1. Module: Session: Advanced Care Paramedicine Oxygen Therapy 5 2

2. Hazards of Oxygen Aids in combustion Is colorless, odorless, tasteless, dry gas Pressurized cylinders Explosive when mixed with petroleum Oxygen toxicity May depress respiratory drive in COPD Patients

3. Oxygen Regulators Reduces the free flow to a usable 40 - 70 psiReduces the free flow to a usable 40 - 70 psi Allows for flow controlAllows for flow control Two types:Two types: BourdonBourdon Compensated Flow MeterCompensated Flow Meter

4. Oxygen Regulators Safety Systems PIN Index Safety System (D tanks) American Standard Thread System (M tank) Humidifiers should be used when O 2 administration exceeds 60 minutes

5. (Tank Pressure - Safe Residual Pressure) X (Cylinder Factor) Flow Rate (lpm) Safe Residual Pressure = 200psi Cylinder Factors D = 0.16 E =0.28 M = 1.56 Oxygen Tank Duration

6. Tank Set-up 1.Select tank 2.Remove protective seal 3.Open valve briefly to clean 4.Attach regulator and tighten 5.Open tank valve 6.Ensure there is NO air leaking A.Correct if present 7.Attach desired oxygen delivery device 8.Adjust flow rate to desired setting

7. Airway Management

8. Head-Tilt Chin Lift

9. Airway Management Modified Jaw Thrust

10. Airway Management Tongue-Jaw Lift Recovery Position

11. Oxygen Masks High Flow Masks  Nasal Cannulae  Simple Face Mask  Venturi Mask High Concentration Masks  Non-Rebreather Positive Pressure Aids  Pocket Mask (with or without Oxygen)  Bag Valve Mask

12. Oxygen Therapy Nasal Cannulae Low to medium concentration 24 - 44 % 1 - 6 liters per minute

13. Oxygen Therapy Simple Face Mask Medium concentration 40 - 60 % 6 - 10 liters per minute

14. Oxygen Therapy Venturi Mask Low to medium concentration 24, 28, 31, 35, 40, 50 % each tip has different oxygen LPM flow Check the tip

15. Oxygen Therapy Non-Rebreather Mask (NRB) High concentration 90 - 100 % 10 - 15 liters per minute  whatever it takes to keep the reservoir full

16. Airway Management Oropharyngeal Airways Used only for unresponsive patients Used to keep tongue off epiglottis Measured from earlobe to corner of mouth May also be measured from the center of mouth to the angle of the jaw Inserted upside down and rotated 180° down behind the tongue

17. Nasopharyngeal Airways Measured from Tip of Nose to the earlobe Not to be used on patients with S/S of a Head Injury Must be lubricated before use Insert with the bevel towards the septum (usually the right nostril) Airway Management

18. Oxygen Therapy Pocket Mask Medium to High Concentration 2 hands make better seal  16 % Alone  50 % with 10 LPM  55 - 85 % with 15 LPM

19. Oxygen Therapy Bag Valve Mask (BVM) High Concentration 90 – 100 % 10 – 15 liters per minute Practice makes perfect 2 hands make better seal

20. Only suction on the way out Insert along the cheek wall Only suction as far as you can see Suction for 10 seconds only Suction

21. OPEN Head-tilt Chin Lift or Modified Jaw Thrust INSPECT Cross finger technique - Look CLEAN Finger sweep and/or suction SECURE OPA OR NPA Steps to Airway Management

22. Advanced Airway Management

23. Advantages of Intubation Cuffed E.T tubes protect the airway from aspiration. Provides access to the tracheobronchial tree for suctioning of secretions. Does not cause gastric distention and associated danger of regurgitation. Maintains a patent airway and assists in avoiding further obstruction. Drug route

24. Indications for Orotracheal Intubation Inadequate oxygenation that is not corrected by supplemental oxygen Inadequate ventilation Need to control and remove pulmonary secretions Any patient in cardiac arrest Ant patient in deep coma who cannot protect his airway. Any patient in imminent danger of upper airway obstruction (e.g. Burns of the upper airways) Any patient with decreased LOC (GCS <= 8.) Severe head and facial injuries with compromised airway Any patient in respiratory arrest Imminent Respiratory failure

25. Contraindications Patients with an intact gag reflex. Patients likely to react with laryngospasm to an intubation attempt.  e.g. Children with epiglottitis. Basilar skull fracture  avoid naso-tracheal intubation and nasogastric/pharyngeal tube.

