# Assisting paramedic with intubation



## slewy (Jan 16, 2013)

Hey guy,

I understand that when a Paramedic is intubating a patient we as EMT's give cricoid pressure. From my understanding the Paramedic will say give me cricoid pressure and you apply pressure on both sides of adams apple. Do you just hold it down? or press once? Also, what are some of the ways we can assist a Paramedic in the intubation process? I remember reading that you can help with the tubing, I believe my teacher called this FIGS. And obviously we will give O2 after. From Orange county, CA.

Also, I understand that OPA's open the airway, but if every ALS call has a Paramedic who is going to intubate a PT, why the need for OPA's? Is the OPA just provided until ALS gets there, so myself can maintain the airway? Last one, would you put an OPA in any unconscious PT, or just in one who needs their airway maintained?

Thanks


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## medichopeful (Jan 16, 2013)

First, welcome to the forum!



slewy said:


> I understand that when a Paramedic is intubating a patient we as EMT's give cricoid pressure. From my understanding the Paramedic will say give me cricoid pressure and you apply pressure on both sides of adams apple. Do you just hold it down? or press once? Also, what are some of the ways we can assist a Paramedic in the intubation process? I remember reading that you can help with the tubing, I believe my teacher called this FIGS. And obviously we will give O2 after. From Orange county, CA.



First, you're a tiny bit mistaken on where it is that you apply cricoid pressure.  The "Adam's apple" is actually above the cricoid cartilage, which is where you would apply the pressure.  To find it, find the Adam's apple and go down.  You'll feel a hard ring-shaped object.  THAT is the cricoid cartilage, and that is where you want to press.








As far as how long to hold it down, let me ask you this: which one would be more helpful, considering the objective (intubation)?  Pressing it down for a second, or holding it there?  We can give you the answer, but you'll learn it better if you're guided there!

As far as other things the EMT can do for intubation, I'm from Mass so what goes here won't necessarily go there and the other way around.  However, some things might include the cricoid pressure like you said, handing/fetching equipment, putting on a tube holder, and pre-oxygenation/hyperventilation.  As far as those things go, keep in mind the scope of practice issues (hopefully someone from the OC can talk on this issue for you).  I'm not familiar with the term "FIGS." :blink:



> Also, I understand that OPA's open the airway, but if every ALS call has a Paramedic who is going to intubate a PT, why the need for OPA's? Is the OPA just provided until ALS gets there, so myself can maintain the airway? Last one, would you put an OPA in any unconscious PT, or just in one who needs their airway maintained?
> 
> Thanks



One thing that has to be considered is that intubation can be a damaging and dangerous procedure.  Putting something into the trachea can cause trauma, and the truth is not everybody needs it.  An OPA can be a great tool for a basic, but that doesn't mean it's not a great tool for a medic too.  If the airway can be secured with an OPA, why do something more invasive?  Unless it's indicated, it's best to do the least invasive thing possible.  

As far as when to use an OPA, what are your thoughts on that?  Think it through! 

I hope this helps!


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## Christopher (Jan 16, 2013)

I'm going to give some possibly strange advice, only because it has not yet become the standard in EMS (it will soon):



slewy said:


> I understand that when a Paramedic is intubating a patient we as EMT's give cricoid pressure. From my understanding the Paramedic will say give me cricoid pressure and you apply pressure on both sides of adams apple. Do you just hold it down? or press once?



Cricoid pressure is performed with wide variation (i.e. definition of "correct" varies) and is not usually helpful. In fact, it has been shown to worsen glottic views.

External laryngeal manipulation is preferred, and that is best left to the paramedic to perform while they are intubating. They may ask you to push down where their fingers were.



slewy said:


> Also, what are some of the ways we can assist a Paramedic in the intubation process? I remember reading that you can help with the tubing, I believe my teacher called this FIGS. And obviously we will give O2 after. From Orange county, CA.



