The “Three Wise Men” of airway management

Airway management is a fundamental skill that all EMT’s and paramedics need to master. It’s been said that paramedics are great at two things, cardiology and airway management. That is quite true and providers need to “own” these important skills.

Airway management is vital to good patient outcomes. A poorly managed airway can have lasting effects long after the call. With aspiration and hypoxic brain injury being two of the most critical.

This article will not go into detail of how to intubate or bls airway management but will discuss three extremely important pieces of the airway management puzzle.

 

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The “Three Wise Men”…

The three wise men consist of:  a properly fitted BVM face mask,  a properly sized oral pharyngeal airway, and a 10cc syringe.

A “hypothetical situation”…..

You’ve determined the need for airway management.

After committing to the airway you select an appropriate size oral pharyngeal airway, and place it using whichever technique your comfortable with. You begin ventilating the patient with an appropriately sized mask and BVM device. At some point the decision to manage the airway using an advanced device is made.

The conversation might go like this. “OK I’m ready to intubate. Stop bagging.” You remove the OPA and typically drop it in a random place..the floor, wherever. You pass the tube and inflate the cuff. As you’ve been taught you immediately remove the syringe, and that too goes wherever. Then you tell your partner to “bag”. They remove the face mask portion and drop that or toss it wherever and attach the device to the tube and ventilate so you can confirm tube placement. You ascultate bilateral breath sounds, no epi-gastric sounds, waveform capnography looks perfect. Tube is secured.  Awesome job, Life is Good!

After making a couple of moves, like from the floor to the stretcher, and then to the ambulance your partner notices it is getting harder to ventilate the pt. (decreased compliance). No problem you say. You ascultate lung sounds and note decreased air movement on one side. Piece of cake, the tube migrated a little deeper all I need to do is slide it on back a bit. Where is the syringe…..DOH!!! “Where’s my ALS bag??!!!” Crap crap crap……

Or you make a few moves and this time you lose the waveform tracing, SPo2 is 80%. GRRR…must have extubated. I know what your thinking, great now we have to go through the entire intubation sequence again. “I’ll pull the tube”, “you bag em’ back up.”

“Hand me the syringe to deflate the cuff” “You can’t find it?!!” “What do you mean you don’t know where the mask went?””Just grab another one out of the cabinet.” “Hey it’s hard to bag.” GRRR….”where’s the OPA?” “Found it here on the floor.” “It’s all cruddy, what do you want me to do?” “Just grab a new one.”

SPo2 is 70%, crap crap crap………”Wheres the OPA” “All I can find are too small or too big.” “What do you want me to do?”

Sounds like one or two wrong moves have turned this into “one of those calls” the wheels have come off and now we’re behind the eight ball so to speak. A poor patient outcome is a very real possibility.

How do we avoid these disasters?

I’m a huge proponent of compartmentalizing each skill. By that I mean take each skill you are going to perform and assemble ALL of the required pieces before you commit. “Build” a workstation within easy reach. It is absolutely OK to use a “check list”.  After enough time and experience most of these skills will become second nature. Muscle memory plays a large part, but you must be able to think on the fly as problems arise, and they always do. Having an organized approach to each skill helps immensely.

view from the air chair
The assembled “workstation” viewed from the airway seat.

 

Airway Management Check-List

  • Oxygen, enough in the tank? Delivery device?
  • Properly sized BVM and face piece.
  • Oral airway, nasal airway
  • Suction, does it work? Tubing and hard or soft suction available?
  • Laryngoscope and blade
  • ETT, plus one size higher and one size lower
  • Stylet or Bougie
  • 10cc syringe
  • Rescue airway device (King, LMA, Combi)
  • Commercial tube securing device
  • End tidal capnometry device
  • Stethescope

Note the first items are typically where airway management starts, then you move into the invasive part of placing the tube, and finally to confirming and securing.

There are a number of these online. A quick Google search will get you plenty of examples.

Check out this one on EMCRIT

Post intubation

Remember “A hypothetical situation” a few paragraphs ago? Where did all of the pieces that were used and no longer needed wind up?

 

 

The photos show one option to keep all three pieces together and within easy reach. You could also place them in your airway roll (contamination problem?) next to the air chair on the shelf. Whatever works best for you, with the main point being to keep them together and available.

The take away’s

  • Practice practice practice…..not until you get it right, until you can not get it wrong!
  • Develop your skills and knowledge
  • Use a check list when performing procedures
  • Use “workstations” to assemble your equipment
  • The less you need to think about the skill, the more mental muscle left to deal with a changing situation

 

Fine Print

The ideas, thoughts, and concepts presented are the opinion of the author. When providing any care follow your state, local, and agency protocols and guidelines.

