Combitube Pilot Program

1
Combitube Pilot Program

• - Made Possible by -
• Kentucky Board of
• Emergency Medical Services
• - And -
• The Authors and Participants in the Kenton County
  Combitube Pilot Program

Kentucky Board Of Emergency Medical Services
2
The Combitube Pilot Program

• The Kentucky Board of Emergency Medical Services
  would like to express their appreciation to the
  following participants in the Kenton County
  Combitube Pilot Program for allowing the
  adaptation of their program for statewide use.

3
Combitube Lecture Outline

• The Pilot Program
• The Combitube Combitube SA
• Airway Maintenance with the Combitube
• Using the Combitube
• Kentucky Protocol
• Summary

4
The Combitube Pilot Program

• Kenton County EMTs and their EMS Agencies
• St. Elizabeth Hospitals
• Department of Emergency Services
• The St. Luke Hospitals
• Department of Emergency Medicine
• Randy Pratt EMT-P. Captain
• Taylor Mill Fire Department

5
The Combitube Pilot Program

• Special thanks to
• Christopher D. Caggiano, MD FACEP
• Medical Director, Kenton County (EMS)
• Medical Director, TransCare of Kentucky

6
The Combitube Pilot Program

• Originally approved for use only in Kenton
  County, Kentucky by EMS Branch September 1999.
• Used successfully as a result of outstanding
  Medical Control and oversight and as a result of
  the dedication and commitment of many fine
  agencies.

7
The CombitubePilot Program

• The original Kenton County program was used as a
  model for the development of this statewide
  program
• The Pilot Program is being implemented statewide
  now as the result of
• Changes in the EMT-Basic Curriculum
• Identified need for more advanced airway control
  procedures for EMT-Basics

8
The Combitube Pilot Program

• Allows EMTs to use the Combitube
• After completing initial training course
• With re-certification each 6 months
• Only on Cardiac Arrest or Apneic Adult Pts.
• Each use evaluated by Paramedics if available and
  receiving Emergency Department Staff.
• Each use evaluated by Medical Director.

9
The Combitube Pilot Program

• Any Kentucky EMS Agency wanting to use the
  Combitube must
• Provide 2 Combitubes of each size on each
  ambulance or response vehicle,
• Make certain that all of their staff have
  received the required Combitube training, and
• Make certain that only trained EMTs perform the
  procedure.

10
The Combitube Pilot Program

• Once trained, an EMT may use the Combitube with
  ANY Kentucky EMS agency that is approved to use
  the Combitube Pilot Program.
• A Combitube Pilot Program approved EMS agency,
  providing mutual aid to a non-approved EMS
  agency, may use the Combitube.

11
Using The Combitube

• ABCs
• Measure (Combitube or Combitube SA?)
• Check Cuffs
• Insert
• Inflate Cuffs
• Ventilate through tube 1
• Check for Breath Sounds
• Switch Ventilate through tube 2 if needed
• Check for Breath Sounds
• Continue Ventilation

12
Check ABCs

• Establish Unresponsiveness
• Verbal / Tactile stimuli
• Look Listen Feel for air movement
• Deliver 2 rescue breaths
• reposition and try again if needed
• clear airway if obstructed
• Check Pulse
• SAED CPR if needed

13
Opening the Airway

• Head Tilt / Chin Lift
• DO NOT USE IF YOU
• SUSPECT NECK INJURY

14
Opening the Airway

• Head Tilt / Chin Lift

15
Measure the patient

• Put loop of measuring device over patients foot.
• Determine which Combitube to use
• Combitube or Combitube SA
• IF LESS THAN 4 FEET - use basic airway
  maintenance techniques
• Select Tube

16
Check the Cuffs

• Inflate Pilot Balloon 1 with 100ccs of air
• check for proper inflation of cuff
• Deflate Cuff
• Inflate Pilot Balloon 2 with 15ccs of air
• check for proper inflation of cuff
• Deflate Cuff

17
Large Syringe Attached to Pilot Balloon 1 Ready
to Inflate with 100ccs of Air
18
Pilot Balloon (1) Remains Inflated.
Large Pharyngeal Cuff Inflated
19
Small Syringe Attached to Pilot Balloon 2 Ready
to Inflate with 15ccs of Air
20
Pilot Balloon 2 for Small Distal Esophageal Cuff
2 Remains Inflated
Small Distal Esophageal Cuff 2 Inflated
21
Lubricate the Combitube

• Use water soluble gel. (Surgilube)
• Spread over tube.
• Use package or gloved hand.

22
Insert the Combitube

• Hold Combitube like a pencil with dominant hand,
• Lift Jaw and tong between thumb and index finger
  of non-dominant hand,
• Insert Combitube into mouth with curve facing
  upward,
• Stop inserting when the upper teeth or gums are
  between the Black Rings.

23
(No Transcript)
24
Insert the Combitube

• If any resistance is met during insertion
• Remove the Combitube,
• Reposition,
• Re-insert one additional time.
• If resistance is met on the second attempt
• Remove the Combitube,
• Maintain airway using basic airway techniques.

