INTUBATION

  • An AEMT may only intubate if patient is apneic.

  •  Consider patient airway anatomy and condition for proper airway adjunct selection.

  • AEMTs can suction tracheostomies

  • {Lighted Stylet Intubation} or {Camera Assisted Intubation} may be utilized.

  • Dual Lumen Airways, e.g., Combitube, Pharyngotracheal Lumen Airway (PtL), King Airway or Laryngeal Mask Airways (LMA), are acceptable airway devices. Use of these devices is limited to patients who need an artificial airway and are apneic.

 A  If two attempts with an ETT are not successful, move to an adjunct device.

  • If approved, adjuncts considered “rescue airways” such as the LMA or Dual Lumen Airways} may be appropriate primary airway devices.

 P LMA is recommended as the primary airway except in extreme cases such as airway edema.

  •  Always secure the ET tube in place, preferably with a commercial tube-securing device.

  •  Cervical collar is effective in maintaining patient’s head in a neutral position.

  • Reassess ET tube placement every time the patient is moved.

  •  Confirm correct placement of advanced airways by at least five methods:

CONFIRMATION METHODS:

  •  CO2 detection methods are recommended and Capnography is the “gold standard.”

  • Auscultation of the epigastrium, anterior chest, midaxillary areas, and then the epigastrium again

  • Rise and fall of the chest

  • Repeat visualization of the tube between the vocal cords

  •  Condensation in the tube

  • Depth placement and measurements:
    • Keeping an oral endotracheal tube at the 20-22 cm mark at the teeth will prevent inserting the ETT too far and greatly reduces the chances of a right mainstem bronchus intubation. Don’t confuse right mainstem intubation for a pneumothorax.

 P Proper depth placement of tracheal tube in the pediatric patient can be calculated by the following formula: Depth of insertion (length of tube at teeth or gum line) = tube size x 3.

 

CONFIRMATION DEVICES:

Electronic End Tidal CO2 (EtCO2) Monitors—Capnography

           Capnography or capnometry is considered the “gold standard” of tube placement confirmation.Waveform EtCO2 is the preferred confirmation device. These devices measure the amount of carbon dioxide in the exhaled ventilations of patients. They can use mainstream sensors, which are located directly on the endotracheal tube, or sidestream sensors, which sample the ventilation more remotely. Capnography can also be used with patients who are not intubated. In-line EtCO2 monitors can be used on patients with or without adequate perfusion. Electronic monitors show changes in real-time.
If this equipment is available, it should be used on EVERY intubation, and always be one of five confirmation steps. MAINTAIN THIS DEVICE UNTIL PATIENT CARE IS TRANSFERRED TO THE RECEIVING HOSPITAL STAFF. Under normal conditions, ventilations should not exceed 10-12 ventilations per minute, as referenced on P. 16. Only if signs of cerebral herniation are present, hyperventilate at 20 ventilations per minute to a goal end tidal value of 30 mmHg.

For any department whose monitors have summary capabilities, that summary must be presented with the patient.

Patients in asystole with a confirmed correct tube placement and a capnography reading < 10 mm/Hg, which does not improve during resuscitative efforts, have essentially no probability of survival and field termination should be strongly considered.

End Tidal Co2 Detector (EtCO2)—Colorimetric

Colorimetric Limitations:

  • The Colormetric EtCO2 detector may be utilized as a confirmation device for patients in cardiac arrest, IF it shows the presence of CO2 (color change to yellow). If there is no color change, use other confirmation methods. The absence of color change in a properly placed tube may be caused by a lack of perfusion, but it may also indicate esophageal intubation.

  • Secretions, emesis, etc. can ruin the device.

  •  A patient with large amounts of carbonated beverage (e.g., beer) in their stomach can give a false positive result. The device may sense the CO2 given off by that beverage and indicate that the tube in the trachea when it is in the esophagus.

  •  The device can be used for no more than two hours.
  • Follow manufacturer’s recommendations for weight restrictions.

Medication Issues:

  •  Intravenous sodium bicarbonate will produce more carbon dioxide resulting in enhanced color.

Esophageal Detector Device (EDD)

This device confirms tube placement mechanically. It is based on the principle that the esophagus is a collapsible tube, while the trachea is rigid. An EDD looks like a bulb syringe. Collapse the bulb first and then place the device on the end of the ETT prior to first ventilation. As the bulb tries to refill with air, it creates suction. If the tube is in the esophagus, the soft tissues will collapse around the holes in the ETT preventing expansion of the bulb. When the bulb does not refill (or refills very slowly), the tube is presumed to be in the esophagus. If the tube is in the trachea, there is nothing to occlude the movement of air. The bulb will rapidly refill, indicating that the ETT is properly placed.

EDD Limitations:

  • A large amount of gastric air (e.g., caused by carbonated beverage, aggressive ventilations, misplacement of ETT) can give a false positive finding. Tracheal obstructions in patients with morbid obesity, late pregnancy, status asthmaticus, or copious endotracheal secretions may yield misleading results.

  •  A cold device may give a false negative result. If the rubber bulb is stiff from the cold, it will fail to fill with air. The ETT will seem to be in the esophagus, when it is actually in the trachea.
  • It cannot be used continuously. It must be removed after confirmation, though it may be used again after patient movement.

  •  Use only for confirmation of endotracheal tube placement, not for any other airways (LMA, King, etc.).

 P  May only be used on pediatric patients older than 5 years old weighing at least 20 kg (44 pounds).

 

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