26. Complications of Orotracheal Intubation Trauma of the teeth, vocal cords, arytenoid cartilages, larynx and related structures. Hypertension and tachycardia can occur from the intense stimulation of intubation  This is potentially dangerous in the patient with coronary heart disease. Transient cardiac arrhythmias related to vagal stimulation or sympathetic nerve traffic may occur

27. Complications Continued… Damage to the endotracheal tube cuff, resulting in a cuff leak and poor seal. Intubation of the esophagus, resulting in gastric distention and regurgitation upon attempting ventilation. Baro-trauma resulting from over ventilating with a bag without a pressure release valve (pneumothorax).

28. Complications Continued… Over stimulation of the larynx resulting in laryngospasm, causing a complete airway obstruction. Inserting the tube to deep resulting in unilateral intubation (right bronchus). Tube obstruction due to foreign material, dried respiratory secretion and/or blood.

29. Equipment Suction Laryngoscope  Blades Oxygen (BVM) Pillow Endotracheal Tube Stylet Spare endotracheal tubes Securing tape/twill Syringe End-tidal CO 2 Detector Toomey Syringe Rescue Airways  Bougie  Surgical

30. Straight blades (Miller)

31. Curved blades (Macintosh)

32. ET tube.

33. ET tube with malleable Stylet

34. Magill forceps.

35. Tube Sizes 9 - 11 years28-36 kg7.0 mm (cuffed) 14 to adults46+ kg7.0 – 80 mm (cuffed) Adult female7.0 – 8.0mm (cuffed) Adult male7.5 – 8.5 mm (cuffed) Use the formula:  (Age + 16)/4 or (Age/4) + 4  May also be determined by the size of the patients little finger Note: patients below the age of 8 require uncuffed ETT due to damage caused by the cuff in younger patients. Always monitor the ECG activity during intubation.

36. Tube sizes Newborn4 kg2.5 mm (Uncuffed) 1-6 months4-6 kg3.5 mm (Uncuffed) 7-12 months6-9 kg4.0 mm (Uncuffed) 1 year9 kg4.5 mm (Uncuffed) 2 years11 kg5.0 mm (Uncuffed) 3-4 years14–16 kg5.5 mm (Uncuffed) 5-6 years18–21 kg6.0 mm (Uncuffed) 7-8 years22-27 kg6.5 mm (Uncuffed)

37. Procedure for Intubation Position yourself at the patient's head Inspect the oral cavity for secretions and foreign material  Suction if needed Put patient into “sniffing” position  Open the patient's mouth with the fingers of your right hand Grasp the lower jaw with your right hand  Draw it forward and upward  Remove any dentures

38. Procedure for Intubation Hold the laryngoscope in your left hand Insert the blade in the right side of the patient’s mouth, displacing the tongue to the left Identify the uvula  Avoid any pressure on the lips or teeth

39. Technique

40. Procedure for Intubation If using a curved blade, advance the tip of blade into the vallecula If using a straight blade, insert the tip of blade under the epiglottis

41. Tip of blade is inserted into vallecula.

42. Lifting to expose vocal cords.

43. Use blade to lift epiglottis

44. Procedure for Intubation Expose the glottic opening by exerting upward traction on the handle  Do not use a prying motion with the handle  Do not use the teeth as a fulcrum

45. Procedure for Intubation Advance the ET tube through the right corner of the patient’s mouth, and under direct vision, through the vocal cords  Remove the stylet (if used)

46. Procedure for Intubation Ensure that the proximal end of the cuffed tube has advanced past the cords about 1 to 2.5 cm (½ to 1 inch)  Observe depth markings on the ET tube during intubation  Inflate the cuff and remove syringe  Attach the tube to a mechanical airway device  Confirm placement  Begin ventilation and oxygenation

47. Depth of insertion in Children For children over the age of 2 can use: Depth = Age (years) + 12 2 Or may use: Depth = internal diameter X 3

48. Confirming Tube Placement Direct re-visualization Auscultation  Epigastric area  Bilateral bases  Apices Other methods Corrective measures

49. Extra help Sellick Maneuver  Helps displace the larynx posteriorily for a better view  This pressure also prevents gastric contents from leaking into the pharynx by extrinsic obstruction of the esophagus. BURP  Brings the larynx into view to ease intubation “Back” “Up” “Right” “Pressure”

