Airway Management Essentials Self-Study Guide

Transcription

1 Airway Management Essentials Self-Study Guide Fourth Quarter 2010

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3 Self-Study Guide Learning Objectives Cognitive Domain 1. Describe the various conditions that cause concern during treatment in the field for essential airway intervention. 2. Discuss the various adjuncts available to maintain an open airway. 3. Describe the proper technique in using each of the adjuncts. Psychomotor Domain 1. Demonstrate how to properly use the various types of airway adjuncts used by your organization. DOT EMT-B Objectives NREMT Requirement 1. Refresher a. Patient assessment b. Medical/behavioral c. Elective 2. Additional related CE Self-Study Tips 1. Review the Instructor Guide. Note Discussion Points in the guide to reference during the video. 2. Review the test and answer key. 3. Watch the program Airway Management Essentials. Note the location of the Learning Objectives in the video presentation. Critical Concepts Discuss the importance of wearing personal protective equipment (PPE) when working with a patient s airway. Discuss why the skills needed to maintain a patient s airway are so important. Review the reasons for maintaining an airway. Describe alternative methods of maintaining a patient airway. Review the controversies surrounding the use of the gold standard for airway control. Discuss the concerns regarding the inability to keep intubation skills current. Discuss dual lumen airways. Review the method for inserting a dual lumen airway. Discuss the advantages and disadvantages of a dual lumen airway. Review the use of an LMA. Discuss the advantages and disadvantages of using an LMA. Discuss how the LMA is inserted and how providers ventilate the patient. Explain how supraglottic airways are utilized. Describe the advantages and disadvantages of the use of supraglottic airways. Review the procedure of inserting the supraglottic airway adjunct. Review why it is essential for every level of EMS provider to have multiple tools for airway management. Describe how EMS providers should be familiar with recognizing when an airway is not being maintained adequately. Review the fundamentals of good airway management. Discuss the necessity for ongoing and continuous practice on airway management EMS Self-Study Guide 1

4 Self-Study Scenarios Self-Study Scenarios Scenario 1: It is a warm Saturday afternoon and a 911 call requests you respond to a fall victim. Your response will take you to a remote area of a common hiking trail. You are told that a young woman was hiking with friends when she fell off of the path into a stream. She is unconscious at this time. When you arrive, you find a woman in her 20s lying supine in a small running stream. What are the potential airway concerns? What would you do to stabilize the patient to prepare her for transportation? What resources will you need to monitor her airway, secure her for movement, and for transportation? Scenario 2: You are resting comfortably in a chair, reading an article on domestic violence in the latest professional emergency services magazine when a call comes in for an unconscious person in a hotel. While responding, you are advised that the patient is a 27-year-old female who is semi-conscious. You are told she is breathing but her respiratory effort is labored. What methods can you prepare for to manage this patient s airway? What techniques or airway adjuncts do you have available to manage the airway? In what order would you use these adjuncts? What other medical considerations should you prepare for? Scenario 4: You and your partner just stopped for lunch when a 911 call is received to respond for a drowning victim at the local beach. You are advised the patient is still in the water and the life guards are initiating a rescue. When you arrive, you find a life guard carrying the patient up the beach. The patient appears limp. What would your next step be to help stabilize this patient? How would you determine the best method to manage his airway and provide oxygenation? What environmental conditions do you need to consider when managing the airway? Scenario 5: While returning from the hospital after dropping a patient off, you are dispatched to a local manufacturing company for difficulty breathing. You arrive to find a male standing outside in acute respiratory distress. You are told by his co-workers that he is asthmatic and was exposed to cleaning chemicals. Your initial assessment shows difficulty breathing. During auscultation, you hear very little air movement in his large airways. How would you treat his medical condition? What would you do to manage his airway? How would you ensure adequate oxygen exchange? Scenario 3: You and your partner are dispatched for a motorcycle accident. You arrive and find a young male lying in the roadway. He has a GCS of 9 with labored breathing. You note the motorcycle is approximately 100 feet from where he is lying. How would you manage this patient s airway? What considerations will you use to make the decision? What specific questions and concerns do you have about managing this airway? EMS Self-Study Guide 2

