Introduction to ALS Sir Sandford Fleming. Outline Work Environment Scope of Practice Training...

Introduction to ALS

Sir Sandford Fleming

Outline

Work Environment Scope of Practice Training Equipment Procedures How PCP/ACP Combos work What will be expected of you?

Work Environment

Many services are up to 40% ALS Presents different challenges

– Bags are different– Dispatched differently– Crew configuration different (>age)– Expectations for level of care higher– Closer scrutiny

Potentially more stress for the crew Combined care (different attendant/driver roles)

Work Environment

Legislation– Narcotics

Check sheets Signatures DMA

– Risk’s/benefit– Higher chance

something will go much better or much worse

Scope of Practice

Lots more drugs Lots more heavy things Special airway equipment Special features on monitor

– Manual defib– Cardioversion– Pacing (transcutaneous)

Scope of Practice

Manual Defibrillation, Pacing and Cardioversion

Advanced Airway

LMA’s , Lited Stylets

BTLS, ACLS ,PALS

IV Therapy

ALS Drugs plus Symptom Relief, Versed, Fentanyl

Activated Charcoal

CXR Interp

Pentaspan

Difficult Airway AlgorithmNeed ETT

Attempt #1 -Without sedation(crash) or nasal ETT

Attempt #2- Midazolam 0.05 mg/kg Fentanyl 1-1.5 mcg/kg

Attempt #3(or RSI Direct) Lidocaine, (atropine) with midazolam and fentanyl (see above) and succinylcholine 1-1.5 mg/kg

Backup- Laryngeal Mask Airway, Lighted Stylet, Surgical Airway

Training

Time lines – roughly 1 year for ALS

Didactic –classroom time Clinical –practice in a

controlled setting– OR– ER– MOP/SOP– OBS/PEDS/ICU– Other (Burn Unit, HSC IV

Team)

Preceptorship/Consolidation

Where it should all come together With a designated preceptor Gradual transition to full care

Equipment

Airway- – Basic airway– Laryngoscope plus ETT for Intubation– Rescue Devices –advanced airway

Lighted stylet LMA – Surgical –Seldinger vs Quik Trach Bougie

Procedures

Cardioversion Pacing Sedation Vagal and CSM Manual Defibrillation IV Bolus and IV

medication Other routes

(PR,IN,IM,ETT,IO)

Intubation Advanced airway Needle decompression IO Thrombolytics VAD Central access

Airway

CONTROL THE AIRWAY

Airway Management Decision ProcessAirway Management Decision Process

(Judge how aggressive you need to be.)(Judge how aggressive you need to be.)

-Time/Distance-Time/Distance

-Personnel-Personnel

-Equipment-Equipment

-Other Considerations?-Other Considerations?

CONTROL THE AIRWAY

““Evaluate for signs of difficult intubation”Evaluate for signs of difficult intubation”

(this may help in your decision as well)(this may help in your decision as well)

-Obesity-Obesity -Small body habitus-Small body habitus

-Small jaw-Small jaw -Large teeth-Large teeth

-Burns-Burns -Trauma-Trauma

-Anaphylaxis-Anaphylaxis -Stridor-Stridor

CONTROL THE AIRWAY

The PCP vs. ACP airway The PCP vs. ACP airway decision may not be based on decision may not be based on one single factor, but rather one single factor, but rather

based on an overall based on an overall assessment of many factors.assessment of many factors.

CONTROL THE AIRWAY

Pre-IntubationPre-Intubation

-Prepare Equipment-Prepare Equipment

-Hyper-oxygenate-Hyper-oxygenate

CONTROL THE AIRWAY

Orotracheal Intubation ProcedureOrotracheal Intubation Procedure

Sweep Sweep Left and Left and

LookLook

CONTROL THE AIRWAY

Backward, Upward, Right Pressure (B.U.R.P.)Backward, Upward, Right Pressure (B.U.R.P.)

Find Your LandmarksFind Your Landmarks

CONTROL THE AIRWAY


CONTROL THE AIRWAY

It may not be perfect!It may not be perfect!


