Digital Intubation
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Transcript Digital Intubation
A
patient who needs intubation may be awake.
Need for airway control may necessitate intubation.
RSI
paralyzes the patient to facilitate
endotracheal intubation.
Anatomical
Differences
Smaller and more flexible than an adult
Tongue proportionately larger
Epiglottis floppy and round
Glottic opening higher and more anterior
Vocal cords slant upward, and are
closer to the base of the tongue
Narrowest part is the cricoid cartilage
A
straight laryngoscope blade is preferred
for most pediatric patients.
Selecting the appropriate tube diameter for
children is critical.
ETT size (mm) = (Age in years + 16) ÷ 4
Matching it to the diameter of the child’s smallest
finger
Use
non-cuffed endotracheal tubes with
infants and children under the age of 8
years.
© Scott Metcalfe
© Scott Metcalfe
© Scott Metcalfe
© Scott Metcalfe
© Scott Metcalfe
© Scott Metcalfe
© Scott Metcalfe
© Scott Metcalfe
Mask
seal can be more difficult
Bag size depends on age of child
Ventilate according to current standards
Obtain chest rise and fall with each breath
Assess adequacy of ventilations by observing
chest rise, listening to lung sounds, and
assessing clinical improvement
“Blind”
procedure without direct
visualization of the vocal cords
Indications include:
Possible spinal injury
Clenched teeth
Fractured jaw, oral injuries, or recent
oral surgery
Facial or airway swelling
Obesity
Arthritis preventing sniffing position
Contraindications
Suspected nasal fractures
Suspected basilar skull fractures
Significantly deviated nasal septum or other nasal
obstruction
Cardiac or respiratory arrest
Advantages
The head and neck can remain in neutral position
It does not produce as much gag response and is
better tolerated by the awake patient
It can be secured more easily than an orotracheal
tube
The patient cannot bite the ETT
Disadvantages
More difficult and time consuming
Potentially more traumatic for patients
Tube may kink or clog more easily
Greater risk of infection
Improper placement more likely
Requires that patient be breathing
Field
extubation may be indicated when:
The patient is clearly able to maintain and
protect his airway.
The patient is not under the influence of
sedatives.
Reassessment indicates the problem that led to
endotracheal intubation is resolved.
Consider
the high risk of laryngospasm
A
dual-lumen airway
The longer, blue port (#1) is the proximal port
The shorter, clear port (#2) is the distal port,
which opens at the distal end of the tube
Two
inflatable cuffs
100-mL cuff just proximal to the distal port
15-mL cuff just distal to the proximal port
ETC Airway
Tracheal Placement
Advantages
Provides alternate airway control
Insertion is rapid and easy
Does not require visualization of the larynx
Pharyngeal balloon anchors the airway
Patient may be ventilated regardless of tube
placement
Significantly diminishes gastric distention
Can be used on trauma patients
Gastric contents can be suctioned
Disadvantages
Suctioning tracheal secretions is impossible when
the airway is in the esophagus.
Placing an endotracheal tube is very difficult with
the ETC in place.
It cannot be used in conscious patients or in those
with a gag reflex.
Disadvantages
The cuffs can cause esophageal, tracheal, and
hypopharyngeal ischemia.
It does not isolate and completely protect the
trachea.
It cannot be used in patients with esophageal
disease or caustic ingestions.
It cannot be used with pediatric patients.
Click here to view a video on ETC.
Two-tube
system:
Proximal cuff seals
oropharynx
Distal cuff seals
either the esophagus
or the trachea
Advantages
Disadvantages
Has
an inflatable
distal end that is
placed in the
hypopharynx and
then inflated
Blind insertion
Disadvantage:
Does not isolate
trachea
It
is designed to
facilitate endotracheal
intubation.
An epiglottic elevating
bar in the mask
aperture elevates the
epiglottis.
Tube is directed
centrally and anteriorly.
© LMA North America
Similar
to the
laryngeal mask
Supraglottic airway
“Cobra
head” of the
airway holds both
the soft tissue and
the epiglottis out of
the way
© Engineered Medical Systems, Inc. Indianapolis, IN
Supraglottic,
singleuse, disposable
airway
Features a special
curve that
replicates the
natural human
airway anatomy
© Ambu Inc. Baltimore, MD
Alternative
airway
Large silicone cuff
that disperses
pressure over a large
mucosal surface area
Stabilizes
the
airway at the base
of the tongue
©Tracey Lemons/King Systems Corporation, Indianapolis, Indiana
Removing
an obstructing foreign body using
Magill forceps or a suction device
You should carry out basic life support
maneuvers first.
If these fail to alleviate the obstruction, direct
visualization of the airway for foreign body
removal is indicated.
You
should use surgical airway procedures
only after you have exhausted your other
airway skills:
Needle cricothyrotomy
Surgical cricothyrotomy
Indications
Massive facial or neck trauma
Total upper airway obstruction
Contraindications
Inability to identify anatomical landmarks
Crush injury to the larynx
Tracheal transection
Underlying anatomical abnormalities
Transtracheal
jet insufflation is required
Complications:
Barotrauma from overinflation
Excessive bleeding due to improper catheter
placement
Subcutaneous emphysema
Airway obstruction
Hypoventilation
It
is preferred to needle cricothyrotomy
when a complete obstruction prevents a
glottic route for expiration.
Its greater potential complications mandate
even more training and skills monitoring.
