2015 airway tips and tricks v.02
•Transferir como PPTX, PDF•
4 gostaram•1,235 visualizações
This document provides airway tips and tricks for EMS providers. It discusses better positioning by elevating the trunk 20-30 degrees, even for infants. It emphasizes the importance of preoxygenation to achieve an SpO2 above 94% before intubation through various techniques. It also discusses maintaining oxygenation through apneic oxygenation techniques using high-flow nasal cannula for over 100 minutes. Other tips include using a two-handed mask seal technique, inserting an OPA and NPA to improve ventilation, and utilizing checklists to plan intubations and improve team performance. Resources for continuing education like blogs and podcasts are recommended.
Recomendados
Recomendados
Mais conteúdo relacionado
Mais procurados
Mais procurados (20)
Semelhante a 2015 airway tips and tricks v.02
Semelhante a 2015 airway tips and tricks v.02 (20)
Mais de Robert Cole
Mais de Robert Cole (20)
Último
Último (20)
2015 airway tips and tricks v.02
- 1. Airway Tips and Tricks Your Patient Cant Live Without! Eastern OR EMS Conference 2015
- 3. What we are going to talk about… • Better…. – Positioning – Oxygenation – Facemask Seal – Ventilation – Nasal ETT – Oral ETT – Planning • Better resources – 5 blogs and podcasts that will change what you do!
- 9. Elevate the trunk 20-30 degrees!
- 11. KEY POINT: Still put towels under shoulders for infants!
- 13. What does Preoxygenation mean to you?
- 14. What the anesthesia world thinks of it • SPO2 > 94% before apnea WITH preoxygenation efforts. – Min of 3 minutes on well fitted NRB at flow rates > 15 LPM OR – 8-10 full inhalation/exhaltion breaths on 100% Oxygen – Nitrogen Washout
- 15. Nitrogen Washout and the Oxygen Resovoir • Normal FIO2 approx. .21-.24 (21-24%) – Remainder is Nitrogen, CO2, and other gasses • Tidal Volume is 600-800 cc – “Dead Air Space” is approx. 150 cc • If we replace that inert gas in the dead air space with 100% Oxygen, what happens? – “Nitrogen Washout” – Dead Air Space (95%) – Plasma (5%)
- 16. KEY POINT • SPO2 >94 % WITHOUT Preoxygenation means NOTHING!
- 17. Why its important: “Safe Apnea”
- 18. What is Desaturation? • Desaturation is defined as saturation below 88% • Safe Apnea period – Time to 90% AFTER preoxygenation
- 19. How quick can desaturation occur? Between IMMEDIATELY and 8 minutes.
- 20. Who is at risk?
- 22. NO DESAT (15 + LPM via NC)
- 23. +LPM
- 25. How long can this be done? • At least 100 min – Nielsen ND, Kjaergaard B, Koefoed-Nielsen J, et al. Apneic oxygenation combined with extracorporeal arteriovenous carbon dioxide removal provides sufficient gas exchange in experimental lung injury. ASAIO J. 2008;54:401-405 – Enghoff H, Holmdahl MH, Risholm L. Oxygen uptake in human lungs without spontaneous or artificial pulmonary ventilation. Acta Chir Scand. 1952;103:293-301. – Holmdahl MH. Pulmonary uptake of oxygen, acid-base metabolism, and circulation during prolonged apnoea. Acta Chir Scand Suppl. 1956;212:1-128..
- 26. Can you not bag at all? • Answer: “Depends” • Considerations: – Obesity – Shunt Physiology – Shock • What should you do? – Cautious Bagging – CPAP? – Bagging with PEEP Valve?
- 27. KEY POINT: • This works best when you have excellent airway positioning!
- 28. BETTER FACE MASK SEAL Tip # 3:
- 29. Better Face Mask Seal ? At least 8 good full tidal volume breaths is “Ideal”
- 30. E-C Techniques
- 33. Which is better? • In every study: 2 handed techniques out performed 1 handed techniques. • The T-E technique marginally delivered better airway pressures and tidal volumes over the E- C technique. • TE produced less failed breaths
- 34. Nu MASK • BLS difficult airway Device • Cheap and easy
- 36. Using a Pedi Mask
- 38. BETTER VENTILATION Tip # 4
- 39. OPA + NPA x2 • Less Turbulant Flow • Better Tidal Volume • Estimated time to placement is 9-10 seconds.
