et intubation

7/25/2019 ET Intubation

1/98

ALS Assist


2/98

Introduction

You may need to be familiar with AEMT and

paramedic skills.

These include:

Advanced airway techniues

!ntravenous "!#$ therapy

%ardiac monitorin&


3/98

Advanced Airway Techniques

Establishin& and maintainin& an airway is

the sin&le most important EMT skill.

Most conscious patients can maintain their own

airway. 'ther patients may reuire an oropharyn&eal or

nasopharyn&eal airway.

Advanced airway mana&ement provides better

airway protection and ventilation.


4/98

Anatomy and Physiology of theAirway "( of )$

The respiratory system consists of all the

body structures used for breathin&.

*pper airway includes the nose+ mouth+ throat

"pharyn,$+ and laryn, "vocal cords$. -ower airway includes the trachea+ bronchi+ and

lun&s.


5/98

Anatomy and Physiology of theAirway " of )$


6/98

Anatomy and Physiology of theAirway "/ of )$

The respiratory system:

0elivers o,y&en to body

1emoves carbon dio,ide

This process takes place on two levels:

Alveolar2capillary e,chan&e

%apillary2cellular e,chan&e


7/98

Anatomy and Physiology of theAirway "3 of )$


8/98

Anatomy and Physiology of theAirway ") of )$

Each livin& cell of the body reuires a

re&ular supply of o,y&en.

4ome cells+ such as those in the heart+ brain+

and nervous system+ need a constant supply tosurvive.

'ther cells can tolerate short periods without

o,y&en.


9/98

Basic Airway Management"( of $

Always assess the airway first in an in5ured

or ill patient.

'pen the airway.

*se the head tiltchin lift maneuver in a patient

with no suspected spinal in5ury.

*se the 5aw2thrust maneuver if there is a

possibility of spinal in5ury.


10/98

Basic Airway Management" of $

Assess the airway and evaluate the need

for suctionin& to remove:

6orei&n bodies

-iuid

7lood

0etermine if the patient needs an airway

ad5unct.


11/98

Endotracheal Intubation "( of $

!nsertion of a tube into the trachea to

maintain the airway

!f done throu&h the mouth+ it is called

orotracheal intubation. !f done throu&h the nose+ it is called

nasotracheal intubation.

Tube passes directly throu&h the laryn,

between the vocal cords and trachea.


12/98

Endotracheal Intubation " of $

#ery effective method

!ndicated for:

8atients who cannot protect their own airway

8atients who need prolon&ed artificial

ventilation


13/98

Equiment "( of 9$

Assemble all the euipment.

-aryn&oscope handle and blade

8roperly sied endotracheal "ET$ tube

4tylet

(;2m- syrin&e


14/98

Equiment " of 9$

Assemble all the

euipment "cont=d$.

Ma&ill forceps

4tethoscope

%ommercial

securin& device

4econdaryconfirmation device


15/98

Equiment "/ of 9$

-aryn&oscope

*sed to sweep the ton&ue out of the way and

ali&n the airway so the vocal cords can be

visualied Endotracheal tubes

8roper2sied tube for adults ran&es from >.; to

9.) mm


16/98

Equiment "3 of 9$


17/98

Equiment ") of 9$

Endotracheal tubes "cont=d$

*se the lar&est2diameter ET tube that will pass

easily throu&h the vocal cords.

6or children+ use a resuscitation tape device.

A standard ()?2mm adapter attaches to any

ventilation device.


18/98


19/98

Equiment "> of 9$

4tylet

!nserted into the

ET tube to add

ri&idity and shapedurin& intubation

7end the tip to

form a &entle

curve. 0o not insert past

Murphy=s eye.


20/98

Equiment "9 of 9$

4yrin&e

*se a (;2m- syrin&e to test for air leaks in the

ET tube before intubation.

'ther euipment

A suction unit may be needed to clear

secretions or blood.

A commercial securin& device ensures that thetube does not move.


21/98

The Sellic! Maneuver

%an be used to intubate a patient who has

no cou&h and?or &a& refle,

elps reduce the chance of re&ur&itation

and aspiration of stomach contents

6ollow the steps in S!ill "rill #$%&.

7e sure to correctly identify anatomic

landmarks.


22/98

The Intubation Procedure "( of >$

You may intubate only if authoried by off2

line or online medical control.

7e sure to use standard precautions.

An intubation attempt should not take more

than /; seconds.

