The author, Vanguard Survival, LLC, its agents, or assigns are not responsible for any misuse, injury, disability, or death that may result by the improper use of the information contained in this article. The information presented in this article is presented “As Is”, without warranty to its accuracy, or applicability in any given situation or circumstance and should only be used by those with training in advanced first aid techniques. You acknowledge that your use of ANY of the information contained in this article, whether an proper use or not, is your SOLE RESPONSIBILITY and you hereby release the Author, Vanguard Survival, LLC, their agents, and assigns from all liability that may result from any misuse, injury, disability, or death.
If you are not trained in Advanced First Aid DO NOT ATTEMPT ANY OF THESE TECHNIQUES!
In Part one of our series we covered a little basic anatomy to give you a better understanding of where things are located. In Part 2 of the series we are going to talk about Airway Management and making sure your patient has a patent (open) airway. Without an open airway they won’t be doing a whole lot of that in and out, in and out, breathing thing that we all need in order to survive.
Basic Airway Management
The first thing you can do to check for an open airway is simply talk to your patient. Ask simple questions and if the patient can answer you without any difficulty they have an open airway. Pretty simple, huh?
If your patient can’t answer questions or you see obvious signs of distress you can use the Head Tilt, Chin Lift, or if you suspect any kind of neck injury, the Jaw Thrust. Both of these techniques open the airway by moving the most common cause of airway obstruction, the tongue.
Check the diagrams for how to perform the Head Tilt, Chin Lift and Jaw Thrust.
In a patient who is conscious and has an intact gag reflex but needs some help maintaining an airway you can use a nasopharyngeal airway (NPA). The correct airway should go from the patients nose to their earlobe, if it goes past their earlobe it is too long and if it doesn’t touch their earlobe it is too short, either situation can be bad for your patient so make sure you have the right airway for the patient you are treating.
The photo below shows the correct way to measure a nasal airway.
Once you have the correct size airway that little package of lubricant you should have does help these things go in faster and it reduces damage to the nasal mucosa but don’t waste too much time coating the NPA with a shiny sheen of lube. Tear open the packet, squirt a clump of lube on the lower half of the NPA and get on with it
It doesn’t need a full, even, double coat of lubrication Bob Vila, and it doesn’t need a Swedish massage either. It needs to get sunk in the nasal passage and you need to get on with managing the airway.
If you took an EMT class they probably made a big deal about placing the bevel toward the septum. That is the preferred insertion technique, but nobody has ever really been able to convincingly explain to me why that is nor have I ever stuck to it like gospel.
Note that most NPAs are designed to be inserted in the right nostril. (If you follow the bevel rule.) But we also tell you to pick the largest nare. So which takes precedence? Should we never use the left nare regardless of how tiny the right one might look? Or perhaps insert the NPA backwards?
Do neither. Insert it in the largest nare with the curve of the NPA oriented toward the mouth and forget about the bevel.
Some folks will tell you to wiggle that thing back and forth like you’re trying to start a fire or something. Take it easy boy scout.
Yes we want you to use a gentle back and forth motion on the NPA as you insert it, but you don’t need to over-do it. Once you reach the midpoint of the NPA you should be able to just sink it.
And your patient will thank you for it later. The wiggling may facilitate the advance of the device but it isn’t terribly comfortable on the patients nose.
For the record these things aren’t going up the patient’s nose. They go straight back into the nasal cavity and turn downward toward the posterior pharynx.
For patients who are unconscious or those who don’t have a gag reflex you can use an oral airway. Like the nasal airway you have to measure it first. You do this by placing the large flange of the airway at the corner of the mouth and measure to the earlobe again. If it goes past the earlobe it is too big and if it doesn’t touch the earlobe it is too same.
The picture below shows how to measure an oral airway.
Remove any dentures, loose or broken teeth, or any other removable dental appliance. Once you are sure there is nothing in the patients mouth it is time to place the airway.