- 40. The “Super Plug”
- 41. Monitor your airway pressures
- 42. Key Point!!! • Airway pressures > 25 cmH2O can cause gastric Distention • Gastric Distention can cause vomiting • Vomiting can cause aspiration • Aspiration causes aspiration pneumonia in most patients • Aspiration Pneumonia kills 40-70% of its patients • Don’t give ventilations at pressures > 25 cmH20
- 43. BETTER NASAL INTUBATION Tip # 4:
- 44. Nasal ETT
- 46. Close up view
- 48. BETTER ORAL INTUBATION Tip # 5:
- 49. Medics: Involve your BLS personnel
- 52. KIWI GRIP
- 55. Better Planning
- 56. Better Planning
- 58. Better Planning
- 59. Checklists!
- 60. Checklists and CRM save lives
- 61. www.projectcheck.org • Checklist are NOT – A protocol – A procedural checklist – An algorithm – A teaching tool – Not an credentialing tool (NREMT) • Checklist do: – Red Label items – Have Pause Points – Have “Challenge and response” – Are TEAM DRIVEN – Are REALITY BASED
- 67. Closing
- 68. Important blogs and web series to start following now! • www.emcrit.org (Emergency Medicine Critical Care) • www.litfl.com (Life in the fast lane) • www.rescusme.com (Resuscitate me) • www.emupdates.com (Emergency medicine Updates) • www.rougemedic.com
Notas do Editor
- Grrimm tv show reference Im going to fill your toolbox/armory with tools for every occasion….
- Preoxygenation for 3 – 5 minutes in a 20° head up position vs supine position:386 seconds vs 283 seconds to desaturate from 100% to 95% O2 saturation (Lane et al. 2005)* 452 seconds vs 364 seconds to desaturate to 93% (Ramkumar, Umesh, and Philip 2011)* 214 seconds vs 162 seconds to desaturate to 92% in patients with BMI > 40 kg/m2 (Benjamin J Dixon et al. 2005)* Also consider reverse Trendelenburg position (head of bed 30º higher than foot) in trauma patients Standard nonrebreather at 15L/minute will deliver 60 – 70% FiO2 The FiO2 can be increased to ≥90% by increasing the flow rate to 30 – 60L/min
- Oxygen consumption is about 250 mL/minute or 3mL/kg/minute A healthy person on room air can have a period of “safe apnea” of ≈ 1 minute A healthy person on high FiO2 can have a period of “safe apnea” of ≈ 8 minutes One study showed time to desaturation of < 90% O2 saturation after succinylcholine administration was 8 minutes (healthy patients), 5 minutes (moderately ill adults), and 2.7 minutes (obese adults) which is shown in the image to the right. (J L Benumof, Dagg, and R Benumof 1997)* Conclusion: It is difficult to predict the time to desaturation after preoxygenation in the ED, but it is important to remember that critically ill and obese patients can desaturate quickly.
- Oxygen consumption is about 250 mL/minute or 3mL/kg/minute The lungs hold 450 mL of oxygen when breathing room air but can increase to 3000 mL when breathing 100% O2 and replacing alveolar nitrogen Study 1: In the operating room at the time of apnea, 5 L/min O2 via nasal cannula vs no O2 was tested to show time to desaturation of 95% and showed no desaturation out to 6 minutes in nasal cannula group vs 3.65 minutes in the no O2 group (Taha et al. 2006)* Study 2: Obese patients in the operating room at the time of apnea, 5L/min O2 via nasal cannula vs no O2 was tested to show time to desaturation of ≥95% and showed a time of 5.29 minutes vs 3.49 minutes respectively (Ramachandran et al. 2010)* Nasal cannula is the device of choice to provide apneic oxygenation and can be left on during pre oxygenation, bag valve mask ventilation, and during attempts for tracheal intubation.
