2Outline Work Environment Scope of Practice Training Equipment ProceduresHow PCP/ACP Combos workWhat will be expected of you?
3Work Environment Many services are up to 40% ALS Presents different challengesBags are differentDispatched differentlyCrew configuration different (>age)Expectations for level of care higherCloser scrutinyPotentially more stress for the crewCombined care (different attendant/driver roles)
4Work Environment Legislation Check sheets Signatures DMA Narcotics Risk’s/benefitHigher chance something will go much better or much worse
5Scope of Practice Lots more drugs Lots more heavy things Special airway equipmentSpecial features on monitorManual defibCardioversionPacing (transcutaneous)
6Scope of Practice Manual Defibrillation, Pacing and Cardioversion Advanced AirwayLMA’s , Lited StyletsBTLS, ACLS ,PALSIV TherapyALS Drugs plus Symptom Relief, Versed, FentanylActivated CharcoalCXR InterpPentaspan
7Difficult Airway Algorithm Need ETTAttempt #1 -Without sedation(crash) or nasal ETTAttempt #2- Midazolam 0.05 mg/kg Fentanyl mcg/kgAttempt #3(or RSI Direct) Lidocaine, (atropine) with midazolam and fentanyl (see above) and succinylcholine mg/kgBackup- Laryngeal Mask Airway, Lighted Stylet, Surgical Airway
8Training Time lines – roughly 1 year for ALS Didactic –classroom time Clinical –practice in a controlled settingORERMOP/SOPOBS/PEDS/ICUOther (Burn Unit, HSC IV Team)
9Preceptorship/Consolidation Where it should all come togetherWith a designated preceptorGradual transition to full care
10Equipment Airway- Basic airway Laryngoscope plus ETT for Intubation Rescue Devices –advanced airwayLighted styletLMA –Surgical –Seldinger vs Quik TrachBougie
11Procedures Cardioversion Pacing Sedation Vagal and CSM Manual DefibrillationIV Bolus and IV medicationOther routes (PR,IN,IM,ETT,IO)IntubationAdvanced airwayNeedle decompressionIOThrombolyticsVAD Central access
13Airway Management Decision Process CONTROL THE AIRWAYAirway Management Decision Process(Judge how aggressive you need to be.)-Time/Distance-Personnel-Equipment-Other Considerations?
14“Evaluate for signs of difficult intubation” CONTROL THE AIRWAY“Evaluate for signs of difficult intubation”(this may help in your decision as well)-Obesity -Small body habitus-Small jaw -Large teeth-Burns -Trauma-Anaphylaxis -Stridor
15CONTROL THE AIRWAYThe PCP vs. ACP airway decision may not be based on one single factor, but rather based on an overall assessment of many factors.
16CONTROL THE AIRWAYPre-Intubation-Prepare Equipment-Hyper-oxygenate
17Orotracheal Intubation Procedure CONTROL THE AIRWAYOrotracheal Intubation ProcedureSweep Left and Look
18Backward, Upward, Right Pressure (B.U.R.P.) CONTROL THE AIRWAYFind Your LandmarksBackward, Upward, Right Pressure (B.U.R.P.)
22Readjusting with Cricoid Pressure CONTROL THE AIRWAYReadjusting with Cricoid Pressure
23Common Provider Mistakes CONTROL THE AIRWAYCommon Provider Mistakes*Making a difficult intubation more difficult*Rushing*Poor equipment preparation*Suction (lack there of)
24CONTROL THE AIRWAY What is your back-up plan today? prolonged BVM… another provider…a smaller tube…better lighting…additional suctioning…
25CONTROL THE AIRWAYHelpful AdjunctsGum Elastic Bougie
26CONTROL THE AIRWAYHelpful AdjunctsLighted Stylette
27Nasotracheal Intubation CONTROL THE AIRWAYNasotracheal IntubationIndications:“Patient still breathing but in respiratory failure and in whom oral intubation is impossible or difficult.”
28Nasotracheal Intubation CONTROL THE AIRWAYNasotracheal IntubationContraindications:-Apnea-Resistance in the nares-Blood clotting or anticoagulation problems-Basilar Skull Fx (?)
29-Prepare patient and nostril -Insert on inspiration STEP 4. CONTROL THE AIRWAYNasotracheal IntubationTechnique:-Prepare patient and nostril-Prepare tube-Insert on inspiration-Take your timeComplications:-Bleeding
31Secure Your Tube SECURE THE AIRWAY Good, Better, Best Tape Improvised devicesCommercial devicesImmobilization (?)
