AIRWAY MANAGEMENT
ALL PROVIDERS
DESIGNATION OF CONDITION
The patient is not breathing, not breathing adequately, or experiencing agonal respirations with inadequate rate and/or depth. See Foreign Body Airway Obstruction Protocol if obstruction suspected.
EMPHASIS ON PATIENT CARE
Maintain a patent airway and assist ventilations
1. Primary Management - Assess ABC’s, manage as indicated.
2. If respirations are inadequate or absent, maintain airway patency by:
a. Positioning maneuvers as indicated by patient condition (jaw thrust, sniffing postion, ramped if spine clear)
b. Suction as needed (oropharynx, nasopharynx, or stoma)
c. Place Nasopharyngeal airway (NPA), Oropharyngeal airway (OPA)
d. Oxygen
e. Continuous SpO2 and EtCO2
f. CPAP up to 10 cm PEEP
g. Assist respiration with BVM 10-12 bpm as needed
h. Place Supraglottic Airway (SGA). LMA preferred.
3. If available may consider Positive Pressure Ventilatory Devices (PPVD)
4. Ensure that the ventilatory device is connected to a supplemental oxygen source, if available, using an adequate oxygen flow (8-12 LPM with an oxygen concentration > 40%).
PARAMEDIC
1. Laryngoscopic (Video or blade) visualization with oral endotracheal intubation
a. During cardiac arrest apply NRB mask at high flow oxygen for first two cycles of CPR. Then apply a NC at 15 liters/minute prior to and during intubation attempts.
b. May attempt x 2 per provider.
c. If you do not have confirmation of ETT placement with capnograph waveform or are unsure of ETT location remove tube and BLS airway or place SGA/EGA.
2. Nasotracheal intubation (blind or visualized if breathing)
a. If you do not have confirmation of NTT placement with capnograph waveform or are unsure of NTT location remove tube and BLS airway or place SGA/EGA.
3. Stoma intubation
4. Surgical cricothyrotomy
5. CPAP PPVD Operation:
a. If the patient is not intubated, make sure the PPVD mask is properly sealed on the patient's mouth and nose. If the patient is intubated, connect the device to the tube.
b. Ventilate the adult patient at a rate of 10-12 bpm, with inspiratory time of 1 - 2 seconds if supplemental oxygen is available. If supplemental oxygen is not available, use an inspiratory time of 2 seconds. Inspiratory/expiratory times should be at a 1:2 ratio.
c. For infants, ventilate at 20-30 bpm, with an inspiratory time of 0.5 - 1.0 seconds and for children, 12 - 20 bpm at 1 - 1.5 seconds.
d. Auscultate lung sounds and watch for symmetric chest rise.
e. Avoid inspiratory pressures >20 cm H2O in non-intubated patients which can lead to gastric distention or barotrauma.
f. Continuously monitor the ventilatory device to ensure there are no malfunctions of equipment or use.
g. Airway adjuncts should be monitored for proper placement.
h. Pulse oximetry (including room air SAO2), end-tidal C02 detectors (ETC02) and capnometry/capnography is the standard for tube placement verification.
POST INTUBATION SEDATION
1. Many intubated patients require sedation to tolerate the tube. There are reasons to add sedation when transporting intubated patients and it shouldn’t be withheld if the patient isn’t in arrest. Consider Fentanyl in patients with painful conditions or injuries. Ketamine serves as both a sedative and an analgesic. Patients who are regaining consciousness or improving their level of consciousness need sedation. Consider whether the patient has improved sufficiently to remove the adjunct from their airway.
2. The following can be used for post-intubation sedation:
A. MIDAZOLAM 5 mg. IV/IO q 10 minutes as needed..
B. KETAMINE 0.5-1.0 mg/kg slow IV/IO q 5-15 minutes as needed and tolerated. Caution advised if increased intracranial pressure is an issue. Consider MIDAZOLAM.
