LOS ANGELES COUNTY EMS AGENCY

1. LOS ANGELES COUNTY EMS AGENCY

2. Instructor: This is a two (2) part program. The first part is slide presentation and the second part is skills practice. All paramedics must practice the skill until proficient, MICNs should practice once.Instructor: This is a two (2) part program. The first part is slide presentation and the second part is skills practice. All paramedics must practice the skill until proficient, MICNs should practice once.

3. DEFINITION Needle Cricothyroidotomy - the introduction of an over-the-needle catheter device into the cricothyroid membrane to provide a temporary airway and oxygenation

4. OBJECTIVESAt the completion of this lecture the participant will be able to: State the indications for needle cricothyroidotomy Identify the equipment necessary to perform needle cricothyroidotomy Identify the landmarks of the cricothyroid membrane These objectives address the, cognitive, psychomotor, and affective domains.These objectives address the, cognitive, psychomotor, and affective domains.

5. Discuss the potential complications of needle cricothyroidotomy Successfully perform needle cricothyroidotomy on a manikin Demonstrate professional concern for the risks associated with needle cricothyroidotomy

6. Complete the �Procedure Report Form� State the procedure for establishing contact with the EMS Agency following the needle cricothyroidotomy procedure Discuss the importance of documentation and data collection

7. INDICATIONS Unconscious patient with a complete airway obstruction unrelieved by all other means appropriate to the situation BASE STATION ORDER Instructor: Stress the importance of attempting other means of airway control. (you may want to review contraindications of Combitube)Instructor: Stress the importance of attempting other means of airway control. (you may want to review contraindications of Combitube)

8. CAUSES OF AIRWAY OBSTRUCTION foreign body aspiration severe facial trauma infections swelling of the airway external swelling from injury Instructor: Foreign body aspiration - if patient is unconscious, perform abdominal thrusts, then attempt Magill Forceps, if unsucessful, attempt to intubate (may push the F/B into one bronchus), as a last resort to provide an airway attempt needle cricothyroidotomy Severe facial trauma, infections, swelling of airway - consider suctioning, BVM, then ET, lastly attempt needle cricothyroidotomy. If the airway is blocked by swelling the Combitube will not ventilate the patient. Instructor: Foreign body aspiration - if patient is unconscious, perform abdominal thrusts, then attempt Magill Forceps, if unsucessful, attempt to intubate (may push the F/B into one bronchus), as a last resort to provide an airway attempt needle cricothyroidotomy Severe facial trauma, infections, swelling of airway - consider suctioning, BVM, then ET, lastly attempt needle cricothyroidotomy. If the airway is blocked by swelling the Combitube will not ventilate the patient.

9. CONTRAINDICATIONS Patient weighing less than 40 kg Unable to identify landmarks Instructor: 40 kg was chosen for consistency because it is the same as contraindication for ET. There is no age cut off, just weight. As we are able to evaluate the procedure of needle cricothyroidotomy, we may begin to use it for patients weighing <40 kg at a later date. Reinforce: If there is so much swelling or deformity, that the PM cannot identify the landmarks, the procedure should not be attempted.Instructor: 40 kg was chosen for consistency because it is the same as contraindication for ET. There is no age cut off, just weight. As we are able to evaluate the procedure of needle cricothyroidotomy, we may begin to use it for patients weighing <40 kg at a later date. Reinforce: If there is so much swelling or deformity, that the PM cannot identify the landmarks, the procedure should not be attempted.

10. CRICOTHYROID MEMBRANE Is located between the thyroid and cricoid cartilage on the anterior neck

11. LANDMARKS Locate the superior aspect of the thyroid cartilage (prominence on the anterior neck) Follow down midline to the indentation of the cricothyroid membrane

12. ALTERNATE IDENTIFICATION Locate the sternal notch Move your finger upward midline until you feel the indentation of the cricothyroid membrane Instructor: Beginning from the sternal notch may help on patients who do not have prominent thyroid cartilage or have short necks. Pause the presentation and allow each participant to identify the cricothyroid membrane on at least 3 people. Landmark identification should be confirmed by the instructor.Instructor: Beginning from the sternal notch may help on patients who do not have prominent thyroid cartilage or have short necks. Pause the presentation and allow each participant to identify the cricothyroid membrane on at least 3 people. Landmark identification should be confirmed by the instructor.

13. SURROUNDING STRUCTURES Thyroid cartilage Thyroid gland Parathyroid glands Instructor: Reinforce: The thyroid gland is very vascular. The paramedic may encounter some minor bleeding from this procedure. Severe bleeding is a complication. Instructor: Reinforce: The thyroid gland is very vascular. The paramedic may encounter some minor bleeding from this procedure. Severe bleeding is a complication.

