Sierra –
Sacramento
Valley EMS
Agency
2015/2016
REGIONAL TRAINING
MODULE
S-SV EMS Agency 2015/2016
Regional Training Module
▪Training Module Agenda:
▪ S-SV EMS Agency General Trauma Management
Treatment Protocol (T-1) Spinal Stabilization
Updates
▪ Sepsis
▪ Advanced Airway Management
S-SV EMS Agency 2015/2016
Regional Training Module
▪Training Module Objectives:
▪ Participants in this course will learn the following:
▪ The history, facts and current guidelines related to prehospital
spinal immobilization/stabilization
▪ S-SV EMS Agency General Trauma Management policy (T-1)
updated spinal stabilization guidelines
▪ Prehospital assessment and treatment of sepsis patients
▪ Advanced airway management education/training that will:
1. Maximize first time attempt success
2. Reduce transient hypoxia and improve patient outcomes
3. Reduce complications, such as unrecognized esophageal intubation
Spinal
Stabilization
Spinal Stabilization
▪History of Spinal Immobilization
▪ A key feature of early EMT training
Spinal Stabilization
▪History of Spinal Immobilization
▪ 1960s: Growing awareness of spinal injuries
▪ “The most frequently mishandled injuries, made worse by hasty and
rough movement from a vehicle or other accident scene, are fractures
of the spine and the femur.” - J.D. Farrington, MD, from DEATH IN A
DITCH, American College of Surgeons, 1967
Spinal Stabilization
▪History of Spinal Immobilization
▪ Early spinal injury research
▪ A 1963 survey of a large series of patients with fatal injuries treated
at the Edinburgh Royal Infirmary showed that 25% of fatal
complications occurred during the period between the accident and
arrival in the ED
▪ This statement was taken by
several papers at the time to
imply that up to 25% of spine
injuries worsened because of
improper EMS packaging and
handling
Spinal Stabilization
▪History of Spinal Immobilization
▪ Early spinal injury research
▪ A 1965 retrospective study of 958 spinal cord injury patients in Toronto
attempted to quantify serious cord damage due to “inept handling of
the patients”
▪ Only 29 patients (3%) had “incontrovertible” evidence of delayed
paralysis, attributed to either pre- or in-hospital inept handling
▪ Authors suspected but could not prove that “a larger number
undoubtedly suffered this fate”
Spinal Stabilization
▪History of Spinal Immobilization
▪ Early spinal injury research
▪ In 1966, USAF Col. L. C. Kossuth first described the use of the long
backboard to “move a victim from the vehicle with a minimum of
additional trauma”
▪ Such movement was to occur with “due regard to maximum gentleness”
Spinal Stabilization
▪History of Spinal Immobilization
▪ Approximately five (5) million patients are immobilized in the prehospital
environment in the U.S. each year
▪ Most have no complaints of neck or back pain or other evidence of spine
injury
Spinal Stabilization
▪The Facts
▪ Greater than 50% of trauma patients with no complaint
of back/neck pain get full spinal immobilization
▪ 13% get immobilized without being asked about pain
▪ Less than 2% of EMS patients per year with suspected
c-spine injury have a fracture
▪ Less than 1% develop neurological deficits
Spinal Stabilization
▪Why Initiate Spinal Stabilization?
▪ 253,000 people in US living with spinal cord injuries
▪ 12,000 new cases each year
▪ In the US, the cost of MVA related spinal cord injury is
estimated to be $34.8 billion per year
Spinal Stabilization
▪Epidemiology of Spinal Cord Injuries
▪ 77.8% males
▪ Average patient age when injury sustained:
▪ 28.7 years old in 1970’s
▪ 39.5 years old in 2005
▪ Causes:
▪ MVC – 42%
▪ Falls – 27%
▪ Violence – 15%
▪ Sports – 7.4%
Spinal Stabilization
▪In some cases, spinal immobilization may not
be in the patient’s best interest
▪“Prehospital spine immobilization is associated with higher
mortality in penetrating trauma and should not be routinely
used in every patient with penetrating trauma”1
▪2001 Large meta-analysis on spinal immobilization
▪ “Effect on mortality, neurologic injury, spinal stability… uncertain.”
