Airway Management and Advanced Airways

Airway Management

• If still obstructed and unable to intubate or ventilate adequately, consider cricothyrotomy
• For patients ≥13 years, use needle or surgical cricothyrotomy; for patients ≤12 years, use needle cricothyrotomy, except for OLMC only, where surgical cricothyrotomy is used for 8-12 years old
• During transport, attempt to ventilate with 15 L O2/BVM

Advanced Airways | Drug-Assisted Intubation (DAI)

• Purpose of DAI: Achieve rapid ETI in patients with intact airway reflexes via use of medications that facilitate intubation
• Consider indications for ADV airway placement, including:
  • Actual or potential airway impairment or aspiration risk that cannot be mitigated by other interventions
  • Actual/impending ventilatory failure (e.g., HF, pulmonary edema, COPD, asthma, anaphylaxis)
  • Increased WOB resulting in severe fatigue
  • GCS ≤ 8 due to an acute condition unlikely to be self-limited
  • Self-limiting conditions (e.g., seizures, hypoglycemia, postictal state, select drug OD)
  • Unable to ventilate/oxygenate effectively with BLS airways and BVM
  • Need for ↑ inspiratory pressure or PEEP to maintain gas exchange & CPAP contraindicated
  • Need for sedation to control ventilations
• Contraindications/restrictions:
  • Coma with absent airway reflexes or known hypersensitivity/allergy to sedatives
  • Use in pregnancy could be potentially harmful to fetus; consider risk/benefit

Intubation Procedure

• IMC: SpO2 & EtCO2 before and after airway intervention | Confirm patent IV / IO; ECG monitor
• Prepare patient: Position for optimal view and access (head up to 45° unless contraindicated) | Assess for difficult intubation
• IV NS consecutive 200 mL IVF challenges up to 20 mL/kg; Goal: SBP ≥ 90 (MAP ≥ 65); reassess after each 200 mL
• Medications:
  • EPINEPHRINE (1 mg/10 mL) titrate in 0.1 mg IVP/IO doses q. 1 min prn to a max total dose [all routes] of 2 mg
  • GLUCAGON 1 mg IVP / IO [ALS] IN / IM [BLS] if on beta blockers & not responding to EPI
  • ALBUTEROL 2.5 mg & IPRATROPIUM 0.5 mg via HHN/mask if wheezing
  • DIPHENHYDRAMINE 50 mg IVP/IO; if no IV / IO give IM

Asthma | COPD

• Assess ventilation/oxygenation, WOB, accessory muscle use, degree of airway obstruction/resistance, speech, cough, cerebral function, fatigue, hypoxia, CO2 narcosis, and cardiac status
• If wheezing without Hx of COPD/Asthma: Consider FB aspiration, pulmonary embolus, vocal cord spasm, HF/pulmonary edema
• If probable cardiac cause (PMH: CVD): Rx per Cardiac SOPs
• If tension pneumothorax: Needle pleural decompress affected side
• Airway/Gas exchange: Assess need for DAI/BIAD if near apnea, coma/depressed mental status, exhaustion, severe hypoxia (SpO2 < 90); hypercapnia (EtCO2 ≥ 60) | CR instability | Impending respiratory failure/arrest
• If chronic hypercarbic state (COPD): Rx ventilatory failure w/ acute resp.acidosis carefully
• Eliminate only extra CO2 (above chronic hypercarbic norms) causing acute ventilatory failure
• Do not hyperventilate and do not over-correct: If rapidly ventilated to EtCO2 of 35-45, pt may suffer lethal dysrhythmias from Ca binding | Slowly reduce PaCO2

Lower Acuity to Emergent

• Mild to Moderate distress with wheezing and/or cough variant asthma:
  • ALBUTEROL 2.5 mg & IPRATROPIUM 0.5 mg via HHN or mask
  • Add O2 6 L/NC if patient is hypoxic (Asthma: SpO2 < 94%; COPD: SpO2 < 92%) & using a HHN
  • Begin transport as soon as neb is started - do not wait for a response
  • Continue nebulizer therapy enroute | May repeat X 1

Critical (Severe distress)

• Severe SOB, orthopnea, accessory muscle use, speaks in syllables, tachypnea, lung sounds diminished or absent; exhausted; HR & BP may be dropping
• IMC special considerations:
  • Prepare resuscitation equipment; anticipate rapid patient deterioration
  • If immediate intubation not needed: O2 /C-PAP 5-10 cm PEEP; use 15 L/NRM or assist w/ 15 L/BVM if CPAP unavailable or contraindicated
  • If SBP falls < 90 (MAP < 65): Titrate PEEP values downward to 5 cm; remove C-PAP if MAP < 60

History of ASTHMA | History of COPD

• EPINEPHRINE (1 mg/1 mL) 0.3 mg IM [BLS] or ALBUTEROL 2.5 mg & IPRATROPIUM 0.5 mg /HHN/ mask/ BVM
• Follow immediately with ALBUTEROL 2.5 mg & IPRATROPIUM 0.5 mg via HHN, mask or BVM; continue enroute [BLS]
• May repeat X 1 as needed
• If severe distress persists: MAGNESIUM (50%) 2 g in 16 mL NS (slow IVP/IO) or in 50 mL NS (IVPB) | Give over 10 min - Max 1 g / 5 min

Tracheostomy | Laryngectomy

• Give 15 L O2 / NRM or CPAP as indicated for ventilatory distress; acute lung injury or ARDS | Assist with BVM if ventilatory failure
• Consider need for ALBUTEROL / IPRATROPIUM standard dose / HHN or in-line neb

SEPSIS

• Risk factors for serious complications:
  • Asthma; COPD; cystic fibrosis; pulm.fibrosis
  • Heart disease (CAD, HF, cardiomyopathies)
  • Endocrine disorders (diabetes mellitus)
  • Obesity with a BMI of 30 or higher
  • Immunocompromised state
  • Coagulation disorders

Pulmonary Embolism

• Difficult to diagnose, and potentially lethal if missed
• Consider possible PE if:
  • Hx: Previous venous thromboembolism (VTE) or pulmonary embolism
  • Venous stasis (obesity, surgery or prolonged immobilization w/in last 30 days)
  • Recent trauma/damage to lining of vessels (CV disease: atherosclerotic changes; HTN, injected drug use; central line; or other IV medical device, inflammation from direct infection, diabetes; smoking)
  • Hypercoagulable state (malignant: cancer currently active or considered cured w/in last year; hematologic (pregnant), or medication induced (oral hormone use))

Learn about airway management techniques, including cricothyrotomy and drug-assisted intubation, for patients of different ages and in various situations.