Transcript

0:12

Pull up. We'll go ahead and introduce Doctor Hoffman. So let's take a look here. Alright. There we go.

0:25

So thumbs up from anybody who can see my screen.

0:32

I can see it.

0:33

Sweet. Alright. Look at here. Coach will be up and going in no time. Excellent.

0:39

Alright. Doctor Hoffman is professor of athletic training and kinesiology at Oregon State. He joined Oregon State in 2000. Primary teaching responsibilities is the athletic training education program. He started as an emergency responder and his youth.

0:54

And he has a passion for emergency medicine ever since. Academically, his early career scholarship focused on his funnel controlled mechanisms associated with lower extremity injuries. And more recently, this scholarship has transitioned to study health and wellness in wildland firefighters during a wildfire season in the Pacific Northwest. He provides medical services. He's dual credentialed as an athlete trainer in the MT intermediate, where he's been the 1st AT employed by the US Force Service in this capacity.

1:27

That's pretty cool. He's a lieutenant EMS coordinator at ADA Rowan Rescue in Oregon in service, Societe Generac College of Public Health And Human Services And Vice Provost. Of international programs. He received a fellowship recognition by ACS M and the NADA Miss Alarmana, Indiana State University honor him with the distinguished award, Doctor Hartman. Doctor Hartman is so good to have you and we look forward to your presentation.

1:55

The floor is yours.

1:57

Alright. Thanks, Ronnie. So you'll just advance my slides for me. Is that correct?

2:01

Yes, sir.

2:02

Alright. We're ready for the next one.

2:04

Alright.

2:06

So this is our conflict of interest slide. I have bolded here the effect that everyone that is interested in using particularly some of the advanced stuff that we talk here about today should make sure that you have coordinated that with your the physicians that you work with in any medical direction that you have. Okay? And then so our learning objectives today are gonna be described by indications, precautions, limitations, of airway adjuncts, and advanced airways. So we'll spend a fair amount of time talking about.

2:38

Some of the things that you as an athletic trainer can utilize to make life a little easier with the situation is difficult and you need to urgently ventilate a patient. So I'm gonna try to help you understand, really how to determine who needs ventilations and who doesn't. It's not just Europe. Patients in respiratory arrest. There's other times when you need to assist patients with ventilation.

3:08

We're gonna talk a little bit about supplemental oxygen, not a whole lot because that's gonna be covered in one of the other talks, explain some of the differences between positive pressure and ventilation and spontaneous ventilations, and then really kinda discussed methods of artificial ventilation and recognizing inadequacy. So that's That would be my biggest goals right there. So maybe if everyone just can take a a little mental inventory before we get started on what's your comfort level. Between 110 on assessing the airway of an unresponsive patient, determining if the patient's respirations are adequate. So do you need to do something else about this?

3:51

And then using all this using all the skills and equipments in your scope to manage the airway in an unconscious patient. So as an athletic trainer, we have we have a pretty decent scope related to things that were taught And and I just wanna make sure that everyone's comfortable using the full scope of your credential. Alright. We are obviously not gonna be doing any hands on skills here today, but I strongly suggest that after you get the knowledge here today, reach out to your local fire department, your EMS department, and ask them if they can give you a little tutorial on some using some of the equipment that we talked about here today, I I would suspect most departments are gonna be more than happy department with you that you can man use their mannequins and become comfortable with what what we've talked about today. The the real part of the anatomy I wanna talk out today is is just this idea of of the upper respiratory system because the the airways that we're gonna talk about are related to the related to inserting an airway either in through the nose or into the mouth.

5:15

So either a nasal airway or either a nasal airway or an oral airway, I apologize if the leaf blowing outside has has crept into the the audio here. Hopefully, they'll be done soon. Alright. Let's move on. The one of the things I really emphasize with with people that I teach this content to, that unless you are by yourself, doing one person, one rescue, or CPR commands their way, you really should be at the head of the patient.

5:56

So you can see the medic in this situation is innovating, which we'll not talk about today, but is in that what I call the airway position. That's the best place to position yourself you can see down the chips. You can see down the airway. I really know what's going on. So ventilation's airway insertion, all of that should happen ideally from this airway position.