▪ “Possibility that immobilization may increase mortality and morbidity
cannot be excluded”
1Spine
immobilization in penetrating trauma: more harm than good?, J Trauma. 2010 Jan; 68(1):115-20
Spinal Stabilization
▪Backboards Cause Pain
▪ 1989 study of 170 trauma victims eventually discharged
from a major ED showed a significant reduction in c- and lspine pain when patients were allowed off the boards
▪ 21% had cervical pain/tenderness on the board but not off, suggesting
that the immobilization process or the boards themselves cause pain
that otherwise would not be there
▪ 1993 study caused 100% of 21 healthy volunteers to report
pain within 30 minutes of being strapped to a backboard
• Headache, sacral, lumbar, and mandibular pain most common
Spinal Stabilization
▪Backboards Cause Pressure Sores
▪ A 1988 prospective study at Charity Hospital of the
association between immobilization in the immediate post
injury period and the development of pressure ulcers in
spinal cord-injured patients
▪ Time on the spinal board was
significantly associated with
ulcers developing within 8
days
Spinal Stabilization
▪Backboards Cause Pressure Sores
▪ A 1995 study at Methodist Hospital of Indiana measured the
interface (contact) pressures over bony prominences of 20
patients on wooden backboards over 80 minutes
▪ Interface pressure > 32 mm Hg causes capillaries collapse, resulting in
ischemia and pressure ulceration.
▪ This study measured mean interface pressures as high as
149 mm Hg at the sacrum, 59 mm Hg at occiput, and 51
mm Hg at heels
Spinal Stabilization
▪Backboards Cause Respiratory Compromise
▪ A 1987 study at Beaumont Hospital of healthy, backboarded
males concluded that backboard straps significantly
decrease pulmonary function
▪ Similar 1999 study showed
15% respiratory restriction in
backboarded adult subjects
▪ 1991 pediatric study showed
decreased forced vital capacity
(FVC) in children due to
backboard straps
Spinal Stabilization
▪Other Concerns
▪ Cervical collars have been associated with elevations of
intracranial pressure (ICP)
▪ Prospective study of 20 patients
▪ Significant (p = .001) increase in ICP from 176.8 to 201.5 mm H20
▪ American Association of Neurological Surgeons (AANS) 2001
Guidelines for Prehospital Cervical Spinal Immobilization
following trauma:
▪ “There is insufficient evidence to support treatment standards”
▪ “There is insufficient evidence to support treatment guidelines”
Spinal Stabilization
▪ 5 year retrospective chart review at University of New Mexico and
University of Malaysia hospitals
▪ All 454 patients with acute spinal cord injuries included during the
5 year study period
▪ None of the 120 U. Malaysia patients were immobilized
▪ All 334 U. of NM patients were immobilized in the field
• Hospitals and treatment otherwise equivalent
• Results: 2x MORE neurologic disability in the University of New
Mexico patients
Spinal Stabilization
▪How well do we immobilize anyway?
▪ Convenience sample of 50 low acuity backboarded subjects
at one Level 1 ED
▪ 30% had at least 1 point where a strap or tape
did not secure the head
▪ 70% had 1 strap with >4 cm slack
▪ 12% had all 4 straps with >4 cm slack
▪ “At 4 cm, movement in any direction along the
board is both possible and probable”
▪ A well secured head and mobile body creates
movement of the neck
Spinal Stabilization
▪How well do we immobilize anyway?
▪ Backboards don’t make patients lie still
▪ A violent or agitated patient is going to fight against a backboard,
threatening his/her spine
▪ A cooperative patient is going to lie still when asked (or if it hurts to
move), regardless of a backboard or straps
Spinal Stabilization
▪How well do we immobilize anyway?
▪ Mock automobile was constructed to scale, and volunteer
patients, with infrared markers on bony prominences, were
extricated by experienced paramedics
▪ “Extricating the driver/subject headfirst by standard technique to a long
spine board was associated with significant cervical spine motion, both
with the collar alone and even with a cervical collar and KED”
▪ “Ultimately, we documented the least movement of the cervical spine in
subjects who had a cervical collar applied and were allowed to simply
get out of the car and lie down on a stretcher”
1Cervical
Spine Motion During Extrication: A Pilot Study, West J Emerg Med. 2009 May; 10(2):74-78
Spinal Stabilization
▪1999 NAMESP Position Paper
▪ “There have been no reported cases of
spinal cord injury developing during
appropriate normal patient handling of
trauma patients who did not have a cord
injury incurred at the time of the trauma.”
