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Introduction to ALS

Introduction to ALS. Sir Sandford Fleming. Outline. Work Environment Scope of Practice Training Equipment Procedures How PCP/ACP Combos work What will be expected of you?. Work Environment. Many services are up to 40% ALS Presents different challenges Bags are different

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Introduction to ALS

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  1. Introduction to ALS Sir Sandford Fleming

  2. Outline • Work Environment • Scope of Practice • Training • Equipment • Procedures • How PCP/ACP Combos work • What will be expected of you?

  3. Work Environment • Many services are up to 40% ALS • Presents different challenges • Bags are different • Dispatched differently • Crew configuration different (>age) • Expectations for level of care higher • Closer scrutiny • Potentially more stress for the crew • Combined care (different attendant/driver roles)

  4. Work Environment • Legislation • Narcotics • Check sheets • Signatures • DMA • Risk’s/benefit • Higher chance something will go much better or much worse

  5. Scope of Practice • Lots more drugs • Lots more heavy things • Special airway equipment • Special features on monitor • Manual defib • Cardioversion • Pacing (transcutaneous)

  6. Scope of Practice Manual Defibrillation, Pacing and Cardioversion Advanced Airway LMA’s , Lited Stylets BTLS, ACLS ,PALS IV Therapy ALS Drugs plus Symptom Relief, Versed, Fentanyl Activated Charcoal CXR Interp Pentaspan

  7. Difficult Airway Algorithm Need ETT Attempt #1 -Without sedation(crash) or nasal ETT Attempt #2- Midazolam 0.05 mg/kg Fentanyl 1-1.5 mcg/kg Attempt #3(or RSI Direct) Lidocaine, (atropine) with midazolam and fentanyl (see above) and succinylcholine 1-1.5 mg/kg Backup- Laryngeal Mask Airway, Lighted Stylet, Surgical Airway

  8. Training • Time lines – roughly 1 year for ALS • Didactic –classroom time • Clinical –practice in a controlled setting • OR • ER • MOP/SOP • OBS/PEDS/ICU • Other (Burn Unit, HSC IV Team)

  9. Preceptorship/Consolidation • Where it should all come together • With a designated preceptor • Gradual transition to full care

  10. Equipment • Airway- • Basic airway • Laryngoscope plus ETT for Intubation • Rescue Devices –advanced airway • Lighted stylet • LMA – • Surgical –Seldinger vs Quik Trach • Bougie

  11. Cardioversion Pacing Sedation Vagal and CSM Manual Defibrillation IV Bolus and IV medication Other routes (PR,IN,IM,ETT,IO) Intubation Advanced airway Needle decompression IO Thrombolytics VAD Central access Procedures

  12. Airway

  13. CONTROL THE AIRWAY Airway Management Decision Process (Judge how aggressive you need to be.) -Time/Distance -Personnel -Equipment -Other Considerations?

  14. CONTROL THE AIRWAY “Evaluate for signs of difficult intubation” (this may help in your decision as well) -Obesity -Small body habitus -Small jaw -Large teeth -Burns -Trauma -Anaphylaxis -Stridor

  15. CONTROL THE AIRWAY The PCP vs. ACP airway decision may not be based on one single factor, but rather based on an overall assessment of many factors.

  16. CONTROL THE AIRWAY Pre-Intubation -Prepare Equipment -Hyper-oxygenate

  17. CONTROL THE AIRWAY Orotracheal Intubation Procedure Sweep Left and Look

  18. CONTROL THE AIRWAY Find Your Landmarks Backward, Upward, Right Pressure (B.U.R.P.)

  19. CONTROL THE AIRWAY Find Your Landmarks

  20. CONTROL THE AIRWAY Find Your Landmarks It may not be perfect!

  21. CONTROL THE AIRWAY Find Your Landmarks

  22. CONTROL THE AIRWAY Readjusting with Cricoid Pressure

  23. CONTROL THE AIRWAY Common Provider Mistakes *Making a difficult intubation more difficult *Rushing *Poor equipment preparation *Suction (lack there of)

  24. CONTROL THE AIRWAY What is your back-up plan today? prolonged BVM… another provider… a smaller tube… better lighting… additional suctioning…

  25. CONTROL THE AIRWAY Helpful Adjuncts Gum Elastic Bougie

  26. CONTROL THE AIRWAY Helpful Adjuncts Lighted Stylette

  27. CONTROL THE AIRWAY Nasotracheal Intubation Indications: “Patient still breathing but in respiratory failure and in whom oral intubation is impossible or difficult.”

