Tag Archive | "endotracheal tube"

The Five Ws of Intubation


Ask yourself “w” questions (i.e., who, what, when, where and why) when starting an intubation. Photo iStockPhoto.com

We learned that airway comes first in the very first class all of us took in EMS. Up until the recent changes in the American Heart Association guidelines, we had the following mantra stuck in our heads: “Annie, Annie, are you OK?” We were to open the airway, then look, listen and feel. So when it comes to managing the airway in the field, this is the first priority and often the most overwhelming to EMS providers.

Airways can be simple or complex depending on the particular patient, the environment and the experience of the provider. The gold standard for a secure airway, however, the ultimate goal is oxygenation with successful first-time insertion of the endotracheal tube (ETT).We reserve the ETT for a particular patient population in the EMS community. Let’s call them the “who.”

Who & When
The “who or “when” would be those patients who are unable to protect their own airways, who are apneic or who require ventilator support—either manually or by ventilator.

In some cases, selecting this group is obvious. If they can’t breathe on their own, then someone or something needs to do it for them. In other patients, it’s a little harder to determine whether we need to intervene with the airway. This is where we providers need to read the signs or look at tea leaves for guidance. We find signs in our assessment with things like rate and quality of respiration, end-tidal CO2, skin color, work of breathing and pulse oximetry. And sometimes, you’ve gotta ask yourself, “What are the voices telling me?”

Sometimes we providers become a bit anxious, regardless of our level of certifications, licensure or experience, about placing an ETT and controlling a patient’s ability to breathe spontaneously. A good example of this is the provider that doesn’t have the correct medications or the experience to perform a rapid sequence intubation (RSI) on a patient, so they attempt to “snow” the patient with narcotics or try to muscle past the patient’s gag reflex. We’re all guilty of this in some form or fashion at some point in our careers. I sometimes hear providers (including physicians) say, “I did the best with what I had.” Is this really our best? Maybe looking at other options and supportive care that is more time consuming, less glorious and in the best interest of the patient would be the better choice.

What
“What” are we really attempting to do when we intubate using direct laryngoscopy? The simple explanation would be to place a tube into the patient’s trachea to allow for ventilation. This is easier said than done. It’s simple enough in concept but requires us to displace the anatomy that stands between the oral opening and the trachea. Part of this challenge is m the largest obstacle in the airway—the tongue. We need to move it out of the visual field to be able to see the laryngeal structures. Usually when you encounter that huge floppy tongue, there’s a big floppy epiglottis attached to the base of it. If you don’t see it right away, look in the pool of pizza, beans and beer oozing out of the airway, lying in the back of the posterior oral pharynx.

What's the structure at the base of the tongue that prevents aspiration?

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Complicating the patient’s own anatomy is the fact that we’re trying to place a large metal stick in this small space and make enough room to guide the ETT through it to the trachea without inadvertently placing it in the esophagus. If we understand the anatomical structures and how they move, we can use that to successfully manipulate the airway.

One of the most common mistakes I see is when providers attempt to pry with the laryngoyscope blade as opposed to lifting the structures. Remember that the structures we’re attempting to displace are still attached to the patient by a large hinge joint known as the jaw, or mandible. If we displace the jaw, the soft structures attached will follow. This holds true for correct manipulation as well as incorrect ones. If we pry back toward the patient’s head, then all the structures we’re attempting to move out of our way are simply coming up in our face. You may hear this referred to as rocking or prying. It’s often associated with contact with the teeth and pulling the oral opening closed.

The most common cause of that is holding high on the laryngoscope handle and using the 90-degree angle of the handle and blade as the fulcrum and rocking back. Remember basic physics from high school? “Every action has an equal and opposite reaction.” If you’re pulling back on the stick, the other end of the stick is going to react as well and pull the structures right into your view. If we lift the stick up and away, say toward the corner of the ceiling, the jaw will lift and the tongue and epiglottis will follow.

Where
“Where” makes a difference—whether it’s on the cot, in the door, on the floor, in the dark on a train and in the rain. (This is starting to sound like a Dr. Seuss book, but it really is true.) We should make our first attempt our best attempt, so we should try to pick a place or modify the conditions to create our best attempt. If we can get the patient to the stretcher and an elevation and position that enhances our ability to obtain direct visualization of the airway, we’re setting ourselves up for success.

One bad habit I see providers have in the field is to slide the patient to the end of the cot and allow their head to hang back or attempting to intubate with the cervical collar in place. Again, think about the anatomy, have you ever tried to talk with a cervical collar on or hang your head over the back of the chair you’re sitting in? Did you notice that your chin was pointing one direction and your airway was going the other? Provide the patient has no cervical injury the ideal position would be to lift the patients head so to bring their ears even with their chest, you may hear this referred to as ear-to-sternal notch or a wedge technique.

Another great trick you might want to think about is a concept that Dr. Richard Levitan introduced in his book, “The Airway Cam Guide to Intubation and Practical Emergency Airway Management”, ELM or bimanual laryngoscopy, where the intubator actually will manipulate the trachea to bring the glottis opening into view. If the patient has a suspected cervical spine injury, hold inline stabilization while another provider secures the airway, allowing the jaw to be manipulated without restriction. We can’t always relocate the patient when we need to control the airway, so try to use gravity and the patient’s own anatomy to assist in locating and securing the airway.