32Developed in 1981 at the Royal London Hospital By Dr Archie Brain ALTERNATIVES TO ETILaryngeal Mask AirwayDeveloped in 1981 at the Royal London Hospital By Dr Archie Brain
33Not a substitute for definitive airway management STEP 7. ALTERNATIVES TO ETILaryngeal Mask AirwayIndications:-When definitive airway management cannot be obtained. (ETT)Not a substitute for definitive airway management
34Contraindication/Limitations: ALTERNATIVES TO ETILaryngeal Mask AirwayContraindication/Limitations:-Obesity-Non-secure-Size based-Not a med route
35Laryngeal Mask Airway Weight Based Sizing <5kg = Size 1 ALTERNATIVES TO ETILaryngeal Mask AirwayWeight Based Sizing<5kg = Size 15-10 kg = Size 220-30 kg = Size 2.5Small Adult= Size 3Average Adult = Size 4Large Adult = Size 5
36*If in doubt, check the LMA ALTERNATIVES TO ETILaryngeal Mask AirwayAverage Adult Woman = 4Average Adult Male = 5*If in doubt, check the LMA
37Laryngeal Mask Airway Procedure: ALTERNATIVES TO ETI -Hyper oxygenate -Check cuff-Lubricate posterior cuff-Head in neutral or slightly flexed position-Insert following hard palate (use index finger to guide)-Stop when met with resistance-Let go and inflate cuff (visualize “pop”)-Confirm and secure
38ALTERNATIVES TO ETILaryngeal Mask AirwayAir volume is variable depending on cuff size and individual patient anatomyGeneral Guideline:Size 1 = 4 mlSize 2 = 10 mlSize 2.5 = 14 mlSize 3 = 20 mlSize 4 = 30 mlSize 5 = 40 ml
39Laryngeal Mask Airway Common Provider Problems: ALTERNATIVES TO ETILaryngeal Mask AirwayCommon Provider Problems:-Failure to seat properly-Sizing difficulties-Aspiration
41King Airway Why Known Issues Unconscious / unresponsive patients without gag reflexBlind insertion techniqueAlternative to E.T.T.Known IssuesObtaining proper seal / placementIs NOT a medication route for Endotracheal drugsMultiple sizes, based on height, also multiple cuff volumesContraindicationsResponsive patients with an intact gag reflex.Patients with known esophageal disease.Patients who have ingested caustic substances.
44User TipThe key to insertion is to get the distal tip of King Airway around the corner in the posterior pharynx, under the base of the tongue.Experience has indicated that the lateral approach, in conjunction with a chin lift, facilitates the placement of the King Airway.Alternatively, a laryngoscope or tongue depressor can be used to lift the tongue anteriorly to allow easy advancement of the airway into place.
48Insertion #3 As the King Airway is advanced around the corner in the posterior pharynx, it is important that the tip of the device be maintained at the midline.If the tip is placed or deflected laterally, it may enter into the piriform fossa and the tube will appear to bounce back upon full insertion and release.Keeping the tip at the midline assures that the distal tip is properly placed in the upper esophagus.
50Insertion #5 Air Volume Required for Cuff Inflation: Size #3: 55 ml
51Insertion #6Attach BagWhile gently bagging, simultaneously withdraw the King Airway until ventilation is easy and free-flowing.Can the King tube device be used for PPV?Yes, in unresponsive non breathing pts
53Is there an optimal head position for insertion? Sniffing position, but the head can be in neutral position.For obese patient’s, elevation of the shoulders & upper back should be considered.How long can the King tube be left in place?Up to 8 hours. For longer procedures it is important to monitor& limit cuff pressure to 60 cm H20 or less.If my patient needs to be on a mechanical ventilator, do I need to replace the tube?Due to the King tube’s improved ventilatory seal, it is less frequent that the tube needs to be exchanged compared to other supraglottic airways.Can a laryngoscope be used?Yes, but it is not routinely used. It may be used by the inexperienced user, or difficult airway.What volume of pressure is needed to properly inflate the cuffs?The least amount needed to create a seal at the desired ventilatory pressures. Each tube size is differentWhat reference point for the centimeter depth markings on the tubes?The cm markings indicate the distance from the distal ventilatory opening. The markings serve as a visual reference after placement and can be used to document insertion depth.
54LAST RESORT! Indications SURGICAL AIRWAYS -Obstruction -Facial Trauma -Intubation or other alternatives impossible-Trismus (clenching)->8 years old (for open procedures)LAST RESORT!
