2015 airway tips and tricks v.02
TRANSCRIPT
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Airway Tips and Tricks Your Patient Cant Live Without!
Eastern OR EMS Conference 2015
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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!
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BETTER POSITIONING
Tip #1:
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Better Positioning
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Elevate the trunk 20-30 degrees!
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KEY POINT: Still put towels under shoulders for infants!
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BETTER OXYGENATION
Tip #1:
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What does Preoxygenation mean to you?
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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
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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%)
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KEY POINT
• SPO2 >94 % WITHOUT Preoxygenation means NOTHING!
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Why its important: “Safe Apnea”
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What is Desaturation?
• Desaturation is defined as saturation below 88%
• Safe Apnea period
– Time to 90% AFTER preoxygenation
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How quick can desaturation occur?
Between IMMEDIATELY and 8 minutes.
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Who is at risk?
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Introducing NO DESAT
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NO DESAT (15 + LPM via NC)
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+LPM
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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 ChirScand. 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..
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Can you not bag at all?
• Answer: “Depends”
• Considerations: – Obesity
– Shunt Physiology
– Shock
• What should you do?– Cautious Bagging
– CPAP?
– Bagging with PEEP Valve?
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KEY POINT:
• This works best when you have excellent airway positioning!
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BETTER FACE MASK SEAL
Tip # 3:
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Better Face Mask Seal ?
At least 8 good full tidal volume breaths is “Ideal”
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E-C Techniques
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The “T-E” Technique
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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
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Nu MASK
• BLS difficult airway Device
• Cheap and easy
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Using a Pedi Mask
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Weyland-Yutani Face Mask
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BETTER VENTILATION
Tip # 4
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OPA + NPA x2
• Less Turbulant Flow
• Better Tidal Volume
• Estimated time to placement is 9-10 seconds.
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The “Super Plug”
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Monitor your airway pressures
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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
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BETTER NASAL INTUBATION
Tip # 4:
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Nasal ETT
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Tennessee Technique
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Close up view
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BETTER ORAL INTUBATION
Tip # 5:
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Medics: Involve your BLS personnel
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KIWI GRIP
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Pistol Grip
• https://www.youtube.com/watch?v=O2OI7Yx7rHE
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BETTER PLANNING
Tip #6:
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Better Planning
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Better Planning
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EMCRIT.org CRICON
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Better Planning
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Checklists!
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Checklists and CRM save lives
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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
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Closing
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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