Pitfalls of Field Airway

7/27/2019 Pitfalls of Field Airway

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Pitfalls of Field Airway

Management


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Misplaced Endotracheal

Tubes in an EMS System

108 intubated patients

27/108 (25%) misplaced tubes

18/27 esophageal intubations 57% ED mortality

9/27 in hypopharynx

33% ED mortality

Katz, Faulk, Annals of Emergency Medicine 2001, 37, 32-7.


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What are we doing now?


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What parts of that might set us

up for failure?


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Uncontrolled environment,

less then optimal situations

The field airway is usually

difficult


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Specifics of a Difficult field

airway

Immobilized trauma patient

Combative patients

Short neck and/or receding mandible

Prominent upper teeth Children

Upper airway conditions

Facial trauma

Laryngeal trauma Limited jaw opening

Uncontrolled environment


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Emotion & Chaos


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Variables & Distracters


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What are the most common,predictable failure points in

field airway management?


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Pitfall #1

Not having a consistent, organized airway

assessment & management approach forEVERY patient encountered.


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When?Performing the intubation is

generally easier than deciding

which intubation technique to use,which in turn is generally easier

than deciding who to intubate,

which in turn is generally easierthan deciding precisely when to

intubate

Ron Walls, MD


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Whats your approach?


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When is an advanced airway

required in the field?

Is there failure to maintain an adequate

airway?

Is there failure to protect the airway against

aspiration?

Is there a failure of ventilation?

Is there a failure of oxygenation?

Is there a condition present, or is there atherapy required that mandates intubation?


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Is there a common approach?

Protocol?

Algorithm?


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Adequate?

Assess Airway, Ventilation, and Level of

Consciousness

Pulse Oximetry and Supplemental

Oxygen

Manual Airway maneuver, OPA, NPA

and/ or

Bag-valve-Mask ventilation

Airway Patent?AHA BLS guidelines for Foreign

Body Airway Obstruction

Direct Laryngoscopy

Gag Reflex

Present?

Respirations and

Gag Reflex

Present

Apnea, Agonal

Respirations and

No Gag Reflex

Orotracheal Intubation

Consider Lidocaine 1 mg/kg IV for

head injury or reactive airway

Afrin X 2 in nostril, Lidocaine Jelly, or

Cetacaine

Nasal Tracheal Intubation

Versed 2-10 mg and/ or Morphine

Sulfate 2 - 10 mg, Cetacaine topically

Assure Endotracheal tube placement

clinically: auscultate epigastrium and 4 lung fields End Tidal CO2 device Pulse Oximetry

Consider Nasogastric Tube

Consider Sedation for intubated

patient

Successful?

If unable to intubate or intubationcontraindicated, consider Bag-Valve-

Mask, Retrograde intubation,

Combitube, OR

Needle/Surgical Crichothrotomy

No

Yes

Yes

No

Yes No

Or

Yes No


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Use more than one person?

Two-person ventilation

More effective pre-oxygenation

Less gastric insufflation

Positioning

Another monitor

Another operatorSomeone elses lucky day?


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The tough ones?

The easy ones?


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Pitfall # 2

Forgetting that airway management is a

team sport.


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Failure to place anendotracheal tube is not

failure to manage an airway.


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Pitfall # 3

Providing spinal traction, not

stabilization during airway management

in suspected spinal trauma.


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Pitfall # 4

Persistent aggressive advanced airwayattempts in ventilatable kids.


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Pitfall # 5

Failure to reassess, over & over & over

& over & over


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Reassessment is a majorchallenge in EMS.

When?

How?


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Pitfall # 6

Using the wrongadvanced airway

approach at the righttime.


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RSI and Surgical crichs are

big offenders!


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Pitfall # 7

Not having a failure contingency plan.


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A failure contingency plan

should be part of all airwaydecision algorithms.

Additional resource response

Combitube

LMA

Crichothyrotomy


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Pitfall # 8

Not understanding the advantages &

limitations of various tube confirmation

processes.

Ch ll i t b


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Challenges in tube

confirmation:

Missed esophageal intubation with BBS,symmetric chest expansion in OR

6/40 (15%) esophageally intubated patients

unable to be detected by chest auscultation.(Anderson & Hald)

Tube condensation occurred duringexpiration in 34/40 (85%) patients with

esophageal intubation (Anderson & Hald) 25/297 (8%) intubations by emergency

physicians initially indicated esophagus


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Confirmation of tube placement

What is the Gold Standard?

Visualize cords?

Breath sounds?

Chest rise?

Color change?Absence of stomach sounds?

End-Tidal CO2?

EDD? Chest X-ray?

Anatomic verification?

Th t ETCO


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Three parameters ETCO2

measures:CO2 production

Tissue perfusion

CO2 perfusion

Cardiac output

Pulmonary perfusion

CO2 elimination

VentilationPatent airway/tube


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Pitfall # 9

Failure to preserve your work.


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Pitfall # 10

Failure to document.


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Summary

Trust nobody, believe nothing,give oxygen.

Perfect Practice Makes Perfect!

You are only as good as your last

one.

Pitfalls of Field Airway

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