CONTROL THE AIRWAY


CONTROL THE AIRWAY

Readjusting with Cricoid PressureReadjusting with Cricoid Pressure

CONTROL THE AIRWAY

Common Provider MistakesCommon Provider Mistakes

**Making a difficult intubation more difficultMaking a difficult intubation more difficult

*Rushing*Rushing

*Poor equipment preparation*Poor equipment preparation

*Suction (lack there of)*Suction (lack there of)

CONTROL THE AIRWAY

What is your back-up plan today?

prolonged BVM…

another provider…

a smaller tube…

better lighting…

additional suctioning…

CONTROL THE AIRWAY

Helpful AdjunctsHelpful Adjuncts

Gum Gum Elastic Elastic BougieBougie

CONTROL THE AIRWAY

Helpful AdjunctsHelpful Adjuncts

Lighted StyletteLighted Stylette

Nasotracheal IntubationNasotracheal Intubation

IndicationsIndications::

““Patient still breathing but Patient still breathing but in respiratory failure and in respiratory failure and

in whom oral intubation is in whom oral intubation is impossible or difficult.”impossible or difficult.”

CONTROL THE AIRWAY

ContraindicationsContraindications::

-Apnea-Apnea

-Resistance in the nares-Resistance in the nares

-Blood clotting or -Blood clotting or anticoagulation anticoagulation problemsproblems

-Basilar Skull Fx (?)-Basilar Skull Fx (?)

CONTROL THE AIRWAY


TechniqueTechnique::

-Prepare patient and nostril-Prepare patient and nostril

-Prepare tube-Prepare tube

-Insert on inspiration-Insert on inspiration

-Take your time-Take your time

ComplicationsComplications::

-Bleeding-Bleeding

STEP 4. CONTROL THE AIRWAY


. CONFIRM THE AIRWAY

Technology BasedTechnology Based

• ETCO2 (monitor)ETCO2 (monitor)

• EDD (bulb)EDD (bulb)

• Colormetric (cap)Colormetric (cap)

• Pulse Ox changePulse Ox change

Intubation ConfirmationIntubation Confirmation

Good, Better, BestGood, Better, BestTraditionalTraditional

• Direct Direct VisualizationVisualization

• Lung SoundsLung Sounds

• Tube Tube Condensation Condensation

SECURE THE AIRWAY

TapeTape

Improvised devicesImprovised devices

Commercial devicesCommercial devices

Immobilization (?)Immobilization (?)

Secure Your TubeSecure Your Tube

Good, Better, BestGood, Better, Best

Laryngeal Mask AirwayLaryngeal Mask Airway

Developed in 1981 at the Royal London Hospital Developed in 1981 at the Royal London Hospital

By Dr Archie BrainBy Dr Archie Brain

ALTERNATIVES TO ETI

Indications:Indications:

-When definitive airway management -When definitive airway management cannot be obtained. (ETT)cannot be obtained. (ETT)

Not a substitute for definitive airway Not a substitute for definitive airway managementmanagement


STEP 7. ALTERNATIVES TO ETI

Contraindication/Limitations:Contraindication/Limitations:

-Obesity-Obesity

-Non-secure-Non-secure

-Size based-Size based

-Not a med route-Not a med route


ALTERNATIVES TO ETI

Weight Based SizingWeight Based Sizing<5kg = Size 1<5kg = Size 15-10 kg = Size 25-10 kg = Size 220-30 kg = Size 2.520-30 kg = Size 2.5Small Adult= Size 3Small Adult= Size 3Average Adult = Average Adult =

Size 4 Size 4 Large Adult = Size 5Large Adult = Size 5


ALTERNATIVES TO ETI

Average Adult Woman = 4Average Adult Woman = 4 Average Adult Male = 5Average Adult Male = 5

*If in doubt, check the LMA*If in doubt, check the LMA

Laryngeal Mask Laryngeal Mask AirwayAirway

ALTERNATIVES TO ETI

Procedure:Procedure:

-Hyper oxygenate-Hyper oxygenate

-Check cuff -Check cuff

-Lubricate -Lubricate posteriorposterior cuff cuff

-Head in neutral or slightly flexed position-Head in neutral or slightly flexed position

-Insert following hard palate (use index finger to guide)-Insert following hard palate (use index finger to guide)

-Stop when met with resistance-Stop when met with resistance

-Let go and inflate cuff (visualize “pop”)-Let go and inflate cuff (visualize “pop”)

-Confirm and secure-Confirm and secure


ALTERNATIVES TO ETI

Air volume is variable depending on cuff size Air volume is variable depending on cuff size and individual patient anatomyand individual patient anatomy

General Guideline:General Guideline:

Size 1 = 4 mlSize 1 = 4 mlSize 2 = 10 mlSize 2 = 10 mlSize 2.5 = 14 mlSize 2.5 = 14 mlSize 3 = 20 mlSize 3 = 20 mlSize 4 = 30 mlSize 4 = 30 mlSize 5 = 40 mlSize 5 = 40 ml


ALTERNATIVES TO ETI

Common Provider Problems:Common Provider Problems:

-Failure to seat properly-Failure to seat properly

-Sizing difficulties -Sizing difficulties

-Aspiration-Aspiration


ALTERNATIVES TO ETI

King Airway

King Airway

Why– Unconscious / unresponsive patients without gag reflex– Blind insertion technique– Alternative to E.T.T.

