Als Section 06

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Section 6

Airway Procedural Protocolsand

Use of Airway Equipment

Rev. June 2004


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Rev. June 20042

CAPNOMETRY (if available)

INTRODUCTION:

Capnography, the measurement and graphical display of expired PCO2 concentration atthe airway, is becoming a standard of care in the pre-hospital setting for critically illpatients. The device can be used for:

1. Verification of tube placement.

2. Early detection of clinically significant ventilatory/circulatory events.

3. Assessment of cardiac arrest patients, and based on those results, speed theinitiation of appropriate therapy or termination of resuscitation.

INDICATIONS:

1. Hand held Capnometers will be utilized on all patients who have an endotrachealtube in place.

2. Pre-hospital experience with Capnometry shows it to be beneficial in thefollowing situations:

A. Ensuring tracheal rather than esophageal intubation.

B. Continuous monitoring of post-intubation airway status (especially duringtransport).

C. Ability to accurately maintain and control ventilatory status in intubatedhead injured patients

D. Assess the effectiveness of CPR.

E. Assessment of the cardiac output in patients with PEA (pulseless electricalactivity). In patients with PEA who have a ET CO2


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PROCEDURE:

1. Connecting capnometer to the patient following intubation:

A. Connect the single-use patient attachment to the capnometer.B. Connect the single-use patient attachment adapter (narrow end) to theproximal end of the endotracheal tube.

C. Connect the single use-patient attachment adapter (broad end) to the bag-valve.

D. Turn the capnometer on by depressing the "on" button.E. Ventilate the patient with BVM; the capnometer will take the average of 4

ventilations before it displays numeric values.F. Observe capnometer reading.G. Make necessary adjustments (proper tube placement, etc.).H. Record results on the patient care form.

I. When disconnecting the capnometer, place a cap over the ETT port.

2. Measuring respiratory rate: The capnometer will display a numerical value forrespiratory rate. The device computes respiration rate from the total number ofseconds for the last 4 breaths.

3. Measuring CO2. What you should expect to see:

A. Adult : Normal value 35 - 45 torr.

B. Newborn: Normal value 35 - 40 torr.

C. Lower than normal reading are to be expected in patients with poorperfusion or those patients hyperventilating or are being hyperventilatedduring resuscitation. Readings of >10 are generally viewed as a positivebenchmark in a resuscitative effort. Since CO2 is normally present inexhaled gas, it can be assumed that intubated patients with adequatecirculation will produce CO2 that can be measured. End Tidal CO2(ETCO2) uses infrared light to measure the concentration of PCO2 emittedby the patient during the expiratory phase of respiration (eitherspontaneous or artificial).

D. The numerical CO2 measurement (torr) is based on a 4-breath average.This measurement is translated into a digital readout and bar graphindicator reading. Listed below are six common pre-hospital situations(what the capnometer might show, and how it can impact treatment).

1. Hyperventilation: Confirmation of low ETCO2 in the presence ofstable circulatory status (within expected clinical setting) will focuson a respiratory cause. Care must be used to differentiate from


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non-functional causes of hyperventilation such as ASA overdose,pulmonary embolus etc.

2. Head Injured Patients: Allows the control of ventilation in the

intubated head injured patient. Whether hyperventilation, moderateventilation, or normal ventilation is desired, the patient can bemaintained at the desired level of ETCO2.

3. Major Trauma/intubation: ETCO2 will be a function of pulmonaryblood flow (in the presence of controlled ventilation). In theintubated trauma patient, ETCO2 reflects the adequacy of cardiacoutput and degree of shock.

4. Severe COPD: ETCO2 can be measured to reflect the presence ofCO2. Continued monitoring will reflect the response to Oxygen

therapy.

5. PEA/CPR (as an aid in the decision to cease resuscitation efforts):ETCO2 is primarily a reflection of pulmonary blood flow, which isdetermined by cardiac output. During low flow states, this mayreflect the success or failure of resuscitative efforts. Persistentlylow levels are a marker of death.

6. Cardiogenic Shock - Cardiac output will be reflected by pulmonaryblood flow and measured by ETCO2.

PRECAUTIONS:

Carbon dioxide is not normally produced in the stomach, but it may be present if thepatient has consumed carbonated beverages or certain medications, or if the carbondioxide that exists from the lungs is transported into the esophagus during ventilation. Ifthe endotracheal tube is inadvertently placed in the esophagus, a small amount of CO2may be present, but is rapidly eliminated within the first few breaths. The capnometermay detect the presence of CO2 in the stomach of the improperly intubated patientimmediately after intubation, but should cease to do so after about six breaths. A failureto detect CO2 after this time suggests esophageal intubation in the patient withadequate blood flow to the lungs.