Why & How
That would leave us with two final questions: why and how. The “why” is pretty simple, to oxygenate my patient. However, that is easier said than done because many of the airway adjuncts we use and the oxygen delivery system are subject to human error, failure or misuse result in injury to the patient, hyper- or hypo-oxygenation, so we must constantly reassess to ensure we are providing adequate oxygenation in a safe manner.

Finally comes the “how?” The simple answer is to do things with the easiest, safest and most efficient means possible. Every situation is different; some patients may require a simple oropharyngeal airway (OPA), a few breaths and transport. Another may need RSI, a definitive airway and the use of video laryngoscopy, which uses a camera and a video monitor to visualize the airway and the glottis, enabling faster intubation. A few may even need a surgical airway.

What benefit might video laryngoscope have that traditional direct laryngoscope does not?

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Conclusion
The patient, the situation, the patient’s illness or injury, the provider’s experience, and the resources available will determine the tools and means of airway control. Ultimately you have to have an airway plan tattooed on your brain so it’s right there every time you need to manage an airway. We’ll save that discussion for another day.

I hope the next time you pick up a laryngoscope or an endotracheal tube you ask yourself these simple questions: who, what, where, when, why and how. Hope to see you soon.

Stay safe,
Jim Radcliffe, BS, MBA, EMT-P

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Intubation for Cardiac Arrest Patients


The debate over whether to intubate cardiac arrest patients remains strong. Photo Kevin Link

The debate over whether to intubate cardiac arrest patients remains strong. Photo Kevin Link

Recently, I came across a destitute colleague who had just responded to a code for a cardiac arrest. During the arrest, the patient was intubated successfully, without interruption of compressions. I was puzzled. Why was my colleague distressed? Surely, she had done her job well, securing the airway in a prompt and efficient manner.

As it turns out, another provider had questioned numerous elements of her care. First, the other provider debated whether to give a paralytic. The other provider vehemently argued that a paralytic was indicated to “best optimize the chance of success.” My colleague did not feel that a paralytic was indicated in cardiac arrest, and intubated without the use of any additional medications.

After the argument about the paralytic, the other provider then had the nerve to question whether the patient should have even been intubated at all! In point of fact, intubation in cardiac arrest is quite controversial, and my downtrodden colleague had every right to feel frustrated.

Should all patients with cardiac arrest be intubated?

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Although endotracheal intubation has long been regarded as the “gold standard” for cardiac arrest, recent guidelines de-emphasize the procedure, especially if intubation is to be achieved at the expense of other evidence-based interventions (i.e., CPR and electrical therapy) associated with improved survival and better neurological outcomes.(1,2)

Now I will admit that when I first read this recommendation, it was difficult to digest. As a paramedic, anesthesiologist, and intensivist, I’ve never thought twice about securing an airway with an endotracheal tube during a cardiac arrest. Historically, to do otherwise would be considered malpractice! However, when one examines the recent literature, it is understandable why intubation for cardiac arrest remains a provocative topic. For starters, the reader is referred to a comprehensive and well-written review on this topic by Dr. J.V. Nable et al.(1)

Intubation has not been shown to positively impact outcomes for cardiac arrest patients, and there are several explanations for this somewhat counterintuitive finding.

First, intubation during cardiac arrest is not always straightforward, and in at least one study, 30% of patients required more than one attempt.(3)

Second, the learning curve to attain competence is steep—one study suggests up to 60 intubations are required to become proficient—and in some systems, EMS providers do not have opportunities maintain this skill.(4) As Nable et al write, “maintaining proficiency in endotracheal intubation is a significant barrier for many prehospital providers.”(1) In Wang et al, intubation success by medics was only 78%.(3)

Third, intubation is followed by positive pressure ventilation (PPV), and PPV has been shown to decrease preload, lower cardiac output, and negatively impact the effectiveness of chest compressions.(1)

Fourth, intubation may require interruption of chest compressions, and this has clearly been linked with worse outcomes.(5) For the abovementioned reasons, in some countries, such as the U.K., a case has been made for abandoning intubation altogether in cardiac arrest.(6)

Coming back to my colleague’s dilemma regarding paralysis for intubation in cardiac arrest, this is also a contentious topic. On one hand, paralysis may enhance intubating conditions and facilitate prompt control of the airway, thereby avoiding airway trauma with multiple laryngoscopic attempts, and preventing aspiration. Moreover, the most feared complication of paralysis—the “can’t intubate, can’t ventilate” scenario—is relatively rare. In one study of more than 6,000 trauma patients at our institution (University of Maryland R Adams Cowley Shock Trauma Center in Baltimore), only four patients required a surgical airway.(7)

On the other hand, the hazards of positive pressure ventilation, hyperkalemia associated with succinylcholine, and the rare instance of failed intubation in a paralyzed patient with a difficult airway, all pose an unacceptable risk/benefit in cardiac arrest. The decision to use paralytics is as difficult as deciding to intubate in cardiac arrest, and the use of these agents can only be recommended for the most highly trained providers.