Contraindications:
Includes children under 12
Cricothyrotomy
Complications:
Incorrect tube placement into a false passage
Cricoid and/or thyroid cartilage damage
Thyroid gland damage
Severe bleeding
Laryngeal nerve damage
Subcutaneous emphysema
Vocal cord damage
Infection
Stabilize larynx and make a 1–2 cm
vertical skin incision over
cricothyroid membrane
Using a curved hemostat,
spread membrane incision open
Terms
Difficult airway
A conventionally trained paramedic experiences difficulty
with mask ventilation, endotracheal intubation, or both
Difficult mask ventilation
Inability of unassisted paramedic to maintain an SpO2 >
90% using 100% oxygen and positive pressure mask
ventilation
Inability of the unassisted paramedic to prevent or
reverse signs of inadequate ventilation during positive
pressure mask ventilation
Terms
Difficult laryngoscopy
(cont.)
Not being able to see any part of the vocal cords with
conventional laryngoscopy
Difficult intubation
Conventional laryngoscopy requires either (1) more than
three attempts, or (2) more than ten minutes
Factors
related to difficult airway are
related to historical information,
anatomical, and poor technique
Historical
Factors:
Patient has had a history of problems with airway
management or anesthesia.
If time and patient condition allows, obtain a
brief airway history.
Anatomical
Considerations
Anatomy of the upper airway varies significantly
across the human species.
The most frequently used system of preintubation airway assessment is the Mallampati
Classification system.
The tonsillar pillars and the uvula are assessed.
Class 1
Class 2
Upper half of tonsil fossa
visible
Class 3
Entire tonsil clearly
visible
Soft and hard palate
clearly visible
Class 4
Only hard palate visible
The Mallampati classification system is at top.
Other
Revised Cormack and LeHane classifications
rating systems
Similar to Mallampati
Assigns 4 classes
POGO
The percentage of the glottis that can be visualized is
scored
From 0 to 100%
Short
neck
Short mandible
Thick neck
Anterior larynx
Restricted range of
Obesity
motion
Anatomical
Dentition
distortion
Small mouth
Patients
who have had a laryngectomy or
tracheostomy breathe through a stoma.
There are often problems with excess
secretions, and a stoma may
become plugged.
Use extreme caution with any suctioning.
Anticipating
complications when
managing an airway
Be prepared to
suction all airways to
remove blood or
other secretions and
for
the patient to vomit.
Tracheostomy cannulae
Wear
protective eyewear, gloves, and face
mask.
Preoxygenate the patient.
Determine depth of catheter insertion.
With suction off, insert catheter.
Suction while removing catheter .
Ventilate patient.
It
is sometimes necessary to remove
secretions or mucous plugs that can cause
respiratory distress.
Hypoxia is a concern.
Use sterile technique.
It may be necessary to instill sterile water
to thin secretions.
A
common problem with ventilating a
nonintubated patient is gastric distention.
You should place a tube in the stomach for
gastric decompression.
Nasogastric tube
Orogastric tube
Indications:
The need for decompression because of the risk
of aspiration or difficulty ventilating
Gastric lavage in hypothermia and some overdose
emergencies
Complications:
Possibility of esophageal bleeding
Increased risk of esophageal perforation
Procedure
Place head in neutral position
Measure tube
Use topical anesthetic
Lubricate and insert tube
Encourage patient to swallow
Advance to pre-determined mark
Verify placement
Apply suction
Secure in place
Device
Oxygen
Percentage
Nasal cannula
40%
Venturi mask
24, 28, 35, or 40%
Simple face mask
40 – 60%
Nonrebreather mask
80 – 95%
Small
Volume Nebulizer
Allows for delivery of medications in aerosol form
(nebulization)
Oxygen
Humidifier
Benefits patients with croup, epiglottitis, or
bronchiolitis, as well as those patients receiving
long-term oxygen therapy
Effective
ventilatory support requires a tidal
volume of at least 800 mL of oxygen at 10 to
12 breaths per minute.
Effective artificial ventilation requires:
A patent airway
An effective seal between the mask and the
patient’s face
Delivery of adequate volumes
Mouth-to-mouth
Mouth-to-nose
Mouth-to-mask
Bag-valve
device
Demand valve device
Automatic transport ventilator
Indicated
in the presence of apnea when no
other ventilation devices are available
Limited by the capacity of the person delivering
the ventilations
Potential for exposing either the rescuer or the
patient to communicable diseases
Prevents
direct contact between you and
your patient’s mouth
Devices usually have a one-way valve that
prevents you from contacting the patient’s
expired air.
May also provide an inlet for supplemental
oxygen
Prehospital
and
emergency
department
personnel most
commonly use the
bag-valve device.
One, two, or three
rescuers may
perform bag-valvemask ventilation.
© Scott Metcalfe
Observe
the patient for chest rise, gastric
distention, and changes in compliance of
the bag with ventilation.
Complications:
Inadequate volume delivery
Barotrauma
Gastric distention
Flow-restricted,
oxygen-powered
ventilation device
Flow is restricted
to 30 cm H2O or
less to diminish
gastric distention
Cannot measure
delivered volumes
or feel lung
compliance
Advantages:
Typically comes with two
or three controls
Maintain minute volume
Mechanically simple and
adapts to a portable oxygen
supply
Rate
Volume
Contraindications
A
significant percentage of claims and
lawsuits involve inadequate patient
ventilation.
Detailed documentation shown could go a
long way toward warding off such a claim.
It is crucial to document in medically correct and legally sufficient
terms exactly what was done in managing the airway.
Anatomy of the Respiratory System
Physiology of the Respiratory System
Respiratory Problems
Respiratory System Assessment
Basic Airway Management
Advanced Airway Management
Orotracheal Intubation
Pediatric Orotracheal Intubation
Nasotracheal Intubation
Managing Patients with Stoma Sites
Suctioning
Gastric Distention and Decompression
Oxygenation
Ventilation
Documentation