Cricothyroidotomy revised 12-12-03 

PTL

RSI revised 12-12-03

SECTION 5

EMERGENCY RESPIRATORY

CARE PROTOCOLS

CRICOTHYROIDOTOMY •revised 12-12-03

 

  1. Overview: Cricothyroidotomy is an invasive, surgical procedure to establish an emergency airway in a critically ill patient. Although it can be a life saving procedure, it has a high incidence of complications and therefore is indicated in only the most dire of circumstances.
  2. Indications: To establish an airway in a patient who will die due to a lack of airway if the procedure is not performed. All other types of airways available to the paramedic should be considered and/or attempted prior to undertaking a surgical airway. This includes oral and nasal airways, endotracheal intubation, and PTL. If the patient is maintaining even a tenuous airway, then attempts should be made to transport the patient to the closest emergency room to have the procedure performed by a physician. However, have tenuous patients prepped and be ready to perform the procedure in necessary, as no patient in the care of Sumner County EMS should die due to airway obstruction.
  3. Examples of patients who might benefit from this procedure:
    1. Trauma patients with severe facial injuries causing airway obstruction.
    2. Patients with food bolus obstructing airway and less invasive methods of relieving the obstruction have failed.

 

  1. Complications:
    1. bleeding, often severe
    2. infection
    3. vocal cord damage
    4. perforation of trachea and/or esophagus
    5. placement of tube into esophagus or surrounding tissues of the neck, rather than the trachea

 

  1. Contra-indications: Given that you will only be performing this procedure on patients who have a very high probability of dying without it, all contra-indications would therefore be relative. Patients at high risk for complications include those on blood thinners, with bleeding disorders or with abnormal anatomy of the neck. Performance of this procedure on patients 2 years of age or less is not possible with the equipment we have available, and therefore should not be attempted.

 

VI. Procedure:

    1. Determine all less invasive measures have been exhausted.
    2. Contact medical control for orders to perform the procedure.
    3. If time permits, prep the site.
    4. Use pediatric kit for children ages 2 to 12.
    5. Identify the cricothyroid membrane (in children, you will be performing a tracheostomy as the cricothyroid membrane is to small. In children, choose a location over the proximal trachea.)
    6. •Assure stable positioning of the neck.
    7. •Puncture the cricothyroid ligament at 90º angle.
    8. •Aspirate air through the syringe during insertion.
    9. •Advance device forward onto the trachea to the level of the stopper.
    10. •With your thumb on the knob and your 2nd and 3rd finger curved under the flange of the tube, exert constant pressure to push the device into the airway until flush with the skin. (The pediatric tube has no flange).
    11. •Remove the stopper.
    12. •Remove the needle and syringe.
    13. •Secure the cannula with neck tape.
    14. •Ventilate and confirm patent airway with CO2 and conventional methods.
    15. •Transport and document - document - document.

 

 Ray Pinkston, M.D.

Medical Director

Sumner County EMS

Feb. 15, 2000

PHARYNGEAL TRACHEAL LUMEN AIRWAY (PTL)

GENERAL CARE GUIDELINES

 

  1. GENERAL OVERVIEW OF THE PATIENT AND CHECK ABC’S
  2. GATHER AND CHECK ALL EQUIPMENT, IF POSSIBLE, ANOTHER PERSON NEEDS TO BE VENTILATING THE PATIENT ADEQUATELY WHILE YOU ARE ASSEMBLING THE EQUIPMENT
  3. ASSESS BREATH SOUNDS BILATERALLY
  4. OBTAIN DEVICE FROM THE PACKAGE WHILE YOUR PARTNER VENTILATES VIA BVM PRIOR TO INSERTION
  5. INSERT TIP OF THE DEVICE INTO THE MOUTH FOLLOWING THE NATURAL CURVATURE UNTIL THE TEETH RING (PRINTED RING) IS SEATED ON THE MOUTH ACCORDINGLY. (DO NOT FORCE)
  6. SECURE THE NECK STRAP
  7. INFLATE BOTH CUFFS SIMULTANEOUSLY. CHECK FOR PROPER TUBE PLACEMENT. (REMEMBER, #2-SHORT GREEN TUBE, #3 LONG CLEAR TUBE)
  8. AFTER CONFIRMING WHICH TUBE YOU ARE VENTILATING THROUGH, RE-ASSESS BILATERAL BREATH SOUNDS AND EPIGASTRIC SOUNDS
  9. CONTINUE VENTILATIONS THROUGH APPROPRIATE TUBE WHILE PERSONNEL INITIATE SECONDARY SURVEY
  10. DOCUMENT ANY CHANGES WITH THE PATIENT BEFORE, DURING, AND AFTER THIS PROCEDURE
  11. TRANSPORT AS INDICATED. NEVER DELAY TRANSPORT OF A CRITICAL PATIENT

 

NOTE: REMEMBER THE WHITE PORT CAP NEEDS TO BE SECURED (CLOSED) Before INSERTION

 

RAPID SEQUENCE INDUCTION AND INTUBATION •revised 12-12-03

 

