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Assisting With ALS Airway Procedures

  • Team Dynamics in Airway Management

    • EMTs commonly collaborate with paramedics during critical patient interventions.

    • The role of the EMT includes:

    • Assisting in the setup for advanced airway procedures.

    • Performing Basic Life Support (BLS) airway maneuvers and ventilation techniques.

    • Monitoring the patient's vital signs throughout the procedure.

Introduction to Advanced Airway Procedures

  • Endotracheal (ET) Intubation

    • Definition: Process of inserting a tube into the trachea for airway maintenance and protection.

    • Methods of Insertion:

    • Oral intubation: ET tube inserted through the mouth.

    • Nasal intubation: ET tube inserted through the nose.

    • Path of ET Tube: Passes through the larynx, between vocal cords, into the trachea.

Patient Preparation for ET Intubation

  • Oxygenation Prior to Intubation

    • The initial step involves providing adequate oxygenation.

    • Methods:

    • Utilizing bag-mask ventilation with oral or nasal airway to ensure a proper seal.

    • Monitoring ventilation rates, volume, and exhalation time.

    • Process of Diffusion: Oxygen enters the bloodstream, enhancing gas exchange in lungs.

    • Preoxygenation: This key phase allows for sufficient oxygen delivery during intubation.

High-Flow Nasal Cannula and Apneic Oxygenation

  • Maintain a high-flow nasal cannula during preoxygenation.

  • Leave nasal cannula in place during intubation, enhancing oxygen delivery when bag-mask ventilation is not feasible.

  • Technique Implemented: Apneic oxygenation to ensure continuous oxygen delivery throughout the intubation phases.

  • Follow local protocols regarding procedure sequencing.

Equipment Setup for Intubation

  • Equipment may vary based on local protocols and preferences.

  • Types of Visualization during Intubation:

    • Direct Laryngoscopy: Involves visualization using a laryngoscope.

    • Video Laryngoscopy: Involves visualization using a camera monitor.

  • Typical Intubation Equipment Set Includes:

    • Personal protective equipment (PPE) - Face mask, eye shield.

    • Suction unit with rigid (Yankauer) and non-rigid (French) catheters.

    • Laryngoscope handle and blade suited to patient needs.

    • Magill forceps and ET tube, sized for the patient.

    • Stylette or tube introducer (gum elastic bougie).

    • Water-soluble lubricant.

    • 10-mL syringe for cuff inflation.

    • Confirmation devices (waveform end-tidal CO2 monitors, colorimetric devices).

    • Securing devices for ET tube and alternate airway management devices (e.g., supraglottic airway, cricothyrotomy kit).

Preparing the Equipment

  • Practical Steps Prior to Procedure:

    • Unpack and lubricate the ET tube with water-soluble lubricant.

    • Attach 10-mL syringe; inflate cuff and pilot balloon as necessary.

    • Test the light on the laryngoscope.

Performing the Intubation Procedure

  • Remember the BE MAGIC mnemonic for steps in intubation:

    • B: Perform Bag-mask preoxygenation.

    • E: Evaluate for airway difficulties.

    • M: Manipulate the patient to facilitate access to the airway.

    • A: Attempt the first-pass intubation.

    • GI: Use a supraglottic airway if intubation is not successful.

    • C: Confirm successful intubation and rectify any issues.

Bag-Mask Ventilation

  • Critical to properly preoxygenate before intubation, especially in high-risk patients.

  • Avoid hyperventilation as it can cause:

    • Gastric distention, increasing aspiration risk.

    • Hypotension from excessive air introduction.

  • Maintain adequate seal during ventilation, ensuring chest rise and delivering breaths at appropriate rates:

    • 1 breath every 6 seconds for adults.

    • 1 breath every 2-3 seconds for infants and children.

Evaluating for Airway Difficulties

  • During preoxygenation, the ALS provider must assess for difficulties affecting intubation.

    • Factors to be aware of include trauma and anatomical deformities that complicate airway access.

  • Assist in preparing necessary equipment to address identified issues.

Special Patient Populations

  • Difficult intubation may arise in:

    • Bariatric patients.

    • Pediatric patients.

    • Patients with suspected cervical spine injuries.

  • Cervical Collar Management: Adjust collar to maintain spine immobilization while facilitating intubation.

Patient Positioning for Intubation

  • Ideally position the patient to provide optimal visibility of the airway.

    • Manipulate the body using towels, blankets, and pillows to achieve the proper alignment.

    • Optimal position: Patients' ear canal should align with the sternal notch, also termed the sniffing position for airway access.

Follow-Up After Intubation

  • After successful intubation, consider placing an oral airway to prevent biting of the ET tube.

  • Confirm Intubation Success:

    • Attach end-tidal CO2 waveform detector between ET tube and bag.

    • Check for positive breath sounds and absence of gastric sounds.

    • Parameters of successful intubation:

    • End-tidal CO2 waveform present.

    • Bilateral breath sounds audible.

    • Absent gastric sounds indicating correct ET placement.

    • Corrective Actions: If intubation is unsuccessful or problems persist, assist team members in resolving airway and breathing complications.