Known Issues– Obtaining proper seal / placement– Is NOT a medication route for Endotracheal drugs– Multiple sizes, based on height, also multiple cuff volumes– Contraindications

Responsive patients with an intact gag reflex. Patients with known esophageal disease. Patients who have ingested caustic substances.

User Tip

The key to insertion is to get the distal tip of King Airway around the corner in the posterior pharynx, under the base of the tongue.

Experience has indicated that the lateral approach, in conjunction with a chin lift, facilitates the placement of the King Airway.

Alternatively, a laryngoscope or tongue depressor can be used to lift the tongue anteriorly to allow easy advancement of the airway into place.

Insertion #1

Insertion #2

Insertion #3

As the King Airway is advanced around the corner in the posterior pharynx, it is important that the tip of the device

be maintained at the midline. If the tip is placed or deflected laterally, it may enter into the

piriform fossa and the tube will appear to bounce back upon full insertion and release.

Keeping the tip at the midline assures that the distal tip is properly placed in the upper esophagus.

Insertion #4

Insertion #5

Air Volume Required for Cuff Inflation:– Size #3: 55 ml

– Size #4: 70 ml

– Size #5: 80 ml

Insertion #6

Attach Bag While gently bagging, simultaneously withdraw

the King Airway until ventilation is easy and free-flowing.

Can the King tube device be used for PPV?

Yes, in unresponsive non breathing pts

Is there an optimal head position for insertion?– Sniffing position, but the head can be in neutral position.– For obese patient’s, elevation of the shoulders & upper back should be

considered. How long can the King tube be left in place?

– Up to 8 hours. For longer procedures it is important to monitor& limit cuff pressure to 60 cm H20 or less.

If my patient needs to be on a mechanical ventilator, do I need to replace the tube?

– Due to the King tube’s improved ventilatory seal, it is less frequent that the tube needs to be exchanged compared to other supraglottic airways.

Can a laryngoscope be used?– Yes, but it is not routinely used. It may be used by the inexperienced user,

or difficult airway. What volume of pressure is needed to properly inflate the cuffs?

– The least amount needed to create a seal at the desired ventilatory pressures. Each tube size is different

What reference point for the centimeter depth markings on the tubes?– The cm markings indicate the distance from the distal ventilatory opening.

The markings serve as a visual reference after placement and can be used to document insertion depth.

IndicationsIndications

-Obstruction-Obstruction

-Facial Trauma-Facial Trauma

-Intubation or other -Intubation or other alternatives impossiblealternatives impossible

-Trismus (clenching) -Trismus (clenching)

->8 years old (for open ->8 years old (for open procedures) procedures)

SURGICAL AIRWAYS

LAST RESORT!

SURGICAL AIRWAYS

-Vertical Incision -Vertical Incision over membraneover membrane

-Pierce -Pierce membrane in membrane in

horizontal planehorizontal plane-Open and -Open and

spread to insert spread to insert 4.0 or 5.0 tube4.0 or 5.0 tube-Secure tube in -Secure tube in

place and place and ventilateventilate

Needle Procedure:Needle Procedure:

-Identify Cricothyroid membrane-Identify Cricothyroid membrane

-Pierce at 45-Pierce at 45° angle ° angle

-Place catheter or styllette-Place catheter or styllette

-Advance dilator per -Advance dilator per manufacturer’s recommendationmanufacturer’s recommendation

SURGICAL AIRWAYS

Needle Needle CricothyrotomyCricothyrotomy

Commercial Needle Cricothyrotomy Devices

Quick Trach Pertrach

SURGICAL AIRWAYS

WHY AN ALGORITHM?

