Section 6

Airway Procedural Protocols and Use of Airway Equipment

Rev. June 2004

CAPNOMETRY
INTRODUCTION:

(if available)

Capnography, the measurement and graphical display of expired PCO2 concentration at the airway, is becoming a standard of care in the pre-hospital setting for critically ill patients. The device can be used for: 1. 2. 3. Verification of tube placement. Early detection of clinically significant ventilatory/circulatory events. Assessment of cardiac arrest patients, and based on those results, speed the initiation of appropriate therapy or termination of resuscitation.

INDICATIONS: 1. Hand held Capnometers will be utilized on all patients who have an endotracheal tube in place. Pre-hospital experience with Capnometry shows it to be beneficial in the following situations: A. B. Ensuring tracheal rather than esophageal intubation. Continuous monitoring of post-intubation airway status (especially during transport). Ability to accurately maintain and control ventilatory status in intubated head injured patients Assess the effectiveness of CPR. Assessment of the cardiac output in patients with PEA (pulseless electrical activity). In patients with PEA who have a ET CO2 <10 resuscitation efforts are usually futile and this can aid in the decision to stop efforts.

2.

C.

D. E.

3.

Changes in the amount of CO2 exhaled which can be caused by: A. Rebreathing of CO2. B. Partial obstruction of the ET tube. C. Partial disconnection of the ventilatory circuit.

Rev. June 2004

PROCEDURE: 1. Connecting capnometer to the patient following intubation: A. B. C. D. E. F. G. H. I. 2. Connect the single-use patient attachment to the capnometer. Connect the single-use patient attachment adapter (narrow end) to the proximal end of the endotracheal tube. Connect the single use-patient attachment adapter (broad end) to the bagvalve. Turn the capnometer on by depressing the "on" button. Ventilate the patient with BVM; the capnometer will take the average of 4 ventilations before it displays numeric values. Observe capnometer reading. Make necessary adjustments (proper tube placement, etc.). Record results on the patient care form. When disconnecting the capnometer, place a cap over the ETT port.

Measuring respiratory rate: The capnometer will display a numerical value for respiratory rate. The device computes respiration rate from the total number of seconds for the last 4 breaths. Measuring CO2. What you should expect to see: A. B. C. Adult : Normal value 35 - 45 torr. Newborn: Normal value 35 - 40 torr. Lower than normal reading are to be expected in patients with poor perfusion or those patients hyperventilating or are being hyperventilated during resuscitation. Readings of >10 are generally viewed as a positive benchmark in a resuscitative effort. Since CO2 is normally present in exhaled gas, it can be assumed that intubated patients with adequate circulation will produce CO2 that can be measured. End Tidal CO2 (ETCO2) uses infrared light to measure the concentration of PCO2 emitted by the patient during the expiratory phase of respiration (either spontaneous or artificial). The numerical CO2 measurement (torr) is based on a 4-breath average. This measurement is translated into a digital readout and bar graph indicator reading. Listed below are six common pre-hospital situations (what the capnometer might show, and how it can impact treatment).
1.

3.

D.

Hyperventilation: Confirmation of low ETCO2 in the presence of stable circulatory status (within expected clinical setting) will focus on a respiratory cause. Care must be used to differentiate from
3
Rev. June 2004

non-functional causes of hyperventilation such as ASA overdose, pulmonary embolus etc.

2.

Head Injured Patients: Allows the control of ventilation in the intubated head injured patient. Whether hyperventilation, moderate ventilation, or normal ventilation is desired, the patient can be maintained at the desired level of ETCO2. Major Trauma/intubation: ETCO2 will be a function of pulmonary blood flow (in the presence of controlled ventilation). In the intubated trauma patient, ETCO2 reflects the adequacy of cardiac output and degree of shock. Severe COPD: ETCO2 can be measured to reflect the presence of CO2. Continued monitoring will reflect the response to Oxygen therapy. PEA/CPR (as an aid in the decision to cease resuscitation efforts): ETCO2 is primarily a reflection of pulmonary blood flow, which is determined by cardiac output. During low flow states, this may reflect the success or failure of resuscitative efforts. Persistently low levels are a marker of death. Cardiogenic Shock - Cardiac output will be reflected by pulmonary blood flow and measured by ETCO2.

