EMS Protocol of the Week - Stridor / Croup / Epiglottitis (Pediatric)

Last month, we discussed prehospital assessment and management of the obstructed airway, as well as the approach to anaphylaxis. This separate protocol for croup and epiglottitis refers to those prior protocols based on the provider’s clinical impression, but on its own, it serves to remind EMTs and paramedics of the warning signs to note and cautions considerations to make when dealing with potentially inflammatory etiologies in kids. Basically – do very little, and get the patient to definitive management with as little fuss as possible.

Easy, right?

www.nycremsco.org or the protocols binder to tide you over til next week!

 Dave

EMS Protocol of the Week - Obstructed Airway (Adult and Pediatric)

Even though they're written out in two separate protocols, the adult and pediatric approaches to the obstructed airway are effectively the same, with the pediatric protocol including considerations for uncuffed endotracheal tubes.

Aside from that, in both instances, CFRs will promote coughing and initiate “airway maneuvers” (think abdominal thrusts, back blows, etc.)

BLS, you’ll notice, will initiate transport, but only after requesting ALS assistance. The reasoning behind this is that if ALS can assist with airway management, great, but if it will take longer for paramedics to arrive than it would to get the patient to the hospital, it may make more sense to just transport to the ED for further management.

If on scene, ALS can perform actual airway interventions, starting with direct laryngoscopy and attempted removal of foreign bodies with Magill forceps. If unsuccessful, they may place an endotracheal tube to maintain the airway, advancing it down the right mainstem bronchus for persistent difficulty with ventilation.

That’s all they got! Maybe someday we’ll see fiber optic bronchoscopes in the backs of ambulances, but until then, you’ll still have something to do when the patient reaches the ED!

www.nycremsco.org or the protocols binder for more!

Dave

Airway Management in a Coronavirus Patient

Today we’re going to forego trauma Tuesday to talk about everyone’s favorite topics nowadays: coronavirus and intubating!

• Your patient has suspected or known COVID-19 and is starting to desaturate on room air.  Now what?

  • Just like any other patient, the first thing to try is oxygen, either via nasal cannula or NRB

  • You can crank up the nasal cannula as high as 6 in order to help maintain oxygenation

• Great, but my patient is continuing to desaturate even with oxygen.

  • This is where things change from any other patient:

  • DO NOT USE BIPAP OR HIGH FLOW NC

    • When these patients get very ill, these modalities have a high likelihood of failing them

    • These 2 modalities also will result in significant aerosolized spread of covid-19

      • Even if you put them in a negative pressure isolation room with the bipap, you will have no way of transporting them

    • SO JUST DON’T DO IT

• OK, so I can’t use bipap or HFNC but my patient is still desaturating…

  • It’s time to intubate!

  • You should intubate early with these patients, and avoid crash intubations whenever possible

  • Step 1: gown up

    • This means gown, gloves, N95, and a mask with face shield over your N95

  • Step 2: pre-oxygenate

    • Pre-oxygenate using NRB

    • You do not want to use apneic oxygenation via nasal cannula, as this will further aerosolize the virus and has marginal evidence supporting it even in the best conditions

    • Do not bag the patient if it can at all be avoided; again, this will aerosolize the virus and result in increased risk of exposure for everyone in the area

  • Step 3: intubate

    • Use VL instead of DL

      • VL allows you to stay farther away from the patients mouth and secretions, helping protect you against the virus

    • The most experienced person should be performing the intubation – you want to maximize the chances for first pass success

  • Step 4: set the vent (or have someone else do it if you’re gowned up)

    • Treat these patients as ARDS patients and use the ARDSnet protocol with low tidal volumes

    • Unlike ARDS, however, steroids do not play a role in management

  • Step 5: de-gown

    • Ideally, have a spotter present so they can help make sure you don’t accidentally contaminate yourself during this process

    • In particular, be careful not to contaminate any mucous membranes, meaning be particularly careful around your eyes, nose, and mouth

    • Wash your hands!

• Congratulations! You have successfully intubated this patient without unnecessarily exposing yourself or your colleagues to coronavirus!