Pitfalls of Field Airway
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Transcript of Pitfalls of Field Airway
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Pitfalls of Field Airway
Management
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Misplaced Endotracheal
Tubes in an EMS System
108 intubated patients
27/108 (25%) misplaced tubes
18/27 esophageal intubations 57% ED mortality
9/27 in hypopharynx
33% ED mortality
Katz, Faulk, Annals of Emergency Medicine 2001, 37, 32-7.
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What are we doing now?
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What parts of that might set us
up for failure?
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Uncontrolled environment,
less then optimal situations
The field airway is usually
difficult
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Specifics of a Difficult field
airway
Immobilized trauma patient
Combative patients
Short neck and/or receding mandible
Prominent upper teeth Children
Upper airway conditions
Facial trauma
Laryngeal trauma Limited jaw opening
Uncontrolled environment
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Emotion & Chaos
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Variables & Distracters
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What are the most common,predictable failure points in
field airway management?
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Pitfall #1
Not having a consistent, organized airway
assessment & management approach forEVERY patient encountered.
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When?Performing the intubation is
generally easier than deciding
which intubation technique to use,which in turn is generally easier
than deciding who to intubate,
which in turn is generally easierthan deciding precisely when to
intubate
Ron Walls, MD
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Whats your approach?
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When is an advanced airway
required in the field?
Is there failure to maintain an adequate
airway?
Is there failure to protect the airway against
aspiration?
Is there a failure of ventilation?
Is there a failure of oxygenation?
Is there a condition present, or is there atherapy required that mandates intubation?
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Is there a common approach?
Protocol?
Algorithm?
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Adequate?
Assess Airway, Ventilation, and Level of
Consciousness
Pulse Oximetry and Supplemental
Oxygen
Manual Airway maneuver, OPA, NPA
and/ or
Bag-valve-Mask ventilation
Airway Patent?AHA BLS guidelines for Foreign
Body Airway Obstruction
Direct Laryngoscopy
Gag Reflex
Present?
Respirations and
Gag Reflex
Present
Apnea, Agonal
Respirations and
No Gag Reflex
Orotracheal Intubation
Consider Lidocaine 1 mg/kg IV for
head injury or reactive airway
Afrin X 2 in nostril, Lidocaine Jelly, or
Cetacaine
Nasal Tracheal Intubation
Versed 2-10 mg and/ or Morphine
Sulfate 2 - 10 mg, Cetacaine topically
Assure Endotracheal tube placement
clinically: auscultate epigastrium and 4 lung fields End Tidal CO2 device Pulse Oximetry
Consider Nasogastric Tube
Consider Sedation for intubated
patient
Successful?
If unable to intubate or intubationcontraindicated, consider Bag-Valve-
Mask, Retrograde intubation,
Combitube, OR
Needle/Surgical Crichothrotomy
No
Yes
Yes
No
Yes No
Or
Yes No
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Use more than one person?
Two-person ventilation
More effective pre-oxygenation
Less gastric insufflation
Positioning
Another monitor
Another operatorSomeone elses lucky day?
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The tough ones?
The easy ones?
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Pitfall # 2
Forgetting that airway management is a
team sport.
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Failure to place anendotracheal tube is not
failure to manage an airway.
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Pitfall # 3
Providing spinal traction, not
stabilization during airway management
in suspected spinal trauma.
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Pitfall # 4
Persistent aggressive advanced airwayattempts in ventilatable kids.
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Pitfall # 5
Failure to reassess, over & over & over
& over & over
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Reassessment is a majorchallenge in EMS.
When?
How?
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Pitfall # 6
Using the wrongadvanced airway
approach at the righttime.
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RSI and Surgical crichs are
big offenders!
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Pitfall # 7
Not having a failure contingency plan.
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A failure contingency plan
should be part of all airwaydecision algorithms.
Additional resource response
Combitube
LMA
Crichothyrotomy
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Pitfall # 8
Not understanding the advantages &
limitations of various tube confirmation
processes.
Ch ll i t b
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Challenges in tube
confirmation:
Missed esophageal intubation with BBS,symmetric chest expansion in OR
6/40 (15%) esophageally intubated patients
unable to be detected by chest auscultation.(Anderson & Hald)
Tube condensation occurred duringexpiration in 34/40 (85%) patients with
esophageal intubation (Anderson & Hald) 25/297 (8%) intubations by emergency
physicians initially indicated esophagus
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Confirmation of tube placement
What is the Gold Standard?
Visualize cords?
Breath sounds?
Chest rise?
Color change?Absence of stomach sounds?
End-Tidal CO2?
EDD? Chest X-ray?
Anatomic verification?
Th t ETCO
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Three parameters ETCO2
measures:CO2 production
Tissue perfusion
CO2 perfusion
Cardiac output
Pulmonary perfusion
CO2 elimination
VentilationPatent airway/tube
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Pitfall # 9
Failure to preserve your work.
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Pitfall # 10
Failure to document.
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Summary
Trust nobody, believe nothing,give oxygen.
Perfect Practice Makes Perfect!
You are only as good as your last
one.