First, open the patient’s mouth using the cross-finger method, placing your thumb on the patient’s bottom teeth and your index finger on the upper teeth, then gently pushing them apart. With the patient’s mouth open as wide as possible, begin inserting the airway upside down (hook up), with the curvature toward the tongue to prevent pushing the tongue back into the pharynx.
Avoid dislodging teeth or damaging mouth tissue by gently sliding the airway over the tongue toward the back of the mouth. When the airway reaches the back of the tongue, rotate the device 180 degrees.
The tip should point down as it approaches the posterior wall of the pharynx, and the curvature should follow the contour of the roof of the mouth.
An alternative method is to hold the airway in its normal upright position and use a tongue depressor to hold the tongue down. Slide the airway carefully over the tongue and into position.
If the patient gags or appears to be gasping for air after insertion, remove the airway immediately. Recheck the size before attempting reinsertion.
Advanced Airway Management
When basic airway management techniques aren’t enough or a longer term solution is needed there are a few advanced airway management techniques you can use to ensure that your patient has a good secure airway.
Intubation is not as difficult as it may first seem. In 1998 the state of Texas concluded a 3 year study on intubation. They took 500 people, 250 Paramedic students and 250 “Average Joe’s and Josie’s” and taught them how to intubate.
They followed the Paramedics after graduation and tallied the number of successful intubations they made over the course of 3 years while actually working in the field and found a 96% success rate.
The “Average Joe’s and Josie’s” had no further contact with intubation during the same time period and were brought in at the end of the study and told to intubate the dummy they had been taught on. The study authors were amazed to find that the “Average Joe’s and Josie’s” had only a slightly lower success rate of 91%, even though they hadn’t intubated anyone or anything in the same 3 year period.
First, evaluate the airway during the initial injury assessment, and administer supplemental oxygen during this time if possible. Continual airway assessment is crucial since subtle changes in mental or respiratory status can occur at any time. Airway characteristics that can make fitting the mask and endotracheal intubation difficult include:
- Short, thick, muscular or fat neck with full set of teeth;
- Full beard, facial burns, or facial injuries;
- Receding or malformed jaw;
- Protruding maxillary incisors; and
- Poor mandibular (lower jaw) mobility.
Co-existing injuries such as known or suspected cervical spine injury, thoracic trauma, skull fractures, scalp lacerations, ocular injuries and airway trauma must be included when planning airway management.
Indications for endotracheal intubation include anatomic traits making airway management with just a mask difficult or impossible, the need for frequent suctioning, prevention of aspiration of gastric contents, respiratory failure or insufficiency, disease or trauma to airway, and traumatic injuries or musculoskeletal malformations making ventilation difficult.
Whenever possible O2 should be used when you intubate a patient, obviously this may not be possible in a survival or SHTF situation so at the very least you should have an appropriate sized Bag-Valve-Mask (BVM) available to provide proper ventilation to the patient while they are intubated.
The list below shows the average ET tube and Laryngoscope blade size to use by age.
Endotracheal tube and Laryngoscope Blade sizes:
|Age:||Preemie||Neonate||6 mo.||1-2 yr.||4-6 yr.||8-12 yr.||Adult|
The picture below shows the equipment needed to perform ET tube or other airway placement.
The following pictures show you the proper blade placement to intubate your patient.
Use the following steps to intubate your patient.
- Gather and check all equipment for proper function. Check light on laryngoscope, inflate ET cuff with 5-10cc air and check for leaks, then deflate and leave syringe attached, you can insert a lubricated stylet so it does not protrude beyond distal end of ET tube and bend into hockey stick form, and have suction on, if available.
- Hyperventilate with 100% O2 for several minutes using BVM, if available.
- Have assistant hold cricoid pressure if aspiration is a risk.
- If orotracheal intubation is planned, hold the laryngoscope in left hand and insert the blade on right side of mouth pushing the tongue to the left in a sweeping motion, and avoiding the lips, teeth and tongue. Holding the left wrist rigid, to avoid using the scope as a fulcrum and damaging the teeth, visualize the epiglottis.
