PROTOCOL POST INTUBATION MANAGEMENT (PEDS) I. Confirmation of correct ETT position a. No single technique is 100% reliable for ETT confirmation b. Pre-hospital EMS providers should use all available means to determine correct ETT position c. A minimum of two clinical and one instrumental method of determination is recommended d. The following methods may be used to confirm correct ETT placement i. Direct visualization of the ETT passing through the vocal cords into the trachea ii. Auscultation of all lung fields to confirm adequate air exchange iii. Auscultation of the epigastrium to confirm the absence of disturbance of the gastric fluids during ventilation iv. Observation of bilateral expansion of the thorax during ventilation v. Use of end tidal CO2 detection 1. Colorimetric devices (pediatric size for child < 15 kg) a. Patient with a pulse i. YELLOW: ETT is in trachea ii. TAN: Consider possible causes of poor perfusion or poor CO2 production. Give 6 breaths and monitor color of detector. If color changes to yellow or remains tan, ETT is in the trachea. If color changes to purple, apply cricoid pressure, remove the ETT, oxygenate with BVM and re-intubate. iii. PURPLE: ETT not in trachea. Apply cricoid pressure, remove ETT, oxygenate with BVM and re-intubate b. Patient without a pulse i. YELLOW: ETT is in the trachea ii. TAN: Consider possible causes of poor perfusion and evaluate quality of CPR. Give 6 breaths and monitor color of detector. If color changes to yellow or remains tan, ETT is in the trachea. If color changes to purple, follow directions for PURPLE below. iii. PURPLE: CO2 is not being detected because the ETT is not in the trachea or no CO2 is being delivered to the lungs in the arrest state. Repeat laryngoscopy. Directly
visualize the ETT in the trachea or remove the incorrectly placed ETT and reintubate. 2. Capnometry device that provides a numeric value for end tidal CO2 3. Capnography device that provides a continuous waveform and digital readout of end tidal CO2 a. Capnography that is continuous and has the capability to electronically download and print data is the preferred device b. Normal values for end tidal CO2 is 5% to 6% which is equivalent to 35-45 mmHg i. End tidal CO2 (ETCO2) closely reflects arterial CO2 (PaCO2), but is not equal 1. With normal physiology, due to ventilation / perfusion mismatching, the ETCO2 will be 5-10 mmHg lower than PaCO2 2. Lung disease and low perfusion states will result in greater variation between ETCO2 and PaCO2
vi. Esophageal intubation detector device (see EID protocol) 1. Useful for pediatric patients in children > 8 y/o vii. Other clinical signs of improved perfusion and improved ventilation and oxygenation 1. Stable heart rate 2. Pupillary response 3. Stable and rising oxygenation saturation 4. Improved skin color e. Depth of ETT placement i. Correct depth avoids right mainstem bronchus intubation and inadvertent extubation ii. General rules of placement 1. Adult male: 21-23 cm 2. Adult female: 19-21 cm 3. Pediatrics: a. Infant: 10-11 cm b. Child over 1 y/o: (12cm + Age/2) or (ETT size X 3) iii. Direct visualization of cuff of ETT below the vocal cords iv. Inflated cuff of the ETT can be palpated in the sternal notch when the pilot balloon is compressed
II.
Securing the ETT a. Initially manually secure ETT in place with your thumb and forefinger b. A commercial ETT securing device with an incorporated bite block is recommended c. At a minimum, place an oral airway and tape the ETT in place. i. If circumferential taping us utilized, use care not to occlude venous blood flow from the head ii. To avoid excess motion, tape the ETT to the maxilla, not the mandible d. To further minimize head movement, place a cervical collar, immobilize with a cervical spine immobilization device and secure patient to a long spine board i. In an adult, 3-5 cm of ETT movement may occur with neck flexion or extension resulting in extubation or right mainstem bronchus intubation e. Following the securing of the ETT, note and document the depth of ETT placement
III.
Ventilation a. With an ETT and 100% oxygen, large tidal volumes and hyperventilation are not necessary and have been shown in recent studies to be detrimental to patient outcome b. Use care to avoid hyperventilation. The exception is the head injured patient with signs of herniation and then only modest hyperventilation is necessary (see below) c. Ventilate with a tidal volume of approximately 6-10 cc/kg or clinically, just enough ventilation to see the chest rise with each administered breath d. Rate of ventilation: i. Adult: 10-12 / min ii. Child: 20 / min iii. Infant / Toddler: 30 / min e. If continuous ETCO2 monitoring is available, maintain an ETCO2 of 3540 mmHg i. If the patient has a head injury and signs of herniation, modestly hyperventilate to an ETCO2 of approximately 30 mmHg
IV.
