Combitube In-service Joe Lewis, M.D.,FACEP Schofield Barracks Ambulance Service.
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Transcript of Combitube In-service Joe Lewis, M.D.,FACEP Schofield Barracks Ambulance Service.
Combitube In-service
Joe Lewis, M.D.,FACEP
Schofield Barracks Ambulance Service
Combitube Intubation Protocol
INDICATIONS
• - Cardiac Arrest
• - Respiratory Arrest/Apnea
CONTRAINDICATIONS
• A patient under age of 18 or less then 4 ft. tall.• A patient who has swallowed a corrosive
substance.• A patient with a known Esophageal Disease.• EMT not trained and authorized to use the
Combitube.®• Suspected cervical spine injury requiring cervical
spine immobilization.
Initial Procedure
• Assure scene safety and use universal blood / body fluid precautions.
• ABC’s.
• Clear airway and ventilate with 2 rescue breaths.
• Check Pulse – if absent, follow the AED Protocol.
Initial Procedure
• After the 2nd analysis cycle (if no shock is indicated) or after the 2nd series of 3 shocks is administered – insert the Combitube ® as per the insertion procedure.
• Continue the Protocol.
Initial Procedure
• If the patient initially has a pulse but is apneic – follow the insertion procedure and perform rescue breathing through the Combitube ®.
• Continually re-assess for spontaneous respirations.
Insertion Procedure
• Continually re-assess for spontaneous respirations and pulse.
• Note that ALS may continue Combitube® use, orally intubate around the Combitube®, or remove the Combitube® at the discretion of the responding Paramedic.
• The Combitube can NOT be used with the demand valve regulator.
Using The Combitube
• ABC’s• Measure (Combitube or Combitube SA?)• Check Cuffs• Insert• Inflate Cuffs• Ventilate through tube #1• Check for Breath Sounds• Switch & Ventilate through tube #2 if needed• Check for Breath Sounds• Continue Ventilation
Check ABC’s
• Establish Unresponsiveness.– Verbal / tactile stimuli.
• Look Listen and Feel for air movement.• Deliver 2 rescue breaths.
– reposition and try again if needed,– clear airway if obstructed.
• Check Pulse.– SAED & CPR if needed.
Measure the patient
• Put loop of measuring device over the patient’s foot.
• Determine which Combitube to use.– Combitube or Combitube SA.
• IF LESS THAN 4 FEET - use basic airway maintenance techniques.
• Select tube if the patient is over 4 feet.
COMBITUBE
COMBITUBE SA
Check the Cuffs
• Inflate Pilot Balloon #1 with 100cc’s of air.– Check for proper inflation of cuff.
• Deflate Cuff.
• Inflate Pilot Balloon #2 with 15cc’s of air.– Check for proper inflation of cuff.
• Deflate Cuff.
Large Syringe Attached to Pilot Balloon #1 Ready to Inflate with 100cc’s of Air
Large Pharyngeal Cuff Inflated
Pilot Balloon (#1) Remains Inflated.
Small Syringe Attached to Pilot Balloon #2 Ready to Inflate with 15cc’s of Air
Small Distal Esophageal Cuff #2 Inflated
Pilot Balloon #2 for Small Distal Esophageal Cuff #2 Remains Inflated
Lubricate the Combitube
• Use water soluble gel. (Surgilube)
• Spread over tube.– Use package or gloved hand.
Insert the Combitube
• Hold tube like a pencil with dominant hand.
• Lift jaw and tong between thumb and index finger of non-dominant hand.
• Insert Combitube into mouth with curve facing upward.
• Stop inserting when the upper teeth or gums are between the Black Rings.
Insert the Combitube
• If any resistance is met during insertion:– Remove the Combitube,– Reposition,– Re-insert one time.
• If resistance is met on the second attempt:– Remove the Combitube,– Maintain airway using basic airway techniques.
Inflate the Cuffs
• Attach Large Syringe to Pilot Balloon #1.
• Inflate cuff #1 with 100cc’s of air.
• Remove syringe.
• Confirm that Pilot Balloon is inflated.– If not - attempt to re-inflate.– If still no inflation - remove Combitube and
maintain airway with basic airway techniques.
Large Syringe Attached to Pilot Balloon #1 Ready to Inflate with 100cc’s of Air
Large Pharyngeal Cuff Inflated
Pilot Balloon (#1) Remains Inflated.
Inflate the Cuffs
• Attach Small Syringe to Pilot Balloon #2.• Inflate cuff #2 with 15cc’s of air.• Remove syringe.• Confirm that Pilot Balloon is inflated.
– If not - attempt to re-inflate.– If still no inflation - Deflate Cuff #1, remove
Combitube and maintain airway with basic airway techniques.
Small Syringe Attached to Pilot Balloon #2 Ready to Inflate with 15cc’s of Air
Small Distal Esophageal Cuff #2 Inflated
Pilot Balloon #2 for Small Distal Esophageal Cuff #2 Remains Inflated
Ventilate
• Attach Bag / Valve and CO2 detector to Tube #1. (Esophageal)
• Ventilate.
• Listen over Chest for breath sounds.– If present - continue ventilation at a rate of 12-
20 breaths per minute.
Removing the Combitube
• If the Combitube needs to be removed at any time -– Get suction ready,– Turn patient on left side,– Deflate both balloons,– Remove tube,– Suction as necessary.
CONTRAINDICATIONS
• A patient under age of 18 and less then 4 ft tall.• A patient who has swallowed a corrosive
substance.• A patient with a known Esophageal Disease.• EMT not trained and authorized to use the
Combitube. ®• Suspected cervical spine injury requiring cervical
spine immobilization.
Possible Complications of Combitube Insertion
• Tear or rupture of esophagus.
• Bleeding.
• Puncture of carotid artery.
• Tear of pharynx.
• Pneumothorax.
• Death from asphyxiation.
• Vocal cord injury.