- If a straight (Miller) blade is used, pass the blade tip beneath the laryngeal surface of the epiglottis and lift forward and upward to expose the glottic opening.
- If a curved (Macintosh) blade is used, advance the tip of the blade into the space between the base of the tongue and the pharyngeal surface of the epiglottis (the vallecula) to expose the glottic opening.
- Insert the ET with the right hand through the vocal cords until the cuff disappears.
- Remove the stylet and advance the tube slightly further. Inflate the cuff with air until no leak is heard when ventilated with bag.
- Usually, adult women use a 6.5 to 7.0mm; men use a 7.5 to 8.0mm ET tube.
- Verify correct placement by listening over both lungs for bilateral, equal breath sounds and observe the chest for symmetric, bilateral movements.
- Listen over the stomach, where you should not hear breath sounds.
- Note depth of insertion by centimeter markings on the tube at the lips, and tape the tube in place.
When the mouth cannot be opened or the patient cannot be ventilated by another means, or if the patient is conscious and requiring intubation, follow steps 1-3 for Orotracheal intubation using a lubricated (water-soluble), size 7-7.5 ET without the stylet.
- Insert the ET tube straight down into the larger of the nostrils until it reaches the posterior pharyngeal wall.
- If doing a blind nasal intubation, listen for the patient to inhale and insert the ET quickly into the trachea with a single smooth motion.
- If intubating under direct visualization, now insert the blade as previously described and pass the ET through the cords.
- Inflate the cuff and verify placement as above.
The Combitube is almost an ideal rescue airway. The availability of a Combitube makes rapid sequence intubation a safe procedure. The standard size will function well in almost any adult. The smaller size is available for persons between 4- and 5-feet tall. Many Asian and Hispanic patients may be less than 5-feet tall. The volume of air in the large balloon is reduced to 80 cc in the 4-feet tall model.
The esophageal tracheal Combitube (Combitube™) is a two-barreled tube that functions well when placed in either the trachea or the esophagus. Insertion does not require neck movement. Note: The short white tube is connected to the end of the tube; the long blue tube is connected to the side holes located between the two balloons.
- The tube is placed blindly with care to keep it midline. It is placed to a depth that lines up the teeth between the 2 proximal markings on the tube. Placing the tube too deeply will occlude the larynx.
- The large 100 cc balloon is inflated in the posterior pharynx; the 15 cc distal balloon is then inflated. While the large cuff is inflating, it will want to move the Combitube in or out. It is conforming to the posterior pharynx and palate. Let it move.
- The short white tube is continuous with the distal opening of the tube. Attach an esophageal intubation detector (EID) and test it for position. Do it twice if the patient has been bag-valve-mask ventilated. Alternatively, simply begin ventilation through the long blue tube and observe for chest rise and listen for breath sounds. About 90% of the time, the Combitube will be in the esophagus. If the tube does not function, it is probably in the trachea.
- If the tube is in the trachea, use it like an endotracheal tube. Ventilate through the short white tube. The large balloon stabilizes the Combitube and keeps it in correct position.
If the Combitube is functioning well, there is no need to replace it during resuscitation or for transfer. However, to avoid error, bend the unused tube down and tape it there
To replace the Combitube with a regular ET tube when it is located in the trachea, pass an ET tube introducer (ETI) through the white tube and remove the Combitube. Pass a regular ET tube into the trachea over the ETI.
It the Combitube is in the esophagus, and you wish to replace it with an ET tube, the trachea can be intubated with difficulty without removing the tube. Deflate the large balloon and move the tube to the side of the mouth. Use a laryngoscope to visualize the larynx by lifting the base of the tongue. The deflated large balloon can still obstruct your vision. If this occurs, rotate the Combitube to change the orientation of the deflated balloon. Intubate with the aid of an ETI.
