Mark Tozer, PhD: Airway Management

Showing posts with label Airway Management. Show all posts

Friday, October 17, 2025

Understanding MARCH - The Importance of Airway Management

Image retrieved from tccc.org.ua

From the MARCH Mnemonic Series – Tactical Trauma Care for EMS Providers

Following the control of massive hemorrhage, the next lifesaving priority in the MARCH algorithm is Airway.

Without a patent airway, oxygen cannot reach the lungs, and death from hypoxia can occur within minutes.

While exsanguination kills fastest, airway obstruction follows closely - especially in cases of head or neck trauma, decreased consciousness, or maxillofacial injury.

In tactical environments, airway management must be both rapid and situationally appropriate. Providers balance lifesaving intervention with operational safety - sometimes working under fire or in low-light, resource-limited conditions.

This article - the second in a five-part series - will focus on that next critical step:

A – Airway Management

A patent airway is one that is open and unobstructed, allowing air to move freely in and out of the lungs. Even a partial obstruction can reduce oxygen delivery and lead to hypoxia, brain injury, or cardiac arrest.

According to the National Safety Council (2023), foreign-body airway obstruction remains the fourth leading cause of unintentional death in the United States - emphasizing the universal need for early recognition and decisive management.

Image retrieved from tccc.org.ua

Principles of Airway Management

1. Assess the Airway Early

Assessment begins with observing the casualty’s level of consciousness, respiratory effort, and ability to speak or make sounds.

The simple question, “Can the patient talk?” remains one of the fastest airway assessments available.

Look and listen for:

Gurgling, snoring, or stridor
Facial or neck trauma
Blood, vomitus, or foreign bodies in the mouth
Absent or inadequate respiratory effort

In tactical settings, assessment must be efficient and, if under threat, may need to wait until the situation is secure enough to act safely.

Image retrieved from tccc.org.ua

2. Basic Airway Maneuvers

If the airway is obstructed or compromised, begin with manual positioning techniques:

- Head-Tilt/Chin-Lift: For non-trauma patients who are unconscious and without suspected spinal injury.

- Jaw-Thrust: For trauma patients or when spinal injury cannot be ruled out.

- Recovery Position: For semi-conscious patients who can maintain their own airway but may vomit.

These simple maneuvers are often enough to restore airway patency temporarily and can be performed quickly even under fire or during evacuation.

Image retrieved from tccc.org.ua

3. Airway Adjuncts

When manual techniques are insufficient, adjunctive devices can maintain airway patency:

- Nasopharyngeal Airway (NPA): Preferred in tactical and field care. Well tolerated in conscious or semiconscious patients and effective even with facial injuries (unless contraindicated by basilar skull fracture).

- Oropharyngeal Airway (OPA): Used only in unconscious patients without a gag reflex. Easy to insert and effective when bag-valve-mask (BVM) ventilation is required.

Advanced airways (e.g., supraglottic devices, endotracheal intubation, or surgical cricothyrotomy) may be indicated in prolonged field care or when BVM ventilation fails, but such interventions should align with provider scope and environment.

4. Clear and Control the Airway

If obstruction is caused by a foreign body, blood, or vomitus, clear it quickly:

- Perform the abdominal thrusts in conscious choking patients.

- Use suction, if available, to remove debris or fluids.

- If foreign-body airway obstruction persists in an unresponsive patient, begin CPR following standard resuscitation protocols.

In tactical contexts, effective airway control often means doing the basics well—not overcomplicating care but ensuring the airway remains open during extraction and evacuation.

5. Ongoing Monitoring and Reassessment

Airway status can change rapidly. A casualty who was breathing adequately moments ago may deteriorate due to swelling, bleeding, or decreased consciousness.

Reassess frequently- especially after movement or as the tactical situation changes.

Key Takeaway for EMS and Tactical Providers

Airway management is the second priority in the MARCH sequence, but it’s equally vital to survival. The tactical provider’s goal is to establish and maintain a patent airway using the simplest effective method appropriate to the situation.

