EMS World

JAN 2019

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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24 JANUARY 2019 | EMSWORLD.com COVER REPORT: AIRWAY MANAGEMENT your preoxygenation time. If the SpO 2 drops below 94% during the three minutes of denitrogenation, change something to get the saturation back above 93% and reset the three-minute period. Likewise, if the SpO 2 drops below 94% during an intubation attempt, bail out and do whatever is needed to get the saturations back above 93% for another three minutes prior to the next attempt. Preventing Peri-Intubation Hypoxia If peri-intubation hypoxia is common and harmful, how do we prevent it? Fortunately the answer is not all that complex: Stop intubating hypoxic patients—it really is that simple. That doesn't imply not doing anything; it means fix the problem first, then proceed with intubation. Frequently this is a matter of taking simple steps to optimize preintubation saturation. EMS educator Jason Cook coined the term SEXY bagging to describe several components of a "preoxygenation toolbox": • S—Use a Second provider when mak- ing a mask seal; • E—Place the patient in an Ear-to-ster- nal-notch position; • X—Use the eXtra stuff available to you; • Y—Have a Yankauer suction catheter ready for use. Unfortunately most EMTs and paramed- ics are not adequately trained and don't practice making a good face mask seal. We were all taught to use a one-handed "EC" seal. Stop doing this. We should instead use the more ef fective t wo-handed, thumbs-down seal, with your fingers lift- ing the mandible up into the mask while your thumbs, facing down toward the patient's feet, hold the seal (Figure 2). This two-handed seal delivers higher tidal vol- umes with less air leak than the traditional one-handed method. 16 All too often, when we realize we don't have an adequate seal, we simply press the mask down harder onto the patient's face. This is actually counterproductive: It press- es the mandible posteriorly, inadvertently occluding the airway. Lift, don't push (the mandible). If the patient needs assistance with ventilation, the second provider will provide these gentle ventilations. Proper positioning is key to effective ventilation, oxygenation, and intubation. While we often pride ourselves on being able to intubate patients in very difficult positions, we really shouldn't. Just because we can do something doesn't mean we should. Positioning is a perfect example of this. There is no law that says we must intubate the patient where we find them. Instead, move your patient into a position where you are more likely to succeed. For oxygenation, ventilation, and intubation, this means elevating the patient's head and placing them in an ear-to-sternal- notch position (Figure 3). This position has the neck extended and the face parallel with the ceiling. The ear canal will be level with the sternal notch. Because we come prepared with all manner of equipment to aid our patients, we should use these extras, including lots Figure 2. Two-handed, two-person mask seal. Figure 3. The head-up, ear-to-sternal-notch position.

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