How many ways can we secure a definitive airway?
We (Paramedics) are by reputation, notorious for either being really good or really bad at RSI. There are only a true few reasons we should be shoving a tube in someone's throat. We have taken the stance that if your service is going to allow RSI, and Intubation Protocols, we should have proactive approach. Any chance we have to train and learn airway procedures, we should be begging for it. I had a short stent with AirMethods, and was able to experience not just the "Critical Care Approach" but also able to listen to David Olvera, hit me with, "you got to know these things cold. You need to be able to walk into any situation and be like, "I got this". This shouldn't be a training, it should be a review". That was the day I decided to train to become an airway specialist so I could nail the "I got this" approach. Which lead to wanting to specialize in all transport medicine concepts and theories. This is a long path that may never be completed, but once started, we can all get better. So I have now taken the first step.
EZ-EMT.org does not support any specific laryngoscope, however we advocate for the use of having a video option.
HEAVEN CRITERIA
Daniel Davis MD, and David Olvera NRP, FPC, CMTE published a paper on a predictive tool for difficult airways. It is surprising at how very simple the approach is. It just takes practice and repetition.
HEAVEN breaks down into the following:
HEAVEN breaks down into the following:
- Hypoxemia
- Extremes of size
- Anatomical Challenges
- Vomit/Blood/Fluid
- Exsanguination/anemia
- Neck Mobility issues.
LEMON Criteria
Lemon Criteria is an older more well known approach to difficult airways and is still widely accepted. I would encourage adopting the HEAVEN approach, but I will still list the LEMON Criteria anyway
- L=Look externally (facial trauma, large incisors, beard or moustache, and large tongue)
- E=Evaluate the 3-3-2 rule (incisor distance <3 fingerbreadths, hyoid/mental distance <3 fingerbreadths, thyroid-to-mouth distance <2 fingerbreadths)
- M=Mallampati (Mallampati score ≥3)
- O=Obstruction (presence of any condition that could cause an obstructed airway)
- N=Neck mobility (limited neck mobility).
SALAD use.
suction-assisted laryngoscopy airway decontamination
Many advanced and proactive agencies have implemented SALAD use in training, in-field, and hospital applications. I often have suggested organizations to practice this concept. Agencies that implement video laryngoscopes know the hardship of having a screen full of blood or vomit. I borrowed a concept from the brilliant Tyler Christifolli and Sam Ireland to have an airway head that we fill with realistic debris. Providers then need to suction and and clear the airway while preforming the specific skill sets. I do like trying to implement the practice of SALAD as a part of the intubation protocol.
EZ-EMT Opinion and Suggestions
If you implement intubation in your practice, make sure to have competencies in place to limit esophogial placement or back up options for complicated airways. If your agency has iGels or KingAirways practice with those as well. EMT's can place iGels and KingAirways so include them in your competency program.
Discuss in detail your sedation and pain management options. Remember Intubation is a very painful intervention for the patient.
If the patient is in a code scenario discuss with your agency if intubation vs blind airways would benefit your practice more. There is a lot of evidence to support delaying airway intervention until after the first round of coding the patient.
Remember that transferring a patient that has been treated by anesthesia may have multiple medications including push dose sedation and push dose pressors. You patient may have a drastic change in hemodynamic status after transport has started. Remember to get a report from anesthesia before accepting transfer.
Please see our sedation page for further review of medications and their uses/consequences.
Discuss in detail your sedation and pain management options. Remember Intubation is a very painful intervention for the patient.
If the patient is in a code scenario discuss with your agency if intubation vs blind airways would benefit your practice more. There is a lot of evidence to support delaying airway intervention until after the first round of coding the patient.
Remember that transferring a patient that has been treated by anesthesia may have multiple medications including push dose sedation and push dose pressors. You patient may have a drastic change in hemodynamic status after transport has started. Remember to get a report from anesthesia before accepting transfer.
Please see our sedation page for further review of medications and their uses/consequences.