Best way to help is to ensure proper preoxygenation and monitoring is ongoing. At a minimum:

Nasal cannula on the patient at 15 L/min
Patient's head is positioned properly with their face parallel to the ceiling and their external auditory meatus (visualized at the tragus) level with their sternal notch; this often means padding under the head
BVM mask held by BLS #1 using jaw thrust + two thumbs down technique
BVM operated by BLS #2 @ 6-8 bpm w/ 15 L/min O2; squeeze using three finger technique (i.e. pointer/middle squeezing towards thumb)
Continuous ECG, SpO2, and NIBP q 2-3min (if possible)
Suction is setup and running with Yankeur attached and soft suction available
Ensure waveform capnography is available and ready to attach to the ETT
Have a stethoscope in hand

This should be done for at least 2 minutes in healthy patients and for as long as you're able to in patients with significant pathology so as to maximize safe apnea time.

Once they pass the tube BLS #1 attaches waveform capnography and starts a new round of vital signs, while ALS listens over the epigastrum/lung fields, while BLS #2 squeezes the bag.



slewy said:


> Also, I understand that OPA's open the airway, but if every ALS call has a Paramedic who is going to intubate a PT, why the need for OPA's? Is the OPA just provided until ALS gets there, so myself can maintain the airway? Last one, would you put an OPA in any unconscious PT, or just in one who needs their airway maintained?



If you use a BVM you'd better use an adjunct.

If one adjunct is good, two are better, and three is best. Yes, your patient will look ridiculous with 2 NPA's and an OPA...but an oxygenated patient is typically a happy patient.

For practical reasons an NPA is your best first line airway adjunct. They can be used with any additional airway device such as nasal cannulas, non-rebreathers, CPAP, BVM, etc.

Brandon put together a wonderful set of articles on Mastering BLS Ventilation which I highly recommend:
Mastering BLS Ventilation: Introduction
Mastering BLS Ventilation: Hardware
Mastering BLS Ventilation: Core Techniques
Mastering BLS Ventilation: Supplemental Methods
Mastering BLS Ventilation: Algorithms


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## Anonymous (Jan 16, 2013)

Nice thread.


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## Christopher (Jan 16, 2013)

slewy said:


> I understand that when a Paramedic is intubating a patient we as EMT's give cricoid pressure. From my understanding the Paramedic will say give me cricoid pressure and you apply pressure on both sides of adams apple. Do you just hold it down? or press once?



Allow me to interject this wonderful picture on twitter from @emchatter:


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## slewy (Jan 17, 2013)

Christopher said:


> For practical reasons an NPA is your best first line airway adjunct. They can be used with any additional airway device such as nasal cannulas, non-rebreathers, CPAP, BVM, etc.



Thanks for the thread, you explained things well. But Why an NPA though? It seems like an OPA would be more practical because it's quicker. If I am going to only use an airway adjunct when i'm BVM a PT, why did you say an NPA can be used with any device? 

Thanks


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## Christopher (Jan 17, 2013)

slewy said:


> Thanks for the thread, you explained things well. But Why an NPA though? It seems like an OPA would be more practical because it's quicker. If I am going to only use an airway adjunct when i'm BVM a PT, why did you say an NPA can be used with any device?
> 
> Thanks



Pt's don't gag with an NPA (if it isn't too long).

Conscious, unconscious...wonderful airway!

OPA is limited by the gag reflex.


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## Brandon O (Jan 17, 2013)

Christopher said:


> Pt's don't gag with an NPA (if it isn't too long).
> 
> ...
> 
> OPA is limited by the gag reflex.



Must... restrain... self...


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## MagicTyler (Jan 17, 2013)

I prefer to have someone grab the lip in the corner of the mouth to hold the right cheek out of the way.


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## AGill01 (Jan 19, 2013)

> If one adjunct is good, two are better, and three is best. Yes, your patient will look ridiculous with 2 NPA's and an OPA...but an oxygenated patient is typically a happy patient.


 We were taught in the ACLS class if three holes can be used for airway management use them.


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## exodus (Feb 3, 2013)

Christopher said:


> Allow me to interject this wonderful picture on twitter from @emchatter:
> https://pbs.twimg.com/media/BAwa2V8CQAEvybb.jpg:large



New AHA updates state cric pressure is now a no no in a CPR.  Not sure if this was just mask ventillation or while intubating though.


