Challenging ResusitationsChallenging Resusitations

Ideas and practical application of difficult and complicated situations

Scott BraithwaiteMobile Intensive Care Paramedic/FTO

The “Stuff” We'll Learn

Recognize the potential of complicated situations and their impact on patient care

Recognize threats to “Complicated ABCs” and apply specialized techniques in order to overcome the complication

Fall back on effective BLS when ALS is compromised

Reassess the difficult patient for recurring problems

What are my Chances?

Controlled Environment:

What are my Chances?

Controlled Environment: A situation in which most, if not all, factors can be precisely manipulated, changed and modified. Example: OR, ER

What are my Chances?

Controlled Environment: A situation in which most, if not all, factors can be precisely manipulated, changed and modified. Example: OR, ER

Uncontrolled Environment:

What are my Chances?

Controlled Environment: A situation in which most, if not all, factors can be precisely manipulated, changed and modified. Example: OR, ER

Uncontrolled Environment: A situation in which most, if not all, factors cannot be modified. Slight variations can complicate the overall situation. Example: “The Field”

Areas To Watch Out For

Airway Breathing Circulation Securing and Moving

AirwayHow would you handle these airways?

Airway Basic anatomy

AirwayNormal Airway

AirwayNormal Airway Abnormal Airway

Identify Difficult AirwaysMEDICTUBES

Mouth, Mandible Excessive Weight Deformity Incisors C-Spine Thyromental Distance Uvula Burns Emesis Stridor

Identify Difficult AirwaysMouth, Mandible

Measure the width of the mouth opening. Anything less than three (3) fingers width can complicate laryngoscopy.

Mandible should be without deformity or dislocation.

Identify Difficult AirwaysExcessive Weight

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Overweight, pregnant or no-neck patients can also be very complicated. Complete repositioning of the patient may be required in order to visualize the airway

Identify Difficult AirwaysDeformity

Assess for any type of deformities, hematomas, tumors, goiters, or similar atypical manifestations.

This patient is a status-post burn victim at home resting.

Bonus: How would you c-spine?

Identify Difficult AirwaysIncisors

Assess for any trauma to teeth, any types of overbite or overjet (buck teeth), dentures or other custom dental appliances.

Identify Difficult AirwaysC-Spine

C-spined pts. Have mis-aligned airway structures, landmarks and pathways.

These pts are NOT to be manipulated when attempting intubation.

Identify Difficult AirwaysThyromental Distance

Distance from chin to thyroid cartilage. Anything less than three (3) fingers width suggests difficult intubation.

Identify Difficult AirwaysUvula

Ideally, you should be able to see the entire oropharynx, including the uvula. Any airways with a partial or complete concealment of this structure may prove difficult to intubate.

Identify Difficult AirwaysBurns

Identify Difficult AirwaysEmesis

Identify Difficult AirwaysStridor

Classic sign of upper airway obstruction. Can be caused by foreign bodies, tumors, cysts, inflammation or trauma.

Techniques Landmark Recognition External Laryngeal Manipulation (ELM) Head- Extension Laryngoscopy Position (HELP) Backwards, Upward, Rearward Pressure (BURP) C-Spine Considerations Paraglossal Intubation “Ice-pick” Digital Intubation Combi-tube Needle Cricothyrotomy

Anatomy

External Laryngeal Manipulation

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HELPHead Elevation Laryngoscopy Position

Vocal cords can be brought into view with head flexion and elevation. This facilitates slack of jaw and tongue, allowing better viewing of vocal cords. Head can then be supported by caregiver's body.

Note: NOT to be used if cervical trauma is suspected!

BURPBackwards, Upward, Rear-ward, Pressure

Similar to ELM, aim towards right ear or right parietal area.

Can be done by another caregiver. Prefered for patients in spinal

motion restriction.

C-Spine Considerations

An east coast field study found that when a Pt in SMR is elevated about 7 degrees, success rates for initial intubation jumped from 84% in the supine Pt, up to 95% in the elevated Pt, and were generally done 10 seconds faster than non-elevated Pts.

(Pinchalk intubation resarchMark Pinchalk, David Hostler, Paul Paris, Ronald Roth)

Paraglossal Intubation The reason straight blades exist Blade slides alongside of tongue. Slight leftward anterior pressure. ET tube may be able to slip through the blades channel, if not go

under the blade and up into vocal cords. Trusted technique for difficult intubation.

Henderson JJ “The use of paraglossal straight blade laryngoscopy in difficult tracheal intubation” Anaesthesia. 52(6):552-560, 1997

“Ice-Pick”

Also called inverse intubation Scope held in right hand,

advanced toward uvula, then pull downward towards anterior

Blade will find “home” Vocal cords will be

inverted- watch for it!

Digital Intubation

Combi-Tube Excellent secondary

airway adjunct. Very versitile, can be

used in most situations. Pts must be

unresponsive, apneic with NO gag intact, over 15 y/o and at least 5 ft tall.

Contraindicated in FBAO, Facial and/or esophageal trauma or disease, Caustic ingestions.

Needle Cricothyrotomy

Consider in cases of FBAO, Severe facial trauma, Laryngospasm, Infections, Soft tissue swelling.

Last resort for advanced airway. Does not allow ventilation, only oxygenation.

Studies show needle cric makes no improvement in mortality of the full arrest Pt. Very detrimental in fact.

CirculationSome cool little tricks to help establish IVNS access

BP cuff for less pronounced veins “Wave”, or “Pulse” Technique

Trendelenburg Stethoscope for EJ

Pitting Edema- Taking Advantage of it's Flaw

Circulation

BP Cuff

Wider is Better! Allows finer control of tourniquet

effect You will see veins that did not appear

with the thinner band

Circulation

The “Wave” or “Pulse” Technique Extremely useful in situations in which you cannot

see any visible veins or “shadows” of the upper forearm.

Starting at the dorsal part of the Pts hand, deeply and quickly brush the skin, feeling for proximal vein “pulsations” with your other hand.

Circulation

Trendelenburg Assists with “autoinfusion”, wherein gravity pulls

additional fluid from the raised extremity into the core. This in turn puts more fluid into dependant extremities, allowing veins to become gorged.

Helpful in full cardiac arrests when attempting IV access.

Circulation

Stethoscope

Acts as a tournequet, helps engorge the external jugular veins.

Assists with stablizing the jugulars.

Circulation

Pitting Edema?

Use pitting edema to your advantage! Pressing fluid away from a site gives you a few

seconds to find a suitible vein, press the fluid away again, and you have another few seconds to establish the IV.

BP cuff could assist with pressing the fluid away.

Securing and Moving

Getting Ready to Move Often enough our pts are

not able to move themselves “Dead weight” needs

consideration when faced with confined space or tight corners

Questions?