In many cases, that means manual maneuvers and an NPA—reserving advanced interventions for when time, equipment, and safety allow.

In every case, the principle remains: “Keep it open, keep it simple, keep reassessing.”

Coming Up Next: Part Three – Respiration

With bleeding controlled and the airway secured, attention turns to respiration—assessing and managing chest injuries that can silently compromise ventilation and oxygenation.

Part Three of our MARCH series will explore the recognition and treatment of life-threatening thoracic trauma, including tension pneumothorax and open chest wounds.

When the airway is open but the chest can’t move air, the mission shifts to restoring the breath.

Monday, September 16, 2024

EMS Medical Terminology - Mackler’s Triad

Mackler’s Triad is a clinical diagnostic tool associated with spontaneous esophageal rupture, also known as Boerhaave Syndrome. It is an example of an eponymous medical term.

It includes three key symptoms:

Vomiting: Usually forceful and occurs before the rupture.

Sudden Onset Chest Pain: Sudden onset after vomiting.

Subcutaneous Emphysema: Air trapped under the skin, often detected around the neck or chest, creating a crackling sensation upon palpation (due to air leaking from the esophagus).

EMS providers should be aware that Boerhaave Syndrome is a life-threatening condition that requires immediate medical intervention.

Early recognition of the symptoms in Mackler’s Triad is critical, as delayed diagnosis and treatment significantly increase the risk of morbidity and mortality.

Key Points for EMS Providers:

High Suspicion Following Forceful Vomiting: If a patient presents with intense chest pain after vomiting, suspect an esophageal rupture.

Subcutaneous Emphysema: Feel for air under the skin, especially in the neck and chest areas.

Need For Rapid Transport: Esophageal ruptures require surgical intervention and antibiotics to prevent fatal infections such as mediastinitis (infection in the chest cavity).

Stabilization: Manage the airway, ensure the patient is NPO (nothing by mouth), administer IV fluids if necessary, and provide pain control.

Who Discovered This?

Dr. Sydney S. Mackler was an American physician and surgeon who first described the triad in 1952. He made significant contributions to understanding and diagnosing Boerhaave Syndrome.

The triad is named after him due to his work linking these three symptoms to spontaneous esophageal rupture, helping to guide clinicians in making this often elusive diagnosis.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Loftus, I. A., Umana, E. E., Scholtz, I. P., & McElwee D. (2023) Mackler's Triad: An Evolving Case of Boerhaave Syndrome in the Emergency Department. Cureus 15 (4): e37978. Accessed September 16, 2024

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell

Turner, A. R., Collier, S. A., & Turner, S. D. (2023) Boerhaave Syndrome. Treasure Island, Florida: StatPearls. Accessed September 14, 2024

Tuesday, September 10, 2024

EMS Equipment - Murphy's Endotracheal Tube

For EMS providers, understanding the Murphy Endotracheal Tube and its key feature, the “Murphy Eye,” is essential for ensuring patient safety during airway management.

The Murphy eye serves as a critical safety mechanism that prevents complete airway obstruction if the main distal opening of the tube becomes blocked. It is also an example of an eponymous medical term.

Recognizing this feature and the overall design of the endotracheal tube can help prevent complications during intubation and ensure the continued delivery of oxygen to patients in emergency situations.

The “Murphy Eye” Explained

The Murphy Eye is the eponymous term for a small hole on the side of most endotracheal tubes (ETTs). It functions as a vent, preventing complete obstruction of the patient’s airway if the primary distal opening of the ETT becomes occluded.

Dr. Francis J. Murphy (1900–1972) was a strong advocate for the continuous supply of oxygen during anesthesia. In 1941, he outlined the nine characteristics of the "ideal" endotracheal tube (ETT). In the same article, he introduced two tubes with innovative features.

One tube was straight with two side holes, while the other was curved with one side hole. Both lacked cuffs and were made from high-quality red rubber that balanced flexibility with resistance to compression or kinking, even after multiple uses and heat sterilizations.

