1. Facilitated Intubation t Sedation (decrease LOC) –Versed (January 2002 with patch) concerns for hypotensive patients helps blunt sympathetic response amnesia t Analgesia (stop pain) –Morphine concerns for hypotensive patients helps blunt sympathetic response –Fentanyl (synthetic opiate 100 x stronger than morphine) concerns for hypotensive patients helps blunt sympathetic response Opiates Not Supported Now Until After Intubation

2. Critical Thinking! t What are the advantages of facilitated intubation? t What if sedation has been delegated and respiratory arrest occurs and you are unable to get the tube? t What if you cannot ventilate? t Explain why it is possible to be unable to ventilate a previously spontaneously breathing patient. t Don’t paint yourself into a corner.

3. Airway Review Landmark - 2 fingers

4. Airway Review

5. Causes of Obstruction t Foreign Body t Trauma t Edema t Neoplasm t Blood

6. Foreign Bodies t Food t More common in children t In adults there are typically co-factors –Alcohol –Aging

7. Fractured Larynx t Blunt trauma t Rapid & severe t Posterior tear t Seldinger Cric can cause expansion of tear t True surgical airway emergency

8. Fractured Larynx - Radiograph

9. Fractured Larynx - Photo

10. Emergency Cricothyrotomy Protocol If a patient cannot be ventilated due to life-threatening suspected upper airway obstruction, the Advanced Care Paramedic may attempt a cricothyrotomy according to the following protocol after receiving orders from the BHP. Indications:  A patient that requires intubation and  Unable to intubate and  Unable to adequately ventilate Conditions:  Patient  40 kg and  12 years old Contraindications:  Suspected fractured larynx  Inability to localize the cricothyroid membrane

11. Emergency Cricothyrotomy Protocol Procedure: 1. Administer 100% O 2. 2. Contact the BHP for on-line medical direction to proceed with this protocol. 3. If every attempt to contact a BHP has failed, the AC Paramedic may continue with this protocol in a life-threatening situation if all other indications and conditions are met. The AC Paramedic should contact the BHP (and the Base Hospital) as soon as possible after the procedure and document the patch failure and decision to proceed. 4. Place patient on his or her back, and then extend the head and neck (provided there are no c-spine injuries). 5. Grasp the larynx with your thumb and middle finger. Locate the cricoid cartilage and the cricothyroid membrane with the index finger. Prep the area quickly. Follow the appropriate procedures following for the specific equipment used. The seldinger cricothyrotomy should be the primary method used but if the equipment is not available, the needle cricothyrotomy procedures should be followed.

12. Emergency Cricothyrotomy Protocol Seldinger (Melker) Cricothyrotomy Kit: 1. While stabilizing the thyroid cartilage make a vertical incision in the midline of the cricothyroid membrane with a scalpel. 2. Use the supplied 18g TFE catheter with the 6cc syringe attached. Insert the catheter into the airway at a 45º caudal angle looking for free air in the syringe. 3. Remove the syringe and needle leaving the catheter in place. Always maintain contact with the guidewire, never let go! 4. Advance the soft flexible end of the wire guide through the catheter and into the airway several centimeters caudally. 5. Remove the catheter leaving the wire guide in place. (STEP # 1) 6. Feed the dilator (with airway catheter in place) over the wire. Ensure that the stiff end of the wire protrudes out of the back of the dilator. 7. Advance the dilator into the airway until the flange of the 15mm airway adapter is resting against the patient's neck. 8. Remove the dilator and wire guide. Use caution to ensure that the wire guide is not lost into the trachea. 9. Secure the flange of the airway adapter to the patient. 10.Attach a BVM and attempt to ventilate the patient. Genesis or other ventilators must not be used. 11.Initiate rapid transport to the closest appropriate hospital. 12.Patch to the Base Hospital if complications arise or further orders are required.