APPENDIX

Table of Contents:

• Use of Paralytic Agents
• Procedure: Rapid Sequence Induction (RSI)
• Needle Cricothyroidotomy
• Surgical Cricothyroidotomy
• Needle Decompression
• Intraosseous Line Placement

Indications:

1. Severe head trauma with need for airway control and hyperventilation.
2. Poor lung compliance with high peak airway pressures.
3. Need to decrease myocardial oxygen demand.
4. Combative patients requiring airway control.
5. Uncontrolled seizure activity (to provide airway control).
6. Status asthmaticus nearing respiratory arrest.

1. Known hypersensitivity to the drug.
2. Hyperkalemia (elevated potassium).
3. Penetrating eye injuries (do not use depolarizing blocker).
4. History of malignant hyperthermia.
5. Unstable fractures (secondary to muscle fasciculation).

Complications:

1. Inability to secure the airway after paralytic administration.
2. Dysrhythmias.
3. Aspiration.
4. Fasciculations.
5. Histamine flush.
6. Tachycardia.
7. Hyperkalemia.
8. Bronchospasm.
9. Increased intraocular pressure.
10. Malignant hyperthermia.
11. Inability to recognize decreased neurologic status.

1. Initial dose of Vecuronium should be 0.10 mg/kg IVP.
2. Repeat dose of 0.08 - 0.10 mg/kg at 15 - 25 minute intervals as needed to maintain paralysis.
3. If patient has been previously medicated with another paralytic, administer first dose of Vecuronium at full initial dosage.

Procedure Overview:

1. The crew is responsible for maintaining the patient's airway (always have a B-V-M available and endotracheal intubation equipment nearby).
2. ventilate with 100% oxygen or with a mechanical ventilator at appropriate oxygen percentage.
3. utilize pulse oximetry and end-tidal co2 monitoring on all patients
4. proper endotracheal tube placement must be documented by at least three different methods. these include:
   1. Presence of bilateral breath sounds.
   2. Absence of breath sounds over the epigastrium.
   3. Presence of condensation on the inside of the endotracheal tube.
   4. End-tidal carbon dioxide monitoring.
   5. Use of an endotracheal esophageal detector.
   6. Visualizing the tube passing through the cords.

      All three verification methods must be documented in the medical record!

5. Maintain spinal immobilization if indicated.
6. Perform baseline neurological exam prior to paralyzing patient.
7. Assess and record vital signs, cardiac rhythm, and pupillary exam at least every 5 minutes.
8. Remain in constant attendance with the patient at all times.
9. Provide emotional support and orientation to the environment.
10. Premedication with the following should be considered:
    1. Valium in 2 - 5 mg IVP or Versed 1-2 mg IVP.
    2. Morphine in 2 - 5 mg IVP.
11. . Document all medications and reactions (i.e. paralysis achieved.) also, document reasons for repeat doses (i.e. increased difficulty ventilating or increased movement).

Indications:

1. A critical need for airway control exists, such as:
   • Persons who cannot tolerate awake intubations.
   • Combative patients with compromised airways.
   • Patients with depressed LOC.
   • Patients with hypoxia refractory to oxygen.
   • Multiple trauma patients who need an airway.
2. Risk for increased intracranial or increased arterial blood pressure such as in head injury, or intracranial hemorrhage when hyperventilation is necessary.
3. At any time risk for potential/actual airway compromise is suspected.

Absolute Contraindications:

1. Patients in whom cricothyroidotomy would be difficult or impossible.
2. Children less than 2 years of age.
3. Massive neck swelling/injury.
4. Patients who would be difficult or impossible to intubate/ventilate after paralysis.
5. Acute epiglottitis.
6. Upper airway obstruction.

Relative Contraindications:

Note: the benefit of obtaining airway control must always be weighed against the risk of complications in these patients

1. known hypersensitivity to the drug (allergy)

Complications:

1. Increased intragastric pressure (emesis).
2. Bradycardia/asystole (especially in children not premedicated with Atropine.)
3. Malignant hyperthermia.
4. Prolonged apnea.
5. Inability to intubate/ventilate.
6. Hypotension.
7. Aspiration.
8. Increased intraocular pressure.

1. Assemble necessary equipment and personnel (suction, B-V-M with correct sized mask, working suction equipment, appropriate sized ET tubes, working laryngoscope, appropriate drugs drawn up in syringes, pulse oximeter, end-tidal CO₂ monitoring device, monitor, and cricothyroidotomy equipment).
2. Position patient properly in sniffing position or use in-line stabilization if indicated.
3. Assure at least one secure well running IV line.
4. Connect patient to cardiac monitor and pulse oximeter.
5. Assign specific duties to personnel on scene (i.e., assistance with bagging, application of cricoid pressure, pushing of medications.)

