adult airway.pdf

ADULT FOREIGN BODY AIRWAY OBSTRUCTION 1. Begin BLS IMC: Determine responsiveness and ability to speak or cough If conscious: Allow patient to assume preferred position If unconscious: Position appropriately to open the airway - No trauma: Head tilt/chin...

ADULT FOREIGN BODY AIRWAY OBSTRUCTION 1. Begin BLS IMC: Determine responsiveness and ability to speak or cough If conscious: Allow patient to assume preferred position If unconscious: Position appropriately to open the airway - No trauma: Head tilt/chin lift - If possible c-spine injury: modified jaw thrust - Maintain in-line spine stabilization/immobilization Check for breathing; assess degree of airway impairment Monitor for cardiac dysrhythmias and/or arrest CONSCIOUS ABLE TO SPEAK or COUGH: 2. Complete IMC: Do not interfere with patient's own attempts to clear airway by coughing or sneezing CANNOT SPEAK or COUGH: 2. 5 abdominal thrusts (Heimlich maneuver) with victim standing or sitting If pregnant > 3 months or extremely obese: 5 chest thrusts REPEAT IF NO RESPONSE: 3. If successful: complete Initial Medical Care and transport 4. If still obstructed: Continue step #2 while enroute until FB expelled or patient becomes unconscious UNCONSCIOUS Note: When efforts to clear the airway are successful complete Initial Medical Care 2. If no effective breathing: Attempt to ventilate. If obstructed: reposition head, reattempt to ventilate. 3. If unsuccessful: Begin CPR Look into mouth when opening the airway to begin CPR Use finger sweep (or suction) to remove visible foreign body ALS 4. As soon as equipment is available: Visualize airway w/laryngoscope and attempt to clear using forceps or suction 5. Intubate; attempt to push the FB into right mainstem bronchus, pull ETT back and ventilate left lung 6. If still obstructed and unable to intubate or ventilate adequately: Consider cricothyrotomy Per SOP: ≥13 yrs: Needle or surgical | ≤12 yrs: Needle Per OLMC only: 8-12 yrs: Surgical Transport; attempt to ventilate with 15 L O2/BVM NWC EMSS 2022 SOP 11 Rev. 3-11-24  ADVANCED AIRWAYS | DRUG-ASSISTED INTUBATION (DAI) Purpose DAI: Achieve rapid ETI in patients with intact airway reflexes via use of medications that facilitate intubation Consider indications for ADV airway placement: Actual or potential airway impairment or aspiration risk that cannot be mitigated by other interventions Actual/ impending ventilatory failure (HF, pulmonary edema, COPD, asthma, anaphylaxis; shallow/labored effort; SpO2 ≤ 90; EtCO2 ≥ 60) Increased WOB (retractions, use of accessory muscles) resulting in severe fatigue GCS ≤ 8 due to an acute condition unlikely to be self-limited Self-limiting conditions: seizures, hypoglycemia, postictal state, select drug OD (GHB, ecstasy) or TBI 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 use of sedatives: Use in pregnancy could be potentially harmful to fetus; consider risk/benefit 1. IMC: SpO2 & EtCO2 before and after airway intervention | Confirm patent IV / IO; ECG monitor Consider & Rx causes of impairment | Suction, manual maneuvers | BLS airways: + Gag: NPA | No gag: OPA 2. Prepare pt: Position for optimal view and access (head up to 45° unless contraindicated) | Assess for difficult intubation 3. PREOXYGENATE 3 minutes (O2 wash in; nitrogen wash out) Apply ETCO2 NC 15 L; maintain before and during procedure – If 2 O2 sources add: RR ≥10 / AWAKE / good ventilatory effort: Consider CPAP at 5-10 PEEP if not contraindicated RR 100, CVD/HTN; on beta blockers, digoxin, MAO inhibitors; or pregnant May repeat in 5 minutes prn; DO NOT DELAY TRANSPORT waiting for a response Consider need for CPAP 3. If wheezing: ALBUTEROL 2.5 mg & IPRATROPIUM 0.5 mg via HHN/mask. Add O2 6 L/NC if SpO2 < 94 [BLS] 4. DIPHENHYDRAMINE 50 mg IVP; if no IV give IM [ALS] | PO if no airway compromise or vomiting [BLS] CRITICAL: Severe SYSTEMIC Reaction/ANAPHYLACTIC SHOCK : Above + Time Severely impaired airway/severe dyspnea; decreased/absent lung sounds; CV collapse/HYPOTENSION sensitive pt (Adult: SBP < 90; MAP < 65 or 30% decrease from baseline), dysrhythmias; AMS, pre-syncope, syncope/coma 2. IMC special considerations: (Resuscitate before intubate) IMMEDIATELY: EPINEPRINE (1 mg/1 mL) 0.5 mg IM (anterolateral thigh) [BLS] If awake w/ spontaneous ventilatory effort: Consider C-PAP if MAP at least 60: 5-7 cm PEEP If respiratory distress persists and CPAP contraindicated/not tolerated: Rx per ADV Airway SOP Attempt vascular access after epinephrine IM If No IV / IO: May repeat EPI (1 mg/1 mL) 0.5 mg IM q. 5 min prn | Max total dose 2 mg | Additional doses: OLMC As soon as vascular access is successful: 3. IV NS consecutive 200 mL IVF challenges up to 20 mL/kg; Goal: SBP ≥ 90 (MAP ≥ 65); reassess after each 200 mL + 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 Reassess after each 0.1 mg (1 mL) | Additional doses: OLMC If on beta blockers & not responding to EPI: GLUCAGON 1 mg IVP / IO [ALS] IN / IM [BLS] 4. If wheezing: ALBUTEROL 2.5 mg & IPRATROPIUM 0.5 mg via HHN/mask. Add O2 6 L/NC if SpO2 < 94 [BLS] 5. DIPHENHYDRAMINE 50 mg IVP/IO; if no IV / IO give IM If cardiac arrest occurs – Begin quality CPR; prolonged CPR indicated while S&S of anaphylaxis resolve Give IVF as rapidly as possible (20 mL/kg; max 2 L) PLUS EPINEPHRINE (1 mg/10 mL) IV / IO per cardiac arrest SOP (Above dose limit does not apply) NWC EMSS 2022 SOP 13 Rev. 3-11-24  ASTHMA | COPD 1. IMC special considerations: Assess ventilation/oxygenation, WOB, accessory muscle use, degree of airway obstruction/resistance, speech, cough (productive or non-productive – color), cerebral function, fatigue, hypoxia, CO2 narcosis, and cardiac status Medications: Time and amount of last dose; duration of this attack If wheezing without Hx of COPD/Asthma: Consider FB aspiration, pulmonary embolus, vocal cord spasm, HF/ pulmonary edema. See appendix for differential. If probable cardiac cause (PMH: CVD): Rx per Cardiac SOPs. Assess for pneumonia, atelectasis, pneumothorax or tension pneumothorax If tension pneumothorax (↓ BP, unilaterally absent lung sounds): 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. If assisted: Ventilate at 6 - 8 BPM (slower rate, smaller tidal volume (6-8 mL/kg), shorter inspiratory time & longer expiratory time to allow complete exhalation | Target SpO2: 92% (COPD) If cardiac arrest: Option: briefly disconnect from BVM and compress chest wall to relieve air-trapping (Class IIa) Monitor ECG: Bradycardia signals deterioration LOWER ACUITY to EMERGENT: Mild to Moderate distress with wheezing and/or cough variant asthma 2. ALBUTEROL 2.5 mg & IPRATROPIUM 0.5 mg via HHN or mask BLS 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, Time tachypnea, lung sounds diminished or absent; exhausted; HR & BP may be dropping sensitive pt 2. IMC special considerations: [BLS] BLS 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 3. EPINEPHRINE (1 mg/1 mL) 0.3 mg IM [BLS] 3. ALBUTEROL 2.5 mg & BLS Caution: HR > 100, CVD/HTN; on beta blockers, IPRATROPIUM 0.5 mg /HHN/ mask/ BVM digoxin, or MAO inhibitors; pregnant; or significant side Begin transport as soon as neb is started effects to albuterol Do not wait for a response Begin transport as soon as Epi is given Continue nebulizer therapy enroute Do not wait for a response May repeat X 1 in 10 min if minimal response May repeat X 1 as needed 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. 4 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 Cover site with cold moist gauze/cold pack to relieve burning NWC EMSS 2022 SOP 14 Rev. 3-11-24  Pts w/ TRACHEOSTOMY | LARYNGECTOMY Adult or peds with Respiratory Distress 1. IMC special considerations: Assess the following: Airway patency & lung sounds; RR; WOB; oxygenation by skin color & temp, SpO2 , EtCO2 (if available); ineffective airway clearance as evidenced by crackles, wheezes; or stridor; need to suction Type & size of trach or laryngectomy tube (marking on tube flange) | tube position Tracheostomy cuff to ensure that it is deflated unless on a ventilator or if pt has excessive secretions Tracheostomy/laryngectomy site - Redness, swelling; character & amount of secretions; purulence, bleeding, subcutaneous emphysema - Tracheostomy ties - should be secure but not too tight - Need of tracheostomy care 2. If