1.1. Step by step process in orderStep by step process in order

2.2. Start simple and work upStart simple and work up

3.3. AlternativesAlternatives

4.4. Be sureBe sure

5.5. Get it doneGet it done

Procedure for Intubation Preoxygenate with 100% (may not need to bag) Prepare equipment (SLOPES-M) Hyperextend –Sniffing position Insert larygoscope into R sweep tongue to left Look for view Insert ETT to 1-3 cm beyond cords Withdraw largy Remove stylet inflate cuff with 5-8 cc air Auscultate neck, chest x 4 Secure ETT Document cm marking and reevaluate often

How you can help as PCP (PRN)

Prepare equipment Preoxygenate patient BURP (backwards upwards and to the right

pressure-thyroid cartilege mvmt) Cric pressure Remove styet when asked Inflate balloon Secure ETT Ventilate patient

http://www.airwaycam.com/402.jpg

Cricoid pressure Only when asked to Know your landmarks

Burp –backwards upwards and to the right (pressure)

Monitor/Defibrillator

LP 12/Zoll has pacing Cardioversion 12 lead NIBP SpO2 ETCo2 (mainstream) detection Manual defibrillation

Symptomatic Patients get treated electrically

Chest pain Shortness of breath Pulmonary edema Hypotension Diaphoresis Decreased LOA

Vagal Manuvers/CSM

For stable patients with signs of clinically significant tachy rhythms

CSM “Fake” the baroreceptors into thinking BP is too high so slows HR down

Vagal manuvers- increase ITP to see if can stimulate a vagal response

Patients <70 or with no bruits in carotid arteries

Synchronized Cardioversion

Unstable tachydysrhythmias

Pad placement

Synchronize the monitor

Sedation, anaelgisics, amnestics

Symptomatic Tachyarrhythmias

Signs & symptoms

Experience and judgment

•Chest pain

•Shortness of breath

•Pulmonary edema

•Altered LOC

•Hypotension

•Syncope

•Diaphoresis

What Does the “SYNC” Button Do?

Tags the R waves

Timing – refractory periods

Do NOT want to cardiovert at this time!

Iatrogenic R on T - Cardioversion

Cardiac arrest

Always double check

Automatic ‘sync’ shutoff

Advanced Care Directive - VT with Pulse

ATTEMPT PATCH IMMEDIATELY

O2 via NRB mask / Intubate PRN

IV access

Bolus 500 cc NS

Lidocaine 1.5 mg/Kg IV

Synchronized cardioversion Monophasic 100J

Synchronized cardioversion Monophasic 200J

Patient Symptomatic?

Sedate PRN

ATTEMPT TO PATCH

Synchronized cardioversion Monophasic 200J or Synchronized cardioversion Monophasic 360J PATCH IF RETURN OF NORMAL RHYTHM

Advanced Care Directive - VT with Pulse

Atrial Flutter Atrial Fibrillation

Synchronized cardioversion 50J


REATTEMPT TO PATCH






REATTEMPT TO PATCH



Considerations

Inform bystanders Skin irritation/burns Arching of current Adjust ECG size EVERYONE CLEAR!

Transcutaneous Pacing

Symptomatic bradycardias Over-ride pacing Quickly available Standby pacing Sedation, analgesics, amnestics

Contraindications

Severe hypothermia

Cardiac arrest > 20 minutes

Open chest wounds

Flail chest

Procedure for Pacing

Explain to patient O2 & IV therapy Sedate – BHP Pad placement

Turn “pacer” on Set HR between 60-

80 Increase mA -

capture Add 10 mA - safe

zone

Defibrillation-ManualALS algorithm for Vfib/Vtach pulseless

CPRDefibrillate Monophasic 200,300,360 J or Biphasic

INTUBATE / IV ACCESS1.0 mg Epi (1:10,000) IV or 2.0 mg Epi ETT

repeat q 3-5 minutes

Defibrillate Monophasic 360 J x3 or Biphasic 200J x31.5 mg/Kg LIDOCAINE IV or 3.0 mg/Kg ETT

Defibrillate Monophasic 360 J x3 or Biphasic 200J x3

Remember in manual mode, the machine will shock regardless of what the rhythm on the monitor is!

Drugs Carried by ALS

NTG ASA Ventolin (MDI,ETT,Neb) Glucagon Epinephrine 1:1000,1:10000 Atropine Lidocaine (preload and spray Lasix Adenosine

Dopamine Midazolam Diazepam Fentanyl Morphine D50W Na Bicarbonate Otrivin Gravol

Treating patients -Differences

Can give NTG if no prior use Increased selection of things to do Also increased responsibility Increased accountability Increased $$$ too!

Read Pages in Bledsoe

Pages 480-486 IO 516-561 ETT Medication review –appropriate pages

chapter 6/7 and Concepts in Pharmacology Look at handouts (2)

Introduction to ALS Sir Sandford Fleming. Outline Work Environment Scope of Practice Training...

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