EMS 153C
Describe the location of the thyroid cartilage in terms of the external landmarks for it. For the second part of the question, explain why this knowledge is key to the paramedic airway operator.
Adam's Apple; external laryngeal manipulation is done by moving the thyroid cartilage
Discuss the advantages and disadvantages to the use of a McGrath Video Laryngoscope
Advantages: Video and can also be used as a regular Mac blade if video becomes obstructed or does not work. No difference in bougie or stylet use from DL. Disadvantage: Still not an underwater camera. Only comes in adult and curved blade
Discuss the advantages and disadvantages to the use of a GlideScope Video Laryngoscope
Advantages: Video. screen is also larger than other VL. Disadvantage: must use glidescope stylet and remove stylet properly. (i.e. extra training) Not an underwater camera.
Discuss the advantages and disadvantages to the use of King Vision Video Laryngoscope.
Advantages:it is video. the channeled option also offers guidance of your tube into the proper place if alined correctly. Disadvantages: tube must be formed to a similar shape, sometimes the best view in the screen is not the best alinement for placement of the tube. Not an underwater camera!
What is the proper initial amount of air to inflate the cuff
Approx. 10ccs.
Explain why we emphasize endotracheal intubation so heavily compared to bag- mask ventilation or the use of a supraglottic airway
ETI fully protects the airway by sealing off the trachea compared to the other two methods. ETI requires much more knowledge and skill maintenance.
Why is "epiglottoscopy" the preferred method to use?
Focuses on carefully finding the landmarks needed to identify the trachea and avoids placing the blade too deep.
Describe your intubation technique when you encounter a Grade 3 or Grade 4 view. There are two parts to this question
Grade 3--use bougie to feel for tracheal rings or hold-up at the carina or distal to the carina (won't hold up in esophagus); Grade 4--come out and try again after changing one or more things (blade size / shape, head position)
Where does the curved blade tip go
In the vallecula
Explain how to test the cuff on an ET tube
Inflate using 10cc syringe and disconnect syringe to be sure it will stay inflated.
What is the difference between a Mac and a Miller blade?
Mac is curved, Miller is straight.
Describe the differences in technique or preparation for most VL devices compared to DL
Most VL devices require the tube curvature to match the scope blade curvature although the Mcgrath does not. Batteries need to be good and video needs to be working
An ETT without a cuff is designed to be used on pediatric patients because of what anatomical characteristic?
Narrowing of the trachea just below the vocal cords.
Describe your method for determining the expected proper tube depth of insertion
Obviously, you will place the tube just past the vocal cords by visualization but...in cases where you are using the bougie for blind placement or in situations where you are evaluating tube placement, this knowledge is helpful. 3x properly sized ETT = expected depth of insertion
When placing the ETT, what is the proper technique for your right hand?
Use your right hand to lift or adjust the elevation/position of the patients head, or to place over an assistants hand on the adams apple for ELM.
You have intubated your patient and visualized the ETT passing the vocal cords. You placed the ETT just past the cords and held it firmly and it has not moved nor has the patient's head flexed, extended or rotated since. You see chest rise although with difficulty. You see a low, square waveform on the EtCO2 with a reading of 8. What can you say for certain about the location of the tip of your ETT?
You are in the trachea---you saw it, it didn't move and you HAVE an EtCO2 reading (not optimal reading but its a reading and a waveform)
Describe the technique for external laryngeal manipulation and explain its importance to the airway operator
airway operator's right hand moves the adam's apple laterally or posteriorly to gain the best view of the glottic opening
Describe a Cormack-Lehane Grade 1 view
all laryngeal structures visible
Where does the straight blade tip go?
below the epiglottis to pick it up
What is the advantage of a curved blade over a straight blade
better control of the tongue.
Discuss the advantages and disadvantages to the use of a macintosh style laryngoscope in terms of tongue and epiglottis control
excellent tongue control but less epiglottic control than a straight blade
Describe the function of the epiglottis
flap valve to cover the glottis and keep food / liquid out of the lungs
What is the generally accepted method for estimating the proper insertion depth of a properly sized ETT?
general rule for adult males is around 22-24 and a bit less than that for females but....if you properly sized the ETT then its depth should be pretty close to 3 times that size (an 8 ETT would be at 23-24).