14. The carotid arteries and jugular veins Additional blood vessels that feed into the thyroid gland

15. Notice the �C� shaped cartilage of the trachea thin area that the needle will penetrate closeness between the trachea and esophagus perforation of the esophagus is a common complication Instructor: The esophagus is directly behind the trachea, and is not protected by cartilage, it is easy to advance the needle too far and perforate the esophagus. Instructor: The esophagus is directly behind the trachea, and is not protected by cartilage, it is easy to advance the needle too far and perforate the esophagus.

16. COMPLICATIONS Penetration of adjacent structures (esophagus) Subcutaneous emphysema Swelling Severe bleeding Damage to the larynx Injury to the thyroid and parathyroid glands

17. EQUIPMENT Personal protective equipment Emergency Transtracheal Airway Catheter ENK Flow Modulator 10 cc syringe Alcohol prep 02 tank capable of delivering 30-60 psi Cloth or silk tape

18. EQUIPMENT (con�t) Emergency Transtracheal Airway Catheter The ribbing on the catheter keeps it from collapsing or kinking Instructor: For practice you can use a 14g or 16g IV needle. The Cricothyroidotomy needle will be damaged during multiple use on the manikin. Using Silicone spray on the manikin may help keep the catheter from getting damaged. Instructor: For practice you can use a 14g or 16g IV needle. The Cricothyroidotomy needle will be damaged during multiple use on the manikin. Using Silicone spray on the manikin may help keep the catheter from getting damaged.

19. ENK Flow Modulator and pressure adapter

20. Connect to 15 L of 02 (1) Instructor: The ET Medication Administration skills sheet is included in the training packet. Medications that can be given via the trachea are: Lidocaine, Atropine, Narcan, EpinephrineInstructor: The ET Medication Administration skills sheet is included in the training packet. Medications that can be given via the trachea are: Lidocaine, Atropine, Narcan, Epinephrine

21. The needle and modulator will come prepackaged They have a 4-year shelf life Both are included in Ref. 703, ALS Unit Inventory Instructor: Since needle cricothyroidotomy is considered a high risk skill, all ALS providers will utilize the same equipment. Any agency choosing to use different equipment must have it approved by the EMS Agency.Instructor: Since needle cricothyroidotomy is considered a high risk skill, all ALS providers will utilize the same equipment. Any agency choosing to use different equipment must have it approved by the EMS Agency.

22. PROCEDURE Once your equipment is assembled, position the patient�s head If trauma - maintain the head in neutral position

23. If no trauma- extend the neck

24. Identify the superior aspect of the thyroid cartilage prominence, midline, anterior neck

25. Follow midline down to the soft cricothyroid membrane (approximately 1 cm) feels like a slight dip in the neck

26. Cleanse the site with an alcohol prep

27. Stabilize the larynx by holding the cartilage between your fingers Direct the needle at a 90o angle to the patient Slowly advance the needle 1/2� - 3/4� with plastic catheter Instructor: Reinforce: The needle needs to be very controlled. The tendency is to insert the needle too far and puncture the esophagus.Instructor: Reinforce: The needle needs to be very controlled. The tendency is to insert the needle too far and puncture the esophagus.

28. Attempt to aspirate free air as you advance if unable to aspirate free air, back the needle up about 1cm at a time while aspirating you may have inserted the needle too far and entered the esophagus

29. Once you have aspirated free air, direct the needle toward the sternal notch

30. Advance the catheter over the needle until you reach the hub Remove the needle

31. Attach the catheter to the ENK Flow Modulator DO NOT LET GO OF THE CATHETER

32. Have an assistant attach the distal end of the ENK Flow Modulator to 15 L of 02

33. The patient is oxygenated by covering the holes of the Modulator for 4 seconds Instructor: Pause or count out 4 seconds.Instructor: Pause or count out 4 seconds.

34. Uncover the holes of the Modulator for 6 seconds to allow for passive exhalation Instructor: Pause or count out 6 secondsInstructor: Pause or count out 6 seconds

35. Assess the patient�s ABCs do not expect to see significant rise and fall of the chest wall if the patient begins spontaneous breathing, time your oxygenation with inhalation Instructor: Covering the holes of the ENK Flow Modulator does not give a large tidal volume, so the paramedic may not see significant chest rise and fall like with a Bag-Valve device. When the ports are uncovered the patient should passively exhale. Instructor: Covering the holes of the ENK Flow Modulator does not give a large tidal volume, so the paramedic may not see significant chest rise and fall like with a Bag-Valve device. When the ports are uncovered the patient should passively exhale.