25
(No Transcript)
26
Inflate the Cuffs

• Attach Large Syringe to Pilot Balloon 1.
• Inflate cuff 1 with 100ccs of air.
• Remove Syringe.
• Confirm that Pilot Balloon is inflated.
• If not - attempt to re-inflate.
• If still no inflation - remove Combitube and
  maintain airway with basic airway techniques.

27
Large Syringe Attached to Pilot Balloon 1 Ready
to Inflate with 100ccs of Air
28
Pilot Balloon (1) Remains Inflated.
Large Pharyngeal Cuff Inflated
29
Inflate the Cuffs

• Attach Small Syringe to Pilot Balloon 2.
• Inflate cuff 2 with 15ccs of air.
• Remove Syringe.
• Confirm that Pilot Balloon is inflated.
• If not - attempt to re-inflate.
• If still no inflation - Deflate Cuff 1, remove
  Combitube and maintain airway with basic airway
  techniques.

30
Small Syringe Attached to Pilot Balloon 2 Ready
to Inflate with 15ccs of Air
31
Pilot Balloon 2 for Small Distal Esophageal Cuff
2 Remains Inflated
Small Distal Esophageal Cuff 2 Inflated
32
(No Transcript)
33
Ventilate

• Attach Bag / Valve and CO2 detector to Tube 1.
  (Esophageal)
• Ventilate.
• Listen over Chest for breath sounds.
• If present - continue ventilation at a rate of 12
  -20 breaths per minute.

34
(No Transcript)
35
Ventilate

• If breath sounds absent
• Switch Bag / Valve CO2 detector to Tube 2 and
  ventilate.
• Listen for breath sounds.
• If present - ventilate
• If Absent - Deflate both balloons and remove the
  Combitube. Maintain airway and ventilate using
  basic airway techniques.

36
(No Transcript)
37
Removing the Combitube

• If the Combitube needs to be removed at any time
  -
• Get suction ready,
• Turn patient on left side,
• Deflate both balloons,
• Remove tube,
• Suction as necessary.

38
KBEMS Combitube Intubation Protocol
39
INDICATIONS

• - Cardiac Arrest
• - Respiratory Arrest/Apnea

40
CONTRAINDICATIONS

• A patient under the age of 18.
• A patient who has swallowed a corrosive
  substance.
• A patient with a known Esophageal Disease.
• EMT not trained and authorized to use the
  Combitube.
• Suspected cervical spine injury requiring
  cervical spine immobilization.

41
Initial Procedure

• Assure scene safety and use universal blood /
  body fluid precautions.
• ABCs.
• Clear airway and ventilate with 2 rescue breaths.
• Check Pulse if absent, follow the SAED Protocol.

42
Initial Procedure

• After the 2nd analysis cycle (if no shock is
  indicated) or after the 2nd series of 3 shocks is
  administered insert the Combitube as per the
  insertion procedure.
• Continue the SAED Protocol.

43
Initial Procedure

• If the patient initially has a pulse but is
  apneic follow the insertion procedure and
  perform rescue breathing through the Combitube .
• Continually re-assess for spontaneous
  respirations.

44
Insertion Procedure

• Continually re-assess for spontaneous
  respirations and pulse.
• Note that ALS may continue Combitube use, orally
  intubate around the Combitube, or remove the
  Combitube at the discretion of the responding
  Paramedic.
• The Combitube can NOT be used with the demand
  valve regulator.

45
AFTER HOSPITAL ARRIVAL

• Distribute Combitube assessment questionnaires
  to the treating paramedic and the ED team caring
  for the patient.
• Collect the completed forms.
• Fill out the Combitube utilization report and
  return it along with a copy of the run report(s)
  and completed paramedic ED assessment forms to
  your Medical Director and Ambulance Service
  Director.

46
Using The Combitube

• ABCs
• Measure (Combitube or Combitube SA?)
• Check Cuffs
• Insert
• Inflate Cuffs
• Ventilate through tube 1
• Check for Breath Sounds
• Switch Ventilate through tube 2 if needed
• Check for Breath Sounds
• Continue Ventilation

47
Check ABCs

• Establish Unresponsiveness.
• Verbal / tactile stimuli.
• Look Listen and Feel for air movement.
• Deliver 2 rescue breaths.
• reposition and try again if needed,
• clear airway if obstructed.
• Check Pulse.
• SAED CPR if needed.

48
Measure the patient

• Put loop of measuring device over the patients
  foot.
• Determine which Combitube to use.
• Combitube or Combitube SA.
• IF LESS THAN 4 FEET - use basic airway
  maintenance techniques.
• Select tube if the patient is over 4 feet.

49
COMBITUBE
COMBITUBE SA
50
Check the Cuffs

• Inflate Pilot Balloon 1 with 100ccs of air.
• Check for proper inflation of cuff.
• Deflate Cuff.
• Inflate Pilot Balloon 2 with 15ccs of air.
• Check for proper inflation of cuff.
• Deflate Cuff.

