Airway Management Part II Adjuncts & Devices Zachary Wm. Drathman

Equipment Know what you need Find an area to work in Check your cuff Lube the tube Shape your tube appropriately Educate your EMTs Capnography

Laerdal’s “The Bag” BVM

Utilize the “C” & “E” grip for a good seal Save the Kung Fu grip for kicking ass!

“C” & “E” grip One handed!

Respect Your BVM 1. Delivers 100% O 2 2. Every Engine has one 3. Your very own CPAP ml of 0 2 at your finger tips 5. EMT + BVM = adjustable ventilator Top five reasons to love the BVM Getting sleepy

Make Your BVM Work For You!  Perfect for those CHFers: Improve gas exchange Decrease V Q mismatch Decrease Work of Breathing (WOB)  No “Plastic Cigar” for those HODs Maintain O 2 saturation while providing better living through Pharmacology.

BVM: One size fits all?  Static BVM volume: 1600ml  Normal human inhalation: 500ml  Max inhalation: 3500ml  Max exhalation: 1200ml  Stuck inside: 2300ml  COPD (Asthma/Empysema) Prolonged Expiratory Phase Prolonged Expiratory Phase Mmmm Cigarettes!

Understanding Air Trapping Bronchospasm leads to an inability to efficiently exhale Increasing ventilatory rate compounds the problem.

Air Trapping in the COPDer Healthy lungs: Supple, Elastic Emphysema Lungs: Distended, Inflexible

You know what they say about big hands?  Firemen like to do things all or nothing.  Define what you are looking for: Volume, Rate, Flow  Listen for O 2 flowing (or not)  Monitor rate & volume being delivered  Check on status routinely  Spread the word of Sellick

Sellick and Burping  “Cric Pressure” should be in every EMTs toolkit… But it’s not.  Very helpful for HODs requiring BVM. “I love the smell of vomit in the morning!”  Teach firemen how to BURP!  Backward  Up  Rightward  Pressure

So you got the tube. Now what?

Colormetric Meter (CO 2 Detector)

Colormetric CO 2 Detection Devise 1.Inflate cuff 2.Remove syringe 3.Affix ETCO 2 detector 4.Observe color change Purple > Yellow

Ascultate For Final Confirmation 1.Use quick shallow ventilations 2.Listen at epigastrum first 3.Listen at both lung fields Dude! You forgot the syringe. Shut up! They’re students. They won’t even notice.

Capnographic Device {Medtronic Microstream EtCO 2 Circuit}

Capnography New devise for old concept. Old devise: Colormetric New devise: Graphical / Quantitative Uses: Tube confirmation (initial / ongoing) CPR effectiveness Numbers: 35 to 40 is great Any number >10 means a good tube

Secure & Re-Confirm  Try for “22 at the teeth” but let lung sounds be your guide  Apply Thomas tube holder After securing Always confirm tube placement: After loading Before unloading After unloading

Thomas Endotracheal Tube Holder Route neck strap prior to intbubation. Secure neck strap THEN clamp tube.

Laryngeal Mask Airway (LMA) Rescue devise NOT tube replacement!

Periodic respiratory rate check Lifepak monitoring With audible QRS Know the character of your patient’s ventilatory phase S PO 2 monitor on EtCo 2 monitor on Monitoring

SPO 2 Monitoring Measuring the ratio of oxygenated hemoglobin to total hemoglobin Two different wave lengths of light used Carboxyhemoglobin gives falsely high reading Dark skin may give falsely high reading (3%-5%)

Capnography Waveforms

Affecting EtCO 2 Increased Ventilation >>> Decreased EtCO 2 Decreased Ventilation >>> Increased EtCO 2 However trapped CO2 will drive up EtCO2 readings. Be alert to a prolonged expiratory phase.

Documentation “He, who does not document will be blamed.” Example: "RSI, laryngoscopy x1, ETT size 7.5, 23cm at teeth, clear breast sound bilateral, positive CO2" “Shit rolls downhill.”