C. FENTANYL 50-150 mcg IV/IO q 5 minutes as needed for pain.
ALL PROVIDERS
DESIGNATION OF CONDITION
The patient is not breathing, not breathing adequately, or experiencing agonal respirations with inadequate rate and/or depth. See Foreign Body Airway Obstruction Protocol if obstruction suspected.
EMPHASIS ON PATIENT CARE
Maintain a patent airway and assist ventilations
1. Primary Management - Assess ABC’s, manage as indicated.
2. If respirations are inadequate or absent, maintain airway patency by:
a. Positioning maneuvers as indicated by patient condition (jaw thrust, sniffing postion, ramped if spine clear)
b. Suction as needed (oropharynx, nasopharynx, or stoma)
c. Place Nasopharyngeal airway (NPA), Oropharyngeal airway (OPA)
d. Oxygen
e. Continuous SpO2 and EtCO2
f. CPAP up to 10 cm PEEP
g. Assist respiration with BVM 10-12 bpm as needed
h. Place Supraglottic Airway (SGA). LMA preferred.
3. If available may consider Positive Pressure Ventilatory Devices (PPVD)
4. Ensure that the ventilatory device is connected to a supplemental oxygen source, if available, using an adequate oxygen flow (8-12 LPM with an oxygen concentration > 40%).
PARAMEDIC
1. Laryngoscopic (Video or blade) visualization with oral endotracheal intubation
a. During cardiac arrest apply NRB mask at high flow oxygen for first two cycles of CPR. Then apply a NC at 15 liters/minute prior to and during intubation attempts.
b. May attempt x 2 per provider.
c. If you do not have confirmation of ETT placement with capnograph waveform or are unsure of ETT location remove tube and BLS airway or place SGA/EGA.
2. Nasotracheal intubation (blind or visualized if breathing)
a. If you do not have confirmation of NTT placement with capnograph waveform or are unsure of NTT location remove tube and BLS airway or place SGA/EGA.
3. Stoma intubation
4. Surgical cricothyrotomy
5. CPAP PPVD Operation:
a. If the patient is not intubated, make sure the PPVD mask is properly sealed on the patient's mouth and nose. If the patient is intubated, connect the device to the tube.
b. Ventilate the adult patient at a rate of 10-12 bpm, with inspiratory time of 1 - 2 seconds if supplemental oxygen is available. If supplemental oxygen is not available, use an inspiratory time of 2 seconds. Inspiratory/expiratory times should be at a 1:2 ratio.
c. For infants, ventilate at 20-30 bpm, with an inspiratory time of 0.5 - 1.0 seconds and for children, 12 - 20 bpm at 1 - 1.5 seconds.
d. Auscultate lung sounds and watch for symmetric chest rise.
e. Avoid inspiratory pressures >20 cm H2O in non-intubated patients which can lead to gastric distention or barotrauma.
f. Continuously monitor the ventilatory device to ensure there are no malfunctions of equipment or use.
g. Airway adjuncts should be monitored for proper placement.
h. Pulse oximetry (including room air SAO2), end-tidal C02 detectors (ETC02) and capnometry/capnography is the standard for tube placement verification.
POST INTUBATION SEDATION
1. Many intubated patients require sedation to tolerate the tube. There are reasons to add sedation when transporting intubated patients and it shouldn’t be withheld if the patient isn’t in arrest. Consider Fentanyl in patients with painful conditions or injuries. Ketamine serves as both a sedative and an analgesic. Patients who are regaining consciousness or improving their level of consciousness need sedation. Consider whether the patient has improved sufficiently to remove the adjunct from their airway.
2. The following can be used for post-intubation sedation:
A. MIDAZOLAM 5 mg. IV/IO q 10 minutes as needed..
B. KETAMINE 0.5-1.0 mg/kg slow IV/IO q 5-15 minutes as needed and tolerated. Caution advised if increased intracranial pressure is an issue. Consider MIDAZOLAM.
C. FENTANYL 50-150 mcg IV/IO q 5 minutes as needed for pain.