Should patients in cardiac arrest be given muscle relaxants to facilitate intubation?

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What about supraglottic airways? This class of airways includes the laryngeal mask airway (LMA), Combitube, laryngeal tube and other various proprietary devices. Although these devices do not represent a “definitive airway,” several studies have shown equivalent outcomes when these devices were compared to endotracheal intubation in cardiac arrest.(1,8) Supraglottic airways have several advantages over intubation. Learning curves are easier, the devices can be placed faster, and there may be fewer complications during device insertion.(9)

To date, no one device has been shown to be conclusively superior to another. Patients eligible for placement of a supraglottic airway require adequate mouth opening, no underlying severe lung disease (i.e., decreased lung compliance), and low risk for aspiration.(1)

At the end of the day, airway management for cardiac arrest may be achieved according to the proficiency and resources available to the provider. EMS providers should not be discouraged by the literature! Airway management is still important. In one study by Wong et al, the best short-term survival was seen in patients who had an advanced airway placed within five minutes of the arrest.(10)

Other studies have failed to show any difference between intubation and use of bag-valve mask ventilation (BVM).(11) However the airway is managed, current recommendations still emphasize the importance of providing ventilatory support during cardiac arrest.(2) In jurisdictions where intubation is used for cardiac arrest, providers should perform the procedure with “sufficient frequency to maintain competence within a highly managed system that actively monitors success rates, complications and patient outcomes.”(9)

If intubation is to be considered in cardiac arrest, it should only be attempted if:

  • The provider is proficient;
  • There are no interruptions in chest compressions; and
  • The attempt takes no more than 10 seconds.(2)

Survivors of cardiac arrest who require intensive care management will usually require definitive airway management with endotracheal intubation at some point, but early in the arrest, providers should focus on providing high-quality CPR.(12)

References
1. Nable JV, Lawner BJ, Stephens CT. Airway management in cardiac arrest. Emerg Med Clin N Am. 2012;30:77–90.

2. Neumar RW, Otto CW, Link MS. Part 8: Adult advanced cardiac life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation. Circulation. 2010;1222(183):S727–S767.

3. Wang HE, Yealy DM. How many attempts are required to accomplish out-of-hospital endotracheal intubation? Acad Emerg Med. 2006;13:373–377.

4. West MR, Jonas MM, Adams AP, et al. A new tracheal tube for difficult intubation. Br J Anaesth. 1996;76:673–679.

5. Kellum MJ, Kennedy KW, Ewy GA. Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest. Am J Med. 2006;119:335–340.

6. Deakin CD, Clarke T, Nolan J. A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group. Emerg Med J. 2008;27:226–233.

7. Stephens CT, Kahntroff S, Dutton RP. The success of emergency endotracheal intubation in trauma patients: A 10-year experience at a major trauma center. Anesth Analg. 2009;109:866–872.

8. Kajino K, Iwami T, Ktamura T, et al. Comparison of supraglottic airway verus endotracheal intubation for the pre-hospital treatment of out-of-hospital cardiac arrest. Critical Care. 2011;15:R236.

9. Thomas MJC. Prehospital intubation in cardiac arrest: The debate continues. Resuscitation. 2011;82:367-368.

10. Wong ML, Carey S, Mader TJ, et al. Time to invasive airway placement and resuscitation outcomes after inhospital cardiopulmonary arrest. Resuscitation. 2010;81:182–186.

11. Shin SS, Ahn KO, Song KJ, et al. Out-of-hospital airway managemetn and cardiac arrest outcomes: A propensity score matched analysis. Resuscitation. 2011. Accessed 18 Feb 2012.

12. Morley PT. The key to advanced airways during cardiac arrest: Well trained and early. Critical Care. 2012;16:104.

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Samuel M. Galvagno Jr., DO, PhD

Dr. Galvagno has been involved with prehospital care for more than 19 years. He started his EMS career as a National Ski Patroller in upstate New York, and became an EMT in 1992 in Maryland. Before and while attending medical school at the New York College of Osteopathic Medicine, he was a paramedic in Maryland and New York. He completed his internship at Saint Vincent’s Midtown Hospital in Hell’s Kitchen, New York before working as an emergency physician and flight surgeon in the U.S. Air Force. On leaving active duty, Dr. Galvagno received residency training at Harvard Medical School, Brigham and Woman’s Hospital, followed by a fellowship in Critical Care Medicine at the Johns Hopkins School of Medicine. He also completed a research fellowship and extensive training in epidemiology and biostatistics at the Johns Hopkins Bloomberg School of Public Health; he is due to receive his PhD in 2012 with a thesis focused on helicopter emergency medical services for adults with major trauma. Dr. Galvagno is the author of numerous publications and book chapters, including his own textbook, Emergency Pathophysiology. He is currently an assistant professor in the Divisions of Trauma Anesthesiology and Adult Critical Care Medicine at the R Adams Cowley Shock Trauma Center, Baltimore. He remains active in the U.S. Air Force, and is the director of critical care Air Transport Team (CCATT) operations and assistant chief of professional services at Joint Base Andrews, Maryland. He is board-certified in anesthesiology, adult critical care medicine and public health.