3.

4.

5.

6.

PRECAUTIONS: Carbon dioxide is not normally produced in the stomach, but it may be present if the patient has consumed carbonated beverages or certain medications, or if the carbon dioxide that exists from the lungs is transported into the esophagus during ventilation. If the endotracheal tube is inadvertently placed in the esophagus, a small amount of CO2 may be present, but is rapidly eliminated within the first few breaths. The capnometer may detect the presence of CO2 in the stomach of the improperly intubated patient immediately after intubation, but should cease to do so after about six breaths. A failure to detect CO2 after this time suggests esophageal intubation in the patient with adequate blood flow to the lungs. DEFINITIONS: Capnometry: The measurement and numerical display of carbon dioxide concentration (partial pressure) at the airway. Capnography: The measurement and graphical display of carbon dioxide concentration (partial pressure) at the airway.
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Rev. June 2004

CO2: Produced by metabolizing tissues carried to the lungs by blood and eliminated by ventilation. PACO2: The partial pressure of CO2 In arterial blood. ETCO2: The end tidal CO2 value (the amount of CO2 in the last portion of air expired).

Rev. June 2004

COMBITUBE
INTRODUCTION: 1. The Combitube has been added to the airway equipment list in the event that traditional endotracheal intubation cannot be readily established and cricothyrotomy is not warranted. This device will offer paramedics and intermediates added flexibility when managing a difficult airway. The Combitube can be used to assist in ventilating a non-breathing patient, regardless of whether the tube is inserted into the trachea or the esophagus. It should only be utilized when intubation cannot be accomplished in a timely manner and the patient is not a candidate for cricothyrotomy. In general, this occurs when the patients airway is judged to be too difficult to intubate after several appropriate attempts by one or more paramedics have been unsuccessful. Use your judgment. There are TWO Combitube sizes, the Combitube and the Combitube SA (Small Adult). Use the appropriate size for the height of the patient.

2.

3.

INDICATIONS: Adult patients in respiratory or cardio-respiratory arrest when intubation is unsuccessful or very difficult. Unsuccessful intubation is defined as a total of four attempts by any number of paramedics. Very difficult is defined as situations where obtaining visualization of the vocal cords cannot be accomplished, whether due to anatomical limitations or limited space to access the patient. In these cases, the paramedic(s) may determine a Combitube is needed even if less than four intubation attempts have occurred. PROCEDURE: 1. Begin artificial respiration or CPR, incorporating usual procedures to verify an open airway. Prior to insertion, test the cuff integrity by inflating each cuff with the prescribed amount of air. A. Inflate the proximal pharyngeal cuff (blue pilot balloon) with 100 ml of air. Deflate air from the blue pilot balloon.
6
Rev. June 2004

2.

B.

Inflate the distal white esophageal cuff (white pilot balloon) with15 ml of air. Deflate air from white pilot balloon. Lubricate tube with water-soluble lubricant to facilitate insertion. Attach the fluid deflector to the clear deflecting lumen marked no 2.

C. D. 3.

In a supine patient, lift the tongue and jaw upward with one hand. This can also be accomplished using a laryngoscope blade and handle to displace the mandible and tongue without visualization (Paramedics only). With the other hand, hold the Combitube so it curves in the same direction as the natural curve of the pharynx. Maintain a midline position. Insert the tip into the mouth and advance in a downward curve until the teeth or alveolar ridges lie between the two painted bands. Don't force the tube! If the tube does not advance easily, redirect it or withdraw and reinsert. Inflate the no.1 blue pilot tube with 100ml of air from the blue coded syringe provided in the kit. The large latex cuff will inflate and may cause the Combitube to move slightly away from the patient's mouth; this is to be expected. Inflate the no.2 white pilot balloon with 15ml of air using the 20ml syringe supplied. Begin ventilation through the longer blue connecting tube no.1. If auscultation of breath sounds is positive, and gastric insufflation is negative, continue ventilation and observe chest for expansion/relaxation. Note: Under this condition, the second connecting tube may be used for the removal of gastric fluids using the suction catheter provided in the kit. If auscultation, of breath sounds is negative, and gastric insufflation is negative, the Combitube may have been advanced too far into the pharynx. Deflate the no.1 pilot balloon/cuff, and withdraw the Combitube approximately 2-3 cm out of the patient's mouth. Reinflate the no.1 pilot balloon/cuff with 100ml of air. If auscultation of breath sounds is positive and gastric insufflation is negative, continue ventilation. If auscultation of breath sounds is negative, and gastric insufflation is positive, immediately begin ventilation through the shorter clear connecting tube. Observe the rise and fall of the chest.

