–
–
–
–
–
–
Prep area of insertion
Insert catheter at 45 degree angle into membrane (pop)
Aspirate with syringe (should get air if in trachea)
Withdraw needle
Attach 3.0 mm ET adapter
Ventilate and assess chest rise/lung sounds
Secure placement
Stabilize larynx and identify
cricothyroid membrane.
Locate/palpate
cricothyroid membrane.
Insert catheter & syringe downward
through membrane toward carina.
Insert large-bore catheter through
cricothyroid membrane.
Apply negative pressure to syringe;
air in syringe indicates
needle is in trachea.
Cannula properly placed
in trachea
Slide catheter off stylet into larynx.
Remove syringe, stabilize catheter, connect
oxygen tubing to oxygen regulator.
Quicktrach
• More expensive than needle crichs, but really
easy to use!
• Silver Cross EMS only allows the 4mm size, no
pediatric Quicktrachs in this system.
Quicktrach
syringe
hub of
catheter
Picture courtesy Christ
Medical Center
neck
strap
stopper
Quicktrach Procedure
• Patient supine with head slightly extended if no
cervical spine trauma suspected
• Locate the cricothyroid membrane
• Cleanse the overlying skin
Quicktrach Procedure cont’d
•
•
•
•
•
•
Puncture cricothyroid membrane at 90 degree angle
Aspirate air through syringe
Change the angle of insertion to 60 degrees
Slide catheter sheath forward to level of stopper
Remove stopper – may be a bit tight.
Advance plastic cannula while removing needle and
syringe
Quicktrach Procedure cont’d
• Ventilate the patient
• Secure catheter in place using the strap provided
• Confirm placement
– Auscultation, bilateral chest rise and fall
Chest Needle Decompression
• Used to decrease intrathoracic pressure
caused by pneumothorax/hemothorax
• Increased pressure causes inadequate venous
return and impaired cardiac output
• Definitive care is thoracostomy (chest tube)
• Air is trapped in the pleural space
Needle Decompression
• Signs/symptoms
–
–
–
–
–
–
–
–
Agitation, diminishing level of consciousness (early)
Pale, ashen, cyanotic skin color (early)
Diminished/absent breath sounds on affected side
Difficulty in breathing
Tachycardia
Narrowing pulse pressures
Tracheal deviation (late)
Subcutaneous emphysema
Needle Decompression
• Life Threatening Emergency
– Affected side lung compressed resulting in tidal
volume decrease
– Trapped air compresses on unaffected lung and
mediastinum
– Internal blood loss can occur
– Pressure increases venous return
Needle Decompression
• Procedure
– BSI
– Ventilate
– Check equipment
• 10-16 ga. Catheter need for decompression
Needle Decompression
• Identify and cleanse landmark
– 2nd intercostal space, mid clavicular line
– 4th intercostal space, mix axillary line
• Insert on the top of rib
• Nerves, arteries and veins at bottom of rib
Needle Decompression
• Reassess patients respiratory status
• Secure catheter
EMT-B Corner!
CPAP
• Both BLS and ALS providers in Silver Cross
EMSS now allowed to use CPAP
– CHF/Pulmonary Edema per SMO.
– Asthma and other respiratory issues with medical
control approval.
And now an Oscar-winning training film!
• Starring Erika Ball, RN, the newest
member of our EMS office!
• She will show the most common
disposable CPAP in the system.
– New info for EMT-B’s, a refresher for
EMT-P’s.
• Turn up your computer speakers…
film audio will come from speakers,
not phone.
Now is your chance…
• Use the text box on the right to ask your CPAP
questions.
• If you are watching the recording, or reading
this Powerpoint online, contact the EMS office
or your EMS coordinator with questions!
• If you wish to watch the film separately, a link
will be posted to the website.
