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Division 1
Introduction to Advanced
Prehospital Care
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 8
Airway Management
and Ventilation
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Respiratory Problems
Respiratory System Assessment
Airway Management
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Respiratory Problems
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Airway Obstruction
The tongue is the most common cause
of airway obstruction.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The tongue as an airway obstruction
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inadequate minute volume
respirations can compromise
adequate oxygen intake and
carbon dioxide removal.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Other Causes of Airway
Obstruction
Foreign bodies
Trauma
Laryngeal spasm and edema
Aspiration
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Respiratory System
Assessment
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Initial Assessment
Is the airway patent?
Is breathing adequate?
Look, listen, and feel.
If patient is not breathing, open the
airway and assist ventilations as
necessary.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Feel for air movement.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Look for chest movement.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Listen for air movement.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bag-valve-mask ventilation
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Focused History
Onset
Symptom development
Associated symptoms
Past medical history
Recent history
Does anything make symptoms
better or worse?
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Physical Examination
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inspection
Skin color
Patient’s position
Dyspnea
Modified forms of respiration
Rate
Pattern
Mentation
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abnormal Respiratory
Patterns (1 of 3)
Kussmaul’s respirations
– Deep, slow or rapid, gasping; common in
diabetic ketoacidosis
Cheyne-Stokes respirations
– Progressively deeper, faster breathing
alternating gradually with shallow, slower
breathing, indicating brain stem injury
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abnormal Respiratory
Patterns (2 of 3)
Biot’s respirations
– Irregular pattern of rate and depth with
sudden, periodic episodes of apnea,
indicating increased intracranial pressure
Central neurogenic hyperventilation
– Deep, rapid respirations, indicating
increased intracranial pressure
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abnormal Respiratory
Patterns (3 of 3)
Agonal respirations
– Shallow, slow, or infrequent breathing,
indicating brain anoxia
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Auscultation
Listen at the mouth and nose for
adequate air movement.
Listen with a stethoscope for normal or
abnormal air movement.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Positions for auscultating
breath sounds
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Airway Sounds
Airflow
Compromise
Gas Exchange
Compromise
Snoring
Crackles
Gurgling
Rhonchi
Stridor
Wheezing
Quiet
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Palpation
Palpate chest wall for tenderness,
symmetry, abnormal motion, crepitus,
and subcutaneous emphysema.
Assess compliance of lungs.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Noninvasive Respiratory
Monitoring
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pulse oximeter
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Colorimetric End-Tidal CO2 Detector
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Electronic End-Tidal CO2 Detector
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Manual Airway Maneuvers
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Head-tilt/chin-lift
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Modified jaw-thrust in trauma
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Jaw-thrust maneuver
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Jaw-lift maneuver
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Airway before
applying Sellick’s
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Sellick’s maneuver
(cricoid pressure)
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Airway with Sellick’s applied (note
compression on the esophagus)
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Basic Mechanical Airways
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Nasopharyngeal airway
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Nasopharyngeal airway, inserted
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert oropharyngeal airway
with tip facing palate.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Rotate airway 180° into position.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Improper placement of
oropharyngeal airway
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Advanced Airway
Management
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal intubation
is clearly the preferred method
of advanced airway management in
prehospital emergency care.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Engaging laryngoscope
blade and handle
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Activating laryngoscope light source
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Laryngoscope blades
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Placement of Macintosh
blade into vallecula
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Placement of Miller blade
under epiglottis
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETT and syringe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotrol ETT
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETT, stylet, and syringe,
unassembled
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETT, stylet, and syringe, assembled
for intubation
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal
Intubation Indicators
Respiratory or cardiac arrest
Unconsciousness