Alternatively, pass a lubricated 14 French gastric tube through the white tube to evacuate the esophagus and stomach. Deflate both balloons, remove the esophageal tracheal Combitube, and intubate as usual.
If the patient is conscious, the Combitube is uncomfortable. Sedation is needed. A Combitube is not adequate to ventilate a patient with laryngospasm unless paralysis is used. Laryngeal edema is a relative contraindication. The latex balloon may be a problem in latex-sensitive individuals.
The Combitube is not suitable for use over a long period (over about 2 to 3 hours). The Combitube offers slight resistance to exhalation when placed in the esophagus.
Needle and Surgical Cricothyroidotomy
Needle cricothyroidotomy involves passing an over-the-needle IV catheter through the cricothyroid membrane. This procedure provides a temporary secure airway to oxygenate and ventilate a patient in severe respiratory distress in whom less invasive techniques (e.g., bag-valve-mask ventilation, laryngeal mask ventilation, endotracheal intubation) have failed or are not likely to be successful (i.e., “can’t intubate, can’t ventilate”).
The delivery of oxygen to the lungs through an over-the-needle catheter inserted through the skin into the trachea using a high pressure gas source is considered a form of conventional ventilation called percutaneous transtracheal ventilation (PTV).
Needle cricothyroidotomy differs from surgical cricothyroidotomy in that surgical cricothyroidotomy involves making an incision in the cricothyroid membrane and passing a tracheostomy or endotracheal tube through it into the trachea.
Needle cricothyroidotomy may be performed on patients of any age but is considered to be preferable to surgical cricothyroidotomy in infants and children up to 10 to 12 years of age because it is anatomically easier to perform with less potential damage to the larynx and surrounding structures.
However, surgical cricothyroidotomy provides more effective ventilation than needle cricothyroidotomy because of the larger diameter tube used and is typically chosen instead of needle cricothyroidotomy in adults and children over 10 to 12 years of age.
Indications for Use
The primary indication is inability to maintain the airway with noninvasive standard airway procedures (e.g., bag-valve-mask ventilation, endotracheal intubation) or rescue procedures (e.g., laryngeal mask airway).
Consider cricothyroidotomy to establish an airway in casualties having a total upper airway obstruction or inhalation burns preventing intubation or placement of a Combitube™.
Needle cricothyroidotomy with percutaneous transtracheal ventilation (PTV) should NEVER be used when the airway is maintainable through noninvasive means!
Gather pre-assembled cricothyroidotomy kit (every medic should have an easily accessible Cric Kit that contains all required items) or minimum essential equipment as below:
- Cutting instrument: #10 or 11 scalpel, knife blade
- 12-14 Gauge catheter-over-needle (e.g., Angiocath) with 10cc syringe attached for needle cricothyroidotomy (below). Syringe can also be used to inflate cuff on ET tube
- IV catheter 12-14 gauge (from above)
- ET tube
- cannula, or any non-collapsible tube that will allow sufficient airflow to maintain O2 saturation.
In a field setting, an ET tube is preferred because it is easy to secure. Use a size 6 -7 and insure that the cuff will hold air.
- 2 Hemostats, needle holder
- tissue forceps
- Other supplies:
- Oxygen source and tubing
- suctioning apparatus
- povidone-iodine prep
- gauze (preferably sterile)
- gloves(preferably sterile)
- silk free ties (for bleeders; size 3-0)
- 3-0 silk suture material on a cutting needle
Needle and Surgical Cricothyroidotomy
- Place the casualty in the supine position (laying on their back) and place a rolled up blanket, poncho, shirts, or jackets under the casualty’s neck or between the shoulder blades to hyperextend the casualty’s neck and straighten the airway. WARNING: Do not hyperextend the casualty’s neck if a cervical (neck) injury is suspected.
- Assemble needle/syringe set if not already done then locate and prep the cricothyroid membrane. Place a finger of your non-dominant hand on the thyroid cartilage (Adam’s apple) and slide the finger down to find the cricoid cartilage.
