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Michael Fraley
EMS1.com Columnists
Assign someone to monitor the patient’s airway visually and with capnography using these five tips
Your EMS crew has just sat down for dinner on a peaceful evening when the tones sound for an ATV crash. A rural first responder discovered the scene as he was enjoying the trails himself. He reports that one patient has been thrown from an overturned vehicle, and is unresponsive and barely breathing.
Once on scene, your primary survey reveals signs of trauma to the patient’s chest. He responds to a sternal rub with just a moan. His airway is patent, but he is hypoventilating. There is no external bleeding. He has a strong radial pulse and warm, dry skin. The first responder reports that the patient’s helmet was found nearby and has significant damage.
Suspecting a mix of both head and chest trauma, you know this patient will require careful airway monitoring and breathing support.
Here are five tips to be sure that the airway and breathing interventions you are providing are not only effective, but also safe.
1. Assign an airway/breathing person
Early in the care of a patient like this, at least one of the crewmembers must be assigned the responsibility of the patient’s airway and breathing. Once assigned this role, the caregiver should stay at the patient’s head to monitor and manage the As and the Bs. Someone else will have to take care of the Cs and everything else.
Constant monitoring is critical. Things can change rapidly, and if the EMT or paramedic does not make a change or fix the problem quickly, the patient will die. It is that simple.
The airway/breathing person does not have to be the highest trained person on scene, but they do need to have the knowledge and skills to monitor for and identify changes.
2. Watch for chest rise
It seems like an easy request, but watching for the rise and fall of the patient’s chest takes practice and effort. First, the chest must be at least partially visible. The patient cannot be completely bundled up in blankets. Next, the person assigned airway/breathing duties will need to focus on watching the chest rise with each breath.
Not only will this identify if the patient is taking their own breaths, but it will also help limit the volume of breath delivered with a bag-valve-mask to just enough to produce slight chest rise. The evidence is now clear that providing too much volume with a BVM is harmful to the patient.
3. Use capnography to monitor ventilation rate
The use of end-tidal capnography (EtCO2) has become the gold standard for assessing airway interventions, and it is invaluable for monitoring spontaneous breathing and assisted ventilations as well. If your service does not have EtCO2 monitoring capabilities, consider seeking a grant to purchase it.
The waveform produced by EtCO2 monitoring is called the capnogram. With just a quick glance at the capnogram, the airway/breathing EMT can see an illustration of the ventilation rate, as well as the duration of each breath. It takes a little experience to be able to look at the waveform and know what is too fast or too slow, but this skill can be learned quickly.
Many monitors also display the respiratory (or ventilation) rate numerically.
4. Use end-tidal carbon dioxide values to adjust the rate of ventilation
Knowing that the normal EtCO2 value is 35-45 mmHg, we can assess the patient’s current disease or injury status to determine if their EtCO2 value is too high or too low. EMTs and paramedics should get in the habit of assessing them on all seriously ill or injured patients. It should be considered mandatory when airway or breathing interventions are needed.
The most common complication of assisted ventilations is “bagging” the patient too quickly and lowering the EtCO2 value. Slow the ventilations slightly to see if the value increases and then continue to adjust the BVM rate until the EtCO2 value gets closer to the normal range.
5. Use teamwork
While it is critical to assign one EMS crew member the full-time duty of monitoring the patient’s airway and breathing status, it is also important that the entire crew works together to support that role.
It is not unheard of for the person with the BVM to lose focus and the ventilation rate starts to trend upwards. The adrenalin coursing through our bodies doesn’t help either. Other team members should feel comfortable pointing out if they feel that the ventilation rate is a little too fast, too slow or if the breaths are being delivered with too much volume. The person performing the BVM ventilations should likewise accept this as patient-centered feedback and not criticism of their efforts.
Team members must also have clear communication with the airway/breathing person when other interventions are being performed or when the patient is going to be moved. Make sure everyone is on the same page.
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