7e&ins when ventilation stops and the

laryn&oscope blade is inserted Ends when ventilation be&ins a&ain


23/98

The Intubation Procedure " of >$

!ntubation is a multiple2person task.

6irst EMT applies and uses the AE0.

4econd and third EMTs perform %81 at a ratio

of /; compressions to ventilations.

6ourth EMT prepares and intubates the patient.

6ollow the steps in S!ill "rill #$%'to

perform orotracheal intubation.


24/98

The Intubation Procedure "/ of >$

You must use a secondary method of

confirmin& proper tube placement.

Esopha&eal detector devices

End2tidal carbon dio,ide detectors

%apno&raphy monitors

These devices are not (;;B &uaranteed.


25/98

The Intubation Procedure "3 of >$

Source: The LIFEPAK 15 defibrillator monitor courtesy of Physio!ontrol" #sed $ith %ermission of Physio!ontrol& Inc"& and accordin' to the (aterial )elease

Form %ro*ided by Physio!ontrol"


26/98

The Intubation Procedure ") of >$

8rimary confirmation is:

0irect visualiation of the tube passin& throu&h

the vocal cords

Auscultatin& &ood bilateral breath sounds

4eein& the patient=s chest rise and fall with each

ventilation

Cever let &o of the ET tube until it issecured.


27/98

The Intubation Procedure "@ of >$

!ntubation complications

!ntubatin& the ri&ht main stem bronchus

!ntubatin& the esopha&us

A&&ravatin& spinal in5ury

!ncreased hypo,ia

8atient vomitin&


28/98

The Intubation Procedure "> of >$

!ntubation complications "cont=d$

-aryn&ospasm

Trauma

Mechanical failure

8atient intolerant of the endotracheal tube

0ecrease in heart rate


29/98

Multilumen Airways "( of 3$

Advanced airways

that do not reuire

visualiation of the

vocal cords forplacement

E,amples include

the %ombitube and

pharyn&eotracheallumen airway.

The Combitube


30/98

Multilumen Airways " of 3$


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Multilumen Airways "3 of 3$

1emovin& the multilumen airway

!f the patient will no lon&er tolerate the airway+ it

should be removed.

1emember that the patient will likely vomit whenthe airway is removed+ so a suction unit must be

readily available.

4imply deflate both balloon cuffs and &ently

remove the tube.


33/98

Single Lumen Airway "( of /$

in& -T airway

4in&le lumen airway that is blindly inserted into

the esopha&us

%onsists of a curved tube with ventilation portslocated between two inflatable cuffs

!ntended in patients who are taller than 3D


34/98

Single Lumen Airway " of /$

Source: !ourtesy of Kin' Systems


35/98

Single Lumen Airway "/ of /$

-aryn&eal mask

airway

%onsists of two

parts: the tube andthe mask or cuff

After blind insertion+

the device molds

and seals itself

around the laryn&ealopenin& by inflation

of the mask.


36/98

(astric Tubes "( of $

4ometimes a patient may reuire

placement of a tube throu&h the nose or

mouth that e,tends into the stomach.

%ardiac arrest patients A nasal or oral &astric tube relieves &astric

distention.

May be used by E0 staff to lava&e the stomach

in cases of overdose


37/98

(astric Tubes " of $

8roper placement can be confirmed by:

Aspiration of stomach contents with a syrin&e

-istenin& with a stethoscope as air is introduced

into the tube with a syrin&e 1adio&raph on arrival at the E0

) ti P iti Ai


38/98

)ontinuous Positive AirwayPressure "( of /$

*sed in breathin& patients who are alert

and able to follow commands and have

reduced function of the alveoli due to:

%on&estive heart failure %hronic obstructive pulmonary disease

Asthma

) ti P iti Ai


39/98

)ontinuous Positive AirwayPressure " of /$

A ti&ht2fittin& mask is placed over the mouth

and nose and connected to an o,y&en

source.

0elivers flow rates of at least ); -?min May be helpful in patients with severe

respiratory distress

) ti P iti Ai


40/98

)ontinuous Positive AirwayPressure "/ of /$

!ourtesy of )es%ironics& Inc"& (urrays*ille& PA" All ri'hts reser*ed"


41/98

Intravenous Theray

0evelop a routine to follow as you assemble

the appropriate euipment.

This will help you keep track of your euipment

and the steps necessary to complete successful!# administration.


42/98

Indications

Many medications used by A-4 crews are

&iven by the !# route.