  28. CONTROL THE AIRWAY Nasotracheal Intubation Contraindications: -Apnea -Resistance in the nares -Blood clotting or anticoagulation problems -Basilar Skull Fx (?)

  29. STEP 4. CONTROL THE AIRWAY Nasotracheal Intubation Technique: -Prepare patient and nostril -Prepare tube -Insert on inspiration -Take your time Complications: -Bleeding

  30. . CONFIRM THE AIRWAY Intubation Confirmation Good, Better, Best • Technology Based • ETCO2 (monitor) • EDD (bulb) • Colormetric (cap) • Pulse Ox change • Traditional • Direct Visualization • Lung Sounds • Tube Condensation

  31. SECURE THE AIRWAY Secure Your Tube Good, Better, Best Tape Improvised devices Commercial devices Immobilization (?)

  32. ALTERNATIVES TO ETI Laryngeal Mask Airway Developed in 1981 at the Royal London Hospital By Dr Archie Brain

  33. STEP 7. ALTERNATIVES TO ETI Laryngeal Mask Airway Indications: -When definitive airway management cannot be obtained. (ETT) Not a substitute for definitive airway management

  34. ALTERNATIVES TO ETI Laryngeal Mask Airway Contraindication/Limitations: -Obesity -Non-secure -Size based -Not a med route

  35. ALTERNATIVES TO ETI Laryngeal Mask Airway • Weight Based Sizing • <5kg = Size 1 • 5-10 kg = Size 2 • 20-30 kg = Size 2.5 • Small Adult= Size 3 • Average Adult = Size 4 • Large Adult = Size 5

  36. ALTERNATIVES TO ETI Laryngeal Mask Airway • Average Adult Woman = 4 • Average Adult Male = 5 • *If in doubt, check the LMA

  37. ALTERNATIVES TO ETI Laryngeal Mask Airway Procedure: -Hyper oxygenate -Check cuff -Lubricate posterior cuff -Head in neutral or slightly flexed position -Insert following hard palate (use index finger to guide) -Stop when met with resistance -Let go and inflate cuff (visualize “pop”) -Confirm and secure

  38. ALTERNATIVES TO ETI Laryngeal Mask Airway • Air volume is variable depending on cuff size and individual patient anatomy • General Guideline: • Size 1 = 4 ml • Size 2 = 10 ml • Size 2.5 = 14 ml • Size 3 = 20 ml • Size 4 = 30 ml • Size 5 = 40 ml

  39. ALTERNATIVES TO ETI Laryngeal Mask Airway Common Provider Problems: -Failure to seat properly -Sizing difficulties -Aspiration

  40. King Airway

  41. King Airway • Why • Unconscious / unresponsive patients without gag reflex • Blind insertion technique • Alternative to E.T.T. • Known Issues • Obtaining proper seal / placement • Is NOT a medication route for Endotracheal drugs • Multiple sizes, based on height, also multiple cuff volumes • Contraindications • Responsive patients with an intact gag reflex. • Patients with known esophageal disease. • Patients who have ingested caustic substances.

  42. User Tip • The key to insertion is to get the distal tip of King Airway around the corner in the posterior pharynx, under the base of the tongue. • Experience has indicated that the lateral approach, in conjunction with a chin lift, facilitates the placement of the King Airway. • Alternatively, a laryngoscope or tongue depressor can be used to lift the tongue anteriorly to allow easy advancement of the airway into place.

  43. Insertion #1

  44. Insertion #2

  45. Insertion #3 • As the King Airway is advanced around the corner • in the posterior pharynx, it is important that the tip of the device be maintained at the midline. • If the tip is placed or deflected laterally, it may enter into the piriform fossa and the tube will appear to bounce back upon full insertion and release. • Keeping the tip at the midline assures that the distal tip is properly placed in the upper esophagus.

  46. Insertion #4

  47. Insertion #5 • Air Volume Required for Cuff Inflation: • Size #3: 55 ml • Size #4: 70 ml • Size #5: 80 ml

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