4.

5.

6.

7.

8.

9.

10.

Rev. June 2004

PRECAUTIONS: 1. When facial trauma produces sharp, broken teeth, use extreme caution when passing the Combitube into the mouth to avoid tearing the cuffs. Remove dentures.

2.

CONTRAINDICATIONS: 1. COMBITUBE: Patients under 5 feet tall. COMBITUBE SA (Small Adult): Patients under 4 feet tall.
4 ft 5 ft 5 ft

Combitube SA Combitube or Combitube SA Combitube

2. 3. 4.

Responsive patients with an intact gag reflex. Patients with known esophageal disease. Patients who have ingested caustic substances.

Rev. June 2004

CRICOTHYROTOMY
DEFINITION: A cricothyrotomy is the creation of a passage between the external environment and the trachea through the cricothyroid membrane (between the thyroid and the cricoid cartilages). Cricothyrotomies are performed when an airway must be established and other methods of achieving a definitive airway have either been unsuccessful. This procedure needs to be completed very quickly. Without Oxygen death of brain cells begins in 4-5 minutes. INDICATION: 1. Indications include, but are not limited to: A. Failure to intubate and/or ventilate despite neuromuscular blockade or existing flaccidity. Upper airway injury which distorts or occludes the normal anatomy such that intubation is impossible (thermal, radiation, infection, inhalation, trauma, or caustic). Complete occlusion of the upper airway that does not respond to first-line therapy, such as FBO maneuvers and laryngoscopy to facilitate visualization and removal of the object with Magill forceps.

B.

C.

PROCEDURE: 1. Place the patient in the supine position with the head secured if not contraindicated by possible existence of cervical trauma. Place two towels under the upper back and place the patient's head into moderate hyperextension. Identify the cricothyroid membrane (the soft spot between the thyroid cartilage and the cricoid ring). Prep the skin with Betadine, using a circular motion. Nick the skin with the provided scalpel. It should be stabbed to its full depth to facilitate passage of the IV catheter. Failure to do this will make passage exceptionally difficult, and may lead to failure to complete the procedure in a timely manner.

2.

3.

4.

Rev. June 2004

5.

Attach the IV catheter to the syringe; both are provided in the Cook-Melker cricothyrotomy kit. Insert the IV catheter through the cricothyroid membrane at a 45 degree angle (toward the feet), aspirating gently as you advance the IV catheter. Stop as soon as air is aspirated. Remove the syringe and stylet IV cath while stabilizing the IV catheter. Pass the soft end of the wire through the catheter until you have several inches of wire within the trachea. Stabilize the wire and remove the IV catheter. Once the wire is in place, extend the nick in the skin around the wire (using the scalpel provided in the kit). The nick should be full thickness made vertically, not horizontally, at least 1cm in length. Insert the gray dilator through the white airway catheter. Insert the guide wire into the tip of the dilator and pass the dilator and airway catheter over the wire and through the cricothyroid membrane. Failure to have created an adequate nick will make passage exceptionally difficult. The dilator is quite firm and could easily be pushed through the posterior wall of the trachea. It is important to be familiar with the curve of the tube, and insert it so that it passes toward the lungs after penetrating the membrane. This depth will rarely be greater than 1-2 cm. Making a note of how far the first needle passed will be helpful.

6.

7. 8.

9.

10. 11.

12.