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Oxygenation & Ventilation Are Not the Same Thing


Combine capnography with pulse oximetry when monitoring ventilation and oxygenation in the prehospital environment. Photos Courtesy Jim Brown, Maryland Institute of Emergency Medical Services Systems

I recently observed a paramedic who made one of the most difficult prehospital clinical decisions I have seen during my 16 years of involvement in prehospital care. We were notified that a motor vehicle crash patient was inbound by helicopter, Category A (the highest in Maryland). Details about the crash were scant, and while the patient was swiftly rolled into our trauma resuscitation unit, I nearly stepped on a slippery, blood-laden tubular object that had fallen off the backboard—the endotracheal tube.

The flight paramedic proceeded to tell me that the patient had been intubated in the field and although there had been an appropriate colorimetric change on the CO2 detection device, lung sounds were difficult to appreciate en route and capnographic waveforms were absent. Yet, the patient’s pulse oximeter continued to read 99% the entire time. Nevertheless, the paramedic pulled the tube shortly before arrival, and proceeded to mask ventilate the patient with an oral airway. One might ask, “What on Earth was this paramedic thinking?”

As it turned out, the paramedic made a difficult but supremely commendable and 100% appropriate decision to extubate the patient. The medic later admitted that he struggled with the decision to remove what was thought to be a “perfectly good endotracheal tube.” But in the end, he knew the difference between ventilation and oxygenation, and based on his assessment, he knew that the former was not being accomplished, and that failure of the later would quickly ensue. These two separate—although highly related—processes are often confused and frequently misunderstood, and comprehending the difference is critical in the prehospital arena. Advanced technologies have an important role in monitoring ventilation and oxygenation, and an understanding of the limitations of these devices is a prerequisite for effective use.

Ventilation vs. Oxygenation
Ventilation and oxygenation are separate physiological processes. Ventilation is the act or process of inhaling and exhaling. To evaluate the adequacy of ventilation, a provider must exercise eternal vigilance. Chest rise, compliance (as assessed by the feel of the bag-valve mask), and respiratory rate are qualitative clinical signs that should be used to evaluate the adequacy of ventilation. Capnography, long the standard of care in the operating room and intensive care unit, can also be used to assess ventilation. Also, continuous quantitative waveform capnography has become the standard of care for monitoring endotracheal tube placement.(1) Capnography can be used to assess end-tidal carbon dioxide ( EtCO2) concentration or tension. Normal values of EtCO2 are 35-37 mmHg, and in normal lungs, the EtCO2 approximates the arterial CO2 concentration in the blood with a value that is usually lower by 2 to 5 mmHg.(2) Use of capnography is not limited to intubated patients; nasal cannulas and face masks can be modified to detect EtCO2.

Do you regularly use quantitative waveform capnography?

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EtCO2 can be measured by colorimetry and capnography. Colorimetric devices provide continuous, semi-quantitative EtCO2 monitoring. A typical device has the following three color ranges:

Purple—EtCO2 is less than 0.5%
Tan—EtCO2 is 0.5–2%
Yellow—EtCO2 is greater than 2%

Normal EtCO2 is greater than 4%; hence, the device should turn yellow when the endotracheal tube is inserted in patients with intact circulation.(2) False positives may occur when the device is contaminated with acidic substances, such as gastric acid, lidocaine or epinephrine. The device will not provide an accurate reading it is expired or if the tube is clogged with secretions. Causes of increased or decreased EtCO2 are listed in Table 1.(2) One of the most common causes of increased EtCO2 is hypoventilation, since CO2 cannot be removed from the body when air exchange is impaired.

Capnography provides both a waveform and digital reading (mmHg of CO2 in exhaled gas). Capnography is no longer merely a standard for the operating rooms; it is a standard for ensuring ventilation after intubation anywhere, and it is now a fundamental objective means for assessing the adequacy of CPR.(1) For example, if the EtCO2 is less than 10 mmHg, the American Heart Association recommends optimizing chest compressions to improve the quality of CPR.(1,3–4) Capnography has prognostic value for trauma and cardiac arrest patients, and it correlates well with such other physiologic parameters as coronary perfusion pressure and cardiac output.(5) For a more in-depth discussion of the physics and use of capnography in the prehospital setting, visit www.capnography.com.

The pulse oximeter is a good way to ensure adequate oxygenation of your patients.

Oxygenation refers to the process of adding oxygen to the body system. There is no way to reliably measure arterial oxygenation via clinical signs alone. Cyanosis, pallor and other physical findings are not reliable. The pulse oximeter, which relies on a spectral analysis of oxygenated and reduced hemoglobin as governed by the Beer-Lambert law, represents the principle means of assuring adequate oxygenation in a patient.(2) Saturation of peripheral oxygen (SpO2) levels measured with a pulse oximeter correlate highly with arterial oxygenation concentrations.(6) An easy way to remember the correlation between SpO2 and approximate partial pressure of oxygen in arterial blood (PaO2) is presented in Table 2.

