Pitfalls of Field Airway Management

Misplaced Endotracheal Tubes in an EMS System

108

intubated patients 27/108 (25%) misplaced tubes 18/27 esophageal intubations

57%

ED mortality
ED mortality

9/27

in hypopharynx

33%

Katz, Faulk, Annals of Emergency Medicine 2001, 37, 32-7.

What are we doing now?

What parts of that might set us up for failure?

Uncontrolled environment, less then optimal situations

The field airway is usually difficult

Specifics of a Difficult field airway

Immobilized trauma patient Combative patients Short neck and/or receding mandible Prominent upper teeth Children Upper airway conditions Facial trauma Laryngeal trauma Limited jaw opening Uncontrolled environment

Emotion & Chaos

Variables & Distracters

What are the most common, predictable failure points in field airway management?

Pitfall #1
Not

having a consistent, organized airway assessment & management approach for EVERY patient encountered.

When?
Performing the intubation is generally easier than deciding which intubation technique to use, which in turn is generally easier than deciding who to intubate, which in turn is generally easier than deciding precisely when to intubate
Ron Walls, MD

Whats your approach?

When is an advanced airway required in the field?

Is there failure to maintain an adequate airway? Is there failure to protect the airway against aspiration? Is there a failure of ventilation? Is there a failure of oxygenation? Is there a condition present, or is there a therapy required that mandates intubation?

Is there a common approach? Protocol? Algorithm?

Assess Airway, Ventilation, and Level of Consciousness

Adequate? Yes Manual Airway maneuver, OPA, NPA and/ or Bag-valve-Mask ventilation

No

Pulse Oximetry and Supplemental Oxygen

Airway Patent?

No

AHA BLS guidelines for Foreign Body Airway Obstruction

Yes Direct Laryngoscopy Gag Reflex Present? No

Yes

Respirations and Gag Reflex Present

Apnea, Agonal Respirations and No Gag Reflex

Consider Lidocaine 1 mg/kg IV for head injury or reactive airway

Afrin X 2 in nostril, Lidocaine Jelly, or Cetacaine

Orotracheal Intubation

Nasal Tracheal Intubation Or Versed 2-10 mg and/ or Morphine Sulfate 2 - 10 mg, Cetacaine topically

Yes

Successful?

No

Assure Endotracheal tube placement clinically: auscultate epigastrium and 4 lung fields End Tidal CO2 device Pulse Oximetry

If unable to intubate or intubation contraindicated, consider Bag-ValveMask, Retrograde intubation, Combitube, OR Needle/Surgical Crichothrotomy

Consider Nasogastric Tube

Consider Sedation for intubated patient

Use more than one person?

Two-person
More

ventilation

effective pre-oxygenation Less gastric insufflation

Positioning Another

monitor Another operator Someone elses lucky day?

The tough ones?

The easy ones?

Pitfall # 2

Forgetting

that airway management is a team sport.

Failure to place an endotracheal tube is not failure to manage an airway.

Pitfall # 3

Providing

spinal traction, not stabilization during airway management in suspected spinal trauma.

Pitfall # 4

Persistent

aggressive advanced airway attempts in ventilatable kids.

Pitfall # 5

Failure

to reassess, over & over & over & over & over

Reassessment is a major challenge in EMS.

When? How?

Pitfall # 6

Using

the wrong advanced airway approach at the right time.

RSI and Surgical crichs are big offenders!

Pitfall # 7

Not

having a failure contingency plan.

A failure contingency plan should be part of all airway decision algorithms.

Additional resource response Combitube LMA Crichothyrotomy

Pitfall # 8

Not

understanding the advantages & limitations of various tube confirmation processes.

Challenges in tube confirmation:

Missed esophageal intubation with BBS, symmetric chest expansion in OR 6/40 (15%) esophageally intubated patients unable to be detected by chest auscultation. (Anderson & Hald) Tube condensation occurred during expiration in 34/40 (85%) patients with esophageal intubation (Anderson & Hald) 25/297 (8%) intubations by emergency physicians initially indicated esophagus

Confirmation of tube placement What is the Gold Standard?

Visualize cords? Breath sounds? Chest rise? Color change? Absence of stomach sounds? End-Tidal CO2? EDD? Chest X-ray? Anatomic verification?

Three parameters ETCO2 measures:

CO2

production
perfusion

Tissue

CO2 perfusion
Cardiac

output Pulmonary perfusion

CO2

elimination
airway/tube

Ventilation Patent

Pitfall # 9

Failure

to preserve your work.

Pitfall # 10

Failure

to document.

Summary
Perfect Practice Makes Perfect! You are only as good as your last one.
Trust nobody, believe nothing, give oxygen.