36. monitor patient�s color and heart rate if available, pulse oximeter may be helpful don�t forget COMPRESSIONS, if pulse is absent

37. Have your assistant run the cloth or silk tape, around the catheter twice Instructor: Reinforce - the paramedic should not let go of the ENK Flow Modulator. It is not necessary to tape, but encouraged. The main idea is for the paramedic to keep the device in place.Instructor: Reinforce - the paramedic should not let go of the ENK Flow Modulator. It is not necessary to tape, but encouraged. The main idea is for the paramedic to keep the device in place.

38. Around the patient�s neck, and around the catheter again

40. THE PARAMEDIC MUST MAINTAIN CONTROL OF AND MONITOR THE PATIENT�S AIRWAY AND CATHETER UNTIL RELIEVED BY HOSPITAL PERSONNEL

41. EMS FORM Document on appropriate area of EMS Form Instructor: The new EMS Forms will include needle cricothyroidotomy (CR). If the paramedic has an older form they can write in CR under ALS procedures.Instructor: The new EMS Forms will include needle cricothyroidotomy (CR). If the paramedic has an older form they can write in CR under ALS procedures.

42. DATA COLLECTION This procedure has been added to Los Angeles County Scope of Practice Since there is very little medical data on needle cricothyroidotomy, it will be followed very closely for 2 years The decision to maintain the procedure will be based on the data collected Instructor: In 1999 needle cricothyroidotomy was added to the California EMS-P Basic Scope of practice. All Los Angeles County paramedics must be taught to the basic scope of practice. The decision was made to add needle cricothyroidotomy to the Los Angeles County policies, as long as data would be collected to monitor the procedure. Another alternate emergency airway is percutaneous tracheostomy (PT). You may encounter a paramedic from another county that has used PT. In April 2000, the State EMS Authority made the decision to suspend any use of PT in the State. The decision was based on the complexity of the procedure and outcome data over an 18 month period. Instructor: In 1999 needle cricothyroidotomy was added to the California EMS-P Basic Scope of practice. All Los Angeles County paramedics must be taught to the basic scope of practice. The decision was made to add needle cricothyroidotomy to the Los Angeles County policies, as long as data would be collected to monitor the procedure. Another alternate emergency airway is percutaneous tracheostomy (PT). You may encounter a paramedic from another county that has used PT. In April 2000, the State EMS Authority made the decision to suspend any use of PT in the State. The decision was based on the complexity of the procedure and outcome data over an 18 month period.

43. PROCEDURE REPORT FORM Complete the procedure report form whether you attempted or completed the needle cricothyroidotomy FAX or mail the form to the EMS Agency Instructor: Stress that the Procedure Report Form is to be sent to the EMS Agency within 24 hours. The paramedic needs to complete the form even if the attempt was not successful.Instructor: Stress that the Procedure Report Form is to be sent to the EMS Agency within 24 hours. The paramedic needs to complete the form even if the attempt was not successful.

44. Instructor: The Procedure Report Form will be sent to all paramedic coordinators for distribution. Additional forms can be obtained through the paramedic coordinator or the EMS Agency by calling (323) 890-7506.Instructor: The Procedure Report Form will be sent to all paramedic coordinators for distribution. Additional forms can be obtained through the paramedic coordinator or the EMS Agency by calling (323) 890-7506.

45. Additionally, call or page the EMS Agency representative Phone number, pager number, and instructions are on the �Procedure Report Form� If your page is not answered within 30 minutes, leave a voice mail message with instructions of how and when you can be reached

46. You will be asked questions about complications, the amount of bleeding and if you felt prepared to perform the skill The data collected is to assess the procedure, not the individual�s skill ability Instructor: The EMS Agency will follow up with the hospital and/or Coroner�s office to inquire about patient outcome and complications from the procedure.Instructor: The EMS Agency will follow up with the hospital and/or Coroner�s office to inquire about patient outcome and complications from the procedure.