  1. OVERVIEW: RAPID SEQUENCE INDUCTION (RSI) IS MEDICAL PROCEDURE USED TO ESTABLISH AN AIRWAY IN A CRITICALLY ILL PATIENT WHEN ALL LESS INVASIVE F0RMS OF AIRWAY CONTROL HAVE FAILED OR HAVE BEEN CONSIDERED AND DEEMED USELESS BY THE PARAMEDIC. ALTHOUGH IT CAN BE A LIFE SAVING PROCEDURE, IT HAS A HIGH INCIDENCE OF COMPLICATIONS, AND THEREFORE SHOULD BE USED ONLY IN THE MOST DIRE OF CIRCUMSTANCES. ONLY PARAMCEDICS WHO HAVE HAD TRAINING AND CHECK-OFF ON THIS PROCEDURE IN THE LAST 6 MONTH BY HIS/HER MEDICAL DIRECTOR MAY USE IT. AT NO TIME SHOULD THE PARAMEDIC FEEL PRESSURED TO PERFORM THIS PROCEDURE, IF HE OR SHE IS NOT COMFORTABLE WITH ITS APPLICATION ON A GIVEN PATIENT.
  2. INDICATION: TO ESTABLISH AN AIRWAY IN A PATIENT WHO IS AT RISK OF DEATH SECONDARY TO LOSS OF AIRWAY OR INABILITY TO VENTILATE, AND THE AIRWAY CONNOT BE CONTROLLED BY CONVENTIONAL MEANS.
  3. EXAMPLES OF PATIENTS WHERE RSI MIGHT BE INDICATED
    1. FACIAL OR HEAD TRAUMA PATIENTS WITH LOSS OF AIRWAY CONTROL.
    2. RESPIRATORY DISTRESS WITH HYPOXIA AND RESPIRATORY EXHAUSTION.
    3. BURN PATIENTS WITH AIRWAY INVOLVEMENT AND RESPIRATORY DISTRESS.
    4. OVERDOSE WITH LOSS OF AIRWAY PROTECTION AND HYPOXIA.

 

  1. CONTRAINDICATIONS:
    1. ALLERGIES TO ANY ONE OF THE AGENTS
    2. HISTORY OF A MALIGNANT HYPERTHERMIA
    3. RENAL FAILURE
    4. SPINAL CORD INJURY GREATER THAN 24 HOURS OLD OR NEUROMUSCULAR DISEASE
    5. SEVERE BURNS GREATER THAN 8 HOURS OLD
    6. MASSIVE CRUSH INJURIES
    7. PESTICIDE POISONING
    8. PENETRATING EYE INJURIES

 

  1. PROCEDURE: (AT LEAST A TWO PERSON JOB)
    1. INITIATE STANDARD TREATMENT AS INDICATED (ABC’s, IV’s, MONITOR, ETC)
    2. PLACE PATIENT ON PULSE-OXIMETER
    3. ATTEMPT LESS INVASIVE AIRWAY CONTROL AND DETERMINE NEED FOR RSI.
    4. PRE-OXYGENATE PATIENT WITH HIGH FLOW OXYGEN BEING CAREFUL TO NOT DISTEND THE STOMACH IF AT ALL POSSIBLE.
    5. ASSEMBLE ALL THE MEDICATIONS WITH THE EXCEPTION OF VECURONIUM (YOU WILL HAVE TIME FOR THIS LATER) AND PLACE THEM IN ORDER OF ADMINISTRATION. ALSO ASSEMBLE AND CHECK ALL NEEDED EQUIPMENT FOR THE PROCEDURE.
    6. IF PATIENT HAS A SUSPECTED HEAD INJURY OR STROKE, ADMINISTER LIDOCAINE 1 MG/KG.
    7. ADMINISTER •VERSED 2 MG IV PUSH OR 0.2 MG/KG IN CHILDREN (THIS STEP MAY BE SKIPPED IN THE OVERDOSE PATIENT).
    8. IN CHILDREN LESS THAN 8 YEARS, ADMINISTER 0.02 MG/KG OF ATROPINE (MINIMUM DOSE OF 0.15 MG).
    9. PERFORM SELLICK’S MANEUVER. IF PATIENT VOMITS, RELEASE AND SUCTION VIGOROUSLY. SELLICK’S SHOULD BE HELD UNTIL PATIENT IS INTUBATED.
    10. ADMINISTER SUCCINYLCHOLINE 1 MG/KG IV PUSH.
    11. INTUBATE WHEN PATIENT BECOMES FLACCID, OFTEN AFTER FASCICULATIONS.
    12. CONFIRM INTUBATION BY CO2 DETECTION AS WELL AS STANDARN MEANS.
    13. HYPERVENTILATE WITH 100% OXYGEN
    14. ADMINISTER VECURONIUM 0.1 MG/KG IV PUSH AFTER INTUBATION ASSURED.
    15. RE-ASSESS PATIENT FOR SEDATION. IF PATIENT IS TACHYCARDIC AND NOT HYPOTENSIVE, CONSIDER VALIUM 0.1 MG/KG OR MORPHINE 0.1 MG/KG.
    16. DOCUMENT

 

 

RAY PINKSTON, M.D.

MARCH 1, 2000