DEFINITIONS:

Capnometry: The measurement and numerical display of carbon dioxide concentration(partial pressure) at the airway.

Capnography: The measurement and graphical display of carbon dioxide concentration(partial pressure) at the airway.


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CO2: Produced by metabolizing tissues carried to the lungs by blood and eliminated byventilation.

PACO2: The partial pressure of CO2 In arterial blood.

ETCO2: The end tidal CO2 value (the amount of CO2 in the last portion of air expired).


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Rev. June 20046

COMBITUBE

INTRODUCTION:

1. The Combitube has been added to the airway equipment list in the event thattraditional endotracheal intubation cannot be readily established andcricothyrotomy is not warranted. This device will offer paramedics andintermediates added flexibility when managing a difficult airway.

2. The Combitube can be used to assist in ventilating a non-breathing patient,regardless of whether the tube is inserted into the trachea or the esophagus. Itshould only be utilized when intubation cannot be accomplished in a timelymanner and the patient is not a candidate for cricothyrotomy. In general, thisoccurs when the patients airway is judged to be too difficult to intubate afterseveral appropriate attempts by one or more paramedics have beenunsuccessful. Use your judgment.

3. There are TWO Combitube sizes, the Combitube and the Combitube SA(Small Adult). Use the appropriate size for the height of the patient.

INDICATIONS:

Adult patients in respiratory or cardio-respiratory arrest when intubation is unsuccessfulor very difficult.

Unsuccessful intubation is defined as a total of four attempts by any number ofparamedics.

Very difficult is defined as situations where obtaining visualization of the vocalcords cannot be accomplished, whether due to anatomical limitations or limitedspace to access the patient. In these cases, the paramedic(s) may determine aCombitube is needed even if less than four intubation attempts have occurred.

PROCEDURE:

1. Begin artificial respiration or CPR, incorporating usual procedures to verify anopen airway.

2. Prior to insertion, test the cuff integrity by inflating each cuff with the prescribedamount of air.

A. Inflate the proximal pharyngeal cuff (blue pilot balloon) with 100 mlof air. Deflate air from the blue pilot balloon.


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B. Inflate the distal white esophageal cuff (white pilot balloon) with15ml of air. Deflate air from white pilot balloon.

C. Lubricate tube with water-soluble lubricant to facilitate insertion.

D. Attach the fluid deflector to the clear deflecting lumen marked no 2.

3. In a supine patient, lift the tongue and jaw upward with one hand. This can alsobe accomplished using a laryngoscope blade and handle to displace themandible and tongue without visualization (Paramedics only).

4. With the other hand, hold the Combitube so it curves in the same direction asthe natural curve of the pharynx. Maintain a midline position. Insert the tip intothe mouth and advance in a downward curve until the teeth or alveolar ridges liebetween the two painted bands.

5. Don't force the tube! If the tube does not advance easily, redirect it or withdrawand reinsert.

6. Inflate the no.1 blue pilot tube with 100ml of air from the blue coded syringeprovided in the kit. The large latex cuff will inflate and may cause the Combitubeto move slightly away from the patient's mouth; this is to be expected.

7. Inflate the no.2 white pilot balloon with 15ml of air using the 20ml syringesupplied.

8. Begin ventilation through the longer blue connecting tube no.1. If auscultation ofbreath sounds is positive, and gastric insufflation is negative, continue ventilationand observe chest for expansion/relaxation. Note: Under this condition, thesecond connecting tube may be used for the removal of gastric fluids using thesuction catheter provided in the kit.

9. If auscultation, of breath sounds is negative, and gastric insufflation is negative,the Combitube may have been advanced too far into the pharynx. Deflate theno.1 pilot balloon/cuff, and withdraw the Combitube approximately 2-3 cm out ofthe patient's mouth. Reinflate the no.1 pilot balloon/cuff with 100ml of air. Ifauscultation of breath sounds is positive and gastric insufflation is negative,continue ventilation.

10. If auscultation of breath sounds is negative, and gastric insufflation is positive,immediately begin ventilation through the shorter clear connecting tube. Observethe rise and fall of the chest.


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PRECAUTIONS:

1. When facial trauma produces sharp, broken teeth, use extreme caution whenpassing the Combitube into the mouth to avoid tearing the cuffs.