▪ “Although early emergency medical
literature identified mis-handling of
patients as a common cause of iatrogenic
injury, these instances have not been
identified anywhere in the peer-reviewed
literature and probably represent anecdote
rather than science.”
Spinal Stabilization
▪Summary
▪ We immobilize way too many patients
▪ Most injured patients will be mechanically stable
▪ Totally unstable patients probably have maximum damage
at time of impact
▪ All immobilized patients can be potentially harmed
▪ Spinal immobilization is a misnomer
▪ Spinal Immobilization is a method of transport, not a therapy
Spinal Stabilization
▪Latest Spinal Injury Guidelines
▪ In July, 2013, NAEMSP and ACS-COT released a joint position
paper on “EMS Spinal Precautions and the Use of the Long
Backboard” that indicated the following:
▪ Utilization of backboards for spinal immobilization during transport
should be judicious, so that the potential benefits outweigh the risks
▪ Spinal precautions can be maintained by application of a rigid cervical
collar and securing the patient to the EMS stretcher, and may be most
appropriate for:
▪ Patients who are found to be ambulatory at the scene
▪ Patients who must be transported for a protracted time, particularly prior to
interfacility transfer
Spinal Stabilization
▪S-SV EMS Agency Protocol T-1
▪ Patients with penetrating trauma to the head, neck or torso
and no evidence of spinal injury should not be stabilized on a
backboard
Spinal Stabilization
▪S-SV EMS Agency Protocol T-1
▪ Spinal stabilization with a backboard should be implemented
for trauma patients who meet any of the following criteria:
▪ Midline spinal pain or tenderness
▪ Limited cervical spine active range of motion
▪ Gross motor/sensory deficits or complaints
▪ High energy impact blunt trauma patients meeting anatomical and/or
physiological trauma triage criteria
Spinal Stabilization
▪S-SV EMS Agency Protocol T-1
▪ Spinal stabilization with or without a backboard should be
considered for trauma patients who have an unreliable
history & physical:
▪ Altered mental status (i.e. dementia or delirium)
▪ Intoxicated (drugs or alcohol)
▪ Injury detracting from or preventing reliable history & exam
▪ Language barrier preventing reliable history & exam
▪ Extremes of age < 5 or > 65 years old
Spinal Stabilization
▪S-SV EMS Agency Protocol T-1
▪ Initiation of spinal stabilization is not necessary for patients
who do not meet any of the criteria listed on the previous 2
slides
▪ Helmet removal guidelines:
▪ Football helmets should not be removed unless they fail to hold the
head securely, interfere with the airway, or prevent proper stabilization
▪ Note: If the helmet is removed, the shoulder pads should also be removed
and/or the head should be supported to maintain neutral stabilization
▪ Motorcycle, bicycle, and other helmets should be removed
Spinal Stabilization
▪Spinal Stabilization Without A Backboard
▪ By maintaining spinal precautions using the ambulance
stretcher, we can protect the spine as best possible without the
downside risks of the backboard
▪ The following are acceptable methods and tools to achieve
spinal stabilization without a backboard:
▪ Fowler’s, semi-fowler’s, or supine positioning on stretcher with c-collar only
▪ Supine position with vacuum mattress device splinting from head to toe
▪ Child car seat with appropriate supplemental padding
▪ Supine positioning on scoop stretcher, secured with strap system and
appropriate padding including head blocks – avoiding log roll movement
adds benefit
Spinal Stabilization
▪Self Extrication
▪ Start with normal
cervical stabilization
with manual techniques
and collar
Spinal Stabilization
▪Self Extrication
▪ If the patient is
comfortable with self
extrication, assist the
patient with the process
as needed
Spinal Stabilization
▪Self Extrication
▪ Assist the patient as needed
to exit the crash setting
▪ The patient’s effort and
collar are used for cervical
stabilization
▪ Addition manual
stabilization is not needed
Spinal Stabilization
▪Self Extrication