Despite years of use in a wide variety of settings, even experienced physicians and nurses have significant knowledge deficits regarding the limitations and interpretation of pulse oximetry.(7–9) Pulse oximetry has several limitations. Hypoxia follows hypoventilation, and it may take 30 seconds or more for the pulse oximeter to reflect conditions of life-threatening hypoxia. Relying on the pulse oximeter alone can decrease the margin of safety because corrective actions taken after the pulse oximeter falls may be too late. Hypovolemia, vasoconstriction, peripheral vascular disease or nail polish may cause false readings. It should be noted that pulse oximetry, while a significant technological advance over the past 20 years, has not been reliably shown in all studies to improve outcomes.(10) However, in studies based on closed claims data (i.e., lawsuits), the use of pulse oximetry, at least in the operating room, has been suggested to reduce the serious mishap rate by at least 35%.(11)

Pulse oximetry is superior to physical examination for monitoring ventilation.

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Conclusion
Ideally, when monitoring ventilation and oxygenation in the prehospital environment, capnography should be combined with pulse oximetry. With capnography, providers are able detect respiratory insufficiency early and are able to institute early interventions, thereby preventing arterial oxygen desaturation. However, as with any monitoring technology, the best “monitor” is the provider. Pulse oximeters and capnometers do not treat patients. Integrating the information from your monitors and clinical assessment to make sound clinical decisions is the key to successful airway management. As evidenced by the astute assessment and action of a paramedic, knowing the difference between ventilation and oxygenation is a critical concept that must be understood.

References
1. Neumar RW, Otto CW, Link MS, et al. Part 8: Adult advanced cardiovascular life support, 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122[Suppl 3]:S729–S767.
2. Galvagno SM, Kodali BS. Critical monitoring issues outside the operating room. Anesthesiology Clin. 2009;27(1):141–156.
3. Lewis LM, Stothert J, Standeven J, et al. Correlation of end-tidal carbon dioxide to cerebral perfusion during CPR. Ann Emerg Med. 1992;21(9):1131–1134.
4. Callaham M, Barton C. Prediction of outcome of CPR from end-tidal carbon dioxide concentration. Crit Care Med. 1990;18(4):358–362.
5. Sanders AB, Atlas M, Wy GA, et al. Expired PCO2 as an index of coronary perfusion pressure. Am J Emerg Med. 1985;3(2):147–149.
6. Galvagno SM. Emergency Pathophysiology. Jackson, Wyo.: Teton NewMedia, 2004.
7. Sinex JE. Pulse oximetry: Principles and limitations. Am J Emerg Med. 1999;17(1):59–67.
8. Elliot M, Tate R, Page K. Do clinicians know how to use pulse oximetry? A literature review and clinical implications. Aust Crit Care. 2006;19(4):139–44.
9. Stoneham M, Saville G, Wilson I. Knowledge about pulse oximetry among medical and nursing staff. Lancet. 1994;344(8933):1339–1342.
10. Pedersen T, Dyrlund Pedersen B, Møller AM. Pulse oximetry for perioperative monitoring. Cochrane Database Syst Rev. 2003;3: CD002013.
11. Tinker J, Dull D, Caplan R, et al. Role of monitoring devices in prevention of anesthetic mishaps: a closed claims analysis. Anesthesiology. 1989;71(4): 541–546.

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Samuel M. Galvagno Jr., DO, PhD

Dr. Galvagno has been involved with prehospital care for more than 19 years. He started his EMS career as a National Ski Patroller in upstate New York, and became an EMT in 1992 in Maryland. Before and while attending medical school at the New York College of Osteopathic Medicine, he was a paramedic in Maryland and New York. He completed his internship at Saint Vincent’s Midtown Hospital in Hell’s Kitchen, New York before working as an emergency physician and flight surgeon in the U.S. Air Force. On leaving active duty, Dr. Galvagno received residency training at Harvard Medical School, Brigham and Woman’s Hospital, followed by a fellowship in Critical Care Medicine at the Johns Hopkins School of Medicine. He also completed a research fellowship and extensive training in epidemiology and biostatistics at the Johns Hopkins Bloomberg School of Public Health; he is due to receive his PhD in 2012 with a thesis focused on helicopter emergency medical services for adults with major trauma. Dr. Galvagno is the author of numerous publications and book chapters, including his own textbook, Emergency Pathophysiology. He is currently an assistant professor in the Divisions of Trauma Anesthesiology and Adult Critical Care Medicine at the R Adams Cowley Shock Trauma Center, Baltimore. He remains active in the U.S. Air Force, and is the director of critical care Air Transport Team (CCATT) operations and assistant chief of professional services at Joint Base Andrews, Maryland. He is board-certified in anesthesiology, adult critical care medicine and public health.

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Trauma Airway Intubation Is a Team Effort


Field intubation of trauma patients should be a team effort.

Have a checklist for intubation of trauma patients, and assign your assisting colleagues a role to ensure success on the first attempt. Photo Courtesy Christopher T. Stephens, MD, MS, NREMPT-P


Greetings colleagues!

