1. Combitube In-service Joe Lewis, M.D.,FACEP Schofield Barracks Ambulance Service

2. Combitube Intubation Protocol

3. INDICATIONS - Cardiac Arrest - Respiratory Arrest/Apnea

4. CONTRAINDICATIONS A patient under age of 18 or less then 4 ft. tall. A patient who has swallowed a corrosive substance. A patient with a known Esophageal Disease. EMT not trained and authorized to use the Combitube.® Suspected cervical spine injury requiring cervical spine immobilization.

5. Initial Procedure Assure scene safety and use universal blood / body fluid precautions. ABC’s. Clear airway and ventilate with 2 rescue breaths. Check Pulse – if absent, follow the AED Protocol.

6. Initial Procedure After the 2nd analysis cycle (if no shock is indicated) or after the 2nd series of 3 shocks is administered – insert the Combitube ® as per the insertion procedure. Continue the Protocol.

7. Initial Procedure If the patient initially has a pulse but is apneic – follow the insertion procedure and perform rescue breathing through the Combitube ®. Continually re-assess for spontaneous respirations.

8. Insertion Procedure Continually re-assess for spontaneous respirations and pulse. Note that ALS may continue Combitube® use, orally intubate around the Combitube®, or remove the Combitube® at the discretion of the responding Paramedic. The Combitube can NOT be used with the demand valve regulator.

9. Using The Combitube ABC’s Measure (Combitube or Combitube SA?) Check Cuffs Insert Inflate Cuffs Ventilate through tube #1 Check for Breath Sounds Switch & Ventilate through tube #2 if needed Check for Breath Sounds Continue Ventilation

10. Check ABC’s Establish Unresponsiveness. –Verbal / tactile stimuli. Look Listen and Feel for air movement. Deliver 2 rescue breaths. –reposition and try again if needed, –clear airway if obstructed. Check Pulse. –SAED & CPR if needed.

11. Measure the patient Put loop of measuring device over the patient’s foot. Determine which Combitube to use. –Combitube or Combitube SA. IF LESS THAN 4 FEET - use basic airway maintenance techniques. Select tube if the patient is over 4 feet.

12. COMBITUBE COMBITUBE SA

13. Check the Cuffs Inflate Pilot Balloon #1 with 100cc’s of air. –Check for proper inflation of cuff. Deflate Cuff. Inflate Pilot Balloon #2 with 15cc’s of air. –Check for proper inflation of cuff. Deflate Cuff.

14. Large Syringe Attached to Pilot Balloon #1 Ready to Inflate with 100cc’s of Air

15. Large Pharyngeal Cuff Inflated Pilot Balloon (#1) Remains Inflated.

16. Small Syringe Attached to Pilot Balloon #2 Ready to Inflate with 15cc’s of Air

17. Small Distal Esophageal Cuff #2 Inflated Pilot Balloon #2 for Small Distal Esophageal Cuff #2 Remains Inflated

18. Lubricate the Combitube Use water soluble gel. (Surgilube) Spread over tube. –Use package or gloved hand.

19. Insert the Combitube Hold tube like a pencil with dominant hand. Lift jaw and tong between thumb and index finger of non-dominant hand. Insert Combitube into mouth with curve facing upward. Stop inserting when the upper teeth or gums are between the Black Rings.

21. Insert the Combitube If any resistance is met during insertion: –Remove the Combitube, –Reposition, –Re-insert one time. If resistance is met on the second attempt: –Remove the Combitube, –Maintain airway using basic airway techniques.

22. Inflate the Cuffs Attach Large Syringe to Pilot Balloon #1. Inflate cuff #1 with 100cc’s of air. Remove syringe. Confirm that Pilot Balloon is inflated. –If not - attempt to re-inflate. –If still no inflation - remove Combitube and maintain airway with basic airway techniques.

24. Large Syringe Attached to Pilot Balloon #1 Ready to Inflate with 100cc’s of Air

25. Large Pharyngeal Cuff Inflated Pilot Balloon (#1) Remains Inflated.

26. Inflate the Cuffs Attach Small Syringe to Pilot Balloon #2. Inflate cuff #2 with 15cc’s of air. Remove syringe. Confirm that Pilot Balloon is inflated. –If not - attempt to re-inflate. –If still no inflation - Deflate Cuff #1, remove Combitube and maintain airway with basic airway techniques.

27. Small Syringe Attached to Pilot Balloon #2 Ready to Inflate with 15cc’s of Air

28. Small Distal Esophageal Cuff #2 Inflated Pilot Balloon #2 for Small Distal Esophageal Cuff #2 Remains Inflated

30. Ventilate Attach Bag / Valve and CO 2 detector to Tube #1. (Esophageal) Ventilate. Listen over Chest for breath sounds. –If present - continue ventilation at a rate of 12- 20 breaths per minute.

31. Removing the Combitube If the Combitube needs to be removed at any time - –Get suction ready, –Turn patient on left side, –Deflate both balloons, –Remove tube, –Suction as necessary.

32. CONTRAINDICATIONS A patient under age of 18 and less then 4 ft tall. A patient who has swallowed a corrosive substance. A patient with a known Esophageal Disease. EMT not trained and authorized to use the Combitube. ® Suspected cervical spine injury requiring cervical spine immobilization.

33. Possible Complications of Combitube Insertion Tear or rupture of esophagus. Bleeding. Puncture of carotid artery. Tear of pharynx. Pneumothorax. Death from asphyxiation. Vocal cord injury.