51
Large Syringe Attached to Pilot Balloon 1 Ready
to Inflate with 100ccs of Air
52
Pilot Balloon (1) Remains Inflated.
Large Pharyngeal Cuff Inflated
53
Small Syringe Attached to Pilot Balloon 2 Ready
to Inflate with 15ccs of Air
54
Pilot Balloon 2 for Small Distal Esophageal Cuff
2 Remains Inflated
Small Distal Esophageal Cuff 2 Inflated
55
Lubricate the Combitube

• Use water soluble gel. (Surgilube)
• Spread over tube.
• Use package or gloved hand.

56
Insert the Combitube

• Hold tube like a pencil with dominant hand.
• Lift jaw and tong between thumb and index finger
  of non-dominant hand.
• Insert Combitube into mouth with curve facing
  upward.
• Stop inserting when the upper teeth or gums are
  between the Black Rings.

57
(No Transcript)
58
Insert the Combitube

• If any resistance is met during insertion
• Remove the Combitube,
• Reposition,
• Re-insert one time.
• If resistance is met on the second attempt
• Remove the Combitube,
• Maintain airway using basic airway techniques.

59
(No Transcript)
60
Inflate the Cuffs

• Attach Large Syringe to Pilot Balloon 1.
• Inflate cuff 1 with 100ccs of air.
• Remove syringe.
• Confirm that Pilot Balloon is inflated.
• If not - attempt to re-inflate.
• If still no inflation - remove Combitube and
  maintain airway with basic airway techniques.

61
Large Syringe Attached to Pilot Balloon 1 Ready
to Inflate with 100ccs of Air
62
Pilot Balloon (1) Remains Inflated.
Large Pharyngeal Cuff Inflated
63
Inflate the Cuffs

• Attach Small Syringe to Pilot Balloon 2.
• Inflate cuff 2 with 15ccs of air.
• Remove syringe.
• Confirm that Pilot Balloon is inflated.
• If not - attempt to re-inflate.
• If still no inflation - Deflate Cuff 1, remove
  Combitube and maintain airway with basic airway
  techniques.

64
Small Syringe Attached to Pilot Balloon 2 Ready
to Inflate with 15ccs of Air
65
Pilot Balloon 2 for Small Distal Esophageal Cuff
2 Remains Inflated
Small Distal Esophageal Cuff 2 Inflated
66
(No Transcript)
67
Ventilate

• Attach Bag / Valve and CO2 detector to Tube 1.
  (Esophageal)
• Ventilate.
• Listen over Chest for breath sounds.
• If present - continue ventilation at a rate of
  12-20 breaths per minute.

68
CONTRAINDICATIONS

• A patient under the age of 18.
• A patient who has swallowed a corrosive
  substance.
• A patient with a known Esophageal Disease.
• EMT not trained and authorized to use the
  Combitube.
• Suspected cervical spine injury requiring
  cervical spine immobilization.

69
Initial Procedure

• Assure scene safety and use universal blood /
  body fluid precautions.
• ABCs.
• Clear airway and Ventilate with 2 rescue breaths.
• Check Pulse if absent, follow the SAED Protocol.

70
Initial Procedure

• After the 2nd analysis cycle (if no shock is
  indicated) or after the 2nd series of 3 shocks is
  administered insert the Combitube as per the
  insertion procedure.
• Continue the SAED Protocol.

71
Initial Procedure

• If the patient initially has a pulse but is
  apneic follow the insertion procedure and
  perform rescue breathing through the Combitube .
• Continually re-assess for spontaneous
  respirations.

72
Insertion Procedure

• Continually re-assess for spontaneous
  respirations and pulse.
• Note that ALS may continue Combitube use, Orally
  intubate around the Combitube, or remove the
  Combitube at Paramedic discretion.
• The Combitube can NOT be used with the demand
  valve regulator.

73
Possible Complications of Combitube Insertion

• Tear or rupture of esophagus.
• Bleeding.
• Puncture of carotid artery.
• Tear of pharynx.
• Pneumothorax.
• Death from asphyxiation.
• Vocal cord injury.

74
The Combitube Pilot Program

• Once trained, an EMT may use the Combitube with
  ANY Kentucky EMS agency that is approved to use
  the Combitube Pilot Program.
• A Combitube Pilot Program approved EMS agency,
  providing mutual aid to a non-approved EMS
  agency, may use the Combitube.

75
The Combitube Pilot Program

• Any Kentucky EMS Agency wanting to use the
  Combitube must
• Provide 2 Combitubes of each size on each
  ambulance or response vehicle,
• Make certain that all of their staff have
  received the required Combitube training, and
• Make certain that only trained EMTs perform the
  procedure.

76
Skills / Testing Stations

• Basic airway maintenance techniques.
• Equipment, techniques, oxygen, suction.
• Combitube familiarity.
• Combitube insertion SAED incorporation.
• Combitube tracheal and problem insertion.
• Written exam.