47. QUESTIONS YOU MAY HAVE When do we start doing needle cricothyroidotomy? At what point during the run should needle cricothyroidotomy be attempted? What if the first attempt is unsuccessful? Answers (ADDRESS EACH QUESTION AND ANSWER SEPERATELY, BEFORE MOVING ON TO NEXT) 1. The needle cricothyroidotomy procedure will be implemented in Los Angeles County December 1, 2000. 2. Patient transport should not be delayed. Initial ceedle criothyroidotomy may be attempted on scene. Successive attempts should be made enroute to the hospital. Each case will vary. 3. If the first attempt is unsuccessful the paramedics may try again. There is no limitations to the number of attempts. Attempts should not delay patient transport. Attempts may be limited by the equipment. Most squads/rescues will only have the one needle. This plastic catheter may start to peal back from the needle. The paramedic should not make further attempts with an IV catheter. (stress: this is the only procedure that we would re-use a contaminated catheter)Answers (ADDRESS EACH QUESTION AND ANSWER SEPERATELY, BEFORE MOVING ON TO NEXT) 1. The needle cricothyroidotomy procedure will be implemented in Los Angeles County December 1, 2000. 2. Patient transport should not be delayed. Initial ceedle criothyroidotomy may be attempted on scene. Successive attempts should be made enroute to the hospital. Each case will vary. 3. If the first attempt is unsuccessful the paramedics may try again. There is no limitations to the number of attempts. Attempts should not delay patient transport. Attempts may be limited by the equipment. Most squads/rescues will only have the one needle. This plastic catheter may start to peal back from the needle. The paramedic should not make further attempts with an IV catheter. (stress: this is the only procedure that we would re-use a contaminated catheter)

48. What if the patient begins to breath spontaneously? What if the catheter becomes dislodged? Can medication be given through the ENK Flow Modulator tubing? Answers: 1. If the patient is breathing through the catheter, the paramedic must adjust the covering and uncovering of the holes in the ENK Flow Modulator tubing with breathing. If the patient begins to breathe through their nose or mouth, the paramedic should leave the catheter in place, place the patient on oxygen bye mask or consider assisting ventilation with BVM. 2. Cover the hole with a dressing. It does not need to be an occlusive dressing. 3. Yes. You may want to review the ET Medication skill sheet in the packet. 10cc is the minimum amount of fluid to be given. It is the same medications that can be given ET. Lidocaine, Atropine, Narcan, Epinephrine.Answers: 1. If the patient is breathing through the catheter, the paramedic must adjust the covering and uncovering of the holes in the ENK Flow Modulator tubing with breathing. If the patient begins to breathe through their nose or mouth, the paramedic should leave the catheter in place, place the patient on oxygen bye mask or consider assisting ventilation with BVM. 2. Cover the hole with a dressing. It does not need to be an occlusive dressing. 3. Yes. You may want to review the ET Medication skill sheet in the packet. 10cc is the minimum amount of fluid to be given. It is the same medications that can be given ET. Lidocaine, Atropine, Narcan, Epinephrine.

49. What if there is bleeding at the site during insertion ? What if subcutaneous emphysema develops? If the needle cricothyroidotomy is done correctly, is the airway stable? Answers: 1. Expect a little bleeding because the area is so vascular. There may even be a little blood aspirated into the syringe. If there is significant bleeding, the paramedic should apply pressure to the site. 2. Some subcutaneous emphysema may be expected from airway trauma and following insertion of the needle. 3. No. This is not a stable airway. This is a temporary measure. The patient must be transported to the most accessible receiving hospital as soon as possible. Answers: 1. Expect a little bleeding because the area is so vascular. There may even be a little blood aspirated into the syringe. If there is significant bleeding, the paramedic should apply pressure to the site. 2. Some subcutaneous emphysema may be expected from airway trauma and following insertion of the needle. 3. No. This is not a stable airway. This is a temporary measure. The patient must be transported to the most accessible receiving hospital as soon as possible.

50. Can the catheter or ENK Flow Modulator be connected to the BVM? What if no one from the EMS Agency answers my page? Who can I contact for questions regarding this procedure? Answer: 1. No. The device was not designed to be used with the BVM. We can be very creative, but use the device as it was intended. 2. Every attempt will be made to answer pages in a timely manner. But, just in case something happens, don�t worry. Just leave a message at the voice mail number (323) 890-7506. Include information on where and when the EMS Agency representative can reach you. 3. Contact Cathy Chidester at the EMS Agency (323) 890-7506.Answer: 1. No. The device was not designed to be used with the BVM. We can be very creative, but use the device as it was intended. 2. Every attempt will be made to answer pages in a timely manner. But, just in case something happens, don�t worry. Just leave a message at the voice mail number (323) 890-7506. Include information on where and when the EMS Agency representative can reach you. 3. Contact Cathy Chidester at the EMS Agency (323) 890-7506.

51. SITUATION A 17 year old male has aspirated a jaw breaker, he is unconscious and apneic What interventions should the paramedics attempt to relieve this airway obstruction? Instructor: Reinforce - the most basic procedures should be attempted prior to the more complex interventions.Instructor: Reinforce - the most basic procedures should be attempted prior to the more complex interventions.

