Rural Emergency Medicine Simulation Training and Resource - British Columbia

Updated January 2022

This is a fairly large page with several topics and components.
However it is also likely one of the most important topics in Emergency Medicine.
It is broken down into 4 parts.
First is oxygenation and  'supraglottic airway' or all the ancillary components to maintaining
a patient's airway - chin lift, OPA, NPA, rescue devices etc.
Second is the 'infraglottic airway' which includes intubation
Third is surgical airway or cricothyrotomy and needle cricothyrotomy

Fourth is "Rapid Sequence and Delayed Sequence Intubation"
Intubation usually then involves ventilating a patient.
Ventilators are covered in the"Ventilators in the ER" page.

Supraglottic Airway Management

(NB: Best viewed in 'Slide Show' format, as videos will only play in 'Slide Show'.)

The video below on proper Bag Valve Mask manoeuvre is also in the Power Point above but is presented here for ease of access.

A technique called "High Flow Nasal Cannula" can deliver up to 60 litres per minute of humidified air and is being increasingly used in ER and even on the medical floors of even small hospitals.

High-Velocity Nasal Insufflation: An Alternative to BiPAP for Respiratory Distress

High-velocity nasal oxygen may improve oxygenation and flush out CO2.

High-velocity nasal insufflation of oxygen (HVNIO) involves use of a specialized cannula to deliver high-velocity oxygen to the nasopharynx. Theoretically, it can improve oxygenation and also improve ventilation by flushing CO2 out of the airways' dead space. Investigators conducted a multicenter, unblinded, randomized noninferiority trial to compare this method to bilevel positive airway pressure (BiPAP) in adult emergency department (ED) patients with respiratory distress. Patient eligibility criteria included no immediate need for intubation, no overdose, and clinician judgment of need for BiPAP.

A total of 204 patients were randomized to HVNIO or BiPAP. HVNIO was statistically noninferior to BiPAP for the main outcome measure, need for intubation within 72 hours (7% and 13%, respectively). Rates of failure of the assigned method within 72 hours were also statistically similar in the two groups (26% and 17%)

The short Power Point below and the 4 videos demonstrate the Airvo 2, one such HFNC system

Below is a link to a MS Word AIRVO 2 Quicksheet for setup for Pediatrics and Adults.

Infraglottic Airway Management

The Power Point link below covers the basics of invasive airway techniques - RSI and Cric.
(NB: Best viewed in 'Slide Show' format, as videos will only play in 'Slide Show'.)

Surgical Airway - Cricothyroidotomy : Scalpel and Needle

Although the 'last resort' airway technique, this has actually been greatly simplified in recent years. The formal, large and imposing 'cric kit' with many instruments and pieces that scared us all, has been replaced by a much simpler, 4 piece technique that is both faster and far less threatening to do. Even the bougie technique is being modified/simplified, which you will see in the second video.

Needle Cricothyroidotomy.

Given the advent of bougie cricothyroidotomy, a needle cric technique
may not be that much quicker.
However, in children below the age of 12, a needle cric is recommended over a surgical cric.

Historically needle cric needed 'insufflation' equipment to attach to the needle.
(who in the ER department knows where the insufflation device is located?)
The video below shows some simple alternatives.
What the video doesn't mention, is that failing having a 3 mm Peds ETT adapter, you can attach a 20 cc syringe to the needle hub, insert a 7 -  7.5 ETT tube, inflate the cuff in the syringe to form a seal and then bag the patient.


This fourth and final section on Airway covers Rapid Sequence Intubation (RSI) (now called 'Drug Assisted Intubation') and Delayed Sequence Intubation in more depth.
The first Power Point covers RSI and DSI in general terms and the actual steps.
The second Power Point goes into more depth of 4 critical conditions and the steps of Intubation
namely: Normotensive, Hypotensive, Increase Intracranial pressure and Asthmatic.
(NB: Best viewed in 'Slide Show' format, as videos will only play in 'Slide Show'.)

The link below is on intubation with the head of the bed elevated.
This is becoming the preferred method as it is better for oxygenation
and decreased aspiration risk.
If done properly should not affect success rates for intubation.

FACE to FACE Intubation (Tomahawk Technique)
This is covered in the Power Point above, but for ease of access is summarized here.
Face to Face intubation should be in your 'toolkit' for airway management, as the patient who is trapped upright (ie MVA), excessive vomiting/hematemesis, or difficult neck anatomy, may be best served by this technique.