Describe the location of the cricoid cartilage in comparison to the thyroid cartilage and, for the second part, explain what advantages and disadvantages there are to exerting pressure on the cricoid to displace it posteriorly
inferior; cricoid pressure (Sellick's maneuver) may occlude the esophagus but may also compress the trachea
You have intubated your patient and visualized the ETT passing the vocal cords. You placed the ETT just past the cords and held it firmly and it has not moved nor has the patient's head flexed, extended or rotated since. You see chest rise although with difficulty. You see a low, square waveform on the EtCO2 with a reading of 8. Your patient is an adult male who is approximately six feet tall and weighs about 300 pounds. The ETT is at 21cm at the teeth. What can you say for certain about the location of the tip of your ETT?
it is IN the trachea---probably just barely but its in for now
You have intubated your patient and visualized the ETT passing the vocal cords. You placed the ETT just past the cords and held it firmly and it has not moved nor has the patient's head flexed, extended or rotated since. You see chest rise although with difficulty. You see a low, square waveform on the EtCO2 with a reading of 8. Your patient is an adult female who is approximately five feet tall and weighs about 100 pounds. The ETT is at 23cm at the teeth. What can you say for certain about the location of the tip of your ETT?
it is IN the trachea--probably pretty deep but its in
Discuss the advantages and disadvantages to the use of a straight-shaped Miller or Wisconsin style laryngoscope blade in terms of tongue and epiglottis control
less tongue control but direct control of the epiglottis
Describe proper technique for bag-mask ventilation in terms of pressure, volume and rate.
low / smooth pressure, volume sufficient to raise chest its normal amount (avoiding excess), rate of no more often than every 6 seconds normally
Describe a Cormack-Lehane Grade 4 view
no structures visible
Describe a Cormack-Lehane Grade 3 view
only epiglottis visible
Describe your method(s) for determining the proper ET Tube size for your patient
patient's little finger diameter or estimation based on length-based reference charts (example: Broselow) or estimate based on rules of thumb
What is the use for the black mark at the distal end of the tube?
placement at the vocal cords
You have intubated your cardiac arrest patient and visualized the ETT passing the vocal cords. You placed the ETT just past the cords and held it firmly and it has not moved nor has the patient's head flexed, extended or rotated since. You see chest rise although with difficulty. You see a low, square waveform on the EtCO2 with a reading of 8. Your patient is an adult male who is approximately six feet tall and weighs about 220 pounds. The ETT is at 21cm at the teeth. What could be causing this patient to have such a low EtCO2?
poor CPR, too rapid ventilation, low metabolism
You have intubated your cardiac arrest patient and visualized the ETT passing the vocal cords. You placed the ETT just past the cords and held it firmly and it has not moved nor has the patient's head flexed, extended or rotated since. You see chest rise although with difficulty. You see no waveform on the EtCO2 with a reading of 0. Your patient is an adult male who is approximately six feet tall and weighs about 220 pounds. The ETT is at 21cm at the teeth. What should you do next about your ETT?
quickly look again with the laryngoscope to see if the tube is between the cords---if it is, leave it alone; if not, pull it out---troubleshoot your EtCO2 next. DON'T pull tubes that are good---LOOK to verify
Describe a Cormack-Lehane Grade 2 view
some of the glottic opening visible but not all
List the steps in preparing the ET tube for intubation
test the cuff, lube the end of the tube, place bougie or stylet, leaving ETT in package as long as possible to keep clean
When securing the ETT, should the c-collar be over or under the ETT holder?
the ETT holder should be closest to the patient's skin. (collar over the tube holder)
Describe the carina and name its corresponding external landmark. There are two parts to this question
the bifurcation of the trachea into the two main bronchi--Angle of Louis is the external landmark
As you prepare your laryngoscope blade for intubation, what are three things about the bulb that you should check?
white, tight, and bright.
What is the advantage of a straight blade over a curved blade
Better control of the epiglottis
Why might a straight blade be a better option for small children
Better control of the longer, floppy epiglottis although you are sacrificing control of the tongue
What is the difference between a Miller and a Wisconsin blade?
Both straight blades but Wisconsin has a higher profile
Describe how to choose the correct size ET Tube for pediatric patients
Broselow tape or use the diameter of their pinky finger.
Describe in order of completion the tasks involved in airway management in a cardiac arrest patient BEGINNING from the point at which your Team Leader assigns you to manage the airway. You can assume that the Team Leader has verified that CPR is ongoing and is handling medication delivery and electrical therapy and is generally "running the code". Further, you can assume that the BLS personnel managing the airway have at least one OPA or NPA in place and have functioning O2 to their BVM. In short, you can start your "Prep". Write down your Prep steps here.
Prep yourself (I need to oxygenate and ventilate---I would like to intubate; I need Plan A, B, C and D and I will move to Cric immediately if I get a CICO situation) Prep the patient (max the O2 flow, position in sniffing) Prep the team (get one at the head handling mask seal / jaw thrust and another to bag--tell them you will give them instructions when ready and that the one at the head will move RIGHT) Prep equipment: 2 to visualize (you prep your laryngoscope, get someone to test the suction and flake out the suction tubing) 2 to place (test your tube cuffs and lube it; place a bougie to stiffen the tube) 2 to confirm (get capnography warmed up and the adapter on the bag; get a stethoscope around a helper's neck to be ready when you need it but not distracting you) 2 to secure (tube holder under the patient's head, c-collar ready to place)