6:22

Probably one of the most important things we need to figure out is are the respirations that the patients having are the attic. And or they're inadequate. And this is assuming that your patient is in respiratory distress as opposed to respiratory arrest, If your patient is breathing, you obviously want to check and see if there's any cyanosis. You wanna look for a low reading on your SPO2 monitor. And and in general, we talked low reading as below 94 the thing that you really wanna make sure is that that little that little beeping scale that is on on our plus oximeters, that's called the pleph.

7:07

And so you wanna make sure that you have a nice, strong pleph because that really tells you how well it is reading the pulse and the content. So make sure you have a good plat, monitor your SPO2 reading, nasal flaring, any patient that is exhibiting nasal flaring, they're working really hard to work. We focus on noises. Right? So are there any wheezes or any other unwelcomed noises when your patient's breathing?

7:37

Those are all indications that things aren't going like they should. If there's little to no chest rise, if they are working real hard to breathe, That's an indication that they're they're likely not adequately exchanging gases. And then intercostal retractions. We don't really see this a whole lot in our adult patients, more common in our pediatric patients. But that's whenever you can really see the intercostal muscles being used to assist in ventilation.

8:08

Alright. So our steps to maintaining an airway is maintaining proper airway positioning. Utilizing their way adjunct, and I'm going to advocate very strongly for the for the athletic trainers to always have good access to oral pharyngeal and nasopharyngeal airways, we'll talk about those determine the need for supplemental oxygen. So anybody that is being ventilated with the bag bulk mask should be receiving additional oxygen through that. And then And then any person that really is below 94% of oxygen saturation should should be receiving rescue oxygen Again, that will be covered more deeply in another presentation.

8:57

And then determine if you need to to assist the patient, their regulations. Most of the time, we're really taught that, you know, patients in respiratory arrest, when they're not breathing at all. Those are the patients we need to ventilate, but there are other situations when you need to support a patient's ventilation with a bag box mask. So our options are oral fair GLRAs. I've got a couple of pictures here on the the next couple slides, your nasal parengeal airways, and those are obviously they're they're going through the mouth and and sit in the oral pharynx or the nasal scoliosis.

9:37

Through the nose, sit in the nasopharynx. And then within the competencies for athletic training is superbotic airways. These are these are not new devices, but the IGLs are relatively new device and and very simply deployed. So we'll talk just a little bit about that. So here you can see for your oral failure geographies, the idea is that it goes into the mouth.

10:02

It's gonna sit right over the tongue, and then rest right there in the back of the Fairnix. Ultimately, it it keeps the tongue out of blocking the airway, which we all know is one of the major obstructions of who the airway, and it can be a real challenge, particularly in CPR, making sure that you have the head tilted and and the chin lifted to keep the tongue out of the way. I can tell you that if you drop an OPA into a patient, Your life is a lot easier as you're ventilating these patients, particularly those that are in respiratory or breast. Retribution needs to be unconscious, and they need to be completely void of a gag reflex. If they have any sort of a gag reflex at all, they're not going to welcome this this airway, they're gonna gag.

10:54

And so that's an indicator that it needs to come out, and you need to go a different direction. But OPAs, they are very, very easy to insert and take up very little space in your in your bed bag. So strongly encourage everybody to have good access to these if you're ever gonna be in a situation where you may have to ventilate a patient. Really, in these situations, you just want your patient bezer pine. You want to determine the right size.

11:25

And so we measure these from the corner of the mouth to the tip of the ear, and then you're just going to look at the sizes that you have and pick the right one. To insert it, we use a a cross thumb and forefinger technique. Really, that just kind of opens and spreads the teeth so you can place the airway into the mouth. And And when it's all said and done, that flange the airway should sit right right around the the front of the teeth. The we used to teach that these would be inserted with with them being rotated a 180 degrees, but the current practice is really to insert them so that the tip of the airway is towards the patient's cheek, and then you only have to rotate it 90 degrees.

12:23

And then it will just sit right there in front of the patient's teeth or or lips to keep that tongue out of the way while you're ventilated your patient. So for your nasopharyngeals, these are often tolerated much better because they don't and do some gag reflex. It's typically not my first go to airway just because it requires lubrication if I needed airway quick. I'm usually just going to grab my OPA and drop that in. But the the MPA is a very, very effective airway.