- Palpate (feel) for the “V” notch of the thyroid cartilage. Slide the index finger down into the depression between the thyroid and cricoid cartilage, the cricothyroid membrane. Prep the skin over the membrane with povidone-iodine. Put on gloves (sterile if available) after assembling equipment and supplies.
- Make a small nick in the skin with a #11 blade to open a hole for the IV catheter to slide through the skin
- Using the needle/catheter/syringe, penetrate the skin and fascia over the cricothyroid membrane at a 90° angle to the trachea while applying suction on the syringe. Advance the catheter through the cricothyroid membrane.
- Once air freely returns into the syringe, STOP advancement, and direct the needle toward the feet at a 45°angle.
- Hold the syringe in one hand, and use the other hand to advance the catheter off the needle towards the lower trachea.
- Slide the catheter in up to the hub. CAUTION: Do not release the catheter until it is adequately secured into place.
- Check for air movement through the catheter by using the syringe to inject air through it and confirm free airflow. If air does not flow freely, straighten the tube and try again or withdraw the catheter and begin again at step b above.
- If air flows freely and the patient is breathing on his own, use the 3-0 suture to make a stitch through the skin beside the catheter. Secure the catheter to the stitch with several knots. Connect catheter to an oxygen source at a flow rate of 50 psi or 15 L/min. See Steps below for wound care and ongoing management.
- If the patient is NOT breathing on his own, attach the syringe to the catheter, remove the plunger and deliver artificial respirations through the syringe and catheter. If the patient does not recover spontaneous respirations after several minutes, or if oxygen source is not available, proceed to Surgical Cricothyroidotomy below.
Surgical Cricothyroidotomy (If Needle cricothyroidotomy is not possible or is insufficient)
- Proceed through the first three steps of Needle Cricothyroidotomy if not already done. Test ET cuff to ensure it holds air.
- Raise the skin to form a tent-like appearance over the cricothyroid space, using the index finger and thumb.
- With a cutting instrument in the dominant hand, make a 1 inch horizontal incision through the raised skin to the cricothyroid space. CAUTION: Do not cut the cricothyroid membrane with this incision.
- Relocate the cricothyroid space by touch and sight.
- Stabilize the larynx with one hand and cut or poke a 1 inch incision through the cricothyroid membrane with the scalpel blade. NOTE: A rush of air may be felt through the opening. Look for bilateral rise and fall of the chest.
- Insert the ET tube or other airway tube through the opening into the trachea at a 90° angle to the trachea. Once in the trachea, direct the tube toward the feet at a 45°angle.
NOTE: Ventilate the casualty several times or allow him to take several breaths between suctioning.
Apply a dressing to further protect the tube or catheter and incision using one of the techniques below.
a. Cut two 4 X 4s or 4 X 8s halfway through. Place them on opposite sides of the tube so that the tube comes up through the cut and the gauze overlaps. Tape securely.
b. Apply a sterile dressing under the casualty’s tube by making a V-shaped fold in a 4 X 8 gauze pad and placing it under the edge of the catheter to prevent irritation to the casualty. Tape securely.
Monitor casualty’s respirations on a regular basis.
a. Reassess air exchange and placement every time the casualty is moved.
b. Assist respirations if respiratory rate falls below 12 or rises above 20 per minute.
What Not To Do:
DO NOT remove needle before advancing the catheter into trachea. (NEEDLE Cricothyroidotomy).
DO NOT forget to insure that the tube is correctly placed, and secured. (SURGICAL Cricothyroidotomy).
DO NOT fail to monitor your patient.
Your patient can only live 3 minutes without air, unless they are some kind of super yoga freak, so securing their airway is of vital importance. Unless there is major arterial bleeding in an extremity nothing should take precedence over airway management.
In Part 3 of our series on Advanced First Aid techniques we will cover advanced care for small wounds. Until then I look forward to seeing your comments and as always, Train to Survive!