Although most ETTs today are made from disposable plastic, they still require a similar balance of flexibility and resistance to compression. Most continue to incorporate the crucial safety feature that bears Dr. Murphy's name: the "Murphy eye."

The featured image show the orginal tube, owned by Dr. Murphy himself, and bears his initials. It features an inflatable cuff located above the "eye," which is inflated via a small side tube attached to the ETT.

Further Reading:

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins.

Sunday, September 08, 2024

EMS Medical Terminology - Sellick's Maneuver

EMS providers should be familiar with the Sellick Maneuver, also known as cricoid pressure, as a technique designed to reduce the risk of regurgitation and aspiration during endotracheal intubation, particularly in patients who are not fasting or at high risk of vomiting. It is an example of an eponymous medical term.

It was first described by Dr. Brian Sellick in 1961 and has been used in emergency and anesthetic situations ever since.

However, it’s essential for EMS providers to apply the right amount of pressure and know that this technique is sometimes debated due to concerns that it may obstruct the airway or complicate intubation in some cases.

Here's what they should know:

Key Concepts

Anatomy Involved:

The cricoid cartilage is a ring-shaped structure located just below the thyroid cartilage in the neck.

When performing the Sellick Maneuver, downward pressure is applied to the cricoid cartilage, which in turn compresses the esophagus against the vertebral column, theoretically reducing the chance of regurgitation by preventing stomach contents from moving into the pharynx.

When to Use It:

Primarily used during rapid sequence intubation (RSI) to protect the airway in emergency situations, especially when there's a high risk of vomiting (e.g., trauma patients, those who have recently eaten, or have decreased consciousness).

It may also be employed during bag-valve-mask (BVM) ventilation to prevent gastric insufflation, although this use is somewhat controversial.

How to Perform It:

The provider places firm, continuous pressure using the thumb and forefinger on the cricoid cartilage (located below the Adam’s apple).

The recommended pressure is about 10 Newtons (≈1 kg of force) initially, increasing to 30-40 Newtons (≈3-4 kg of force) once the patient loses consciousness, as the risk of vomiting increases at that point.

Controversies & Limitations:

Questionable Efficacy: Studies over the years have raised doubts about the effectiveness of the Sellick Maneuver in completely preventing regurgitation or aspiration. In some cases, it may even impair ventilation or visualization of the airway during intubation, particularly in difficult airway scenarios.

Potential Complications: Incorrect application of the maneuver (too much force or misplacement of pressure) can result in airway obstruction or displacement of the esophagus laterally rather than compressing it.

Many modern airway protocols have deemphasized its routine use and instead focus on optimal intubation techniques and preparation for managing airway complications.

Training & Clinical Judgment:

EMS providers should be well-trained in applying the maneuver correctly, but also be aware that if it interferes with ventilation or intubation, it should be discontinued.

It’s essential to assess the specific patient scenario (e.g., suspected difficult airway) and weigh the benefits and risks of applying cricoid pressure.

Summary

The Sellick Maneuver was historically considered a key technique for preventing aspiration during emergency intubation, but its effectiveness is now debated.

EMS providers should understand the anatomy, application method, and potential complications, and apply it judiciously based on the clinical situation.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins.

Ebright, C. (2024) Unique Patient Signs: A Case Study. EMS1. Accessed May 1, 2024

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell

Friday, September 06, 2024

EMS Airway Emergencies - Esophageal Varices

Esophageal Varices are abnormally dilated veins in the lower part of the esophagus that develop as a result of portal hypertension, commonly due to liver cirrhosis.

These varices pose a high risk of massive upper gastrointestinal (GI) bleeding, which can be life-threatening.

When esophageal varices rupture, they can cause severe hematemesis (vomiting of blood), shock, and potentially death if not managed promptly.

Causes and Pathophysiology

- Portal Hypertension: The most common cause of esophageal varices is liver cirrhosis (often due to chronic alcohol use, hepatitis B or C, or fatty liver disease).

Portal hypertension occurs when the liver becomes scarred and obstructs blood flow, leading to increased pressure in the portal venous system.

