Mark Tozer, PhD

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.

Tuesday, July 30, 2024

EMS Airway Management - RSI v DSI

EMS providers should understand the key differences between Delayed Sequence Intubation (DSI) and Rapid Sequence Intubation (RSI) to determine the most appropriate approach for managing a patient's airway in critical situations.

Here are some things to know:

1. PURPOSE AND INDICATIONS

Rapid Sequence Intubation (RSI):

Purpose:

RSI is designed to secure the airway quickly and efficiently by inducing unconsciousness and paralysis in a matter of seconds, allowing for immediate intubation.

Indications:

RSI is used in situations where a patient requires immediate airway control, such as in cases of severe respiratory failure, trauma, or cardiac arrest, and where the patient is unable or unlikely to tolerate laryngoscopy without pharmacologic assistance.

Delayed Sequence Intubation (DSI):

Purpose:

DSI is a modified version of RSI that allows for the controlled induction of unconsciousness in a patient who needs preoxygenation but is either combative, anxious, or unable to tolerate preoxygenation.
The key difference is that DSI provides a window for preoxygenation after sedation but before paralysis.

Indications:

DSI is particularly useful in patients with conditions like severe hypoxia, agitation, or anxiety, where cooperative preoxygenation is necessary but not possible without sedation.
It’s often employed in cases where hypoxemia needs to be optimized before intubation.

2. SEQUENCE OF STEPS

RSI Steps:

Preoxygenation: The patient is preoxygenated, typically with a non-rebreather mask or BVM.
Induction and Paralysis: Sedative and paralytic agents are administered almost simultaneously to rapidly induce unconsciousness and paralysis.
Intubation: The patient is immediately intubated once paralysis sets in, typically within seconds to a minute of drug administration.

DSI Steps:

Sedation: The patient is sedated first, usually with a dissociative agent like ketamine, allowing them to tolerate preoxygenation without agitation.
Preoxygenation: After sedation, the patient is preoxygenated in a more controlled manner, improving oxygen reserves before proceeding to intubation.
Paralysis and Intubation: Once adequate preoxygenation is achieved, a paralytic is administered, and the patient is then intubated as in RSI.

3. KEY DIFFERENCES IN APPROACH

Sedation Timing:

RSI: Sedation and paralysis occur almost simultaneously, leaving little time for any further patient preparation or intervention.
DSI: Sedation is performed first, allowing the patient to be more effectively preoxygenated while still breathing spontaneously.

Oxygenation Focus:

RSI: The priority is rapid intubation, often under the assumption that the patient has been adequately preoxygenated beforehand.
DSI: The focus is on improving oxygenation in patients who are at risk of severe hypoxia before intubation, using the sedation phase to achieve better preoxygenation.

Patient Condition:

RSI: Best suited for patients who can be adequately preoxygenated before the induction of anesthesia and paralysis.
DSI: Ideal for patients who are agitated, hypoxic, or otherwise unable to cooperate with preoxygenation due to altered mental status, respiratory distress, or other factors.

4. ADVANTAGES AND DISADVANTAGES

Rapid Sequence Intubation:

Advantages:

Quick and efficient airway control.
Reduces the risk of aspiration and airway trauma.

Disadvantages:

In patients who are not adequately preoxygenated, the risk of hypoxia during the apneic period is higher.
May be challenging in patients who are difficult to preoxygenate or who have an unstable airway.

Delayed Sequence Intubation :

Advantages:

Allows for better preoxygenation in high-risk patients.
Reduces the risk of hypoxia during intubation by optimizing oxygen levels before paralysis.

Disadvantages:

Takes longer than RSI, which may not be suitable in situations requiring immediate airway control.
Requires careful monitoring to ensure that the patient remains adequately sedated without losing airway reflexes prematurely.

5. CLINICAL CONSIDERATIONS

Patient Selection:

RSI: Preferred in situations where time is of the essence, and the patient is at immediate risk of airway compromise.
DSI: Considered in cases where there is enough time to optimize the patient’s oxygenation before paralysis, especially in patients who are at high risk for desaturation or in those who are uncooperative.

Skill and Experience:

Both RSI and DSI require advanced airway management skills. EMS providers must be adept at assessing the patient’s condition and deciding which approach is most appropriate.

CONCLUSION

Understanding the differences between DSI and RSI allows EMS providers to tailor their approach to the specific needs of the patient. While RSI is the standard for rapid airway control, DSI provides an important alternative for patients who need improved oxygenation before intubation.

The choice between the two depends on the patient's condition, the urgency of the situation, and the provider's assessment of the most effective strategy for ensuring a successful intubation.