5 Self-Study Tips Select a comfortable, quiet space with good lighting. Allow enough time to complete the lesson without interruption. Have available a working TV and DVD player, or computer. Review the Learning Objectives. Take the Pre-Test. Review Discussion Points. Complete the lesson. Complete the Self-Study Practices and Exercises. Review the recommended Web sites and related reading. Take the Post-Test. Self-Study Exercises Overview The following exercises are designed to assist with developing these skills. Exercise 1: Review the following scenario and discuss with another EMS professional potential outcomes and hidden problems. Be prepared to answer the following questions. What are some of the obvious challenges presented that will need to be addressed immediately? How would you choose what airway adjunct would be best for this patient? What would you do with the resources you currently have available? How would you assess the effectiveness of the treatment? Exercise 2: When completing the lesson without other EMS professionals participating with you, the following exercises will help you to develop the required skills. Review the listed portion of the article Cardiac Arrest Management Part 2, written by Bob Sullivan. ADVANCED AIRWAY MANAGEMENT Perhaps no issue in EMS today is more controversial than endotracheal (ET) intubation in advanced airway management. Until recently, getting the tube was considered one of the most important cardiac arrest interventions. The latest guidelines more clearly define the risks and benefits of advanced airway placement and do not recommend placing them until later in the arrest. ENDOTRACHEAL INTUBATION Endotracheal intubation is performed by visualizing landmarks in the patient's throat and passing a tube into the trachea to provide a clear path to deliver oxygen to the lungs and prevent aspiration. Long considered the gold standard of airway management, the procedure brings a high rate of complications when performed by people with inadequate training, little opportunity for practice and inadequate mechanisms to monitor placement. 1 The most common complication of intubation is that compressions must often be stopped for several seconds while the procedure is performed. If the patient is difficult to intubate, the benefits of the tube will probably not be worth a long pause in compressions. The pause can be minimized by preparing all equipment before the attempt, stopping compressions only long enough to visualize the landmarks, and resuming compressions as soon as the tube is placed. Other complications are caused by ventilating too forcefully and too frequently. This results in higher intrathoracic pressure (the bad pressure that lowers cardiac output from CPR) and decreased oxygen delivery to the brain. 1 The most serious complication of intubation is not recognizing when the tube is mistakenly placed in the esophagus. Many studies have demonstrated unacceptably high rates of misplaced tubes in EMS, which has led some experts to believe that the procedure should be abandoned altogether. No one method of confirming placement is 100% reliable, so the AHA recommends using multiple methods. One is to listen for gastric sounds over the stomach on the first ventilation through the tube. If sounds are heard, the tube is most likely misplaced and should be removed. Listen over each side of EMS Self-Study Guide 3

6 the chest for breath sounds. Equal breath sounds likely indicate correct placement. Another confirmation method is to use the esophageal detection device (EDD) a self-inflating bulb that should be pushed in, then placed over the tube before the first ventilation. Rapid reinflation of the bulb generally indicates correct placement. One of the most reliable methods of tube confirmation is end-tidal carbon dioxide (ETCO 2 ) detection. A device placed on the end of the tube changes color if carbon dioxide is exhaled, which indicates proper placement. The lack of color change, however, does not necessarily mean that the tube is misplaced. Carbon dioxide may not be detected in patients who have been in cardiac arrest for a long time or have had inadequate CPR. An even better method of tube confirmation is waveform capnography, which measures the amount of carbon dioxide exhaled in mmhg and displays a waveform on a screen with each breath. If the tube is dislodged, it will appear immediately on the monitor. One study that evaluated the association of continuous ETCO 2 monitoring and unrecognized misplaced ET tubes in a regional EMS system that used continuous ETCO 2 monitoring showed no misplaced tubes, compared with a 23% unrecognized misplacement rate when monitoring was not used. 4 Continuous ETCO 2 measurement provides additional benefits for managing cardiac arrest. Waveform capnography provides real-time feedback on how fast the patient is being ventilated, which helps avoid hyperventilation and delivering tidal volumes that are too high. The measurement of exhaled carbon dioxide indirectly shows how effective CPR is. Carbon dioxide is a byproduct of metabolism, and higher readings generally indicate better circulation. If there is a return of spontaneous circulation, the ETCO 2 reading may rapidly rise before a pulse can be felt. are placed blindly and designed to isolate the trachea for ventilation. While many consider these devices only as backups when intubation is not successful, they can be placed in less time and ventilate as well as an ET tube. ETCO 2 detection can be used to confirm placement and ventilation rate with these devices as well. Any device should be secured according to local protocol, and placement should be reassessed after movement. Look for specific findings relative to your knowledge of the use of airway adjuncts in your area and write a summary of the information you found. Include how this information will impact your treatment of patients. Have the medical director or a senior crew member review the document and discuss your summary. Based on the information you have obtained, develop a minimum of 10 questions that you want to be able to answer at the end of your discussion. Review your local protocols on the use of all airway adjuncts available and determine if they can be updated to improve patient care. Exercise 3: Review the local protocols for use of airway adjuncts. Determine how EMS providers are evaluated on their skills and competency. Ascertain if the current policies, training, and evaluation method is effective. Create an educational program for your service based on the results of your research. OTHER ADVANCED AIRWAY DEVICES Other available advanced airway devices bring fewer potential complications than intubation. Most common are the dual-lumen airway (Combitube), laryngeal mask airway (LMA) and the King LT. Rather than placing a tube directly into the trachea, they EMS Self-Study Guide 4