- Collateral Circulation Formation: To relieve this increased pressure, the body forms collateral blood vessels (varices) in the esophagus and stomach. These varices are thin-walled and prone to rupture.

- Rupture and Hemorrhage: When pressure becomes too high or if the varices are mechanically disrupted (e.g., vomiting, coughing), they can rupture, leading to severe bleeding.

Signs and Symptoms of Esophageal Variceal Bleeding

EMS providers should be alert for the following symptoms in patients with a known history of liver disease or portal hypertension:

- Profuse Hematemesis: Patients often present with large volumes of bright red blood in vomit, which is the hallmark sign of a ruptured varix.

- Melena or Hematochezia: Blood may pass through the GI tract and present as black, tarry stools (melena) or bright red rectal bleeding (hematochezia), depending on the speed and severity of the bleed.

- Hypovolemic Shock: Tachycardia and hypotension are common signs. Cool, clammy skin, altered mental status, and pallor indicate worsening shock.

- Signs of Liver Disease:

Jaundice (e.g., yellowing of the skin and eyes)
Ascites (e.g., swollen abdomen due to fluid accumulation)
Spider Angiomata (e.g., visible, web-like blood vessels on the skin)
Hepatic Encephalopathy (e.g., confusion, altered consciousness)

Prehospital Assessment

- Scene Size-Up and Initial Impression: Evaluate the scene for large amounts of blood, which can indicate massive hemorrhage.

Assess for a patient history of liver disease, alcoholism, or known cirrhosis.

- Airway & Breathing: Monitor for airway obstruction due to blood in the mouth or pharynx.

Be prepared to suction the airway frequently to prevent aspiration.

Assess respiratory status and provide high-flow oxygen if needed.

- Circulatory Assessment: Check for signs of shock (e.g., tachycardia, hypotension).

Establish large-bore IV access (18 gauge or larger) for potential fluid and medication administration.

Monitor mental status and skin condition (pallor, coolness).

- Focused History & Physical Exam: Ask about the patient’s history of liver disease, alcohol use, hepatitis, or prior variceal bleeding.

Inquire about recent triggers (e.g., vomiting, straining, recent alcohol binge) that may have precipitated bleeding.

Prehospital Treatment and Management

Managing esophageal varices in the prehospital setting is challenging and requires prompt, aggressive intervention to control bleeding and prevent shock.

1. Airway Management

- Suctioning: Keep a suction device readily available for continuous use to clear the airway of blood.

- Airway Positioning: Consider placing the patient in the left lateral recumbent position if unconscious to reduce the risk of aspiration.

- Definitive Airway: If the patient is at risk of losing their airway (e.g., massive hematemesis or altered mental status), consider early endotracheal intubation, if within your scope and if protocols allow.

2. Hemodynamic Support

- IV Fluid Resuscitation: Establish two large-bore IVs and begin fluid resuscitation with isotonic crystalloids (e.g., normal saline) if the patient shows signs of hypovolemic shock.

Avoid aggressive fluid overload, as it can increase portal hypertension and worsen bleeding.

- Blood Products: If available (e.g., in critical care transport), consider initiating blood transfusion early in patients with significant bleeding or hemorrhagic shock.

3. Medications

- Vasoactive Agents (for ALS Providers): If within your scope and protocol, consider octreotide or vasopressin, which can reduce portal pressure and control variceal bleeding (requires medical control consultation).

- Anti-Emetics: Administer antiemetics (e.g., ondansetron) to prevent retching and reduce the risk of worsening the variceal tear.

4. Rapid Transport and Early Notification

- Transport Priority: All patients with suspected variceal bleeding should be considered critical and require rapid transport to the nearest facility with endoscopic capabilities and surgical backup.

- Early Notification: Notify the receiving hospital as early as possible about the suspected diagnosis, so the facility can mobilize appropriate resources.

Differentiating from Other GI Bleeds

- Peptic Ulcer Disease: Often presents with coffee-ground emesis and less profuse bleeding.

- Mallory-Weiss Syndrome: Similar to varices but generally involves small, non-life-threatening mucosal tears with moderate bleeding.