▪ Move the patient to the
ambulance stretcher
Spinal Stabilization
▪Self Extrication
▪ Place the patient in a
position of comfort on the
ambulance stretcher &
secure with stretcher straps
Sepsis
Sepsis
▪Sepsis Facts
▪ There are 750,000 cases of sepsis in the US each year
▪ More than 2/3 are seen in the ED
▪ 10th leading cause of death in the US
▪ 250,000 deaths each year
▪ Mortality rate estimated at 25-50%
▪ Most common cause of death in non-coronary ICUs
▪ Greater than 1/3 of ED patients with infections, severe
sepsis and septic shock receive their initial care from EMS
▪ Patients that arrive by EMS have higher mortality rate
Sepsis
▪Sepsis Information
▪ Sepsis is a rapidly progressing, life threatening condition due
to systemic infection
▪ Sepsis must be recognized early and treated aggressively to
prevent progression to shock and death
▪ Sepsis can be identified when the following markers of the
Systemic Inflammatory Response Syndrome (SIRS) are
present in a patient with suspected infection:
▪ Temperature > 100.4° F OR < 96.8° F
▪ Respiratory Rate > 20 breaths/min
▪ Heart Rate > 90 beats/min
Sepsis
▪ETCO2 Assessment
▪ Severe sepsis is characterized by poor perfusion, leading to a
buildup of serum lactate and resulting metabolic acidosis
▪ EtCO2 levels decline in the setting of both poor perfusion and
metabolic acidosis
▪ As lactate levels rise in septic patients, ETCO2 levels drop
▪ In patients with ≥ 2 SIRS criteria, an ETCO2 measurement of
≤ 25 mmHg is strongly correlated with lactate levels > 4
mM/L and increased mortality
Sepsis
▪Prehospital Sepsis Management
▪ Early identification and prehospital management can significantly
decrease patients ICU stays, hospital stays and mortality
▪ S-SV EMS General Medical Treatment Protocol (M-6) is currently
being updated to address assessment/treatment/ED notification
▪ Provide early hospital notification for suspected sepsis/SIRS pts
▪ Provide early and appropriate fluid resuscitation
▪ The goal of the fluid resuscitation is to get enough fluid in the
vasculature to increase the BP enough to perfuse vital organs
▪ Unlike hypovolemic shock, septic shock doesn’t need more oxygen
carrying fluid - Isotonic fluids are adequate, especially in the initial
phases of treatment
Advanced
Airway
Management
Advanced Airway Management
▪Factors suggestive of the need for invasive
airway management
▪ Apnea or agonal respirations
▪ Airway reflexes compromised (ventilatory effort adequate,
e.g. unconscious without a gag reflex)
▪ Ventilatory effort compromised (airway reflexes adequate,
e.g. pulmonary edema)
▪ Injury or medical condition directly involving the airway
▪ Adequate airway reflexes and ventilatory effort, but potential
for future airway or ventilatory compromise due to course of
illness (head or other), or medical treatment
Advanced Airway Management
▪Additional Findings
▪ Increased respiratory rate
▪ Muscular retractions
(suprasternal, intercostal, abdominal)
▪ Labored breathing
▪ Impaired speech
▪ Decreased level of consciousness
▪ Agitation
▪ Pallor or cyanosis
▪ Increasing end-tidal carbon dioxide (capnography)
▪ Inadequate oxygen saturation (pulse oximeter)
Advanced Airway Management
▪Definitions
▪ Unsecured Airway
▪ A compromised airway in which ventilation is possible by Bag Mask but
in which intubation has failed or has not been attempted
▪ Can’t intubate, can ventilate
▪ Uncontrolled (Unmanageable) Airway
▪ A compromised airway in which intubation has been unsuccessful after
two attempts, rescue airways are unsuccessful, and in which BVM
ventilation does not provide satisfactory oxygenation or ventilation
▪ Can’t intubate, can’t ventilate
Advanced Airway Management
▪Advanced Airway Placement PEARL #1
▪ “Getting the tube in is not the only goal when attempting to
effectively manage an airway”
▪ Avoid aspiration, hypoxia, delaying CPR or defibrillation
▪ An endotracheal tube or rescue airway is just a method to supply
oxygen and ventilate, sometimes basic airway management is best
▪ There may be adverse patient consequences for placing an advanced
