1. Airway & Ventilation Methods: ALS Pharmacologic Assisted Intubation (“RSI”) Neuromuscular Blockade Contraindications Most are Specific to the medication inability to ventilate patient once paralysis is induced Advantages enables to provider to intubate patients who otherwise would be difficult or impossible to intubate minimizes patient resistance to intubation reduces risk of laryngospasm

2. Airway & Ventilation Methods: ALS Pharmacologic Assisted Intubation (“RSI”) Mechanism of Action for NMB agent acts at the neuromuscular junction where ACh normally allows nerve impulse transmission binds to nicotinic receptor sites at skeletal muscle depolarizes or does not depolarize specific to med blocks further action by ACh at receptor sites therefore, blocks further depolarization resulting in muscular paralysis

3. Airway & Ventilation Methods: ALS Pharmacologic Assisted Intubation (“RSI”) Disadvantages & Potential Complications Does not provide sedation or amnesia Provider unable to intubate or ventilate after NMB Aspiration during procedure Difficult to detect motor seizure activity Side effects and adverse effects of specific meds

4. Airway & Ventilation Methods: ALS Pharmacologic Assisted Intubation (“RSI”) Common Used NMB Agents Depolarizing NMB agents succinylcholine (Anectine®) Non-depolarizing NMB agents vecuronium (Norcuron®) rocuronium (Zemuron®) pancuronium (Pavulon®)

5. Airway & Ventilation Methods: ALS Pharmacologic Assisted Intubation (“RSI”) Summarized Procedure Prep all equipment and medications while ventilating patient Hyperventilate Administer induction/sedation agents & pretreatment meds (e.g. lidocaine or atropine) Administer NMB agent Sellick maneuver Intubate per usual Continue NMB and sedation/analgesia prn

6. Airway & Ventilation Methods: ALS Examples of Secondary Tube Placement Confirmation Devices (From AMLS, NAEMT) From AMLS, NAEMT

7. Airway & Ventilation Methods: ALS Needle Thoracostomy (chest decompression) Indications Positive sx/sx of tension pneumothorax Cardiac arrest with PEA or Asystole when the possibility of trauma and/or tension pneumo exist Contraindications Absence of indications

8. Airway & Ventilation Methods: ALS Tension Pneumothorax Sx/Sx severe respiratory distress  or absent lung sounds (unilateral usually)  resistance to manual ventilation Cardiovascular collapse (shock) asymmetric chest expansion anxiety, restlessness or cyanosis (late) JVD or tracheal deviation (late)

9. Airway & Ventilation Methods: ALS Needle Thoracostomy Prep equipment Locate landmarks: 2nd intercostal space at midclavicular line one-way valve

10. Airway & Ventilation Methods: ALS Chest Escharotomy Indications In the presence of severe edema to the soft tissue of the thorax as with circumferential burns: inability to maintain adequate tidal volume even with PPV inability to obtain adequate chest expansion with PPV Rarely needed

11. Airway & Ventilation Methods: ALS Chest Escharotomy Considerations must rule out the possibility of upper airway obstruction Procedure Intubate if not already done Prep site and equipment Vertical incision to anterior axillary line Horizontal incision only if necessary Cover and protect

12. Airway & Ventilation: Risks & Protective Measures BSI Gloves Face & eye shields Respirator if concern for airborne disease Be prepared for coughing spitting vomiting biting

13. Airway & Ventilation Methods Saturday’s class Practice using the equipment orotracheal intubation nasotracheal intubation gastric tube insertion surgical airways needle thoracostomy combitube retrograde intubation