50. Intubation with Spinal Precautions Requires a minimum of two rescuers Procedure  Prone position method

51. Indications for Nasotracheal Intubation Nasotracheal intubation may the airway of choice in patients with:  Spontaneous respirations  Cervical spine compromise Examples:  Medication OD  Asthma/COPD  Stroke  Status Epilepticus  Altered LOC

52. Complications Epistaxis Vagal stimulation Damage to turbinates or septum Laceration in the retropharyngeal Vocal cord injury Damage to the arytenoids Esophageal placement Intracranial placement (basil skull)

53. Procedure Prepare equipment as in orotracheal intubation (Select ET 1 mm smaller – No Stylet) Preoxygenate the patient Lubricate the ET tube with water soluble or lidocaine jel Insert the tube into the nasal cavity along the floor of the nostril  If resistance, attempt other nostril  If still unsuccessful consider a tube 0.5 mm smaller Provide cricoid pressure and advance the ETT until maximum airflow is heard Gently and swiftly advance ETT during inspiration Inflate cuff and Verify tube placement If intubation fails retract ETT, reoxygenate and reattempt

54. Indications for Digital Intubation Though not common practice, may be useful in patients:  Entrapment where view of airway is compromised  Large amounts of fluid or secretions hampering a good view  Equipment failure

55. Procedure Prepare equipment as in orotracheal intubation (stylet may be used) Preoxygenate the patient and insert bite stick to protect yourself Insert index and middle finger into pt’s mouth and ‘walk’ fingers over tongue pulling it and the epiglottis away from glottic opening Once the epiglottis has been located maintain control with middle finger Using the index finger as a guide, insert the ETT into the airway A Sellick’s maneuver may be helpful at this point Inflate cuff and Verify tube placement

56. Other Adjuncts

57. Transillumination Technique (Lighted Stylet) Description Indications Contraindications Advantages Disadvantages

58. Multi-Lumen Airways Description Indications Advantages Disadvantages Contraindications

59. Other adjuncts Laryngeal Mask  May be used in blind intubation  Has inflatable membrane to secure over the glottic opening May loose some of the air causing a possible leak and lead to aspiration

60. Other adjuncts Gum Bougie  Allows for relatively blind intubation  Curved tip designed to allow medic to feel “click” as it passes the rings  ET tube able to be introduced over it for insertion into trachea

61. Other adjuncts Endotrol Endotracheal Tube  designed for dealing with emergency situations and pathway abnormalities  is ideal for nasal intubation  all the features and benefits of a standard cuffed ET tube, plus the convenience of a controllable tip that permits faster, easier intubation.

62. Other adjuncts Retrograde wire/catheter Guided Intubation

63. The Difficult Airway

65. Goals Predict a difficult airway based on clinical criteria Plan for appropriate action in the difficult airway Initiate appropriate plans of attack with confidence in the “Can’t Ventilate/Can't Intubate” (CVCI) situation

66. Ideal conditions for intubation Ideal Lighting, positioning, etc. Plenty of assistance Time to prepare, plan, discuss Option to Abort Empty Stomach Back up available

67. Ideal Pt. for intubation Intact, clear airway Wide open mouth Pre-Oxygenated Intact respiratory drive Normal dentition/good oral hygiene Clearly identifiable and intact Neck and Face Big open Nostrils Good Neck Mobility Greater than 90 KG, Less than 110 kg.

69. Ped and Adult Normal Trachea

70. How many of our Pt’s are like That?

71. In Reality Our patients are: Immobilized Traumatized Compromised Prioritized Beer-n-Pizza-ized

72. They Tend to look like this

73. And This:

74. And This (after failed ETT attempt)

75. Most of our Patients are already “difficult airways” by “OR” Standards. Why should EMS personnel try to further identify a difficult airway?

77. The American Society of Anesthesiology (AMA) has noted:  “… there is strong agreement among consultants that preparatory efforts enhance success and minimize risk.”  And “…The literature provides strong evidence that specific strategies facilitate the management of the difficult airway “  Thus Identifying a potentially difficult airway is essential to preparation and developing a strategy. AMA

78. What does this mean to us? Well, many Anesthesiologist have the option to “Abort” induction, or to work through a problem with as much assistance as needed. In the REAL WORLD of EMS that is seldom the case for Paramedics. However many of the BASIC principles are valid in the clinical evaluation of Patients, and thus valuable in our education as medics. Knowing these principles will improve our decision making process and Patient Care;.