- Gastric Cancer or Erosive Gastritis: May have chronic, low-volume bleeding rather than acute hemorrhage.

Who Discovered Esophageal Varices?

Esophageal Varices themselves are not attributed to a specific individual. They were gradually recognized as a consequence of portal hypertension in patients with liver disease, a concept that evolved over centuries of clinical observation.

The condition was first described in detail in the early 20th century, as the understanding of cirrhosis and portal hypertension advanced.

The development of endoscopy in the mid-20th century allowed for more precise diagnosis and management of this life-threatening condition.

Key Considerations for EMS Providers

- Early Recognition: Suspect esophageal varices in any patient with massive hematemesis and a history of liver disease or alcohol abuse.

- Airway Safety: Suctioning and airway management are critical to prevent aspiration.

- Shock Management: Focus on maintaining perfusion with controlled fluid resuscitation.

- Definitive Treatment is Hospital-Based: EMS management is primarily supportive, with rapid transport to a facility that can perform endoscopy and possible surgical interventions.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Meseeha, M., & Attia, M. (2023) Esophageal Varices. StatPearls. Treasure Island, Florida: StatPearls. Accessed September 28, 2024

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell

Monday, August 05, 2024

EMS Airway Management - The 9 P’s of Rapid Sequence Intubation (RSI)

The 9 P’s of Rapid Sequence Intubation (RSI) is a systematic approach that EMS providers use to ensure the safe and effective management of airway control in critically ill or injured patients.

Here's what EMS providers need to know about each step:

1. Plan

Strategic Planning:
- Assess the need for intubation based on the patient's condition, such as respiratory failure, decreased level of consciousness, or impending airway compromise.
- Consider alternative airway management strategies in case RSI fails (e.g., supraglottic airway, surgical airway).
Backup Plan:
- Establish a clear plan for what to do if initial attempts at intubation fail, including calling for additional help or preparing for an alternative airway.

2. Preparation

Drugs:
- Prepare and draw up all necessary medications for induction (e.g., etomidate, ketamine) and paralysis (e.g., succinylcholine, rocuronium).
- Check drug dosages based on the patient’s weight and condition, and label syringes clearly.
Equipment:
- Ensure all airway equipment is ready, including laryngoscope blades, endotracheal tubes (ETTs) of various sizes, stylets, and backup devices like the iGel.
- Check the functionality of suction devices, bag-valve masks (BVMs), and capnography monitors.
People:
- Assign roles to team members, ensuring clear communication about who will administer medications, who will perform the intubation, and who will monitor the patient.
- Designate someone to manage the patient’s cervical spine if trauma is suspected.
Place:
- Prepare the environment by ensuring adequate space, lighting, and a stable surface for the procedure.
- Ensure that all necessary equipment and personnel are within reach.

3. Protect the Cervical Spine

Cervical Spine Precautions:
- If trauma is suspected, manually stabilize the cervical spine to prevent movement and further injury.
- Consider in-line stabilization while maintaining the cervical collar and minimizing neck movement during intubation.

4. Positioning

Optimal Positioning:
- Position the patient in the “sniffing” position, with the head slightly elevated and the neck extended, to align the oral, pharyngeal, and laryngeal axes for better visualization during intubation.
- In patients with suspected cervical spine injuries, maintain manual in-line stabilization without compromising the airway.
Consider Post-Paralysis:
- In some cases, optimal positioning is achieved after paralysis and induction to ensure proper relaxation of the muscles.

5. Preoxygenation

Maximize Oxygen Reserves:
- Preoxygenate the patient using a non-rebreather mask or BVM with 100% oxygen for 3-5 minutes to increase oxygen reserves and reduce the risk of hypoxia during the apneic period.
- In spontaneously breathing patients, consider passive oxygenation via nasal cannula in addition to preoxygenation.
Avoid Hyperventilation:
- Ensure proper ventilation rate and tidal volume, avoiding hyperventilation which can cause hypoventilation.