Advance the dilator/catheter into the trachea (there should be minimal resistance to this) until the flange of the airway catheter rests against the patient's throat at the cricoid membrane. The guide wire should be visible at the opposite end of the dilatory. Remove the guide wire and dilator together. Secure the airway catheter to the patient. Ventilate. The patient can be ventilated using a bag-valve device connected to the airway catheter. Assess adequacy of ventilation by performing a 5-point auscultation assessment. Watch the chest for rise and fall. Note: Ensure that necessary monitoring equipment is available and placed into
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Rev. June 2004

13. 14. 15.

16.

service as time permits. This may include pulse oximetry and end-tidal CO2 monitoring if available. PRECAUTIONS: 1. Advance the angiocath slowly and carefully (insure you are midline). Careful performance minimizes complications. Placing the wire properly in the airway is the most critical maneuver. The dilator will go wherever the wire is. This may be the subcutaneous tissues, or through the posterior wall of the trachea and into the esophagus so knowing where the wire is of critical importance. The nick should be made vertically (not horizontally) with the blade of the scalpel moving upward. Some bleeding can be expected and should be controlled with direct pressure. In the event that the tube in the kit fails, and a standard ETT is used, remember that it only needs to be inserted a short distance past the cuff.

2.

3.

COMPLICATIONS: 1. Puncturing carotid artery or external jugular vein, or lacerating the vagus and phrenic nerve (generally impossible it you are in the midline). Perforating the thyroid gland, or injuring the vocal cords. This is rare if the cricothyroid membrane has been correctly identified. Penetrating and cannulating the esophagus. This is the most likely catastrophe. Easy aspiration of air through the catheter and subsequent easy passage of a long length of wire is critical to gaining confidence in the proper location and passage of the tube.

2.

3.

NOTES: All cases should have a needle cricothyrotomy report filled out and returned to the Board of Medical Examiners.

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Rev. June 2004

RAPID SEQUENCE INTUBATION (RSI) WITH NEUROMUSCULAR BLOCKING AGENTS

INDICATIONS: 1. 2. Respiratory insufficiency or arrest. Acute or threatened airway obstruction (angioedema, FBO, burns, expanding hematoma) Unconscious or altered mental status (GCS<9) where the airway is compromised, or where the airway may become compromised. Situations that required positive pressure ventilation (Flail chest, Pulmonary edema).

3.

4.

And has: 1. 2. 3. A clenched jaw, or An active gag reflex, or Uncontrollable combative behavior

CONTRAINDICATIONS: Succinylcholine should not be given to any patient with a prior neuromuscular injury or disorder (pre-exisiting long term paralysis, severe burns, or muscular dystrophy etc.), as it can precipitate fatal hyperkalemia. Vecuronium does not carry this contraindication, but requires Salem Hospital Physician contact for its use. PROCEDURE: 1. 2. Establish an open airway using head-tilt/chin lift or jaw thrust as required. Pre-oxygenate the patient if time allows. Any patient who needs to be intubated in the field is likely to be in extremis. If the patient can breathe passively then supply 100% Oxygen in an effort to get pulse oximetry to 100%.

12

Rev. June 2004

However, most of these patients will require bag-valve-mask positive pressure ventilation (BVM/PPV), and 100% Oxygen prior to paralysis. It is imperative that cricoid pressure be held (if possible) whenever BVM-PPV is being employed to prevent gastric distention and subsequent reflux while the patient is paralyzed and you are trying to intubate the patient. 3. Assemble required equipment. For pediatric patients have tube sizes above and below what you think you will need immediately available to you. You should check the balloon on the ETT tube (if it has one) if time allows and shape the ETT with the stylet in place to optimize success. Have suction, laryngoscope, and BVM in place and ready for use. Secure a patent IV line with Normal Saline. If time allows, attach monitoring equipment (ECG, pulse oximetry) to the patient. Premedicate the patient if these conditions are present: A. Head injury or suspected intracranial bleed: Lidocaine before paralysis. Thought to reduce an increase in intracranial pressure that has been reported in patients while being intubated. CHILDREN less than 12 years old should receive Atropine Sulfate to prevent reflex bradycardia. Sedation. All patients should receive Versed before paralysis. Post intubation; repeated Midazolam administration is preferred over paralysis for continued agitation. This will allow for neurologic assessment to continue when the patient reaches the hospital. Administer Succinylcholine. Remember to continue cricoid pressure as paralysis sets in, and until ET tube is in place with the balloon up.