79. How can we further identify a difficult airway? PMHx Basic Physical Exam “Lemon” Law Mallampati Classification Cormick and Lehane Classification

80. Past Medical History Rheumatoid Arthritis Ankylosing Spondylitis  Painful Stiffening of the Joint Cervical Fixation Devices Klippel-Fiel Syndrome  Short wide neck, reduction in number of cervical vertebrae, and possible fusion of vertebrae. Thyroid or major neck surgeries Pierre Robin Syndrome  Small Jaw, cleft Pallet, No Gag reflex, downward displacement of tongue Acromegaly  Thickening of Jaw, Soft tissue structures of the face, associated with middle age

81. Past Medical History (Continued) Reduced Jaw Mobility Epiglottitis Tumors, Known Abnormal Structures Previous Problems in surgery

82. Basic Physical Exam Anything that would limit movement of the neck Scars that indicate neck surgeries Kyphosis Burns Trauma, especially instability of the facial and neck structures.

83. Lemon Law Look externally. Evaluate the 3-3-2 rule. Mallampati. Obstruction? Neck mobility.

84. L: Look Externally Obesity or very small. Short Muscular neck Prominent Upper Incisors (Buck Teeth) Receding Jaw (Dentures) Burns Facial Trauma S/S of Anaphylaxis Stridor FBAO

85. E: Evaluate the 3-3-2 rule 3finger breadths of mouth opening 3finger breadths from Front of Chin to Hyoid 2finger breadths from mandible to thyroid cartilage

86. M: Mallampati Classification Class I: Faucial pillars, soft palate and uvula visualized Class II: Faucial pillars and soft palate visualized, but uvula masked by the base of the tongue Class III: Only soft palate visualized Class IV: Soft palate not seen Blood A Method used by Anesthesiologist Open mouth and view oral cavity

87. Cormack & Lehane Grading Grade I:the vocal cords are visible Grade II:the vocals cords are only partly visible Grade III:only the epiglottis is seen Grade IV:the epiglottis cannot be seen Another method which involves direct laryngoscopic view of the larynx  Reliable to predict difficult direct Laryngoscopy  A Class I view is a Grade I Intubation 99% of the time  A Class IV view is a Grade III or IV intubation 99% of the time

88. O: Obstruction? Blood Vomitus Teeth (“chicklets”) Epiglottis Dentures Tumors Impaled Objects

89. N: Neck Mobility Spinal Precautions Impaled Objects Lack of access See PMHx for others.

90. What do we do when we have a difficult airway?

91. The AMA calls a Failed/Difficult Laryngoscopy a:  Any airway that takes more than 3 attempts  Any airway that takes more than 10 minutes to secure an airway  No wonder they say they have a 90 % success rate  If we had those standards our Pt’s would be dead.

92. So what do we do?

93. A little pre-planning goes a long way…

94. Before intubation Is there another means of getting our desired results BEFORE we attempt Direct Oral ETT? (Especially if we RSI) CPAP ? PPV with BVM or Demand Valve? Nasal ETT? Do we have all the help we need, all Airway equipment with us? (Suction?)

95. What are we going to do if we don’t get the Tube? Plans “A”, “B” and “C” Know this answer before you tube.

96. Plan “A”: (ALTERNATE) Different Length of blade Different Type of Blade Different Position

97. Plan “B”: (BVM and BLIND INTUBATION Techniques ) Cam you Ventilate with a BVM? (Consider two NPA’s and a OPA, gentile Ventilation) Combi-Tube? PTLA (No Longer produced) EOA? LMA an Option? Retrograde Intubation?

98. What do we do when faced with a Can’t Intubate Can’t Ventilate situation?  Plan “C”: (CRIC) Needle, Surgical, Plan “C”

99. Do YOU feel ready to enact Plans A, B, C at a drop of a hat? Feel familiar with all those tools and techniques? ?

100. OK, Here You Go! Mandibular Aplasia

101. Foreign Body Removal Initiate treatment measures for FBO Check to see if the obstruction was relieved.  Foreign body is visible in the oropharynx attempt to remove it manually or using Magill forceps  Foreign body is not evident visualize the laryngopharynx using the laryngoscope  Foreign body is visualized by laryngoscopy Attempt to grasp and remove it using Magill forceps. You should visualize the FB before attempting to remove it Do not probe the pharynx blindly with any instrument  Foreign body is not readily visible attempt to ventilate. Continue with BLS protocols and prepare for immediate transport.  Foreign body is removed Assess airway and if apnic - Attempt ventilations Unable to remove the FBO  Consider other options?