Maintenance of Sedation, Analgesia, Neuromuscular Blockade a. Purpose: To provide additional sedation, analgesia, and/or neuromuscular blockade in order to maintain ETT placement to facilitate continued oxygenation and ventilation in an intubated patient
b. Indications i. Patients awakening from medications used for drug assisted intubation ii. Comatose patients recovering from paralytic drugs used for rapid sequence intubation iii. Patients initially intubated without pharmacologic assistance but are now recovering due to improved oxygenation and ventilation c. Medications : All should be administered IV or IO and in smaller, titrated doses in the elderly, debilitated or unstable patient i. Sedation a. Benzodiazepines are the most commonly used medications for continued sedation b. Repeat doses of Etomidate (Amidate) should be avoided due to inhibition of endogenous steroid synthesis. Single dose for initial intubation is safe and acceptable and is actually the preferred choice. c. Midazolam (Versed):Adult and Peds dose: 0.05-0.1 mg/Kg IV, repeat every 5 min PRN d. Diazepam (Valium) i. Adult: 1-5 mg IV, repeat every 5 min PRN ii. Peds: 0.1-0.5 mg/kg IV, repeat every 5 min PRN to a total dose of 5mg in child < 5 y/o or 10 mg in child > 5 y/o e. Lorazepam (Ativan) i. Adult: 1-2 mg IV, repeat X 1 PRN ii. Peds: 0.05 mg/kg IV, repeat X 1 PRN ii. Analgesia a. Appropriate pain control will facilitate ventilation and oxygenation and allow the use of smaller doses of sedatives and may avoid the need for pharmacologic paralysis with neuromuscular blockers b. Narcotics are the primary medications used for analgesia in intubated patients c. Fentanyl i. Potent analgesic and respiratory depressant ii. No histamine release as compared to Morphine iii. Large doses can rarely cause chest wall rigidity requiring neuromuscular blockade iv. Rapid onset (5 min) and short duration (15 min)
v. Dosage: Adult and Peds: 1-2 mcg/kg IV, may repeat every 15-20 min PRN 1. Administer over 1-2 min 2. Note concentration and dose: a. Concentration: 50 mcg/ml b. Dose: 1-2 mcg/kg 3. Fentanyl 100 mcg = 10 mg Morphine d. Morphine i.Classic narcotic used for analgesia ii.Histamine release causes vasodilation resulting in decreased venous return, decreased B/P, and relief of pulmonary congestion a.Valuable for the cardiac patient but a dangerous side effect for the debilitated patient or unstable trauma patient b.More of a sedation effect than Fentanyl iii.Dosage: 1. Adults: 2-5 mg IV every 10-15 min PRN 2. Peds: 0.1 mg/kg IV every 10-15 min PRN e. Combination of sedatives and analgesics will produce the desired effects with lower amounts of each drug due to drug synergy iii. Neuromuscular Blocking Drugs (NMB’s)(Paralytics) a. The non-depolarizing class of NMB’s are preferred for maintenance of paralysis in the RSI patient or for the initial paralysis of the successfully intubated patient with DAI meds or in patients intubated without pharmacologic assistance b. In the RSI patient, additional NMB will have to be administered quickly as the effects of the initial Succinylcholine will begin to wear off in approximately 5 minutes c. Vecuronium (Norcuron) is the preferred NMB of choice although any non-depolarizing NMB in appropriate dose may be successfully utilized i. Dosage: 0.1 mg/kg IV initially and 0.05 mg/kg IV PRN for repeat dosing
d. CAUTION: i. MAINTAIN ADEQUATE SEDATION AND ANALGESIA WHEN ADMINISTERING PARALYTICS ii. CONTINUOUSLY MONITOR OXYGENATION, VENTILATION, AND ETT POSITION WHEN ADMINISTERING PARALYTICS, SEDATION, AND ANALGESIA V. Re-Confirming ETT Position a. b. c. d. e. Anytime patient is moved Anytime dislodgement is suspected Anytime care is transferred to another provider Perform the initial ETT confirmation steps Repeat laryngoscopy and directly confirm ETT position in the trachea if there is any question of correct position or any of the other confirmatory tests are equivocal
VI.
Documentaion a. Full report to the receiving physician or designated staff i. Specifically report any difficulties or complications related to airway management ii. Include times and dosages of sedatives, analgesics, or NMB’s b. Complete the EMS-Pro PCR c. Complete the NAEMSP supplemental airway form and place the completed form in the Medical Director’s Box in the office