Risk of aspiration
Obstruction due to foreign bodies, trauma,
burns, or anaphylaxis
Respiratory extremis due to disease
Pneumothorax, hemothorax,
hemopneumothorax with respiratory difficulty
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Advantages of
Endotracheal Intubation
Isolates trachea and permits
complete control of airway
Impedes gastric distention
Eliminates need to maintain a mask
seal
Offers direct route for suctioning
Permits administration of some
medications
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Disadvantages of
Endotracheal Intubation
Requires considerable training and
experience
Requires specialized equipment
Requires direct visualization of vocal
cords
Bypasses upper airway’s functions
of warming, filtering, and humidifying
the inhaled air
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Complications of
Endotracheal Intubation
Equipment malfunction
Teeth breakage and soft tissue
lacerations
Hypoxia
Esophageal intubation
Endobronchial intubation
Tension pneumothorax
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Personal protective equipment
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hyperventilate patient.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Prepare equipment.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Apply Sellick’s maneuver
and insert laryngoscope.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Visualize larynx and
insert the ETT.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Glottis visualized
through laryngoscopy
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inflate cuff, ventilate,
and auscultate.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Confirm placement with
an ETCO2 detector.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Esophageal detector device, bulb style
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
If the bulb does not refill,
the tube is improperly placed.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Attach device to endotracheal tube
and squeeze the detector.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
If bulb refills easily upon release, it
indicates correct placement.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Secure tube.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Lighted stylet for
endotracheal intubation
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insertion of lighted stylet/ETT
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Lighted stylet/ETT in position
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Transillumination of a lighted stylet
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Blind orotracheal
intubation by digital method
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Digital Intubation (1 of 2)
Insert your
middle
and index
fingers
into patient’s
mouth.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Digital Intubation
(2 of 2)
Walk your fingers
and palpate the
patient’s epiglottis.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Digital intubation—insertion
of the ETT
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation with
In-line Stabilization
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hyperventilate patient and
apply c-spine stabilization.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Apply Sellick’s maneuver
and intubate.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilate patient
and confirm placement.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Secure ETT and
apply a cervical collar.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Reconfirm placement.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Rapid Sequence Intubation
A patient who needs intubation may be
awake. RSI paralyzes the patient to
facilitate endotracheal intubation.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation
in a Child
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Pediatric Airway
Smaller and more flexible than an
adult.
Tongue proportionately larger.
Epiglottis floppy and round.
Glottic opening higher and more
anterior.
Vocal cords slant upward, and are
closer to the base of the tongue.
Narrowest part is the cricoid cartilage.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Selecting ETT size according to
child’s age
ETT size (mm) =
(Age in years + 16)
4
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hyperventilate the child.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Prepare the equipment.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert the laryngoscope.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert ETT and
ventilate the child.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Confirm placement
and secure ETT.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Reconfirm ETT placement.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilation of
Pediatric Patients
Mask seal can be more difficult.
Bag size depends on age of child.
Ventilate according to current standards.
Obtain chest rise and fall with each
breath.
Assess adequacy of ventilations by
observing chest rise, listening to lung
sounds, and assessing clinical
improvement.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Nasotracheal intubation may be
useful in some situations:
Possible spinal injury
Clenched teeth
Fractured jaw, oral injuries, or recent
oral surgery
Facial or airway swelling
Obesity
Arthritis preventing sniffing position
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Advantages of
Nasotracheal Intubation
The head and neck can remain in
neutral position.
It does not produce as much gag
response and is better tolerated by the
awake patient.
It can be secured more easily than an
orotracheal tube.
The patient cannot bite the ETT.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Disadvantages of
Nasotracheal Intubation
More difficult and time-consuming to perform
than orotracheal intubation.
Potentially more traumatic for patients.
Tube may kink or clog more easily than an
orally placed tube.
Poses a greater risk of infection.
Improper placement is more likely when
performing blind nasotracheal intubation.