As the second part of this three-part series on the traumatic airway, we will now focus on intubating the trauma patient case that was introduced in the previous article, “Managing the Traumatic Airway.”

(Missed the first part of this three-part series? Click here to read Part I.)

Why is intubation of trauma patients being scrutinized across the nation, you ask? As an instructor of trauma airway management, I can assure you that it isn’t because you as field providers don’t know how to effectively intubate! In short, there are studies (whether sound or not) that are suggesting worse outcomes in patients who are intubated in the field.

So what, you ask? Sicker patients are sicker and need an endotracheal tube, right? Everyone agrees that there are some patients out there who just need to be intubated. Obstructed airways, vomit, blood and poor anatomy make traumatic airways challenging to manage in the field. In fact, these airways can be challenging in the trauma centers as well. Many patients simply can’t be oxygenated and ventilated effectively with a supraglottic airway—a or bag-valve mask (BVM) and oral airway for that matter, right? These are the cases that get our sympathetic nervous system going and put us in that position where “critical decision making” becomes extremely important.

The Intubation
So you have decided to intubate this trauma patient—who is 110 kg and looks like a small linebacker for your local professional football team. Here are some questions for you:

1. What help do you have?
2. What environment are you in (i.e., street, ditch or ambulance)?
3. Are you able to effectively oxygenate/ventilate this patient with basic tools as discussed previously?
4. Will you plan to do a blind nasal intubation or drug-facilitated oral intubation (rapid sequence intubation/RSI)?

These are some of the questions that must be thought about ahead of time, and a plan must have already been made so that the EMS team can be successful.

I like to teach EMTs and paramedics to think like pilots. Have a checklist and start at the top and work your way down. You will never miss anything this way. Assign your assisting colleagues a role to get the patient intubated successfully on the first attempt.

Ideally, you should have four EMS providers to intubate a trauma patient. The team leader is the one intubating. At this point, the team leader should be assisting the patient’s airway and pre-oxygenating with 100% oxygen via a BVM. Pre-oxygenation is VERY important. It will buy you more time to get that tube in the right hole. You should do this for blind nasal intubations as well. Trauma patients tend to desaturate at an alarming rate because most have been hypoventilating to this point due to pain, semiconsciousness, pneumo- or hemothoraces, etc. And remember, all trauma patients are full stomachs. Some have already aspirated prior to your arrival, which also works against you. All of these conditions make your intubation attempts less forgiving, and you must be prepared to act quickly if the patient becomes challenging and/or desaturates.

Once you have pre-oxygenated your patient for at least 60 seconds, attempt your intubation. If it’s a blind nasal intubation, you may have more time because the patient is still breathing. You also have the luxury to just assist them to the hospital if it fails. If you’re planning a drug-facilitated intubation, then all bets are off. Once you have decided to push drugs, you had better have your skills, colleagues and equipment ready for action.

During pre-oxygenation of the patient, the team leader must assign roles. The second medic will draw up and be responsible for pushing drugs, then handing supplies to the intubating team leader (i.e., endotracheal tube, suction, bougie, another blade, video laryngoscope, etc).

The third provider is responsible for removing the front of the cervical collar (yes, the front of the c-collar MUST be removed PRIOR to laryngoscopy) and holding cricoid pressure correctly. Note: Cricoid pressure needs to be learned correctly and practiced. Some protocols have done away with cricoid pressure; I feel that it’s still an important tool to be used in traumatic airways with full stomachs.

The fourth provider will hold in-line manual stabilization of the cervical spine throughout the intubation. When the team leader states that they’re ready, the second medic should push the appropriate drugs and appropriate doses. This is a decision that has to be made correctly and using expert paramedic critical decision techniques. Understanding the physiology/pharmacology of rapid sequence intubation (RSI) is as important as the skill itself. How sick is the patient? What are their vital signs prior to pushing drugs? Do they have pulses (central or peripheral?) Are they in shock? Do they have signs of a head injury?

Which of roles below do you most often play during the field intubation of a trauma patient?

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These are questions that must be answered during a rapid primary and secondary survey while preparing to intubate the patient. Is the patient combative due to shock, head injury, alcohol/drugs, or all of the above? If able, try and get a baseline set of vital signs prior to pushing drugs. This will help guide your drug choice and dosing. Drug selection and dosing is an EXTREMELY important topic for trauma patients and should be discussed at length with your medical director and training supervisors. Anesthetic agents are powerful and can make patients worse if used incorrectly.

There are many issues to think about when dealing with a traumatic airway, and hopefully you will have some time to work through a good plan of action so if things start to go wrong, your checklist and plan will be there for you to fall back on.

Once the patient has been relaxed with succinylcholine or an alternative paralytic agent, the team leader should perform their laryngoscopy with the blade they’re most comfortable using. Remember, your first shot is always your best shot! I teach trauma airways with a Macintosh 3 blade for most adults because I find it easier for medics and trainees to keep the tongue out of the way with the wider Macintosh blade.