6. Pretreatment (Optional)

Medications for Specific Situations:
- Atropine: May be used in pediatric patients to prevent bradycardia during intubation, especially in those under the age of 1.
- Fentanyl: May be used in patients with increased intracranial pressure or cardiac conditions to blunt the sympathetic response.
- Lidocaine: May be administered to reduce the risk of increased intracranial pressure during intubation, though its use is less common.
Timing:
- Administer pretreatment drugs 3 minutes before induction to allow them to take effect.

7. Paralysis and Induction

Induction:
- Administer the induction agent (e.g., etomidate, ketamine) rapidly to induce unconsciousness, followed immediately by the paralytic agent.
Paralysis:
- Administer the neuromuscular blocking agent (e.g., succinylcholine or rocuronium) to achieve complete paralysis, facilitating intubation.
Sequence:
- The sequence is critical: induction agent first to prevent patient awareness, followed by the paralytic to facilitate intubation.

8. Placement with Proof

Intubation:
- Insert the endotracheal tube (ETT) with the help of a laryngoscope, ensuring the tube passes through the vocal cords and into the trachea.
Confirmation:
- Confirm ETT placement by visualizing the tube passing through the vocal cords, auscultating for bilateral breath sounds, and using capnography to verify end-tidal CO2.
- Look for chest rise, misting in the tube, and the absence of epigastric sounds to confirm proper placement.
Secure the Tube:
- Secure the ETT with a tube holder or tape to prevent dislodgement during transport.

9. Post-Intubation Management

Ongoing Sedation and Analgesia:
- Continue sedation and analgesia to keep the patient comfortable and prevent awareness during mechanical ventilation.
- Administer medications such as midazolam or propofol for sedation, and opioids like fentanyl for pain control.
Ventilation and Monitoring:
- Ensure proper ventilation settings on the mechanical ventilator or BVM, and continuously monitor oxygenation, ventilation, and hemodynamics.
- Regularly reassess ETT placement and patency, ensuring that the tube remains secured.
Management of Complications:
- Be prepared to manage any complications, such as hypotension due to sedatives, or difficulties with ventilation.

Conclusion

The 9 P’s of Rapid Sequence Intubation provide a comprehensive framework for EMS providers to manage critical airways effectively and safely. Understanding each step, from planning and preparation to post-intubation management, ensures that providers are prepared to handle the challenges of RSI in the field.

Continuous training, adherence to protocols, and effective teamwork are key to successful outcomes in airway management.

Saturday, August 03, 2024

EMS Airway Management - 7 Es of Advanced Airway Management Education

The article by Terry Riddle, FP-C, emphasizes a structured approach to training in advanced airway management for medical professionals.

The "7 Es" framework includes the following key components:

Education - Focusing on foundational knowledge.
Evaluation - Regular assessment of skills.
Experience - Gaining practical, hands-on experience.
Environment - Understanding the importance of a conducive learning and working environment.
Equipment - Familiarity with and access to the right tools.
Errors - Learning from mistakes to improve practice.
Excellence - Striving for the highest standards in patient care and professional development.

This approach aims to ensure comprehensive, high-quality training that prepares healthcare providers for the complexities of airway management in various clinical settings.

For more information, access the article link here.

Thursday, August 01, 2024

EMS Airway Management - iGel Supraglottic Airway Device

The iGel supraglottic airway device is an essential tool for EMS providers when managing a patient's airway, especially in situations where endotracheal intubation may be difficult or not immediately feasible.

Here’s some thing EMS providers need to know about the iGel:

1. Indications and Contraindications

- Indications: Emergency airway management in unconscious patients with absent or inadequate respiratory effort.

Alternative to endotracheal intubation during cardiac arrest, respiratory arrest, or when intubation is not possible.
Can be used in prehospital settings in combination with anesthesia, sedation, or other airway management situations requiring a secure airway.

- Contraindications:Conscious or semi-conscious patients with intact gag reflex.

Patients with known esophageal disease or pathology, such as esophageal varices.
Patients with a high risk of aspiration or who have ingested a large meal recently.
Severe airway trauma or obstruction that may prevent insertion.