A fluid bolus may be indicated for patients

who: Are dehydrated because of vomitin& or

e,cessive diarrhea

ave e,perienced blood loss because of

hemorrha&e


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Assembling the Equiment


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)hoosing an I* Solution "( of /$

!n the prehospital settin&+ the choice of !#

solution is limited to:

!sotonic crystalloids

Cormal saline

-actated 1in&er=s solution

0)< is often reserved for administerin&

medication.


45/98

)hoosing an I* Solution " of /$

Each !# solution ba&

is wrapped in a

protective sterile

plastic ba&.

Fuaranteed to

remain sterile until

the posted e,piration

date

'nce the wrap istorn+ the !# solution

has a shelf life of

3 hours.


46/98

)hoosing an I* Solution "/ of /$

The bottom of each

ba& has two ports:

An in5ection port for

medication

An access port for

connectin& the

administration set

The more commonprehospital volumes

are (+;;; m- and

);; m-.

)hoosing an Administration


47/98

)hoosing an AdministrationSet "( of /$

An administration

set moves fluid

from the !# ba&

into the patient=svascular system.

Each set has a

piercin& spike

protected by aplastic cover.



48/98

)hoosing an AdministrationSet " of /$

0rip sets come in

two primary sies.

A microdrip set

allows @; &tt?m-. A macrodrip

set allows (; to

() &tt?m-.



49/98

)hoosing an AdministrationSet "/ of /$

8reparin& an administration set

#erify the solution and check for clarity.

To spike the ba& with the administration set+

follow the steps in S!ill "rill #$%+. 4aline locks "buff caps$ are a way to maintain

an active !# site without runnin& fluids throu&h

the vein.


50/98

)atheters

ollow+ laser2sharpened needle inside a

hollow plastic tube that is inserted into a

vein

4elect the catheter sie based on the: Ceed for the !#

%ondition of the patient=s veins

-ocation for the !#


51/98

Starting an I* "( of $

Apply a tourniuet pro,imal to the site

where venipuncture is to be performed.


52/98

Starting an I* " of $

*se tape or a commercially available device

to secure the catheter.

Always wear &loves durin& the procedure.

S!ill "rill #$%#covers how to start an !#.


53/98

Securing the Line

Tape the area so that the catheter and

tubin& are securely anchored in case of a

sudden pull on the line.

Avoid circumferential tapin& around anye,tremity because it can act like a

constrictin& band and stop circulation.

Alternative I* Sites and


54/98

Alternative I* Sites andTechniques "( of $

!ntraosseous "!'$

needles

*sed for emer&ency

venous access when

other !# access is

difficult or impossible

'ften patients are

e,periencin& a life2

threatenin& situation.

Fenerally inserted in

the pro,imal tibia

Alternative I* Sites and


55/98

Alternative I* Sites andTechniques " of $

E,ternal 5u&ular !#

8rovides venous access throu&h the e,ternal

5u&ular veins in the neck

%atheter is inserted midway between the an&leof the 5aw and the midclavicular line.

8unctures can be difficult because these veins

are surrounded by a very tou&h+ fibrous sheath.

Possible )omlications of I*


56/98

Possible )omlications of I*Theray

-ocal reactions include problems like

infiltration and phlebitis.

4ystemic complications include aller&ic

reactions and circulatory overload.


57/98

Local I* Site ,eactions "( of 3$

!nfiltration

Escape of fluid into the surroundin& tissue when

the !# catheter is not in the vein

%an cause a localied are of edema or swellin& 4top the flow+ remove the catheter+ and reinsert

it at an alternative site.


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59/98


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Local I* Site ,eactions "3 of 3$

ematoma

Accumulation of blood in the tissues

surroundin& an !# site

1esult from vein perforation or catheter removal !f a hematoma develops when !# catheter insert

is attempted+ the procedure should stop.


61/98

Systemic )omlications "( of >$

A systemic complication can evolve from

reactions or complications associated with

!# insertion.

*sually involve other body systems and can belife threatenin&

Aller&ic reactions

True anaphyla,is is possible and must be

treated a&&ressively.


62/98

Systemic )omlications " of >$

Aller&ic reactions "cont=d$

%an be related to a person=s une,pected

sensitivity to an !# fluid or medication

0iscontinue the !# fluid and remove thesolution+ maintain the airway+ and monitor A7%s

and vital si&ns.

S )


63/98

Systemic )omlications "/ of >$

Air embolus

8atients who are already ill or in5ured can be

adversely affected if air is introduced into the

circulatory system.