2. Remove dentures.

CONTRAINDICATIONS:

1. COMBITUBE: Patients under 5 feet tall.COMBITUBE SA (Small Adult): Patients under 4 feet tall.

4 ft 5 ft 5 ft

Combitube SACombitube or Combitube SACombitube

2. Responsive patients with an intact gag reflex.

3. Patients with known esophageal disease.

4. Patients who have ingested caustic substances.


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CRICOTHYROTOMY

DEFINITION:

A cricothyrotomy is the creation of a passage between the external environment andthe trachea through the cricothyroid membrane (between the thyroid and the cricoidcartilages). Cricothyrotomies are performed when an airway must be established andother methods of achieving a definitive airway have either been unsuccessful.

This procedure needs to be completed very quickly. Without Oxygen death of braincells begins in 4-5 minutes.

INDICATION:

1. Indications include, but are not limited to:

A. Failure to intubate and/or ventilate despite neuromuscular blockadeor existing flaccidity.

B. Upper airway injury which distorts or occludes the normal anatomysuch that intubation is impossible (thermal, radiation, infection,inhalation, trauma, or caustic).

C. Complete occlusion of the upper airway that does not respond tofirst-line therapy, such as FBO maneuvers and laryngoscopy tofacilitate visualization and removal of the object with Magill forceps.

PROCEDURE:

1. Place the patient in the supine position with the head secured if notcontraindicated by possible existence of cervical trauma.

2. Place two towels under the upper back and place the patient's head intomoderate hyperextension.

3. Identify the cricothyroid membrane (the soft spot between the thyroid cartilageand the cricoid ring). Prep the skin with Betadine, using a circular motion.

4. Nick the skin with the provided scalpel. It should be stabbed to its full depth tofacilitate passage of the IV catheter. Failure to do this will make passageexceptionally difficult, and may lead to failure to complete the procedure in atimely manner.


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Rev. June 200411

service as time permits. This may include pulse oximetry and end-tidal CO2monitoring if available.

PRECAUTIONS:

1. Advance the angiocath slowly and carefully (insure you are midline). Carefulperformance minimizes complications. Placing the wire properly in the airway isthe most critical maneuver. The dilator will go wherever the wire is. This may bethe subcutaneous tissues, or through the posterior wall of the trachea and intothe esophagus so knowing where the wire is of critical importance.

2. The nick should be made vertically (not horizontally) with the blade of the scalpelmoving upward. Some bleeding can be expected and should be controlled withdirect pressure.

3. In the event that the tube in the kit fails, and a standard ETT is used, rememberthat it only needs to be inserted a short distance past the cuff.

COMPLICATIONS:

1. Puncturing carotid artery or external jugular vein, or lacerating the vagus andphrenic nerve (generally impossible it you are in the midline).

2. Perforating the thyroid gland, or injuring the vocal cords. This is rare if thecricothyroid membrane has been correctly identified.

3. Penetrating and cannulating the esophagus. This is the most likely catastrophe.Easy aspiration of air through the catheter and subsequent easy passage of along length of wire is critical to gaining confidence in the proper location andpassage of the tube.

NOTES: All cases should have a needle cricothyrotomy report filled out and returned tothe Board of Medical Examiners.


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Rev. June 200412

RAPID SEQUENCE INTUBATION (RSI)WITH NEUROMUSCULAR BLOCKING AGENTS

INDICATIONS:

1. Respiratory insufficiency or arrest.

2. Acute or threatened airway obstruction (angioedema, FBO, burns, expandinghematoma)

3. Unconscious or altered mental status (GCS


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However, most of these patients will require bag-valve-mask positive pressureventilation (BVM/PPV), and 100% Oxygen prior to paralysis. It is imperative thatcricoid pressure be held (if possible) whenever BVM-PPV is being employed toprevent gastric distention and subsequent reflux while the patient is paralyzed

and you are trying to intubate the patient.

3. Assemble required equipment. For pediatric patients have tube sizes above andbelow what you think you will need immediately available to you. You shouldcheck the balloon on the ETT tube (if it has one) if time allows and shape theETT with the stylet in place to optimize success. Have suction, laryngoscope,and BVM in place and ready for use.

4. Secure a patent IV line with Normal Saline.

5. If time allows, attach monitoring equipment (ECG, pulse oximetry) to the patient.

6. Premedicate the patient if these conditions are present:

A. Head injury or suspected intracranial bleed: Lidocaine before paralysis.Thought to reduce an increase in intracranial pressure that has beenreported in patients while being intubated.