2. Device Design and Features

Supraglottic Airway: The iGel is designed to sit above the glottis, creating a seal around the laryngeal inlet without inflating a cuff.
Gel-Like Cuff: The cuff is made of a soft, gel-like material that molds to the patient’s anatomy, minimizing trauma and reducing the need for precise sizing.
Integral Bite Block: Built-in bite block helps prevent the patient from biting down and occluding the airway.
Gastric Channel: The device includes a gastric channel that allows for the insertion of a gastric tube to decompress the stomach and reduce the risk of aspiration.
Sizing: The iGel comes in multiple sizes, typically based on patient weight, ranging from neonates to large adults.

3. Preparation and Insertion

Sizing: Select the appropriate size based on the patient’s weight.
Typical Ranges:

Size 1: Neonates (2-5 kg)
Size 2: Pediatric (10-25 kg)
Size 3: Small adult (30-60 kg)
Size 4: Medium adult (50-90 kg)
Size 5: Large adult (90+ kg)

Lubrication:Cover the back, sides, and cuff of the device with a water-based lubricant.

Avoid over-lubricating the front of the device to prevent blocking the airway opening.

Insertion Technique: Position the patient’s head in a neutral or slightly extended position.

Open the patient’s mouth and gently insert the iGel along the natural curve of the airway until resistance is felt, indicating it is seated correctly.
Avoid excessive force during insertion to prevent trauma.

Confirmation: Confirm placement by observing chest rise, listening for bilateral breath sounds, and using capnography (if available).
Security: Secure the device with a strap or tape to prevent dislodgement.

4. Maintenance and Monitoring

Ongoing Assessment: Continuously monitor for effective ventilation, chest rise, and oxygen saturation.

Regularly check for signs of dislodgement, obstruction, or leakage.

Gastric Decompression: If necessary, insert a gastric tube through the gastric channel to decompress the stomach and reduce the risk of regurgitation and aspiration.
Ventilation: Connect the device to a bag-valve mask (BVM) or ventilator, ensuring adequate tidal volume and oxygen delivery.

5. Complications and Troubleshooting

Airway Obstruction: If ventilation is inadequate, reassess the device placement, and consider repositioning or reinsertion.
Aspiration Risk: Despite the gastric channel, there is still a potential risk of aspiration; be prepared to manage this complication if it occurs.
Device Dislodgement: Regularly check the device's position and secure it properly to avoid dislodgement, especially during patient movement or transport.
Trauma or Discomfort: Monitor for signs of airway trauma or discomfort, particularly if insertion was difficult.

6. Removal

Timing: The iGel should be removed once the patient regains consciousness and airway reflexes, or if endotracheal intubation is indicated.
Technique: Gently withdraw the device while monitoring for any signs of obstruction, aspiration, or respiratory distress.

Prepare to manage the airway immediately if complications arise during removal.

7. Training and Proficiency

Simulation Training: Regular practice with the iGel device in simulated scenarios to maintain proficiency in its use.
Familiarization: EMS providers should be familiar with the different sizes and specific features of the iGel, including the gastric channel and the appropriate insertion technique.
Continuing Education: Stay updated on best practices, new developments, and guidelines related to supraglottic airway management.

8. Legal and Ethical Considerations

Scope of Practice: Ensure the use of the iGel is within the provider’s scope of practice as defined by their certification level and local protocols.
Informed Consent: While typically used in emergencies where consent cannot be obtained, providers should be aware of the ethical considerations in airway management.
Documentation: Document the size of the device used, time of insertion, confirmation methods, patient response, and any complications encountered.

Conclusion

The iGel supraglottic airway device is a valuable tool in the EMS provider’s airway management arsenal. Proper selection, insertion, and management are crucial to ensure effective ventilation and patient safety.

It was invented by Dr. Muhammed Aslam Nasir and is manufactured by Intersurgical.

Continuous training and familiarity with the device will enhance the provider's ability to use the iGel effectively in emergency situations.