Intubation

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Intubation Advanced Airway Management

• Captain Marc West, CCEMT-P, AAS
• January, 2007

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Mission Statement of the United States Coast
Guard

• We protect life and property at sea, enforce
  federal laws and treaties, preserve marine
  natural resources, and promote national security
  interests.

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Mission Statement of the Critical Care Paramedic

• We protect the airway and ensure adequate
  respirations, maintain hemodynamic stability and
  body systems homeostasis, to ensure adequate pain
  management to all patients we transport and we
  are patient advocates during their time in our
  charge.

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Wheres our video.?
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Important point to understand

• The ability to breathe and the ability to
  protect the airway are not always the same.

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Protecting the patients airway is the single most
important objective and treatment skill set a
paramedic should be proficient at. For without
it, any other medical interventions are worthless
and a waste of time.
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DEFINITIONS

• Hypoxemia
• Reduction of O2 in arterial blood
• Hypoxia
• Insufficient O2 available to meet O2
  requirements
• Hypercarbia
• Increased level of CO_at_ in blood

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Objectives for Airway Assessment

• Rapidly assess the patients need for intubation
  and the urgency of the situation
• Determine the best method of airway management,
  given the circumstances
• Deciding on which pharmacological agents to use
• Managing the airway in the context of the
  patients overall condition
• Airway devices to achieve definitive airway and
  minimize hypoxia and hypercarbia
• Having a PLAN B and being ready to use it

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AHA 2005 recommendations

• Lower tidal volume
• (6-7ml/Kg or 500-600 ml over 1 second)
• 8 to 10 breaths per minute MAX
• No pauses for breaths during CPR
• ETT only by skilled, no gt 10sec
• Confirmation of ETT placement
• 6-18 misplaced ETT prehospital 0

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Corollary Number One

• The paramedic is responsibly for airway
  management in the field and during transport.

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ASSESSMENT

• BSI/ scene safety
• General impression
• Identify and correct any life threatening
  conditions
• Responsiveness/ c-spine
• Airway
• Breathing
• Circulation

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ASSESSMENT

• Primary Survey- quick crude
• Airway
• Breathing
• Circulation
• Secondary Survey- slower refined

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Assessment

• POSITION
• Tripod
• Bolt upright
• COPD
• CHF
• Able to speak in sentences

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ASSESSMENT

• Adequacy of breathing
• Expose the chest
• Patients demeanor
• Blockages
• Mild
• Severe or complete
• Concerns that set off our alarms

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ASSESSMENT

• Adequacy of breathing
• Expose the chest
• Patients demeanor
• Blockages
• Mild
• Severe or complete
• Concerns that set off our alarms

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AIRWAY

• Is it patent?
• Snoring, gurgling or stridor may indicate
  potential problems
• Secretions, objects, blood, vomitus present
• Neck
• JVD (jugular vein distention)
• TD (tracheal deviation, tugging)

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Corollary Number Two

• Any patient that requires the establishment of an
  airway also requires protection of that airway.

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BREATHING

• Adequacy?
• Rate and quality?
• Spontaneous regular
• effortless
• Chest rise
• Equal and present excursion
• Deformity/ crepitus
• Ecchymosis
• Subcutaneous emphysema
• Paradoxical (asymmetric)
• Flail chest

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BREATHING EFFORT

• Normal
• Labored/ dyspnic
• Tachypnic/ bradypnea
• Accessory muscle use
• Intercostal retractions
• Suprasternal
• Abdominal muscle use
• Pediatrics
• Grunting
• Nostril flaring

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BREATH SOUNDS

• CTA bilat
• Diminished
• Rhonci
• Rales
• Wheezing

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Modified Forms of Respiration

• Reflexes which act to protect the respiratory
  system
• Cough- forceful, spasmodic exhalation of a large
  volume of air
• Sneeze- sudden forceful exhalation from the nose
• Hiccough- sudden inspiration caused by spasmodic
  contraction of the diaphragm glottic closure
• Gag reflex- spastic pharyngeal esophageal
  reflex caused by stimulation of posterior pharynx
• Sighing- hyperinflation of lungs, opens atelectic
  alveoli

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RESPIRATORY PATTERNS

• Cheyne Stokes
• Regular pattern of increasing rate volume
  followed by gradual decrease and a short period
  of apnea
• Brain stem insult
• Kussmauls
• Deep, gasping regular respirations
• Diabetic coma

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RESPIRATORY PATTERNS

• Biots
• Irregular rate volume with intermittent periods
  of apnea
• Increased ICP
• Central Neurogenic Hyperventilation
• Regular, deep and rapid
• Increased ICP
• Agonal
• Slow, shallow, irregular
• Brain hypoxia

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PULSUS PARADOXUS

• Decrease in systolic BP gt 10 mm HG during
  inspiration
• Caused by increase in intrathoracic pressure
• COPD
• Interference with ventricular filling
• Results in decreased BP

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Corollary Number Three

• The gag reflex does not correlate well with
  airway protection and is of NO CLINICAL VALUE
  when assessing the need for intubation.

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Corollary Number Three

• The gag reflex does not correlate well with
  airway protection and is of NO CLINICAL VALUE
  when assessing the need for intubation.

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Advanced Airway Management

• Manual airway control
• Ventilation
• Oxygenation
• Proceed to advanced management
• Allows for correction of
• Profound hypoxia
• hypercarbia

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Cortisol

• The principal glucocorticoid secreted by the
  adrenal cortex, in response to adrenocorticotropic
  hormone (ACTH).
• Sometimes referred to as the stress hormone.
• Marker of the extent of stress placed on the
  human body.