- The difference in oxygen and carbon dioxide movement across the alveolar membrane is due to the significant differences in gas solubility in the blood, as well as the affinity of hemoglobin for oxygen. This causes the net pressure in the alveoli to become slightly subatmospheric, generating a mass flow of gas from pharynx to alveoli. This phenomenon, called apneic oxygenation, permits maintenance of oxygenation without spontaneous or administered ventilations. Under optimal circumstances, a PaO2 can be maintained at greater than 100 mm Hg for up to 100 minutes without a single breath, although the lack of ventilation will eventually cause marked hypercapnia and significant acidosis.54
- In patients who do not achieve an O2 saturation of >93 – 95% with 3 minutes of high FiO2 consider using positive pressure ventilation These patients most likely have shunt physiology (i.e.alveoli are perfused but not ventilated), and require positive pressure ventilation and not more O2 to increase their oxygen saturation This is extremely useful in obese patients: (Futier et al. 2011)* 66 patients with BMI of approximately 46 kg/m2 5 minutes of pre oxygenation with non-invasive positive pressure ventilation (NIPPV) vs spontaneous breathing of 100% FiO2 After preoxygenation, NIPPV group had a mean SpO2 of 98% vs spontaneous breathing group of 93% During intubation NIPPV group only decreased SpO2 to 93% vs spontaneous breathing group of 81% Positive pressure can be applied in one of three ways:
- Walls RM, Murphy MF. Chapter 9: Bag-Mask Ventilation. Manual of Emergency Airway Management, 4th ed. Philadelphia: Lippincott, Williams & Wilkins, 2012. Gerstein NS, Carey MC, Braude DA, et al. Efficacy of facemask ventilation techniques in novice providers. J Clin Anesth, 2013 May; 25(3): 193–7.
- Walls RM, Murphy MF. Chapter 9: Bag-Mask Ventilation. Manual of Emergency Airway Management, 4th ed. Philadelphia: Lippincott, Williams & Wilkins, 2012. Gerstein NS, Carey MC, Braude DA, et al. Efficacy of facemask ventilation techniques in novice providers. J Clin Anesth, 2013 May; 25(3): 193–7.
- von Goedecke A, Wagner-Berger HG, Stadlbauer KH, et al. Effects of decreasing peak flow rate on stomach inflation during bag-valve-mask ventilation.Resuscitation, 2004; 63: 131–6.
- t’s possible to limit the potential for high ventilation (inspiratory) pressures by placing a pressure manometer on your BVM each time one is used. High intrathoracic pressure is also a detriment to the critically ill patient, as it decreases venous return to the heart. Decreased venous return results in decreased preload. That in turn results in decreased stroke volume, decreased cardiac output and decreased blood pressure. So, overventilation in an already hemodynamically compromised patient can make them more hypotensive. To avoid these complications, deliver ventilations slowly, over 1–2 seconds. Use as low of a tidal volume as needed to achieve normal chest rise and fall (typically about 5–7 mL/kg). Avoid unnecessarily high ventilation rates. If your patient has a pulse and pulse oximetry can be monitored, consider lowering your ventilation rate to one that achieves your goal of adequate oxygenation at as few breaths per minute as possible. In other words, if you can achieve acceptable oxygenation levels (94%–100% SpO2) at 8 breaths a minute, there is no reason to ventilate at 12.6 Monitoring the pulse oximetry in patients in cardiac arrest or extreme low-flow states is not an option. In such patients, relying on a predetermined ventilation rate—for example, 12 times a minute for an adult—is prudent. Another adjunct that can be used to gauge the effectiveness of ventilation is EtCO2 monitoring. Use of a capnometer (a unit that gives a quantitative numerical readout) or capnograph (a unit that gives an EtCO2waveform) can be valuable in ventilated patients. Ventilation rate can be adjusted to maintain an EtCO2 of acceptable levels, most often 35–45 mmHg.
- Kiwi Grip invented by Paul Baker (per airwaycam.com)
- The aircraft was an Airbus A320-200, registered N106US, operating as a US Airways scheduled domestic commercial passenger flight from LaGuardia Airport in New York City to Seattle–Tacoma International Airport in SeaTac, Washington. About three minutes into the flight, at 3:27 p.m. EST, the plane struck a flock of Canada geese during its initial climb out from LaGuardia, just northeast of theGeorge Washington Bridge. The bird strike caused both jet engines to quickly lose power. First Officer Skiles was at the controls of the flight when it took off to the northeast from Runway 4 at 3:25 pm, and was the first to notice a formation of birds approaching the aircraft about two minutes later, while passing through an altitude of about 2,700 feet (820 m)[4] on the initial climb out to 15,000 feet (4,600 m). Descison, checklists, and successful ditching occurred injust over 3 minutes.