55-Vertical Incision over membrane -Pierce membrane in horizontal plane SURGICAL AIRWAYS-Vertical Incision over membrane-Pierce membrane in horizontal plane-Open and spread to insert 4.0 or 5.0 tube-Secure tube in place and ventilate
56Needle Cricothyrotomy SURGICAL AIRWAYSNeedle CricothyrotomyNeedle Procedure:-Identify Cricothyroid membrane-Pierce at 45° angle-Place catheter or styllette-Advance dilator per manufacturer’s recommendation
58Step by step process in order Start simple and work up Alternatives WHY AN ALGORITHM?Step by step process in orderStart simple and work upAlternativesBe sureGet it done
59Procedure for Intubation Preoxygenate with 100% (may not need to bag)Prepare equipment (SLOPES-M)Hyperextend –Sniffing positionInsert larygoscope into R sweep tongue to leftLook for viewInsert ETT to 1-3 cm beyond cordsWithdraw largyRemove styletinflate cuff with 5-8 cc airAuscultate neck, chest x 4Secure ETTDocument cm marking and reevaluate often
60How you can help as PCP (PRN) Prepare equipmentPreoxygenate patientBURP (backwards upwards and to the right pressure-thyroid cartilege mvmt)Cric pressureRemove styet when askedInflate balloonSecure ETTVentilate patient
61Cricoid pressureOnly when asked toKnow your landmarks
62Burp –backwards upwards and to the right (pressure)
64Symptomatic Patients get treated electrically Chest painShortness of breathPulmonary edemaHypotensionDiaphoresisDecreased LOA
65Vagal Manuvers/CSMFor stable patients with signs of clinically significant tachy rhythmsCSM “Fake” the baroreceptors into thinking BP is too high so slows HR downVagal manuvers- increase ITP to see if can stimulate a vagal responsePatients <70 or with no bruits in carotid arteries
66Synchronized Cardioversion Unstable tachydysrhythmiasPad placementSynchronize the monitorSedation, anaelgisics, amnestics
67Symptomatic Tachyarrhythmias Chest painShortness of breathPulmonary edemaAltered LOCHypotensionSyncopeDiaphoresisSigns & symptomsExperience and judgment
68What Does the “SYNC” Button Do? Tags the R wavesTiming – refractory periodsDo NOT want to cardiovert at this time!
69Iatrogenic R on T - Cardioversion Cardiac arrestAlways double checkAutomatic ‘sync’ shutoff
70Advanced Care Directive - VT with Pulse ATTEMPT PATCH IMMEDIATELYO2 via NRB mask / Intubate PRNIV accessBolus 500 cc NSLidocaine 1.5 mg/Kg IVSynchronized cardioversion Monophasic 100JSynchronized cardioversion Monophasic 200J
71Advanced Care Directive - VT with Pulse Patient Symptomatic?Sedate PRNATTEMPT TO PATCHSynchronized cardioversion Monophasic 200J or Synchronized cardioversion Monophasic 360J PATCH IF RETURN OF NORMAL RHYTHM
75Contraindications Severe hypothermia Cardiac arrest > 20 minutes Open chest woundsFlail chest
76Procedure for Pacing Turn “pacer” on Set HR between 60-80 Increase mA - captureAdd 10 mA - safe zoneExplain to patientO2 & IV therapySedate – BHPPad placement
77Defibrillation-Manual ALS algorithm for Vfib/Vtach pulselessCPRDefibrillate Monophasic 200,300,360 J or BiphasicINTUBATE / IV ACCESS1.0 mg Epi (1:10,000) IV or 2.0 mg Epi ETTrepeat q 3-5 minutesDefibrillate Monophasic 360 J x3 or Biphasic 200J x31.5 mg/Kg LIDOCAINE IV or 3.0 mg/Kg ETTRemember in manual mode, the machine will shock regardless of what the rhythm on the monitor is!
78Drugs Carried by ALS Dopamine NTG Midazolam ASA Diazepam FentanylMorphineD50WNa BicarbonateOtrivinGravolNTGASAVentolin (MDI,ETT,Neb)GlucagonEpinephrine 1:1000,1:10000AtropineLidocaine (preload and sprayLasixAdenosine
79Treating patients -Differences Can give NTG if no prior useIncreased selection of things to doAlso increased responsibilityIncreased accountabilityIncreased $$$ too!
80Read Pages in Bledsoe Pages 480-486 IO 516-561 ETT Medication review –appropriate pages chapter 6/7 and Concepts in PharmacologyLook at handouts (2)