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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EMSWORLD.com | JANUARY 2019 25 of oxygen. While too much oxygen can be harmful, this doesn't apply when preoxygenating a patient. Give them as much as you can temporarily during the intubation, then titrate down to the lowest fraction of inspired oxygen (FiO 2 ) needed to maintain your goal saturation. Use two sources of oxygen, one for the BVM and another for a nasal cannula. Turn both sources up as far as the regulator will go. Often this is past the highest number on the dial. Using a nasal cannula under a BVM does two things: It provides an extra source of oxygen to further increase the FiO 2 , and, most important, it allows you to easily transition to apneic oxygenation during the intubation attempt. Use waveform capnography before, during, and after the intuba- tion attempt. In addition to confirming tube placement, the wave- form can also be used as an indirect measure of tidal volume. We typically try to assess chest rise to judge the adequacy of ventila- tions; however, because of large patient size, truly judging chest rise is often a bit of a crapshoot. Waveform capnography allows us to estimate tidal volume and is the most sensitive and specific means of verifying ET tube placement. Have a PEEP valve attached to your BVM. With PEEP attached and on to at least 5 cm H2O, a BVM is capable of delivering oxy- gen without squeezing. Our goal is to avoid squeezing the BVM in spontaneously breathing patients with adequate tidal volumes. Doing so leads to increased intrathoracic pressure, decreased car- diac preload, lower blood pressure, and gastric insufflation of the stomach. All of these are to be avoided. If you are still unable to achieve adequate saturations despite good tidal volume, maximal oxygen flow through two sources, a good seal, good positioning, and an adequate respiratory rate, increase the PEEP. This often increases alveolar recruitment sufficiently to raise saturations. A common cause of failed airway attempts is secretions/vomit in the airway. Fortunately we have suction for this, provided it is available and turned on, and we are using a large-bore suction catheter. While we use the term Yankauer synonymously with all suction catheters, we really shouldn't. Not all catheters are created equal. Use a large-bore catheter for the industrial-strength airway material we frequently encounter. Use all the SEXY bagging tricks in your toolbox to adequately preoxygenate your patients and prevent peri-intubation hypoxia. Evidence for the Preoxygenation Toolbox Placing the patient in a heads-up position improves the percent- age of glottic opening (POGO) as the head elevation increases, improving intubation. 17 Head elevation also prolongs the safe apnea period, delaying the time until SpO 2 begins to drop. 18 Using a BVM or noninvasive positive-pressure ventilation (NIPPV) provides better preoxygenation than a nonrebreather mask. 19,20 Using a nasal cannula under the NIPPV mask does not increase air leakage and eases the transition from preoxygenation to apneic oxygenation. 21,22 Using NIPPV, which includes BiPAP, CPAP, or BVM with flush-rate oxygen and PEEP, provides improved oxygenation and less peri-intubation hypoxia compared with NRM alone. 23 Implementing a bundle of care aimed at good preoxygenation was associated with decreased rates of desaturation from 58% to 14% and improved intubation success from 89% to 98%. 24 Main- taining a preintubation SpO 2 greater than 93% for more than three minutes was associated with 380% higher odds of FPS without hypoxia. 25 Apneic oxygenation works. It was associated with decreased desaturation in healthy OR patients after paralysis for up to 55 minutes (do not try this at home; each of these patients had a pH less than 7), 26 is associated with 120% higher odds of FPS without hypoxia, 27 and decreased the rate of peri-intubation hypoxia from 29% to 7%. 25 In a systematic review and meta-analysis, apneic 888-458-6546 3121 Millers Lane Louisville, KY 40216 Tel: 502-775-8303 Fax: 502-772-0548 S A F E T Y A P P L I A N C E C O M P A N Y www.junkinsafety.com PROUDLY MANUFAC TURED IN THE USA JSA-365 Plastic Backboard Specifications Dimensions: 72" L x 16" W Load Capacity: 400 lbs. Shipping Weight: 16 lbs. Color: Bright Yellow Rugged one piece lightweight polyethylene spineboard with twelve large hand holes for easy handling and built in runners. It has a low profile and is X-ray translucent. The Model JSA-365-S Plastic Backboard with speed clip pins is also available. JSA-365 JSA-365

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