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## Brandon O (Feb 4, 2013)

exodus said:


> New AHA updates state cric pressure is now a no no in a CPR.  Not sure if this was just mask ventillation or while intubating though.



Not so much a no-no as "not routinely recommended." That's for BVM ventilation, not to assist with visualization during laryngoscopy.


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## Carlos Danger (Feb 4, 2013)

Christopher said:


> Best way to help is to ensure proper preoxygenation and monitoring is ongoing. At a minimum:
> 
> Nasal cannula on the patient at 15 L/min
> Patient's head is positioned properly with their face parallel to the ceiling and their external auditory meatus (visualized at the tragus) level with their sternal notch; this often means padding under the head
> ...



The mask ventilation is only in patients with low Sp02, right?


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## Christopher (Feb 4, 2013)

old school said:


> The mask ventilation is only in patients with low Sp02, right?



That depends. I would say it would be for those with inadequate rate or depth, regardless of SpO2. Our job during preox for RSI is to wash out the nitrogen in their lungs to provide a longer safe apnea time.

If they have adequate respiratory rate/depth, then NPAx2+NC@15+NRB@15 would be my choice (did this yesterday and it works marvelously).

In patients who were really bad off before preox I will do ~1 minute of BVM ventilation (8 full tidal volume breaths) after the sedative goes onboard and during 30s-1min of paralysis, just to ensure an adequate buffer.


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## Carlos Danger (Feb 4, 2013)

Christopher said:


> That depends. I would say it would be for those with inadequate rate or depth, regardless of SpO2. Our job during preox for RSI is to wash out the nitrogen in their lungs to provide a longer safe apnea time.



You aren't concerned with increasing the risk of aspiration?


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## Christopher (Feb 4, 2013)

old school said:


> You aren't concerned with increasing the risk of aspiration?



With good technique and adequate adjuncts in place, bagging is a relatively easy affair. I would agree that if the technique is poor you can certainly add quite a bit of air into the stomach.

I tend to bag my sick patients with their heads elevated too.


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## Carlos Danger (Feb 4, 2013)

Christopher said:


> With good technique and adequate adjuncts in place, bagging is a relatively easy affair. I would agree that if the technique is poor you can certainly add quite a bit of air into the stomach.
> 
> I tend to bag my sick patients with their heads elevated too.



Just so I understand.....you are saying that you routinely:

1) give the paralytic
2) ventilate for several minutes, even if their Sp02 is adequate, and then
3) place the tube


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## Christopher (Feb 4, 2013)

old school said:


> Just so I understand.....you are saying that you routinely:
> 
> 1) give the paralytic
> 2) ventilate for several minutes, even if their Sp02 is adequate, and then
> 3) place the tube



Negative, close but a bit drawn out. If it were roc (~60-90s onset of action), this would be close if "several minutes" was 2 minutes. With succ it is BVM -> sedative -> continue BVM ~30 seconds -> succ -> continue BVM ~30-60 seconds more -> clear to tube. With an NC on it is much closer to 30s or less as they are persistently 99-100%.


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## Carlos Danger (Feb 4, 2013)

Christopher said:


> Negative, close but a bit drawn out. If it were roc (~60-90s onset of action), this would be close if "several minutes" was 2 minutes. With succ it is BVM -> sedative -> continue BVM ~30 seconds -> succ -> continue BVM ~30-60 seconds more -> clear to tube. With an NC on it is much closer to 30s or less as they are persistently 99-100%.



What sedative and dose are you using?

Is this your agencies protocol or just your personal practice?


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## Christopher (Feb 4, 2013)

old school said:


> What sedative and dose are you using?
> 
> Is this your agencies protocol or just your personal practice?



Etomidate 0.3mg/kg / Succ 1.5-2 mg/kg (in the ED they'll sub Roc 1 mg/kg).

Protocol is simply, "preox, sedative, paralytic (if succ; swap order for roc), intubate." PreOx/ApOx w/ NC@15 are new additions in 2012. My timings are based on onsets of action for each of the drugs. Etomidate is ~20-40 seconds, Succ is ~30-60 seconds (granted this seems to vary widely on the lower end of dosing).