As an alternative, you may also use a video laryngoscope, such as the Glidescope Ranger, for your intubation. The Glidescope Ranger has been useful for managing traumatic airways. It allows everyone assisting to see what the team leader is seeing, which can therefore help them anticipate what the team leader may need to get the job done, such as suction, bougie or a smaller endotracheal tube. As with any piece of airway equipment, there’s a learning curve with video laryngoscopy. You must practice it on mannequins, cadavers in airway labs and on live patients in the operating room, if possible.

I want to say a few words about the intubating stylet or bougie. Since I manage traumatic airways for a living, in my opinion, the bougie is the single most important piece of intubating equipment. This little flexible styllete has been my savior during many a difficult airway in the trauma center. That being said, a bougie and video laryngoscope is a VERY effective combination of equipment to intubate the trauma patient. I encourage each of you to grab an airway mannequin, a bougie and a demo Glidescope Ranger and practice this technique. This is going to be the wave of the future for airway management, especially in the uncontrolled field environment, where help can be lacking.

If you can’t see a view of the vocal cords or confirm the tube to be in the esophagus, you must go to Plan B. This may include changing blades, switching to a video laryngoscope, or perhaps allowing another, more-experienced airway operator to assist. Do NOT forget to attempt oxygenating and ventilating the patient with an oral/nasal airway and BVM between intubation attempts. Do your best to get the patient as close to 100% oxygen saturation as possible prior to your next intubation attempt.

If the second attempt fails, consider either placing a supraglottic airway device or simply performing BVM assisted ventilations with an oral/nasal airway throughout transport. Remember, this technique sometimes requires two rescuers to perform adequately. If you can’t intubate and can’t ventilate the patient, you must proceed to a surgical airway—either a needle or open surgical cricothyroidotomy. We will discuss this in the next article.

The Confirmation
Once the endotracheal tube is placed, it’s important for tube confirmation to be established. This can be done in many ways. Chest rise and bilateral breath sounds are important but can sometimes be misleading. If the patient is warm and still perfusing, tube fogging should be noted, as well as end-tidal carbon dioxide (ETCO2). Either an easy cap (calorimetric) ETCO2 or continuous waveform capnography should be employed as the gold standard for tube confirmation. Continuous waveform capnography ideally should be used by every medic unit that’s intubating patients in the field. This will be discussed further in the next article.

Once the correct tube location is confirmed, be certain that the tube is secured well, the cervical collar is replaced, and the tube location is reassessed after securing because tubes sometimes migrate into the right mainstem bronchus when being secured. At this point, you’re still not out of the woods! Now that you have successfully intubated the patient, you must worry about their physiology while transporting. This is a point that many field providers dismiss when managing airways in the field and a topic that may prevent medical directors from removing intubation from protocols around the nation. So there you have it—four providers ideally to get the task done correctly!

Stay tuned for the final article in this series of managing the traumatic airway.

Do you have access to a video laryngoscope?

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Christopher T. Stephens, MD, MS, NREMT-P

Completed BS in Biology from Loyola Marymount University. Completed paramedic school at Houston Community College and trained with the Houston Fire Department. Paramedic in Houston, Texas and Galveston, Texas. University of Houston College of Pharmacy (MS in Pharmacology), University of Texas Medical Branch School of Medicine – (MD, Anesthesiology Residency) Trauma Anesthesiology Fellowship – University of Maryland Shock Trauma Center Currently Assistant Professor of Anesthesiology at University of Maryland School of Medicine and Attending Trauma Anesthesiologist - R Adams Cowley Shock Trauma Center, Baltimore, MD. Director of Education, Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center. Medical Director, Maryland Fire&Rescue Institute. Instructor for Maryland State Police Aviation Command; Flight Physician, Tactical Physician

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Airway Algorithms


Airway Management AlgorithmIn my last EMS Airway Clinic article, “How to Make the Difficult Airway Less Difficult,” we looked at situations that can make airway management difficult; one of those situations was not having a strategy. Today, I’ll share with you the airway algorithm that has helped me over the years, and I want to give you some tips for building your own algorithm.

As professionals, we should know our protocols. We should be able to deliver quality patient care without looking up the details. I believe these ambitions, but folks, I’m just not one of those medics who remembers every nook and cranny of the protocol book. My worst example is the Glasgow Coma Scale. What a great tool to objectively record the conscious state of a patient. Let’s see, I know that if I’m dead for two weeks, I get a three, and I’m a 13 or a 14 when I get up in the morning. Otherwise, I’ve got to either look it up or use a memory aid, such as an algorithm.

An algorithm is “a step by step procedure for solving a problem.”(1) Medical algorithms help us deliver better patient care. They standardize treatment therapies, so we collectively deliver similar care in similar situations. They help us successfully navigate low-incidence, high-consequence incidents. They reduce medical errors. In EMS, we typically use two types of algorithms: flowcharts and checklists.

Flow charts guide us through a series of “if-then” situations that help us respond quickly and effectively in critical situations; if the patient is in ventricular fibrillation, then defibrillate them. A checklist is a memory aid to make sure we don’t forget something, especially in a situation that we don’t face regularly. A checklist for rapid sequence intubation (RSI) helps us remember to check patients for all contraindications.