airway
Advanced Airway Management
▪SOAP ME Mnemonic
▪ S – Suction
▪ O – Oxygen
▪ A – Airway
▪ P – Positioning
▪ M – Monitoring
▪ E – End-Tidal Carbon Dioxide (ETCO2)
Advanced Airway Management
▪S – Suction
▪ Ensure that a suction unit with Yankauer suction tip is readily
available
Advanced Airway Management
▪O – Oxygen
▪ Saturation vs pO2
100
▪ A drop in saturation can mean a
precipitous drop in blood oxygen
level
▪ Note how steep the curve drops
with the saturation (SP02) important to maintain high level of
O2
▪ Pulse Ox on a distal extremity has
a lag time of 60 – 90 seconds
SpO2 (%)
▪ Maintain saturation above 90% in
patients requiring supplemental O2
80
60
40
20
0
0
50
100
150
pO2 (mmHg)
200
250
Advanced Airway Management
▪O – Oxygen
▪ Procedure for maintaining adequate oxygenation during
advanced airway procedures:
▪ Apply a nasal cannula with a flow rate of 5 - 15 L/min as tolerated
▪ If patient is breathing spontaneously and cooperative, apply an
additional non-rebreather mask with a flow rate of at least 15 L/min,
using a secondary oxygen source
▪ If possible, allow patient to breathe for three (3) minutes or ask the
patient to perform eight (8) maximal exhalations and inhalations
Advanced Airway Management
▪O – Oxygen
▪ Procedure for maintaining adequate oxygenation during
advanced airway procedures (continued):
▪ Just prior to advanced airway placement, increase nasal cannula flow
rate to 15 L/min and replace non-rebreather mask with BVM ventilation
at appropriate rate
▪ Perform jaw thrust to maintain pharyngeal patency
▪ Apply advanced airway
▪ Maintain nasal cannula at a flow rate of 15 L/min until advanced
airway is secured
Advanced Airway Management
▪A – Airways
▪ Select & utilize appropriate advanced airway according to
your scope of practice and individual patient circumstances
▪ Orotracheal Intubation
▪ Nasotracheal Intubation (utilizing Endotrol® ET Tube and BAAM)
▪ King Airway Device
▪ No more than two (2) total attempts per patient at placing
the endotracheal tube
▪ Intubation attempt - introduction of an ET tube past the patient’s teeth
▪ If orotracheal intubation is unsuccessful, a King Airway Device shall be
utilized if an advanced airway remains necessary
Advanced Airway Management
▪P – Positioning
▪ Position the patient in a semi-recumbent position
(approximately 200) or in Reverse Trendelenburg, if possible
Advanced Airway Management
▪M – Monitor (& Verify)
▪ “Regardless of the quality of the laryngeal view, or the confidence
of the intubator, verification of tracheal placement must be
performed on every patient.”
▪ Richard M. Levitan, M.D. Guide to Intubation and Practical Airway Management,
2004
▪ “Clinical verification, as a sole means of verifying endotracheal
tube placement is not uniformly reliable. EMS services performing
endotracheal intubation should be issued equipment for
confirming proper tube placement.”
▪ NAEMSP Position Paper on Verification of Endotracheal Intubation, July 1999
Advanced Airway Management
▪M – Monitor (& Verify)
▪ Confirming placement must be done:
▪ Using multiple methods
▪ Immediately after placement
▪ After major movement of patient
▪ After manipulation of neck
▪ After giving ET medications
▪ If absent ETCO2 waveform or unexpected ETCO2 detector color change
Advanced Airway Management
▪M – Monitor (& Verify)
▪ Clinical Verification
▪ Direct visualization of tube passing cords (orotracheal intubation)
▪ Rise and fall of chest
▪ Absent epigastric sounds
▪ Present breath sounds
▪ Good BVM compliance
▪ Condensation in tube
▪ Tube fogging alone is not a
reliable differentiator between
tracheal and esophageal
intubation
Advanced Airway Management
▪M – Monitor (& Verify)
▪ Methods to confirm ET tube placement after clinical verification
▪ Esophageal Intubation Detector Device
▪ ETCO2 measurement - waveform capnography is preferred
Advanced Airway Management
▪E – ETCO2
▪ Pitfalls of colorimetric CO2 detection devices:
▪ Cannot provide a specific CO2 value
▪ May fail if litmus paper gets wet (airway secretions, vomit, etc.)