Rapid Sequence Intubation or Drug Assisted Intubation  Checklist   (covered in more detail in PPT above)

  1. Pre-oxygenate with NRB/+/- OPA or OPA/BVM or LMA/BVM at 15 lpm x 4 minutes
  2. Positioning – sniffing position, ideally head up 30 degrees
  3. Decide on RSI meds below (16, 17, 18) – ask RN to draw up.
  4. Have RN draw up post intubation vent sedation (Fentanyl or Morphine)
  5. Have someone get the ventilator, plug in and attach to wall Oxygen.
  6. Designate someone to watch monitor. Announce if Sats < 93% or MAP < 65 mmHg.
  7. Have someone (or yourself) draw up Push dose pressor of choice (Epi or Phenylephrine)
  8. Check for dentures – in for bag mask, out for intubation.
  9. Attach in line EtCO2 monitor to BVM
  10. Check neck for potential cricothyrotomy, have cric kit available.
  11. Have OPA, NPA and LMA available in proper size if not already in use.
  12. Pick ET tube. Check balloon with 10 cc air, leave syringe attached. Place stylet or have bougie handy.
  13. +/-‘Lube the tube’ – put small amount of sterile lube jelly on ETT tip
  14. Choice of laryngoscope. Blade size. Check bulb working. Have spare laryngoscope handy.
  15. Suction – turn on, place handle under right shoulder of patient or under pillow.

      Normotensive, neurologically stable patient:
 16. Pretreatment agent? – Fentanyl 3 mcg/kg
 17. Induction agents – Ketamine 2 mg/kg or Propofol 1.5 – 3 mg/kg (or Midazolam 0.3 mg/kg TBW), or Etomidate 0.3 mg/kg
 18. Neuromuscular blocking agents – Succinylcholine 2 mg/kg or Rocuronium 1.2 mg/kg
     Hypotensive/Shock patient
 16. Consider? Atropine 0.4 mg IV
 17. Induction agents – Ketamine 0.25 mg/kg or Propofol 0.1 – 0.15 mg/kg or Etomidate 0.3 mg/kg
 18. Neuromuscular blocking agents – Succinylcholine 2 – 2.5 mg/kg
Elevated ICP/Traumatic head injury patient
 16. Have Labetalol 20-25 mg IV on hand for elevated systolic pressure.
 17. Induction agents – Ketamine 2 mg/kg or Etomidate 0.3 mg/kg
 18. Neuromuscular blocking agents – Succinylcholine 2 mg/kg
    Asthmatic patient
16. If time permits can give Lidocaine 1.5 mg/kg 3 minutes prior
  17. Induction agents – Ketamine 2 mg/kg
  18. Neuromuscular blocking agents – Rocuronium 1.2 mg/kg or Succinylcholine 2 mg/kg

 19.Ask the team “anything we have missed, any concerns…?”
Give Drugs - announce to team "PARALYTICS IN"
 21.Cricoid Pressure if needed – BURP
 22. Intubate – place ETT 23 cm to lips for males, 21 cm to lips for females. Inflate balloon. Secure tube.
 23. Confirm – listen to chest, check EtCO2 (or colorimetric after 8 breaths)
 24. Order CXR to confirm ETT depth
 25. Post intubation medications – Fentanyl or morphine infusion. +/- sedation
 26. Place OroGastric tube, in line suction
 27. Head of bed up 30-45 degrees.
 28. Foley catheter.
 29. Ventilator settings.
        Mode: AC        FiO2: 100%
        RR 10-14 bpm for     Normotensive or Hypotensive.
               14 - 18 bpm for   ICP
               6 - 10 bpm for     Asthmatic  (or match RR to Pt’s pre intub RR)

      Tidal Volume 8 cc/kg IBW for all patients (except pneumonia, may be less: 6-8)
                  PEEP   5 or as needed for all except asthmatics.          0 for asthmatics initially.
                  Give bronchodilators continuously for asthmatics.
30.  ABG within 30 minutes post intubation.

This video link below is a presentation by Dr. Jo Deverill from Australia on the difference between Direct versus Video Laryngoscopy and why he thinks 'DL is dead'.

There are a host of You Tube and internet sites discussing RSI techniques which you are encouraged to search out.
The  important point is to get comfortable with your equipment ("Own It").
Which exact techniques you employ you will develop with time,
but become comfortable with them and remember always have a backup!
The most important thing is to PRACTICE, PRACTICE, PRACTICE.