I’ve found several characteristics that are commonly found in good emergency airway management algorithms. First and foremost, the algorithm must be based on your world—your patient population, distance to hospitals, available equipment and staff, as well as your own training, experience and confidence. It’s convenient to borrow an algorithm, but it won’t work if it doesn’t fit your operational environment. Using a hospital-based airway algorithm just doesn’t work in the parking lot of the Piggly Wiggly. A second feature of a good algorithm is comfort. If it’s awkward and unfamiliar, then you won’t use it well if at all. You make it comfortable by practicing and making adjustments. Finally, a good algorithm has to be systematic. It must logically and easily flow from one step to the next.

My Algorithm
I’ve used my current airway algorithm for about 15 years. Now, I didn’t just sit down at the kitchen table one morning and put it on paper. I started out using someone else’s algorithm, and then I gradually changed it to fit my needs. My algorithm will always be a work in progress. When I started, I didn’t consider video laryngoscopy or a bougie. Now, they both sit in a place of prominence.

Every patient receives oxygen at every possible moment. Do everything you can to wash out all of the nitrogen in the patient’s lungs and replace it with oxygen. A hyper-oxygenated patient will tolerate short periods of apnea better than a patient with low oxygenation.

Every EMS provider must be proficient at bag-valve-mask (BVM) ventilation. I think BVM ventilation is so important that it’s mentioned six times in my algorithm. I start with BVM to get a feel for compliance and how well the patient responds. Some folks do quite well with a little oxygen, an oral airway and gentle BVM ventilation. If my attempts at laryngoscopy or an alternative airway are unsuccessful, I reach right for the BVM.

Should we intubate?

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I’ve found that more than two attempts at laryngoscopy is usually a waste of a patient’s precious time because chances of success decrease with each attempt. I prepare to successfully place an endotracheal tube on my first attempt. I do everything to make my first attempt my best attempt. I have a second laryngoscopy attempt in the algorithm as an opportunity to make a course correction if I encounter an unanticipated condition, a technique or equipment failure, or I fail to prepare well enough.

I used to have supra-glottic airway placement as steps five and six in the algorithm until a colleague pointed out his success with nasal-tracheal intubation and digital intubation. Out of respect for Steve, I’ve changed these steps to use of an alternative airway. Similar to my experiences with multiple attempts at laryngoscopy, I’ve found that more than two attempts with an alternative airway become futile and detrimental to the patient. If you displace the tongue sufficiently and use adequate lubricant, first-pass success is likely. I’ve included a second attempt in the algorithm to give myself the opportunity to address an unexpected condition or a misstep in my preparation.

Step seven is our familiar friend, BVM ventilation and a quick ride to the hospital.

How long should you spend on each intubation attempt? Wow, that’s a loaded question. I wish I could give you a solid number backed up with a stack of studies, but I can’t. The time spent depends on the patient’s physiological condition, the level of difficulty you experience and your skill level. Many of us were taught to spend no more than 30seconds on an intubation attempt, and I think that’s a pretty safe number. From the moment you insert the blade into the patient’s mouth, it should take you about 10 seconds to locate the glottic structures, and then no more than another 10 seconds or so to place the tube, inflate the cuff and withdraw the stylette. The remaining 10 seconds are a pad for handling any surprises you might find.

I’d like to hear your thoughts on this. How much time do you think we should spend securing an airway?

Your Turn
Feel free to use this algorithm as template from which you build your own. A word of caution; an algorithm is one tool. It isn’t a replacement for sound clinical judgment. Please let me know how you fare in creating your own airway algorithm. In my next EMS Airway Clinic article, I’ll talk about some of the things you can do to improve your first pass success rate.

Be safe my friends.
Charlie

References
1. Merriam-Webster. www.m-m.com/dictionary/algorithm.

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Charlie Eisele, BS, NREMT-P

Charlie Eisele, BS, NREMT-P has been active in EMS since 1975. After 22 years of service, he recently retired from the Maryland State Police, Aviation Command where he served as a State Trooper, flight paramedic, instructor, flight operations supervisor, director of training, and tactical paramedic. For over 25 years, Charlie has been a collegiate level educator and curriculum developer. He has served numerous programs including the University of Maryland, and its R Adams Cowley Shock Trauma Center, College of Southern Maryland, Grand Canyon National Park, Marine Corps Base Quantico, Virginia Department of Fire Programs, and Maryland State Police. Charlie is the co-developer of the internationally delivered advanced airway program at the R Adams Cowley Shock Trauma Center. He is the Airway and Cadaver Lab Course manager for the University of Maryland critical care emergency medical transport program. He’s the co-developer of the EMS Today airway and cadaver lab program. Charlie has been recruited nationally to provide airway management curriculum and education for a variety of private, federal, state and local organization. Charlie is an Eagle Scout and a published author. He serves on the Journal of Emergency Medical Services Editorial Board and is a member of the program board for the EMS Today Conference & Exposition.

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EMS Airway Clinic is a new site offering best practices in airway management and education for EMS professionals and educators, featuring:
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    Featured Airway Products

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