4. 5. 6.

B.

C.

D.

7.

If patient is well oxygenated (a working pulse ox shows 100%) stop BVM/PPV as the paralysis starts to take hold and intubate the patient while an assistant continues to hold cricoid pressure. However, if patient is clearly still hypoxic as they often are (e.g. blue, or functioning pulse ox is reading below 90%) then BVM/PPV should continue assuming firm cricoid pressure is in place. Once paralysis is achieved, intubate the patient. The same holds true for failed attempts. If patient was well oxygenated prior to the attempt then BVM/PPV can be withheld as long as one to two minutes. However, If hypoxic then BVM/PPV should continue while preparations are being made for next attempt. If the patient cannot be intubated then proceed with continued BVM/PPV and consider other airway adjuncts.
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Rev. June 2004

8.

9.

Once the tube is in place, release cricoid pressure, inflate balloon and confirm proper placement with standard physical exam techniques (chest rise, breath sounds etc.), and use of continuous capnometry and pulse oximetry if available. Once proper placement is confirmed secure tube into place. Place oral gastric tube and confirm placement if time allows, and decompress the stomach.

10.

RSI Intubation chart for Adults:

Weight

Lidocaine Kg
50 55 70 80 95 105 115

Midazolam cc
3.75 4 5 6 7 8 9

Succinylcholine cc
5 5 5 5 5 5 5

Vecuronium mg 5 5.5 7 8 9.5 10 10 cc 5 5.5 7 8 9.5 10 10

Lb
110 120 150 180 210 230 250

mg
75 80 100 120 140 160 180

mg
5 5 5 5 5 5 5

mg
75 80 100 120 140 160 180

cc
3.75 4 5 6 7 8 9

RSI Intubation chart for pediatrics:

Weight Lidocaine (Head Injury) kg 3.5 7 10 15 20 25 30 35 40 45 5 10 15 20 30 35 45 50 60 65 mg cc 0.25 0.5 0.75 1.0 1.5 1.75 2.25 2.5 3 3.25 Atropine Sulfate Midazolam Succinylcholine Vecuronium

lb 7 15 22 33 44 55 66 77 88 99

mg 0.1 0.14 .02 0.3 0.4 0.5 0.6 0.7 0.8 0.9

cc 1.0 1.4 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0

mg 0.5 1.0 1.0 1.0 2.0 2.0 3.0 3.0 4.0 4.0

cc 0.5 1.0 1.0 1.0 2.0 2.0 3.0 3.0 4.0 4.0 10 20 20 30 40 50 60 70 80 90

mg 0.5 1.0 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5

cc

mg 0.35 0.7 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5
Rev. June 2004

cc .035 0.7 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5

14

CONTINUED CARE OF THE INTUBATED PATIENT

For continued management of the intubated patient, consider: 1. 2. 3. 4. The patients ability to resist the intubation/ventilation. Medications used to accomplish the procedure. Distance from the hospital. Any deterioration in the patients clinical status.

Procedure: 1. 2. Additional doses of Midazolam Vecuronium. It is preferred that this be avoided. However, if Midazolam is not effective in the above doses, and patient care remains compromised, contact Salem Hospital on-line medical control for Vecuronium orders. If not already done, place oral-gastric tube and confirm its placement. Then connect to suction to decompress/empty patients stomach. A cervical collar is recommended on all intubated patients. This minimizes head movement, thus reducing the risk of distal displacement of the ET tube. For nontrauma patients with c-spine immobilization, use of the collar alone, or additional mechanical securing with tape and foam blocks can be applied as dictated by the situation. Continuously monitor tube placement with pulse oximetry, and physical exam techniques until arrival at hospital. All patients should have continuous capnometry.

3.

4.

5. 6.

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Rev. June 2004