102. Percutaneous Cricothyroidotomy Necessary equipment  12 or 14 gauge needle  10 ml syringe  Alcohol or betadine swabs  Adhesive tape  Oxygen tubing and oxygen supply

103. Percutaneous Cricothyroidotomy Advantages  Simple to perform  Effective airway  Minimal spinal manipulation  Can be done quickly Disadvantages  Invasive technique  Requires constant monitoring  Does not protect the airway  Does not allow for efficient CO 2 elimination  Time restraints (30 – 45 minutes of good ventilation)

104. Percutaneous Cricothyroidotomy Complications  May cause Pneumothorax with high pressures  Hemorrhage at site of insertion  Perforation of the thyroid and/or esophagus  Does not allow for direct access for suctioning  May result in SubQ Emphysema

105. Percutaneous Cricothyroidotomy Procedure  Attach needle to the syringe  Place pt in the supine position  Identify the cricothyroid membrane  Stabilize larynx with one hand  With other hand, insert the needle through the membrane at a 45° angle towards the carina applying negative pressure to the syringe during insertion  Advance the catheter over the needle and remove needle/syringe holding the hub of the catheter  Attempt ventilations

106. Surgical Cricothyroidotomy Necessary equipment  Scalpel blade  6.0 or 7.0 ET Tube  Antiseptic solution  Oxygen  Suction device  BVM

107. Surgical Cricothyroidotomy Contraindications  Inability to identify landmarks Underlying anatomical abnormality (tumor, sub-glottic stenosis)  Tracheal transection  Acute laryngeal disease/trauma  Child under 10 y/o

108. Surgical Cricothyroidotomy Complications  Prolonged execution time  Hemorrhage  Perforation of the thyroid and/or esophagus  Injury to vocal cords  Injury to carotid and jugular vessels  May result in SubQ Emphysema

109. Surgical Cricothyroidotomy Procedure  Place pt in the supine position  Identify the cricothyroid membrane Make a 2” horizontal incision through skin Make a vertical incision through the membrane or open membrane incision with scalpel handle and rotate 90° Or Make a 2” vertical incision through skin/membrane Make a horizontal incision through the membrane or open membrane incision with scalpel handle and rotate 90°  Insert ETT and inflate cuff  Provide ventilation  Confirm placement

110. Pulse Oximetry Pulse Oximetry is a method to measure hemoglobin saturation in arterial blood

111. Pulse Oximetry The light emitting diode (LED) part of the sensor transmits through the vascular bed in the finger, earlobe, lateral foot in infants, and measures the amount of saturated versus unsaturated hemoglobin What is it saturated with?

112. Pulse Oximetry Hypoxemia  Lack of oxygen in the blood  May be caused by CO 2 Poisons Infections (Gangrene) ↓O 2 in atmosphere COPD Hypoperfusion (MI, CHF…) Hypovolemia (Anemia, blood loss…) Hypothermia

113. Pulse Oximetry Hypoxia  Lack of oxygen to the tissue caused by hypoxemia Cyanosis  The external sign of hypoxia characterized by the appearance of ‘blue’ tissue

114. Pulse Oximetry Signs of oxygen deficiency  Restlessness  Confusion  Pallor  Cyanosis  Tachypnea  Tachycardia

115. Pulse Oximetry Conditions that affect the readings  Lack of hemoglobin  COPD  Hypovolemia  Anemia  CO, CO 2  Hypothermia  Bright light  Vasoconstriction (↑cap refill)  Fingernail polish

116. Pulse Oximetry Normal Ranges 95 – 100 % O 2 required90 – 95 % Consider A/W Management< 90 % How does this relate to what you have seen in the field previously?

117. Pulse Oximetry Use SpO 2 as a guide Use clinical judgment/patient presentation as a more accurate guide to need for supplemental oxygen Treat the patient, Not the monitor! SpO 2 and SaO 2 are only accurate when compared to ABG’s

118. Pulse Oximetry Is it possible to show 100 % SpO 2 and still be hypoxic?