8roperly flush the !# line.

Treat a patient by placin& him or her on the left

side with the head down.

S i ) li i


64/98

Systemic )omlications "3 of >$

%irculatory overload

An unmonitored !# ba& can lead to circulatory

overload.

8roblems occur when the patient has cardiac+pulmonary+ or renal dysfunction.

The most common cause in the prehospital

settin& is failure to read5ust the drip rate after

flushin& an !# line.

S t i ) li ti


65/98

Systemic )omlications ") of >$

%irculatory overload "cont=d$

To treat a patient:

4low the !# rate to keep the vein open.

1aise the patient=s head to ease respiratorydistress.

Administer hi&h2flow o,y&en.

Monitor vital si&ns and shortness of breath.

S t i ) li ti


66/98

Systemic )omlications "@ of >$

#asova&al reactions

4ome patients have an,iety concernin& needles

or in response to the si&ht of blood.

8atients can present with an,iety+ diaphoresis+nausea+ or syncopal episodes.

-ower the head of the stretcher+ administer

o,y&en+ and monitor vital si&ns.

S t i ) li ti


67/98

Systemic )omlications "> of >$

%atheter shear

8otential complication when startin& an !#

%ould have a devastatin& effect on your patient

May occur if you attempt to reinsert the needlethrou&h the catheter after the needle has been

partially withdrawn

T bl h ti


68/98

Troubleshooting

4everal factors influence !# flow rate.

8erform the followin& checks after

completin& !# administration.

%heck your administration set.

%heck the hei&ht of the !# ba&.

%heck the type of catheter used.

%heck the tourniuet.

Age%Secific )onsiderations


69/98

Age%Secific )onsiderations"( of $

!# therapy for pediatric patients

A child has smaller veins.

A small2&au&e catheter should be used

"2&au&e to 32&au&e$. #olume control is important.

*se a special type of microdrip set called a

#olutrol+ which fills the lar&e drip chamber with a

specific amount of fluid.

Age%Secific )onsiderations


70/98

Age%Secific )onsiderations" of $

!# therapy for &eriatric patients

4maller catheters may be preferable.

The use of tape can lead to skin dama&e+ so be

careful when tapin& !# catheters and tubin&. 7e careful when usin& macrodrips because they

can allow infusion of fluids+ which may lead to

fluid overload.

) di M it i


71/98

)ardiac Monitoring

(2lead E%F can help in the earlyidentification of an acute myocardial

infarction "AM!$.

The interpretation of cardiac rhythm may not bean EMT skill.

owever+ it is helpful to be able to place

electrodes and leads.

Electrical )onduction System


72/98

Electrical )onduction System"( of $

Cetwork of specialied tissue capable ofconductin& electrical current throu&hout the

heart

%ontains: 4inoatrial "4A$ node

Three intermodal pathways

Atrioventricular "A#$ node 7undle of is

1i&ht and left bundle branches

Electrical )onduction System


73/98

Electrical )onduction System" of $

El t d d -


74/98

Electrodes and -aves

The E%F electrodes pick up the electricalactivity of the heart+ and the E%F machine

converts them to waves.

The way an E%F tracin& looks depends onwhere the lead is placed.

The E)( )omle


75/98

The E)( )omle. "( of /$

'ne comple, represents one beat in theheart.

The comple, consists of several waves: the

8+ G14+ and T waves. A se&ment is a specific portion of the

comple,.

The E)( )omle. " f /$


76/98

The E)( )omle. " of /$

The E)( )omle. "/ f /$


77/98

The E)( )omle. "/ of /$

An interval is the distance+ measured intime+ occurrin& between two cardiac events.

The time between the be&innin& of the 8 wave

and the be&innin& of the G14 comple, is known

as the 821 interval.

E)( Paer


78/98

E)( Paer

The paper on which an E%F is recordedcontains a &rid.

Each little bo, represents (?) of a second+ or

;.;3 second.

Each bi&&er bo, is composed of five smaller

bo,es+ or ;.; second.

6ive bi& bo,es eual ( second.

/ormal Sinus ,hythm "( f $


79/98

/ormal Sinus ,hythm "( of $

4inus rhythm is a rhythm in which the 4Anode acts as the pacemaker.


80/98

/ormal Sinus ,hythm " of $

The 0ormation of the E)( "( f /$


81/98

The 0ormation of the E)( "( of /$

8roduction of the heart=s rhythm is acontinuous process+ with no actual period of

rest or inactivity.

