- Tongue is the most likely source of obstruction
- Adjuncts used to control the tongue:
- OPA- used in patients with no gag-reflex
- NPA- for the patient that is still semi-responsive or clenched
- Supraglottic airways in current prehospital setting:
- King LT, Combitube, LMA, and iGel
- As ALS providers, sometimes we are too quick to jump to advanced airway placement and forget and that the combination of a BVM/Adjunct (OPA/NPA), and suction can function as a PATENT airway
- There is hesitance to “bag” a patient that is in distress prior to ALS procedures. WHY?!?!?!? Positive-pressure ventilation save lives!
- Our main goal is to prevent hypoxia at all costs
- Patients will position themselves to optimize oxygenation; i.e. “tripoding to increase tidal volume
- By placing patients in an upright position, you allow gravity to work with you; allows for better lung expansion and less diaphragmatic resistance
- It’s something we all should have learned in EMT class… FOR THE LOVE OF GOD, SIT THESE PEOPLE UPRIGHT!!
- These patients generate their own PEEP, so why “bag” one of these patients, or put them on CPAP?
- THEY ARE TIRED! The respiratory structures are exhausted and need help.
- Give them help before they go into respiratory failure or arrest!
- Early intervention typically prevents advanced airway placement
- They need high flow O2 because CO2 builds up
- These patients don’t need help ventilating, they need help oxygenating
- They have shunt physiology
- Use PEEP early!
- Titrate to effect between 5-10cmH2O
PREOXYGENATION FOR THE PERI-ARREST/ARRESTED PATIENT
- Head of the bed needs to be at least 20° high
- Prevents atelectasis in posterior lung fields
- Increases tidal volume improving oxygenation
- Main goal is to denitrogenate the lungs and increase oxygen reservoir for advanced airway placement
- By improving the oxygen supply, you are increasing the amount of time a patient can be apneic without significant desaturation
- >85% is the goal, preferably in the >93% range
- Oxygenation Techniques:
- A NRB MASK DOES NOT SUPPLY 100% FIO2!! IT ONLY SUPPLIES AROUND 60-70%!!
- Semi-responsive patient that has a patent airway, but is going to be intubated due to the length of procedures or expected digression:
- NRB @15lpm and supplemental NC @15lpm as well
- Yes… A nasal cannula can go up to 15lpm…
- For the patient that cannot maintain their own airway:
- BVM @15lpm and supplemental NC@15lpm
- Adjunct preferable, but not a prerequisite for success; deliberate manual positioning works!
- Remember… Apneic preoxygenation with a NC does not necessarily show marked benefit in a patient with shunt physiology
- SGA placement by an ALS provider does not signify failure!
- Several studies are showing that SGA placement yield better results
- Before all of you go up in arms, we are not advocating for an all BLS airway system…
- We will eventually be doing a podcast covering the difference between BLS/ALS airways and the pros/cons of each.
- Don’t kill someone by being overly eager to rush to ALS and forgetting the importance of BLS airway maintenance and preoxygenation.
- Direct Laryngoscopy Terminated