Blind nasotracheal intubation requires that
the patient be breathing.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Blind nasotracheal intubation
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Other Intubation Devices
Esophageal Tracheal CombiTube (ETC)
Pharyngo-tracheal Lumen (PtL)
Laryngeal Mask Airway (LMA)
Intubating Laryngeal Mask Airway (iLMA)
Cobra Perilaryngeal Airway (CobraPLA)
Ambu Laryngeal Mask (ALM)
Esophageal Gastric Tube Airway (EGTA)
Esophageal Obturator Airway (EOA)
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETC airway –
esophageal placement
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETC airway –
tracheal placement
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pharyngo-tracheal
lumen airway
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Laryngeal mask airway
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Intubating laryngeal mask airway
LMA North America
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cobra perilaryngeal airway
Supralaryngeal device
designed to be
positioned in the
hypopharynx where it
abuts the structure of
the laryngeal inlet
Engineered Medical Systems, Inc.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ambu laryngeal mask
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Continuously recheck
and reconfirm the placement of
the endotracheal tube.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Foreign body removal with direct
visualization and Magill forceps
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Magill forceps
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The only indication
for a surgical airway is
the inability to establish an
airway by any other method.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Direct visualization of the larynx with a
laryngoscope may enable the removal
of an obstructing foreign body.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomical landmarks
for cricothyrotomy
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Locate/palpate
cricothyroid membrane.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Proper positioning for
cricothyroid puncture
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Advance the catheter
with the needle.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cannula properly
placed in trachea
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Jet ventilation with
needle cricothyrotomy
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Open Cricothyrotomy
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Locate cricothyroid membrane.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Stabilize larynx and make a 1–2 cm
skin incision over cricothyroid membrane.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Make a 1 cm horizontal incision
through the cricothyroid membrane.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Using a curved hemostat,
spread membrane incision open.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert an ETT (6.0)
or Shiley (6.0).
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inflate the cuff.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Confirm placement.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilate.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Secure tube, reconfirm
placement, evaluate patient.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Tracheostomy cannulae
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patients with Stoma Sites
Patients who have had a laryngectomy
or tracheostomy breathe through a
stoma.
There are often problems with excess
secretions, and a stoma may become
plugged.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Suctioning
Anticipating complications when
managing an airway is the key for
successful outcomes.
– Be prepared to suction all airways to
remove blood or other secretions and for
the patient to vomit.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Suctioning Techniques
Wear protective eyewear, gloves, and
face mask.
Preoxygenate the patient.
Determine depth of catheter insertion.
With suction off, insert catheter.
Turn on suction and suction while
removing catheter (no more than
10 seconds).
Hyperventilate the patient.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Tracheostomy suction technique
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Gastric Decompression (1 of 3)
Common problem with ventilating a
nonintubated patient is gastric
distention.
Occurs when the procedure’s high
pressures trap air in the stomach.
Once patient has gastric distention,
you should place a tube in the
stomach for gastric decompression,
using either the nasogastric or
orogastric approach.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Gastric Decompression (2 of 3)
To place a nasogastric or orogastric tube:
Prepare patient’s head in neutral
position while preoxygenating.
Determine length of tube insertion by
measuring from the epigastrium to the
angle of the jaw, then to the tip of the
nares.
If patient is awake, suppress the gag
reflex with a topical anesthetic applied
into the posterior oropharynx or with IV
lidocaine.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Gastric Decompression (3 of 3)
Lubricate the distal tip of the gastric tube and
gently insert into the nares and along the
nasal floor, or into the oral cavity at midline.
Advance tube gently, and if patient is awake,
encourage swallowing to facilitate tube’s
passage.
Advance to predetermined mark on tube.
Confirm placement.
Apply suction and note gastric contents that
pass through the tube.
Secure the tube in place.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygenation
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygen Supply and Regulators
To calculate how long an oxygen tank will last:
D cylinder tank life in minutes =
(tank pressure in psi × 0.16) ÷ liters per minute
E cylinder tank life in minutes =
(tank pressure in psi × 0.28) ÷ liters per minute
M cylinder tank life in minutes =
(tank pressure in psi × 1.56) ÷ liters per minute
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygen Delivery Devices
Device
Oxygen
Percentage
Nasal cannula
40%
Venturi mask
24, 28, 35, or 40%
Simple face mask
40 – 60%
Nonrebreather mask
80 – 95%
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilation Methods
Mouth-to-mouth
Mouth-to-nose
Mouth-to-mask
Bag-valve device
Demand valve device
Automatic transport ventilator
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bag-valve mask with
built-in colorimetric
ETCO2 detector
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilation of Pediatric
Patients
Mask seal can be more difficult.
Bag size depends on age of child.
Ventilate according to current standards.
Obtain chest rise and fall with
each breath.
Assess adequacy of ventilations by
observing chest rise, listening to lung
sounds, and assessing clinical
improvement.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Demand valve and mask
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Portable mechanical ventilator
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
Respiratory Problems
Respiratory System Assessment
Airway Management
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