!f the heart is functionin& normally+ theprocess will repeat over and over

continuously.

The 0ormation of the E)( " f /$


82/98

The 0ormation of the E)( " of /$

The 0ormation of the E)( "/ f /$


83/98

The 0ormation of the E)( "/ of /$

Arrhythmias "( of )$


84/98

Arrhythmias "( of )$

Abnormal rhythm of the heart

4inus bradycardia

%onsistent 8 waves+ consistent 821 intervals+

re&ular heart rate less than @; beats?min

Source: FromArrhythmia Recognition: The Art of Interpretation, courtesy of Tomas +" ,arcia& (-"

Arrhythmias " of )$


85/98

Arrhythmias " of )$

4inus tachycardia

%onsistent 8 waves+ consistent 821 intervals+

re&ular heart rate more than (;; beats?min

May cause a decrease in cardiac output

Source: FromArrhythmia Recognition: The Art of Interpretation&courtesy of Tomas +" ,arcia& (-"

Arrhythmias "/ of )$


86/98

Arrhythmias "/ of )$

#entricular tachycardia

8resence of three or more abnormal ventricular

comple,es in a row with a rate of more than (;;

beats?min

#ery re&ular rhythm


Arrhythmias "3 of )$


87/98

Arrhythmias "3 of )$

#entricular fibrillation 1apid+ completely disor&anied ventricular rhythm with

chaotic characteristics

*ndulations of varyin& shapes and siesH no specific

patternH no discernable 8+ G14+ or T waves Co or&anied beatin& of the heart


Arrhythmias ") of )$


88/98

Arrhythmias ") of )$

Asystole

%omplete absence of any electrical cardiac

activity

8atient is clinically dead at this point.


Assisting -ith )ardiac


89/98

Monitoring

You may have a 32lead E%F or a (2leadE%F system.

Cew cardiac monitors include several new

features usin& modern technolo&y. They are compact+ li&ht+ and portable and

combine defibrillation and monitorin&

capabilities.

Lead Placement "( of )$


90/98

Lead Placement "( of )$

A 32lead E%F uses four leads+ which areelectrodes attached to wires.

The four leads are called the limb leads.


91/98

Lead Placement " of )$

!t does not matterwhere the leads

are placed on the

limbs+ as lon& as

all four are at least

(; cm from the

heart.

Lead Placement "/ of )$


92/98

Lead Placement "/ of )$

6or the (2lead E%F+ electrodes are placedas a 32lead placement as well as in very

specific locations on the chest.

#(

and #.

on each side of the sternum #3at the midclavicular line

#/between #.and #3

#)at the anterior a,illary line+ and #@in the

mida,illary line

Lead Placement


93/98

"3 of )$

Lead Placement ") of )$


94/98

Lead Placement ") of )$

!t is very important to have direct skincontact when obtainin& an E%F.

!f the skin is wet or oily+ wipe and clean the skin

thorou&hly.

!f the skin is hairy+ use a raor.

Advanta&es of (2lead monitorin&

Early identification of acute ischemia

Accurate identification of arrhythmias

ST%Segment ElevationM di l I f i 1STEMI2


95/98

Myocardial Infarction 1STEMI2

4pecific type of myocardial infarction inwhich the 4T se&ment of the cardiac cycle is

elevated

Treatable by techniues that rapidly restoreperfusion to the coronary arteries

ITime is muscle.J

SummarySummary "( of /$"( of /$


96/98

SummarySummary "( of /$"( of /$

There may be cases in which an EMT mayfind it necessary to be familiar with skills

normally practiced at the AEMT and

paramedic level. These skills include

advanced airway techniues+ !# therapy+

and cardiac monitorin&.

SummarySummary " of /$" of /$


97/98

SummarySummary " of /$" of /$

An advanced airway techniue isendotracheal intubation+ the insertion of a

tube into the trachea to maintain the airway.

Additional advanced airway care devicesinclude the %ombitube+ pharyn&eotracheal

lumen airway+ the in& -T+ and the laryn&eal

mask airway.

SummarySummary "/ of /$"/ of /$


98/98

SummarySummary "/ of /$"/ of /$

!# therapy is used to replace fluids in apatient with shock or to administer

medications.

%ardiac monitorin& with an E%F is anadvanced skill that the EMT may provide in

assistance to the AEMT or paramedic.

et intubation

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