 

 

 

 

 

 

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Carboxyhemoglobin

 

The little red delivery trucks in our blood called hemoglobin have a really important job. We all know the system. The hemoglobin travel into the lungs and down to the alveoli and swing past the pulmonary capillaries to pick up oxygen and drop off waste and CO2. When a person takes an inspiration of atmospheric air they will inhale oxygen, nitrogen and a small amount of other trace gases. In the alveoli diffusion is based on pressure gradients. At inspiration the partial pressure of oxygen in the alveoli is about 104mmhg, at the pulmonary capillary the partial pressure of the oxygen is about 40mmhg. This pressure gradient makes it really easy for the oxygen to diffuse across the capillary membrane and load onto the hemoglobin. At the same time the CO2 pressure gradient is higher in the capillary and lower in the alveoli so the CO2 can diffuse off and be exhaled.

But what if we inhale a higher percentage of something else like carbon monoxide (CO)?  Then at the alveoli the hemoglobin see a higher partial pressure of CO and get really excited. The hemoglobin have much higher affinity for CO than oxygen. They prefer CO up to 200 times more than oxygen. So the CO can grab a seat on the hemoglobin easier than oxygen. When the hemoglobin carries more CO than oxygen it becomes carboxyhemoglobin.

The problem with carboxyhemoglobin stems from a couple of different things. Due to the higher affinity the hemoglobin has for the CO it binds more tightly than oxygen. Not only does the CO prevent the oxygen from binding, it also makes the oxygen that is bound hold on more tightly and not diffuse off at the cellular level. This results in anaerobic metabolism, tissue and organ hypoxia.  This is termed histotoxic hypoxia. Typically the organs highly dependent on oxygen like the brain and heart show some of the earliest signs of elevated CO levels.

This can manifest in the form of cardiac ischemia causing chest pain, tachycardia, shortness of breath, and disrhythmia. Also changes in mental status, headache, dizziness and confusion in the setting of CO exposure are pertinent findings.

Signs and symtoms

Mild: headache, nausea, abdominal pain, dizziness

Moderate: confusion, dyspnea, ataxia, tachycardia, chest pain

Severe: seizures, coma, cardiac dysrhythmia, hyperthermia

 

Pt’s complaining of flu like symptoms when the ambulance has been requested for the CO detector activation should be taken seriously.  A thorough assessment can help flesh out some of the details and guide your treatment decisions. Fire departments testing atmospheric CO levels and CO-oximetry monitoring are both valuable tools. Typical CO-oximetry readings are <3% for a non-smoker, and up to 10-15% for a smoker. CO-oximetry readings >25% should be treated as a significant exposure. Definitive diagnosis is through arterial or venous blood sampling. Remember that during your assessment finding a Spo2 reading of 100% is not of value when CO exposure is suspected. Also assess for and consider other causes of altered mental status and cardiac dysfunction.

Transport management

CO-oximetry

100% oxygen

ABC’s

Intubation

Benzodiazepines

So how do we treat CO poisoning? Responder safety is paramount!  You should not enter a building with elevated CO levels. Have the pt’s brought from the dangerous atmosphere to a fresh air environment. Perform CO-oximetry if available, and administer 100% oxygen immediately. Manage ABC’s. If seizures are present benzodiazepines are indicated. Also remember the level of carboxyhemoglobin does not directly correlate with how symptomatic someone will present.

Once the pt is removed from the toxic environment the CO has a half life of 3-4 hours at room air. With 100% oxygen the half life is reduced to 30-90 minutes. Hyperbaric therapy for severe exposures can reduce the half life to about 20 minutes.

A couple of updates.

So I have the blog up, now what?  My original idea was to get my content from you guys. The contact button in the menu on the right side of this page is now functional.

You can use this to get your questions to me. Don’t be afraid to ask whatever’s on your mind. I probably had the same question and so do lots of other people.

Also I continue to work out other details and sources. The Twitter and Facebook buttons are linked to accounts I manage so if you get a chance check those out. I appreciate your follows likes and friend requests keep them coming!

So let’s get the questions rolling……..

The Medic Zero Project

Hi! Thanks for stopping by.  My name is Michael and I’m a paramedic.

What the heck is the Medic Zero Project? Great question! The Medic Zero Project is a site designed to answer questions you didn’t know you had until you started practicing. The target audience is the recently graduated paramedic and paramedic students….medic zero.  Medic zero? What that means to me is a provider who are early in their career and developing skills and knowledge (which should never stop). So many questions and no one to ask, I was in that exact same spot myself.

I remember graduating paramedic training and going to work for a large commercial agency. The clearing process was a little lacking as their main interest was getting an ALS provider out on the road to start earning. Good for them but not the best environment to develop competent providers.  So I started out as medic zero and spent most of the first year or so of my career in sort of this constant state of not really having any idea what was going on most of the time with my patients. Fumbling through calls and trying to figure it all out.

So here I am well into my career as a paramedic. Lots of trial and error, sometimes learning how not to do something, but always continually learning.