Oxygenation:

1. The goal of rapid sequence induction is to facilitate a controlled intubation. (an adequately preoxygenated patient can remain apneic for 2 to 3 minutes without serious hypoxia).
2. It is ideal to allow the patient to spontaneously breathe 100% oxygen for 4 - 5 minutes to "wash out" the nitrogen reservoir and establish an oxygen reservoir.
3. If the patient is not breathing adequately or if unable to wait 4 - 5 minutes, 4 vital capacity breaths (spontaneous or bagged) are adequate, although 1 - 2 minutes of preoxygenation with 100% oxygen via B-V-M is preferred.

Procedure:

1. Preoxygenate patient as above with 100% nonrebreather mask or B-V-M if patient condition permits.
2. Premedicate as appropriate:
   1. Lidocaine (1.0 - 1.5 mg/kg IVP) 2 - 3 minutes before intubation to control intracranial pressure (ICP) in patients with possible head injuries, for patients with cns pathology (hypertensive crisis or bleed), or for dysrhythmia control in patients at risk for ventricular dysrhythmias. Lidocaine is contraindicated if there is known hypersensitivity to the drug.
   2. Sedation. Versed (0.10 - 0.15 mg/kg IVP) for awake patients to achieve amnestic effect. Pediatric dosage is 0.03 mg/kg. versed is contraindicated if the patient is hypotensive.
   3. Atropine (0.5 mg IVP) for adults exhibiting bradycardia. The pediatric dosage is 0.01 mg/kg IVP. This should be administered prior to RSI in all pediatric patients <3 years of age.
3. Administer 0.10 mg/kg of Vecuronium IVP in adults and in children greater than 3 years of age. Children less than 3 years of age may require slightly higher doses. NOTE: complete paralysis typically occurs in 2.5 - 3.0 minutes following administration. complete paralysis lasts approximately 25 - 30 minutes.
4. Apply cricoid pressure to occlude esophagus until intubation is successfully completed and the cuff is inflated.
5. Continue to oxygenate with 100% oxygen via B-V-M for 30 - 60 seconds following complete paralysis. Jaw relaxation and decreased resistance to manual ventilations indicates that conditions are acceptable and the patient is ready to be intubated. Suction oropharynx if necessary.
6. Perform controlled endotracheal intubation with in-line stabilization if indicated. Confirm placement by auscultating for bilateral breath sounds, checking oxygen saturations, and by checking for presence of end-tidal carbon dioxide (ETCO₂).
7. If inadequate relaxation is present, administer a second dose of Vecuronium at 0.10 mg/kg.
8. If intubation is unsuccessful, remove the tube and ventilate the patient with 100% oxygen via a B-V-M until ready to attempt re-intubation. You should be able to successfully use a B-V-M to hyperoxygenate the patient or successfully ventilate until the effects of the vecuronium are gone. Prepare to suction emesis. maintain cervical immobilization if necessary.
9. Repeat steps 6 and 7. If repeated intubation attempts fail, ventilate the patient with 100% oxygen via a B-V-M until spontaneous respirations return. If repeated intubation attempts fail, and you are unable to adequately ventilate the patient, perform a cricothyroidotomy.
10. Once intubation is completed and tube placement is confirmed, inflate the cuff and continue to ventilate with 100% oxygen via B-V-M.
11. Release cricoid pressure.
12. Secure ET tube in place.
13. Restrain patient if indicated.
14. If prolonged paralysis is required, administer Vecuronium 0.10 mg/kg IVP per protocol. Avoid prolonged paralysis to facilitate hospital evaluation unless necessary.

Considerations:

1. Once a neuromuscular blocking agent is given you assume complete responsibility for maintaining an adequate airway and ventilations.
2. Be prepared to perform a surgical airway if intubation cannot be executed and ventilation with a B-V-M is not possible. (This will be rare.)
3. Paralysis can be maintained with Vecuronium 0.1 mg/kg IVP per protocol.
4. Monitor oxygen saturations and end-tidal carbon dioxide. You can ventilate with 100% oxygen via B-V-M with cricoid pressure if needed.

Indications:

1. A patient in respiratory arrest or near arrest in whom an airway cannot be secured with intubation.
2. Situations in which standard endotracheal intubations cannot be done such as:
   1. Excessive oropharyngeal hemorrhage.
   2. Massive traumatic or congenital deformities.
   3. Complete airway obstruction precluding ET tube placement.
3. Cervical spine fracture with respiratory embarrassment in patients who cannot be endotracheally intubated.
4. Unsuccessful attempts by both flight crew members at endotracheal intubation in situations where delays would result in hypoxic injury.