▪ Subject to expiration (usually 2 years)
▪ Requires six breaths in cardiac arrest patient to get accurate reading
Advanced Airway Management
▪E – ETCO2
▪ Benefits of waveform capnography:
▪ Provides important indicators for overall respiratory function
▪ Airway integrity/proper advanced airway placement
▪ Provides indication of clinical death and return of spontaneous
circulation (ROSC)
▪ Quantifies the effectiveness of interventions
▪ Assisted ventilations
▪ Hyperventilation
Advanced Airway Management
▪E – ETCO2
▪ Waveform capnography additional notes:
▪ Adjust rate of ventilations based on capnography readings
▪ If ETC02 goes above 45, increase rate of assisted ventilations (no more
than 12/minute)
▪ If ETCO2 falls below 35, slow rate of assisted ventilation
▪ ETCO2 should be maintained around 35 in head injured patients
Advanced Airway Management
▪Additional Notes
▪ Suspected head/brain Injury guidelines
▪ Consider prophylactic Lidocaine 1.5mg/kg IV/IO for suspected
head/brain injury patients
▪ Lidocaine should be administered 3 minutes prior to intubation
whenever possible
▪ Sedation
▪ If the patient regains consciousness while the advanced airway is in
place, do not remove the advanced airway. Use restraints as necessary
and consider sedation with midazolam:
▪ IV/IO – 0.1 mg/kg (max dose 4 mg)
▪ IM/IN – 0.2 mg/kg (max dose 8 mg)
Advanced Airway Management
▪Assessing the difficult airway (LEMON)
▪ L – Look externally (short/fat/hairy etc.)
▪ E – Evaluate (3-3-2 Rule)
▪ M – Mallampatti (evaluate on awake patient ahead of time)
▪ O – Obstruction (airway/vomitus/oral trauma)
▪ N – Neck (cervical collar, short fat necks)
If each of these categories was given a point, the closer the
score is to 5, the higher the likelihood of a difficult airway
Advanced Airway Management
▪L - Look Externally
▪Obesity or very small
▪Short muscular neck
▪Prominent Upper Incisors
(buck teeth)
▪Receding jaw (dentures)
▪Burns
▪Facial trauma
▪Edema
▪Facial hair
Advanced Airway Management
▪E - Evaluate the 3-3-2 Rule
▪3 – Mouth opening: Should open wide enough for 3 fingers to
be inserted between upper and lower teeth
▪3 – Mandible length: 3 fingers is normal length (measured
from the tip of the chin to the hyoid bone)
▪2 – Distance from the hyoid bone to the thyroid notch:
Should be at least 2 fingerbreadths
Advanced Airway Management
▪M - Mallampati Classification
▪A method used by anesthesiologists
▪A reliable tool used to predict difficult direct laryngoscopy
▪Best success with intubation is a Class I or II
Class I
Class II
Class III
Class IV
Advanced Airway Management
Mallampati Class II
Advanced Airway Management
Mallampati Class IV
Advanced Airway Management
▪O - Obstruction
▪ Blood
▪ Vomitus
▪ Teeth
▪ Dentures
▪ Tumors
▪ Impaled objects
▪ Peritonsillar abscess
▪ Epiglottis
▪ Edema
Advanced Airway Management
▪N - Neck
▪ Spinal precautions
▪ A c-collar can prevent manipulation
and movement of the mandible
▪ Utilize a 2nd rescuer to apply manual
in-line stabilization and release the
collar for the duration of the attempt
▪ Impaled objects
▪ Lack of mobility
Advanced Airway Management
▪Importance of First Pass Success
▪ Hypoxia associated with multiple attempts (2833 attempts)1
▪ First attempt - 4.8%
▪ Second attempt - 33.1%
▪ Third attempt - 62%
▪ Fourth attempt - 85%
1Mort
TC. Emergency Tracheal Intubation Anesth Analg. 2004: 99:607-13
Advanced Airway Management
▪Maximizing First Time Success
▪ Pre-oxygenate
▪ Suctioning as necessary
▪ Position the patient – increased head elevation
▪ Utilize Macintosh #4 blade for orotracheal intubation
▪ External laryngeal manipulation (ELM)
▪ Straight-to-cuff ET tube with stylet or tube inducer as
indicated
Advanced Airway Management
▪External laryngeal manipulation (ELM)
▪ Backwards Upwards Rightwards Pressure (BURP)
▪ A simple technique that may improve laryngeal visualization
and facilitate intubation
Advanced Airway Management
▪Problem-solving
▪ If ventilation becomes difficult or the patient desaturates
after intubation, consider DOPE:
▪ D – Dislodgement
▪ O – Obstruction
▪ P – Pneumothorax
