To become a fantastic airway assistant

Thanks for putting up with multiple posts this month and hope I’ve prompted some good ideas, thoughts and discussions (even just in your heads : ).
This is the final post with a lot of learning points before the SIM practice C & C.

On this post, I’ll talk about things I can think of to become a fantastic airway assistant for the advanced airway management.

1) Know your equipment
Have you played with the advanced airway roll yet? If you haven’t, please check the roll and be familiar with what’s in there, how to put them together, etc.
Yes, this message is for all of you guys including EMTs : )

2) Practice RSI prep
The most of the RSI prep is about doing a good basic airway care . Hence you should not need the list to complete most of the prep if you are a savvy airway operator.
We will discuss more at C & C but here are some comments added to the RSI prep checklist.

9.2 Preparation for RSI

  • Attach nasal prongs (for supplementary oxygen administration during RSI). primarily during laryngoscopy/ETI but may need to be used during the pre-oxygenation added to the reservoir mask.
  • Pre-oxygenate using a reservoir mask at 10 litres/minute. – Preox is a big subject in itself so will talk about it later as a separate topic. However here is a brief rundown: Preox is not only increasing SPO2, but most importantly replacing nitrogen with O2 in the lungs, and this process is called denitrogenation. Preox with non-rebreather mask may need to be augmented with the higher flow (15l), + nasal prongs (15l), or use BVM + PEEP (DO NOT ventilate, unless supportive vent is indicated or apnoec) if SPO2 don’t come up above 93~95%.
  • Attach monitoring with ECG, NIBP and SpO2. – 12 lead, please.
  • Prepare ETCO2 if this is available. – set this up on BVM
  • Position the monitor so that it can be seen, leaving space to the right of the patient’s head for the intubation roll.
  • Gain IV access, preferably in two sites. – please double check they are patent.
  • Prepare a running line of 0.9% NaCl.
  • Place a folded towel under the head. – or better if you can do whatever required to achieve…yes that sniffing position (HELP) you know well. (unless of course if you need to keep Pt in neutral alignment for C-spine protection.)
  • Place an ETT holder with the strap under the head.
  • Ensure suction is working and place the rigid sucker under the towel.
  • Prepare a manual ventilation bag with a PEEP valve attached + EtCO2 as mentioned above.
  • Obtain a set of vital signs.
  • Prepare the area:
    –  If the patient is in an ambulance, clear away as much unnecessary equipment as possible and consider moving toward backup if appropriate. – please have a yellow rubbish bag out.
    –  If the patient is not in an ambulance, clear the area so that there is access to both sides if possible *

*  If the weather and privacy concerns allow, gaining 360-degree access is useful (180-degree access only if you are in an ambulance). Preparing Pt on a stretcher just at the rear of the ambulance is a great option!  Here is the reason why !

3) Learn laryngoscopy (+magill forceps)
I hear this is going to be in the next CCE for Paras and EMTs.
We will practice laryngoscopy on our next C & C and will create a separate post for the skill…soon.

4) Learn the failed intubation algorithm

Please be familiar with the failed intubation drill, and how you can support ICPs during the each step. Like other skills, we need to actually practice this.

Here is a good video demonstration of airway operator and assistant going through the failed intubation drill.

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OK, that’s probably enough for this week. We will have more on laryngoscopy and intubation on another post.
Most importantly, knowing the skill won’t get you anywhere near being a great airway operator or assistant. We don’t want to be geeky medics that all talk, but no action, and the only way to become a smooth operator who can perform under pressure is to…

“Practice, practice, practice!”

I hope to see many of you at the airway C & C!

Adios,

Tatsu

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7 Comments Add yours

  1. judegi says:

    •Prepare ETCO2 if this is available. – set this up on BVM
    This was discussed in the video, do want the ETC02 on the BVM?
    Your thoughts on the 3 airway adjuncts?? Hedghogging??
    Jude

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    1. Tatsu Kuwasaki says:

      You don’t need to used capnography on every BVM obviously, but if you think the patient needs intubation (cold or RSI) then sure go ahead and attach the probe to BVM. I don’t know why but even when asked, many people attach the EtCO2 probe to LP15 but appear to be hesitant in setting it up on BVM. Hope this C & C will get everyone up to speed on the proper set up of BVM including EtCO2.
      As discussed on the Basic Airway Care (https://chchparamedics.wordpress.com/2016/08/19/basic-airway/), we should always use OPA if applying jaw thrust. Hedgehogging may also be helpful for the basic airway care. However, if you choose to use nasal prong then NPAs may need to be taken out.

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      1. Tatsu Kuwasaki says:

        And…there is also another method of apnoec oxygenation using NPAs (http://doi.org/10.1186/s13049-016-0200-0). This is all part of preox and apnoec ox, that deserve totally separate discussion. I hope we will do this as a part of RSI, DSI C & C some stage in near future.

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  2. mahiaboi says:

    Hey tats just been chatting to one of the rsi icps from
    Wfa and here rsi drill involves the 3 15s. Nasals at 15 litres bagmask at 15 litres and peep at 15 as part of there pre oxygenation just thought an interesting concept. They state gives them quite a few mins before a fall in sp02

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    1. Tatsu Kuwasaki says:

      Yes it’s called the rule of 15. However, concern has been raised for the amount of O2 required in the prehospital environment. We are on our way to Hanmer but will try finding out the links for you to look later.

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