B. CHILDREN less than 12 years old should receive Atropine Sulfate toprevent reflex bradycardia.

C. Sedation. All patients should receive Versed before paralysis. Post

intubation; repeated Midazolam administration is preferred over paralysisfor continued agitation. This will allow for neurologic assessment tocontinue when the patient reaches the hospital.

D. Administer Succinylcholine. Remember to continue cricoid pressure asparalysis sets in, and until ET tube is in place with the balloon up.

7. If patient is well oxygenated (a working pulse ox shows 100%) stop BVM/PPV asthe paralysis starts to take hold and intubate the patient while an assistantcontinues to hold cricoid pressure. However, if patient is clearly still hypoxic asthey often are (e.g. blue, or functioning pulse ox is reading below 90%) thenBVM/PPV should continue assuming firm cricoid pressure is in place. Onceparalysis is achieved, intubate the patient.

8. The same holds true for failed attempts. If patient was well oxygenated prior tothe attempt then BVM/PPV can be withheld as long as one to two minutes.However, If hypoxic then BVM/PPV should continue while preparations are beingmade for next attempt. If the patient cannot be intubated then proceed withcontinued BVM/PPV and consider other airway adjuncts.


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9. Once the tube is in place, release cricoid pressure, inflate balloon and confirm

proper placement with standard physical exam techniques (chest rise, breathsounds etc.), and use of continuous capnometry and pulse oximetry if available.

Once proper placement is confirmed secure tube into place.

10. Place oral gastric tube and confirm placement if time allows, and decompressthe stomach.

RSI Intubation chart for Adults:

Weight Lidocaine Midazolam Succinylcholine Vecuronium

Lb Kg mg cc mg cc mg cc mg cc

110 50 75 3.75 5 5 75 3.75 5 5120 55 80 4 5 5 80 4 5.5 5.5

150 70 100 5 5 5 100 5 7 7

180 80 120 6 5 5 120 6 8 8

210 95 140 7 5 5 140 7 9.5 9.5

230 105 160 8 5 5 160 8 10 10

250 115 180 9 5 5 180 9 10 10

RSI Intubation chart for pediatrics:Weight Lidocaine

(Head Injury)Atropine Sulfate Midazolam Succinylcholine Vecuronium

lb kg mg cc mg cc mg cc mg cc mg cc

7 3.5 5 0.25 0.1 1.0 0.5 0.5 10 0.5 0.35 .035

15 7 10 0.5 0.14 1.4 1.0 1.0 20 1.0 0.7 0.7

22 10 15 0.75 .02 2.0 1.0 1.0 20 1.0 1.0 1.0

33 15 20 1.0 0.3 3.0 1.0 1.0 30 1.5 1.5 1.5

44 20 30 1.5 0.4 4.0 2.0 2.0 40 2.0 2.0 2.0

55 25 35 1.75 0.5 5.0 2.0 2.0 50 2.5 2.5 2.5

66 30 45 2.25 0.6 6.0 3.0 3.0 60 3.0 3.0 3.0

77 35 50 2.5 0.7 7.0 3.0 3.0 70 3.5 3.5 3.5

88 40 60 3 0.8 8.0 4.0 4.0 80 4.0 4.0 4.0

99 45 65 3.25 0.9 9.0 4.0 4.0 90 4.5 4.5 4.5


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CONTINUED CARE OF THE INTUBATED PATIENT

For continued management of the intubated patient, consider:

1. The patients ability to resist the intubation/ventilation.

2. Medications used to accomplish the procedure.

3. Distance from the hospital.

4. Any deterioration in the patients clinical status.

Procedure:

1. Additional doses of Midazolam

2. Vecuronium. It is preferred that this be avoided. However, if Midazolam is noteffective in the above doses, and patient care remains compromised, contactSalem Hospital on-line medical control for Vecuronium orders.

3. If not already done, place oral-gastric tube and confirm its placement. Thenconnect to suction to decompress/empty patients stomach.

4. A cervical collar is recommended on all intubated patients. This minimizes headmovement, thus reducing the risk of distal displacement of the ET tube. For non-trauma patients with c-spine immobilization, use of the collar alone, or additionalmechanical securing with tape and foam blocks can be applied as dictated by the

situation.

5. Continuously monitor tube placement with pulse oximetry, and physical examtechniques until arrival at hospital.

6. All patients should have continuous capnometry.

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