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Cortisol

• Because one of our lower brain main functions is
  to protect our airway, the release of cortisol is
  a good marker for stress. (normal 7mcg 28
  mcg/dl)
• The only time cortisol levels exceed those during
  intubation is during a
• mid-sternotomy think about it..

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Endotracheal Intubation

• When ventilating an unresponsive patient through
  conventional methods cannot be achieved
• Protect the airway
• Prolonged artificial respiration required
• Patients with or likely to experience upper
  airway compromise
• Decreased tidal volume- bradypnea
• Airway obstruction

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Advantages

• Controls the airway
• Facilitates ventilation/ O2
• pH issues (acidosis alkalosis)
• Prevents gastric inflation
• Allows for direct suctioning
• Medication administration

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Monitoring

• Pulse oximetry
• End tidal CO2
• Quantitative
• capnography
• Qualitative
• Colormetric
• Purple to yellow

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Disadvantages

• Requires extensive and ongoing training for
  proficiency
• Requires specialized equipment
• Bypasses physiological function of upper airway
• Warm
• Filter
• Humidify

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Complications with Intubated Patients

• Displacement
• Obstruction
• Pneumothorax
• Equipment failure
• Contraindicated in epiglottitis

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Possible Occurring Complications

• Bleeding
• Laryngeal swelling
• Laryngospasm
• Vocal cord damage
• Mucosal necrosis
• Barotrauma
• Dental trauma
• Laryngeal trauma
• Esophageal placement

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Pathophysiology

• Increased interstitial fluid due to injury
• Pulmonary edema
• Destruction of alveoli
• ARDS
• Impaired gas exchange
• Hypoxemia
• Hypercarbia
• Increased mortality

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Laryngoscope

• Move tongue and epiglottis
• Allows visualization of cords and glottis
• Miller- straight
• Lift epiglottis
• pediatrics
• Macintosh- curved
• Fits in valeculla
• More room for visualization
• Reduced trauma/ gag reflex

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Endotracheal Tube

• 15mm universal adapter
• 2.5-9.0mm diameter
• 12-32cm length
• Male- 23cm 8.0-8.5mm (lets talk)
• Female- 21cm 7.5-8.0mm (lets talk)
• Balloon cuff
• Occludes tracheal lumen
• Pilot balloon
• magill forceps

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Verify Placement

• Esophageal intubation detector
• CO2 detector
• Auscultation
• EtCO2 Capnography
• 35-45mm Hg
• Hyperventilation in head injury with herniation
  30-35mm HG

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CAPNOGRAPHY- EtCO2

• Standard of care in hospital
• during transport
• Immediate response to extubation
• Stand up in court to prove intubation
• Waveform indicative
• Normal
• Obstructed airway- do you NEED a beta-2 agonist?

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WAVEFORM

• Normal
• Acute upstroke- exhalation
• Acute down stroke- inhalation
• Straight across
• Shark fin- lower airway obstruction

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ASPIRATION

• Partially dissolved food
• Protein dissolving enzymes
• Hydrochloric acid

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Prevention

• Cricoid pressure
• Suctioning
• Tonsil tip
• Whistle tip
• Positioning

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Hazards of Suctioning

• Cardiac dysrhythmias
• Increased BP/ HR
• Decreased BP/ HR
• Gag reflex bucking on the tube
• Cough
• Increased ICP
• Decreased CBF

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Multilumen Airways

• Combitube
• Pharyngotracheal Lumen Airway (COPA)
• King LT
• PAX
• GO2 Airway

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Advantages

• Blind insertion
• Facial seal is not necessary
• Can be placed in esophagus or trachea

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Indications

• Over 4' tall.
• 4' - 5' 6" are considered small adult5' 6" are
  considered adult
• B. Patients anatomy will accept CombiTube.C. If
  you are unsuccessful at TWO intubation attempts,
  use the CombiTube.

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Contraindications

• Ingestion of caustic substances
• Esophageal disease
• Presence of gag reflex

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Corollary Number Four

• Acute, progressive anatomical airway distortion
  is a potential time bomb. Intubate early, before
  deterioration occurs.

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Corollary Number Five

• If the patient is leaving the relative safe
  confines of the ED, intubate early before
  deterioration and airway compromise occur

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Corollary Number Six

• Arterial blood gas values are rarely helpful in
  the decision to intubate and may lead to faulty
  decision making.

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AHA 2005 recommendations

• Lower tidal volume
• (6-7ml/Kg or 500-600 ml over 1 second)
• 8 to 10 breaths per minute MAX
• No pauses for breaths during CPR
• ETT only by skilled, no gt 10sec
• Confirmation of ETT placement
• 6-18 misplaced ETT prehospital 0

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Special Airway Management Techniques

• BURP
• Digital Intubation
• NasoTracheal Intubation
• Sky-Hook Technique
• Lighted Stylet
• Retrograde Intubation
• Needle Cricothyroidomy
• Surgical Cricothyroidomy

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Airway Pharmacology

• Opiates
• Morphine
• Fentanyl
• Neuromuscular Blocking Agents
• Succinylcholine (depolarizing, biphasic)
• Vecuronium
• Atracurium
• Pancuronium
• Rocuronium
• Benzodiazepines

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Rapid Sequence Induction

• Preoxygenate
• Prepare
• Induce
• Sellicks maneuver
• Consider premedication
• Paralyze
• Intubate
• ET confirmation
• Secure ETT
• Maintain paralysis / pain management

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Triad of Death

• Hypothermia
• Acidosis
• Coagulopathy

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• Followed by advanced adjunct placement ASAP
• Prevent gastric inflation
• Prevent aspiration
• Endotracheal tube
• Grandview blade
• Viewmax blade
• Gum Bougie
• CombiTube
• COPA
• PAX
• King LT
• PtL
• LMA
• LMA FasTrach or LMA-I