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Waitin’ In The Wings

Waitin’ In The Wings. CombiTube-SA. Jerry D. Andrews, NREM T-P EMS LIA ISON EMS DISTR ICT 6 802-371-4516 Work 802-371-4481 Fax Jerry.Andrews@hitchcoc k.org www.cvmc.hitchcoc k.org. CombiTube Kit. General Description. The CombiTube is

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Waitin’ In The Wings

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  1. Waitin’ In The Wings

  2. CombiTube-SA Jerry D. Andrews, NREMT-P EMS LIAISON EMS DISTRICT 6 802-371-4516 Work 802-371-4481 Fax Jerry.Andrews@hitchcock.org www.cvmc.hitchcock.org

  3. CombiTube Kit

  4. General Description • The CombiTube is • A double-lumen tube with one blind end which functions as an esophageal obturator airway and the other as a “standard cuffed ET tube” • Inserted blindly and “seals” the oral and nasal pharyngeal cavities

  5. 1) Esophageal Lumen C) Blind-end Tube B) 12cc Cuff A) 85cc Cuff D) Open-end Tube 2) Tracheal Tube

  6. Indications • Ventilation in normal and abnormal airways • Failed intubation • Airway management in trapped patients

  7. Contraindications • Crush injury to oropharynx or throat • Intact gag reflexes • Known esophageal pathology • Ingestion of caustic substances • Under 4 feet tall • Over 5½ feet* with CombiTube-SA • CONSIDER: Latex Allergy

  8. And The Survey Says*:

  9. Advantages • Requires minimal training • May be more useful in non-fasted patients • Successful passage and ventilation in many patients via esophageal route • Portable, useful in remote setting • Functions in either the trachea or esophagus

  10. Disadvantages • Only adult and small adult sizes • Potential for esophageal trauma • Problems maintaining seal in some patients

  11. Special Features • Techniques for Conventional ET intubation via CombiTube and CombiTube-SA have been described • May be used electively to avoid intubation - not usually a choice in the prehospital setting!

  12. Tips for Success • Curve the distal tip (“Lipp maneuver”) just prior to insertion • Withdraw gently from the airway if ventilation is inadequate; suction must be at hand • If included in the Scope of Practice; use a laryngoscope to facilitate placement

  13. Prepare Equipment • Personal Protective Equipment • Gloves • Masks for all providers • Eye protection for all providers • CombiTube-SA • Test BOTH balloons with recommended volumes

  14. Mask elbow (to deflect fluids) • Suction & Suction Catheter at patient side • Water soluble lubricant • Tube holder • Tape • Commercial tube holder • BVM with oxygen supply connected

  15. Insertion Technique

  16. Patient’s head in a neutral, semi-flexed position • Sniffing position should be avoided! • Neutral position is an advantage in patients with suspected or evident cervical spine injury • The EMT may be • behind the patient • to one side of the patient’s head • or face to face

  17. The patient’s tongue and lower jaw are grasped between the thumb and forefinger of the non-dominant hand, while a jaw lift is performed • Use caution not to • Cut your fingers on sharp or broken teeth • Get bitten during seizure activity

  18. The lubricated CombiTube-SA • Should not be inserted along the palate • Should be inserted along the tongue • Insert CombiTube-SA. following the natural curve, gently in a curved downward movement along the tongue

  19. Insert until printed ring marks lie between teeth or alveolar ridges • Do not use brute force!

  20. Inflate oropharyngeal balloon first with the large syringe (blue dot) with 85 cc (40-85) of air • Then with small syringe, inflate distal cuff with 12 cc (5-12) of air

  21. You may see slight outward movement during inflation, this is normal and should not interfere with ventilation! CAUTION!

  22. Esophageal Intubation • There is high probability of esophageal placement (90-97%) of the CombiTube or CombiTube SA • Therefore, test ventilation is started via the longer, blue tube #1 • Air cannot escape at the distal end of the blocked esophageal lumen and enters the pharynx via the perforations • Since mouth, nose, and esophagus are sealed by the balloon and the cuff, air is forced into the trachea

  23. If auscultation over the lungs is positive (and epigastric insufflation is absent), ventilation may be continued • The tracheal lumen serves to decompress the esophagus and the stomach

  24. Tracheal Intubation • On occasion (3-10%), the CombiTube is placed blindly into the trachea • If this is the case, ventilate the shorter, clear tube #2, leading to the tracheal lumen • Air is blown directly into the trachea • In a few cases, ventilation does not work, via the esophageal or tracheal lumen

  25. The oropharyngeal balloon may be inserted too deep, occluding the laryngeal aperture • Pull the CombiTube-SA out about 2 to 3 cm, and start ventilation again via the blue tube

  26. Paramedics, Physicians • Use a laryngoscope whenever feasible! • If adequate ventilation; DO NOT remove • Place an Orogastric suction tube

  27. Placement Confirmation • Absence of abdominal inflation • Breath sounds in the chest • Chest inflation • Colormetric CO2 detection • Mist in the tube • Pulse oxymetery

  28. Colormetric CO2 Detection For patients >15 kg For patients 1 to 15 kg

  29. Removal of CombiTube-SA • Tube placement cannot be determined • Patient no longer tolerates tube – gags • Patient vomits past either distal or proximal tube • Palpable pulse and spontaneous breathing • Staff to place ET tube are present and ready

  30. Removal Technique

  31. Preoxygenate the patient • Increase the depth, not the rate, of ventilation • Have suction at hand and turned on! • Turn the patient to LEFT side, if possible • Deflate the large cuff of tube #1 • Deflate the small cuff on tube #2

  32. Withdraw the tube quickly and smoothly • Be prepared for vomiting!!! !!! !!! • Administer oxygen at 2-6 lpm via nasal cannula • Avoid the use of masks due to potential of vomiting

  33. Documentation • Time of procedure • Tube size • Combitube • Combitube-SA • Tube air volume (CombiTube-SA) • Tube #1 (40 to 85 cc’s) • Tube #2 (5 to 12 cc’s)

  34. Placement check • Manner of check; mist, breath sounds, etc. • Perform multiple checks • Degree of difficulty, if any • Complications encountered, if any • EMT performing procedure • EMT performing check; generally should NOT be by EMT performing procedure

  35. Summary • Assessment must be appropriate to the patient presentation • Remember: noisy breathing is obstructed breathing, but “quiet” breathing maybe absent • Find and correct any threats to life • Assess, document, and report your findings, interventions and changes in patient status

  36. Thank You! • Care for the physical and emotional aspects of the patient • Remember - the next patient could be you or your loved one • Be safe, take care of each other as well • Go home safe from all calls

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