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## NomadicMedic (Feb 4, 2013)

Brandon Oto said:


> Not so much a no-no as "not routinely recommended." That's for BVM ventilation, not to assist with visualization during laryngoscopy.



Just a point of order: Cric pressure isn't to "assist visualization during laryngoscopy". It was designed to compress the esophagus and prevent regurgitation. Bimanual manipulation or the BURP maneuver is what you should be using to assist with visualization.

Some infor for the new guys here: 

http://www.airwaycam.com/bimanual-laryngoscopy.html
http://nmcp-anesthesia.net/subspeci...iatric-airway/cricoid_pressure_indication.pdf


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## Carlos Danger (Feb 4, 2013)

Christopher said:


> Negative, close but a bit drawn out. If it were roc (~60-90s onset of action), this would be close if "several minutes" was 2 minutes. With succ it is BVM -> sedative -> continue BVM ~30 seconds -> succ -> continue BVM ~30-60 seconds more -> clear to tube. With an NC on it is much closer to 30s or less as they are persistently 99-100%.



Providing PPV to a non-NPO patient unnecessarily (i.e. a patient who is not hypoxic) is a dangerous practice. The whole reason that RSI was developed was to prevent having to do that.

I understand the thinking behind Dr. Weingart's "delayed sequence intubation" thing, but I believe the rationale is somewhat flawed and not applicable for most prehospital situations. 

It may make sense in a small subset of patients _(those who you know have little FRC and who you expect to be a difficult intubation and who are not cooperating with pre-oxygenation efforts)_, if you are in a hospital where you have plenty of help - and if you have ketamine available, which maintains the patient's protective airway reflexes. Even then though, I don't think it makes a whole lot of sense, because you still have other options.    

The entire premise behind the DSI technique is that it supposedly allows you to avoid having the patient "crash" on you. Well, fortunately, that doesn't _usually_ happen. And if it does, THAT is when you provide PPV and/or quickly place your supraglottic airway. 

It just doesn't make sense to intentionally expose the patient to a _known_ hazard in order to mitigate a _potential_ hazard.


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## Brandon O (Feb 4, 2013)

n7lxi said:


> Just a point of order: Cric pressure isn't to "assist visualization during laryngoscopy". It was designed to compress the esophagus and prevent regurgitation. Bimanual manipulation or the BURP maneuver is what you should be using to assist with visualization.[/url]



That may be a bit strong. Applying cricoid pressure isn't "designed" for anything, per se. It's been used for several purposes, or at least with several theories behind it. Occluding the esophagus to reduce the lumen size to both insufflated air and regurgitated stomach contents is one use. But it's also been used for a very long time to assist with laryngoscopy.

Whether it works well for any of these purposes is another matter. I would counter your point of order, however, by noting that BURP is essentially a specific form of cricoid pressure.


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## Christopher (Feb 4, 2013)

old school said:


> Providing PPV to a non-NPO patient unnecessarily (i.e. a patient who is not hypoxic) is a dangerous practice. The whole reason that RSI was developed was to prevent having to do that.



Agreed, and if they are taking adequate tidal volume breaths on their own prior to RSI they'll just get NPA+NC+NRB. If they do not have adequate tidal volume/rate, they'll need some form of PPV or PEEP depending on a number of things. Routine application is not necessary unless the patient is hypoxemic prior to initiation. Besides, if you go to rescue ventilation during the apneic period it will be with a BVM anyways, and studies into aspiration during this have shown it to be rare and likely present prior.

(The nice thing about the onset of paralysis is that it improves BVM ventilation. If given an opportunity to improve oxygenation prior to your intubation attempt you should take it.)

Perhaps I'll be more specific when describing this in the future, but I don't think we're far off. I was describing a setup for BLS to assist in an intubation, not necessarily one done as an elective RSI. Nor was this a description of DSI, as that goes a bit differently in practice (and we don't have ketamine with which to utilize this).



old school said:


> It just doesn't make sense to intentionally expose the patient to a _known_ hazard in order to mitigate a _potential_ hazard.



I believe the known hazard, as found in the literature, is an excursion down the dissociation curve into critical hypoxia. To your point, the other known hazard is excessive tidal volume during PPV and that is a problem with BVM usage prehospital and inhospital alike.


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