airway patent and respiratory effort/ventilation adequate: Support ABCs, complete IMC; suction as needed to clear secretions Maintain adequate humidity to prevent thick, viscous secretions (if “artificial nose” available at scene) Position head of stretcher up 45 degrees or sitting position as patient tolerates 3. Partial dislodgement of trach tube: Deflate cuff (if air-filled); advance tube into stoma until flange is flat against neck; reinfate cuff; secure trach tube 4. Complete dislodgement: Completely deflate cuff; remove inner cannula if double lumen tube Insert obturator Lubricate tube including cuff with water soluble gel Gently advance tube into stoma until flange is flat against neck Remove obturator and replace inner cannula; secure trach tube In an emergency, insert an appropriately sized ETT into stoma until cuff just passes stoma; assess patency Caution: A fresh trach or laryngectomy (100°F (37.8°C), productive cough, isolated crackles; SpO2 < 95%; HR >100 Standard precautions / Disinfection 1. For close contact (w/in 6 feet of pt): Droplet / Aerosolization Precautions and BSI Nonsterile gloves for contact w/ potentially infectious material; hand hygiene immediately after glove removal Surgical/procedural mask on pt and mask on each EMS responder (surgical/procedural, N95, or other respirator per CDC / IDPH / Local policy) Wear disposable isolation gown and eye protection when required by CDC/IDPH guidelines Consider when splashes or sprays of respiratory secretions or other infectious material are possible 2. Disinfect stethoscope heads and other frequently-handled items after each patient 3. General recommendation for ambulance: Thoroughly clean all planes and crevices; spray with System- approved disinfectant registered by the EPA to kill viruses (coronavirus, norovirus, rotavirus, adenovirus) and TB If using a spray, hold dispenser 10” from surface and atomize with quick short strokes, spraying evenly on (potentially) contaminated areas until wet. Allow wet dwell time per manufacturer’s instructions. Prefer products with 1 minute dwell time. After that, wipe down with a clean towel dampened with clean water then dry thoroughly. Remove/clean residue that may be left behind from disinfectant. Mild illness/low risk for complications: 4. IMC: Supportive care. If w/in 24 hours of onset, encourage pt to contact PCP to receive anti-viral agent. Encourage rest, fluids, and non-aspirin OTC pain relievers and fever reducers. Cough suppressants, decongestants, and antihistamines may alleviate symptoms. Moderate to Severe S&S | High risk for complications Respiratory/ventilatory failure with severe hypoxemia and hypercarbia may occur in pts with associated pneumonia or exacerbation of underlying comorbid diseases 5. 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 6. Assess for SEPSIS: Time-sensitive pt. Risk factors for serious complications Asthma; COPD; cystic fibrosis; pulm. fibrosis Adults 65 years and older Endocrine disorders (diabetes mellitus) Children < 5 yrs old, but especially those < 2 yrs Heart disease (CAD, HF, cardiomyopathies) Pregnant women and up to 2 weeks post-partum Kidney, liver, metabolic disorders People in congregate living facilities Neurological and neurodevelopmental conditions Immunocompromised state Obesity with a BMI of 30 or higher Coagulation disorders Pulmonary embolism: Difficult to diagnose, and potentially lethal if missed. Time sensitive pt. Size/location determines S&S. 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). Also consider presence of air, fat or amniotic fluid as source of emboli. S&S Acute onset pleuritic chest pain; unilateral lower limb pain/edema; tachypnea disproportionate to fever and tachycardia; SpO2; small, square capnography waveform and very low reading (increased dead space and hyperventilation); HR ≥100; SBP may drop due to HF; cough may be productive with hemoptysis; shock IMC based on the patient presentation, VS, and signs of shock/instability. 12 L ECG. Definitive Rx (at hospital) of an embolus due to blood clot may be fibrinolysis or thrombectomy – limit scene time NWC EMSS 2022 SOP 16 Rev. 3-11-24