Procedure:

1. Place the patient in the supine position.
2. Palpate the cricothyroid membrane between the thyroid and cricoid cartilages.
3. Prep the area.
4. Attach a #14 gauge 2.
5. Puncture the skin midline, directly over the cricothyroid membrane.
6. Direct the needle at a 45°degree angle caudally.
7. Carefully insert the needle through the lower half of the membrane, aspirating as the needle is advanced.
8. Aspiration of air signified entry into the tracheal lumen.
9. Withdraw the stylet while carefully advancing downward into position, being careful to avoid the posterior tracheal wall.
10. Attach catheter needle hub to a 3.0 mm pediatric endotracheal tube adapter and oxygenate with 100% oxygen via a B-V-M.
11. Connect this adapter to oxygen tubing with a y-connector at 15 lpm (50 psi). adequate pao2 can be maintained for only 30 to 45 minutes.
12. Observe lung inflations and auscultate for adequate ventilation.
13. Secure apparatus to neck.
14. Document and record responses.

Complications:

1. Exsanguinating hematoma.
2. Subcutaneous and/or mediastinal emphysema.
3. Inadequate ventilations resulting in hypoxia and death.

Procedure:

1. Place patient in the supine position with the neck in a neutral position. Palpate the cricothyroid membrane between the thyroid and cricoid membranes for orientation.
2. Prep the area.
3. Stabilize the thyroid cartilage with non-dominant hand.
4. Use Cook Crico kit or make an incision until the membrane is perforated. Carry the incision in each direction until the total length is approximately 1.5 to 2.0 cm. NOTE: hold the scalpel between the thumb and index finger so that only the tip of the blade can enter the trachea during the initial stab incision.
5. Insert the scalpel handle and rotate 90° to the incision, use a curved hemostat, or your index finger to open the airway.
6. Insert an appropriately sized (preferably 5 - 7 mm) cuffed ET tube or tracheostomy tube into the airway, directing the tube distally into the trachea.
7. Inflate cuff and ventilate the patient.
8. Observe lung inflations and auscultate chest for adequate ventilation.
9. Secure tube to prevent inadvertent dislodging.
10. Document and record responses.
11. This procedure is not recommended in children under age 12.

Complications:

1. Creation of false passage.
2. Hemorrhage or hematoma formation.
3. Laceration of the esophagus.

Indications:

1. Tension pneumothorax.
2. Trauma CPR patients may require bilateral chest decompression.

Procedure:

1. Assess chest and respiratory excursion.
2. Apply oxygen per nonrebreather mask or with 100% with B-V-M.
3. Identify second intercostal space, midclavicular line on the affected side.
4. Prep the area.
5. Locally anesthetize the area if patient conscious or if time permits.
6. Snugly attach a 14 or 16 gauge angiocath to a 10 ml syringe or use arrow kit.
7. Insert the needle into the skin and over the rib into the 2nd or 3rd intercostal space in mid-clavicular line.
8. Puncture the parietal pleura.
9. Aspirate air as necessary to relieve patient's symptoms.
10. Leave the plastic catheter remaining but remove the stylet.
11. Secure the catheter to the chest.
12. Connect the catheter to a one way valve such as a Heimlich Valve.
13. Reassess ventilatory status, jugular veins, tracheal position, pulse, blood pressure.
14. Document procedure and responses.

Complications:

1. pneumothorax.

Indications:

1. Emergent need for vascular assess in a child less than 6 years of age in cardiac arrest or in a near arrest situation.
2. Urgent need to administer fluids and/or medications.

1. Infection at or near the site.
2. Congenital bony deformity or disease.

Procedure:

1. Assess the patient and the need for the procedure.
2. Evaluate the lower extremities and tibial tuberosity for infection or abscess.
3. Prep site with betadine (povidone iodine solution.)
4. Locally anesthetize area if necessary.
5. Direct on intraosseous needle with stylet into the anterior surface of the tibial plateau 1-3 cm below the tibial tuberosity. The needle should be directed perpendicular or slightly inferior to avoid the epiphyseal plate.
6. correct placement is evidenced by:
   1. A lack of resistance after the needle penetrates the bony cortex.
   2. The needle stands upright without support.
   3. Aspiration of bone marrow contents.
   4. Free flow of the fluid without evidence of infiltration.
7. Secure the needle and attach the appropriate solution.
8. Document procedure and report responses to therapy.

Complications:

1. Variability of flow rate secondary to placement.
2. Osteomyelitis.

Copyright © 1997