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Intubation

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We protect life and property at sea, enforce federal laws and ... Tripod. Bolt upright. COPD. CHF. Able to speak in sentences. ASSESSMENT. Adequacy of breathing ... – PowerPoint PPT presentation

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Title: Intubation


1
Intubation Advanced Airway Management
  • Captain Marc West, CCEMT-P, AAS
  • January, 2007

2
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.

3
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4
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.

5
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6
Wheres our video.?
7
Important point to understand
  • The ability to breathe and the ability to
    protect the airway are not always the same.

8
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.
9
DEFINITIONS
  • Hypoxemia
  • Reduction of O2 in arterial blood
  • Hypoxia
  • Insufficient O2 available to meet O2
    requirements
  • Hypercarbia
  • Increased level of CO_at_ in blood

10
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

11
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

12
Corollary Number One
  • The paramedic is responsibly for airway
    management in the field and during transport.

13
ASSESSMENT
  • BSI/ scene safety
  • General impression
  • Identify and correct any life threatening
    conditions
  • Responsiveness/ c-spine
  • Airway
  • Breathing
  • Circulation

14
ASSESSMENT
  • Primary Survey- quick crude
  • Airway
  • Breathing
  • Circulation
  • Secondary Survey- slower refined

15
Assessment
  • POSITION
  • Tripod
  • Bolt upright
  • COPD
  • CHF
  • Able to speak in sentences

16
ASSESSMENT
  • Adequacy of breathing
  • Expose the chest
  • Patients demeanor
  • Blockages
  • Mild
  • Severe or complete
  • Concerns that set off our alarms

17
ASSESSMENT
  • Adequacy of breathing
  • Expose the chest
  • Patients demeanor
  • Blockages
  • Mild
  • Severe or complete
  • Concerns that set off our alarms

18
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)

19
Corollary Number Two
  • Any patient that requires the establishment of an
    airway also requires protection of that airway.

20
BREATHING
  • Adequacy?
  • Rate and quality?
  • Spontaneous regular
  • effortless
  • Chest rise
  • Equal and present excursion
  • Deformity/ crepitus
  • Ecchymosis
  • Subcutaneous emphysema
  • Paradoxical (asymmetric)
  • Flail chest

21
BREATHING EFFORT
  • Normal
  • Labored/ dyspnic
  • Tachypnic/ bradypnea
  • Accessory muscle use
  • Intercostal retractions
  • Suprasternal
  • Abdominal muscle use
  • Pediatrics
  • Grunting
  • Nostril flaring

22
BREATH SOUNDS
  • CTA bilat
  • Diminished
  • Rhonci
  • Rales
  • Wheezing

23
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

24
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

25
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

26
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

27
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.

28
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.

29
Advanced Airway Management
  • Manual airway control
  • Ventilation
  • Oxygenation
  • Proceed to advanced management
  • Allows for correction of
  • Profound hypoxia
  • hypercarbia

30
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.

31
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..

32
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33
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34
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35
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36
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

37
Advantages
  • Controls the airway
  • Facilitates ventilation/ O2
  • pH issues (acidosis alkalosis)
  • Prevents gastric inflation
  • Allows for direct suctioning
  • Medication administration

38
Monitoring
  • Pulse oximetry
  • End tidal CO2
  • Quantitative
  • capnography
  • Qualitative
  • Colormetric
  • Purple to yellow

39
Disadvantages
  • Requires extensive and ongoing training for
    proficiency
  • Requires specialized equipment
  • Bypasses physiological function of upper airway
  • Warm
  • Filter
  • Humidify

40
Complications with Intubated Patients
  • Displacement
  • Obstruction
  • Pneumothorax
  • Equipment failure
  • Contraindicated in epiglottitis

41
Possible Occurring Complications
  • Bleeding
  • Laryngeal swelling
  • Laryngospasm
  • Vocal cord damage
  • Mucosal necrosis
  • Barotrauma
  • Dental trauma
  • Laryngeal trauma
  • Esophageal placement

42
Pathophysiology
  • Increased interstitial fluid due to injury
  • Pulmonary edema
  • Destruction of alveoli
  • ARDS
  • Impaired gas exchange
  • Hypoxemia
  • Hypercarbia
  • Increased mortality

43
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

44
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

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

46
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?

47
WAVEFORM
  • Normal
  • Acute upstroke- exhalation
  • Acute down stroke- inhalation
  • Straight across
  • Shark fin- lower airway obstruction

48
ASPIRATION
  • Partially dissolved food
  • Protein dissolving enzymes
  • Hydrochloric acid

49
Prevention
  • Cricoid pressure
  • Suctioning
  • Tonsil tip
  • Whistle tip
  • Positioning

50
Hazards of Suctioning
  • Cardiac dysrhythmias
  • Increased BP/ HR
  • Decreased BP/ HR
  • Gag reflex bucking on the tube
  • Cough
  • Increased ICP
  • Decreased CBF

51
Multilumen Airways
  • Combitube
  • Pharyngotracheal Lumen Airway (COPA)
  • King LT
  • PAX
  • GO2 Airway

52
Advantages
  • Blind insertion
  • Facial seal is not necessary
  • Can be placed in esophagus or trachea

53
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.

54
Contraindications
  • Ingestion of caustic substances
  • Esophageal disease
  • Presence of gag reflex

55
Corollary Number Four
  • Acute, progressive anatomical airway distortion
    is a potential time bomb. Intubate early, before
    deterioration occurs.

56
Corollary Number Five
  • If the patient is leaving the relative safe
    confines of the ED, intubate early before
    deterioration and airway compromise occur

57
Corollary Number Six
  • Arterial blood gas values are rarely helpful in
    the decision to intubate and may lead to faulty
    decision making.

58
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

59
Special Airway Management Techniques
  • BURP
  • Digital Intubation
  • NasoTracheal Intubation
  • Sky-Hook Technique
  • Lighted Stylet
  • Retrograde Intubation
  • Needle Cricothyroidomy
  • Surgical Cricothyroidomy

60
Airway Pharmacology
  • Opiates
  • Morphine
  • Fentanyl
  • Neuromuscular Blocking Agents
  • Succinylcholine (depolarizing, biphasic)
  • Vecuronium
  • Atracurium
  • Pancuronium
  • Rocuronium
  • Benzodiazepines

61
Rapid Sequence Induction
  • Preoxygenate
  • Prepare
  • Induce
  • Sellicks maneuver
  • Consider premedication
  • Paralyze
  • Intubate
  • ET confirmation
  • Secure ETT
  • Maintain paralysis / pain management

62
Triad of Death
  • Hypothermia
  • Acidosis
  • Coagulopathy

63
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64
  • 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
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