EKG Strip O’ the Month
• AV Blocks
Review - AV Junction
• AV Junction = AV Node and Bundle of His
• Pacemaker cells located throughout AV
Junction
124
Review - Functions of AV Node
• Backup pacemaker for SA Node
• Creates delay between atrial and ventricular
depolarizations
• Physiologic block for rapid supraventricular
rhythms
125
Degrees of AV Blocks
• First Degree - Delay in conduction
• Second Degree - Some impulses blocked
• Third Degree - All impulses blocked
126
First Degree AV Block
• An abnormal slowing of AV Junction
conduction
127
First Degree AV Block ECG Criteria
• Rate - Dependent on underlying rhythm
– Interpretation must include underlying rhythm
• Rhythm - Dependent on underlying rhythm
• P-Waves - Normal morphology with one PWave for each QRS
• PRI - > .20 seconds and constant
• QRS - Dependent on underlying rhythm
128
First Degree AV Block Clinical
Significance
• Not usually detrimental and often resolves
when ischemia corrected
• Must consider entire patient
129
Second Degree AV Blocks
• Type I
– Also called “Wenckebach”
– Also called Mobitz I
• Type II
– Also called Mobitz II
130
Second Degree AV Block, Type I
• Intermittent block in which AV conduction
gradually slows until an impulse is blocked
• “Long, longer, longer, drop! Long, longer,
longer, drop!”
131
Second Degree AV Block, Type I
ECG Criteria
 Rate - Atrial rate unaffected but ventricular rate
is less than atrial rate
 Rhythm - Atrial rhythm usually regular.
Ventricular rhythm is irregular with more PWaves than QRS Complexes.
 P-Waves - Unaffected with more P-Waves than
QRS Complexes
 PRI - Progressively increases for consecutively
conducted P-Waves until QRS Complex is
dropped
 QRS - Unaffected
132
Second Degree AV Block, Type I
Etiology
• Often caused by increased parasympathetic
tone or drug effect
• Can be caused by MI
133
Second Degree AV Block, Type I Clinical
Significance
• Usually transient with good prognosis
• Can reduce cardiac output due to bradycardia
134
Second Degree AV Block, Type II
• Intermittent block in which not all P-Waves
are conducted to ventricles but there is no
progressive prolongation of PRI
• “Extra” p-waves.
135
Second Degree AV Block, Type II
Etiology
• Usually due to MI or other organic heart
disease
• Rarely the result of increased parasympathetic
tone or drug effect
136
Second Degree AV Block, Type II
Clinical Significance
• Poorer prognosis than Type I
• Usually requires pacemaker
• Frequently develops into Complete Block
137
Second Degree AV Block, Type II
ECG Criteria
 Rate - Atrial rate is unaffected but ventricular
rate is less than atrial
 Rhythm - Atrial rhythm regular, Ventricular
irregular with more P-waves than QRS
Complexes
 P-Waves - Normal morphology with more PWaves than QRS Complexes
 PRI - Constant for consecutively conducted PWaves
 QRS - Usually wide but may be narrow if block
is at His level or above
138
Second Degree AV Block, Type II
Example
139
Third Degree AV Block
• Complete blockage of impulse conduction
through AV Junction
• Results in “AV dissociation” (very very bad
thing)
• P’s and QRS’s “march to their own drummer”
140
AV Dissociation
• No relationship between P-waves and QRS
complexes
141
Third Degree AV Block Etiology
• MI
• Increased parasympathetic tone
• Drug toxicity
142
Third Degree AV Block ECG Criteria
•
•
•
•
Rate - Atrial > 60, Ventricular based on escape
Rhythm - Atrial and ventricular regular
P-Waves - Normal
PRI - No association between P-Waves and
QRS complexes (P’s and QRS’s are divorced
and do their own thing)
• QRS - Narrow if intranodal, Wide if infranodal
143
Transcutaneous Pacing (TCP)
• Non-invasive electrical therapy for
symptomatic bradycardias/complete heart
blocks
• Fast to set up
• Reasonably reliable
144
TCP Equipment
• Give the patient Versed if they are awake, per
SMO
• Set milliamps (adjustable 0-200mA typical)
– Start low if they are awake, and high if they are
out.
• Set rate to 70.
• Similar controls across brands
• Be familiar with your equipment!
145
Typical TCP Controls
146
Assess Electrical and Mechanical
Capture
• Electrical
– Displayed on monitor
• Mechanical
– Pulse
147
Questions?
• Recording of this session will be sent out
shortly.
• Please feel free to type questions in the text
box to the right before we sign off.
• Or email questions to afinkel@silvercross.org
• Thank you!