52. Open the airway Abdominal thrusts Laryngoscopy and Magill Forceps Attempt to intubate and push the obstruction into one bronchiole Instructor: If the ET tube pushes the obstruction to one bronchiole, the patient�s other lung can be ventilated with the ET tube. Ventilating one lung is better than nothing. Instructor: If the ET tube pushes the obstruction to one bronchiole, the patient�s other lung can be ventilated with the ET tube. Ventilating one lung is better than nothing.

53. All the previous methods have failed Base contact is made and needle cricothryoidotomy is ordered

54. SITUATION A 14 year old 120 # male is found unconscious and apneic after he ran into a low tree branch while on roller blades What airway interventions should be attempted?

55. Open airway using jaw thrust BVM there is poor compliance because swelling to the soft tissue of the airway ET ET is unsuccessful due to swelling of the airway Should the paramedics attempt the Combi-tube? Instructor: Reinforce - the use of spinal precautions. Paramedics are unable to ventilate with the BVM due to airway obstruction from swelling. Reinforce - Combi-tube is contraindicated in patients with a less than 16 year body size. Additionally, the Combi-tube is not indicated in this case because of the airway swelling. Instructor: Reinforce - the use of spinal precautions. Paramedics are unable to ventilate with the BVM due to airway obstruction from swelling. Reinforce - Combi-tube is contraindicated in patients with a less than 16 year body size. Additionally, the Combi-tube is not indicated in this case because of the airway swelling.

56. Base contact is made and needle cricothyroidotomy is ordered Because of external swelling and subcutaneous emphysema the paramedics are unable to identify any landmarks Needle cricothyroidotomy is contraindicated in this situation Instructor: Needle cricothyroidotomy is contraindicated if the landmarks cannot be identified.Instructor: Needle cricothyroidotomy is contraindicated if the landmarks cannot be identified.

57. SITUATION Paramedics are treating an unconscious, apneic patient with a self-inflicted gunshot wound to the face, the lower jaw is missing What airway interventions should the paramedics attempt?

58. Attempt to open the airway (maintaining spinal precautions) Suction if necessary Attempt to intubate

59. After suctioning and attempting to intubate the patient, the paramedics are unable to identify the epiglottis or vocal cords Should the paramedics attempt inserting a Combi-tube? Instructor: Repeated intubation attempts are not indicated because you are unable to identify the vocal cords. The Combi-tube may be considered if the the airway is not obstructed by blood, bone, or tissue and the 100cc balloon can occlude the oropharynx. The patient in this situation has no jaw, so the Combi-tube is not indicated.Instructor: Repeated intubation attempts are not indicated because you are unable to identify the vocal cords. The Combi-tube may be considered if the the airway is not obstructed by blood, bone, or tissue and the 100cc balloon can occlude the oropharynx. The patient in this situation has no jaw, so the Combi-tube is not indicated.

60. Base contact is made and needle cricothryoidotomy is ordered If the needle cricothyroidotomy is successful, to which facility should the patient be transported? Instructor: The most accessible receiving hospital. This patient has an unstable airway.Instructor: The most accessible receiving hospital. This patient has an unstable airway.

61. SITUATION A 49 year old male burn victim is having difficulty breathing What airway interventions should the paramedics attempt?

62. Open the airway Attempt to assist with BVM Attempt to intubate

63. Paramedics are unable to intubate due to swelling of the upper airway The patient becomes unconscious and apneic Base contact is made and needle cricothyroidotomy is ordered Should the needle cricothyroidotomy attempt be made in the field or enroute to the hospital? Instructor: Again Combi-tube is not indicated because the airway is obstructed by swelling. It is up to the paramedics to use good judgement when deciding to attempt the needle cricothyroidotomy procedure. Reinforce - transport should not be delayed.Instructor: Again Combi-tube is not indicated because the airway is obstructed by swelling. It is up to the paramedics to use good judgement when deciding to attempt the needle cricothyroidotomy procedure. Reinforce - transport should not be delayed.

64. This program was the preliminary training for needle cricothyroidotomy To maintain proficiency, the paramedic should review this packet and practice the skill every 6 months Instructor: Encourage the paramedics and any Captains participating in the program to do station drills on EMS topics and skills, such as ET, Combi-tube, and needle cricothyroidotomy.Instructor: Encourage the paramedics and any Captains participating in the program to do station drills on EMS topics and skills, such as ET, Combi-tube, and needle cricothyroidotomy.