▪ E – Equipment
Advanced Airway Management
▪Advanced Airway Placement PEARL #2
▪ “Do not attempt to re-establish an advanced airway unless
you have changed something”
▪ Move location/position
▪ Different advanced airway device
▪ Blade Change
▪ Suctioning
▪ Magill Forceps
▪ ELM/BURP
▪ Flexguide
Advanced Airway Management
▪Video Laryngoscopy
▪ Video Laryngoscopy is within the paramedic scope of
practice and may be utilized by S-SV EMS approved ALS
providers
▪ Due to the many models of devices available and the lack of medical
literature recommending one device over another, the decision on
which device to utilized rests with the individual provider
Advanced Airway Management
▪ET Tube Introducer
▪ Considered first choice by many physicians for difficult
airways when epiglottis can be visualized but vocal cords
cannot
▪ Patients with suspected c-spine injury in whom epiglottis
could be seen had 100% successful intubation within 21-45
seconds use of introducer
Advanced Airway Management
▪ET Tube Introducer
▪ In simulated patients with c-spine injuries and Mallampati
Class 3, first attempts were more successful with tube
introducer than laryngoscope alone
▪ Can be passed through laryngeal opening despite limited
visibility
▪ Angled end is directed anterior
▪ Passes more easily than ET tube when supraglottic or
laryngeal edema present
▪ Vibrates over tracheal ring in 65-90% of placements
Advanced Airway Management
▪ET Tube Introducer Utilization Steps
1. Use standard orotracheal
intubation preparation and
procedures, including cricoid
pressure.
2. When blade optimally
exposes all or some of the
laryngeal opening,
introducer is advanced.
Advanced Airway Management
▪ET Tube Introducer Utilization Steps
3. Holding introducer in right
hand and the angled tip
upward, gently advancing
anteriorly (under the
epiglottis) to the glottic
opening (cords).
(It is important to note the
orientation of the upturned
tip as the introducer is
inserted)
Advanced Airway Management
▪ET Tube Introducer Utilization Steps
4. If the cords are visualized,
direct through the cords.
For other situations, direct
the introducer under the
epiglottis, and feel for a
vibrating sensation as the
tip ‘washboards’ across the
tracheal rings.
Advanced Airway Management
▪ET Tube Introducer Utilization Steps
5. For epiglottis only views,
the upturned distal tip
must be kept midline and
immediately underneath
the epiglottis.
Advanced Airway Management
▪ET Tube Introducer Utilization Steps
6. The length of the device
allows it to be advanced
until resistance is
encountered (at the carina).
7. If no resistance is
encountered and the entire
length of the introducer is
inserted, the device is in
the esophagus.
Advanced Airway Management
▪ET Tube Introducer Utilization Steps
8. Correct placement is
assumed when the device
is directed through the
cords, the tip is felt
vibrating against the
trachea, or you meet
resistance while advancing
(at the carina).
Introducer in trachea
Advanced Airway Management
▪ET Tube Introducer Utilization Steps
9. Advance until the thick
black line is at the lipline.
This ensures that enough of
the introducer is protruding
from the mouth to allow
tube passage.
Advanced Airway Management
▪ET Tube Introducer Utilization Steps
10.Have the intubator
maintain visualization of
the of the epiglottis with
the laryngoscope while the
assistant feeds the tube
over the introducer.
11.Remove the introducer,
confirm airway patency,
and secure the tube.
Advanced Airway Management
▪Advanced Airway Placement PEARL #3
▪ “Even the best can miss, don’t be invested in your airway”
▪ Don’t be afraid to allow another person to intubate
▪ Even the best will have a bad day and not be able to perform the skill
▪ Convincing yourself you placed the tube properly and ignoring clinical
signs could lead to a poor patient outcome….Death
Advanced Airway Management
▪Critical Thinking and Clinical Decision Making
▪ Must be able to “think outside the box”
▪ Early identification and anticipation of airway management
needs is the key to survival
▪ Be proactive vs. reactive