13:02

It does need some lubrication, a water based lubrication. And really, the only contraindications for these are any patient with a severe head trauma or potential basal basal skull fracture just because In theory, they can if the bottom of the the cranium is compromised, you could potentially insert this airway into the brain From my understanding in clinical practice, this has only happened ever once. But so it's really rare, just something you wanna be aware of. And I can tell you the last time I the last cardiac arrest that I worked, we arrived. The patient there jaws locks, so they we could not open their airway and get a an OPA in them.

13:56

Patient was cyanotic, and we put in a nasopharyngeal airway. And within about 3 minutes after ventilating them with a 100% oxygen in in a bag belt mask, they went their color chain and their SPO 2 went from mid eighties up to to 98. So the the nasal parent geo airway is a is a very, very effective airway and log in for those just because you don't have to worry about them having a having a gag reflex. But to put those in, you need to get some assessment of the size of the nasal passage pick the airway that looks like it's gonna fit in the nose, and then the length of the airway is also determined by comparing the airway links from the tip of the nose to the corner of the jaw. And okay.

14:57

Next slide. And like I said, these need to be lubricated with with the water soluble lubricant. So we always keep your pack of lube with our NPAs. You wanna gently push the the tip of the nose up And then you just insert the airway. And and really what happens is it goes straight back a lot of times when we practice these, we want we visualize them going kind of up the nose, but really once you open that nostril with a little upward pressure, that airway just goes pretty much straight back.

15:31

Now we typically shoot for the right nostril first just because it has typically, this just a little bit smaller or a little bit larger in all people. And then when you look at these nasal varieglerways, they have a bevel on them, and so that's slanted side needs to always be inserted towards the septum. So we talk about the bevel to the septum, And when you get your hands on these and get a chance to put them in a manicenter, you'll you'll get a little bit better appreciation for how that works. And then, again, just making that note that they really just go straight back. And then the advanced airways, these are hydels.

16:11

And they anybody that is going to accept an oral pharyngeal area will typically accept one of these I gels. They are really becoming very popular in EMS. And the idea is that they go back into the pharynx. They sit right above the glottis. And they ensure that ventilations that are being put down this tube go into the lungs and not into the belly, which is a major complication for for ventilating a patient.

16:43

So these are really helpful in cardiac arrest patients, people that can't be intubated or were an ET 2 innovation isn't available. Contradications, they there's a this is a kind of a long list, they're they're pretty rare. So if they have any reflexes, if they have a known esophageal disease, You don't wanna be putting things back there that could rupture blood vessels if they have some type of caustic ingestion. So anybody that has any type of petroleum ingestion. Upper airway obstructions, four bodies, obviously, you're not gonna put this on top of something that might already be in there, and then if they aren't able to open there.

17:28

Not able to get their jaw open, then then they're not gonna work. But really strong ace, recommend everybody get trained up on these. They're they're very effective and really simple to use. Yeah. So there, this is just kind of a nice little a nice little visual.

17:53

You can see how it just goes down through the patient's airway. And the tip of it sits right there on the esophagus so that any air that is coming into the tube goes straight into the trachea and then into the lungs where you want it. So I just cannot emphasize how super easy these are to insert and how much how much benefit there is to the patient if can get an advanced airway in there. Alright. Just wanted to ready.

18:25

Knowles a little bit about positive pressure ventilation using the EC clamp to use a mask. By definition, positive pressure ventilation is when you use some sort of pressure device from the outside to push air into the lungs and In our setting, we typically either use a rescue mask or a BBM or bag valve mask. Again, just a a nudge here to everyone to have good, quick access to a BBM and some airways because It not only makes your life a lot easier, but your work on the patient is much more effective if you have a combination of a a bag belt mask and some sort of an airway. And then just noting that we provide positive pressure regulations for people that are app So they don't they're not breathing at all. People are breathing real fast if they're not moving enough tidal volume to to get fresh air to their lungs.

19:27

Or if they are really real slow. They are there's techniques where we assist them in their ventilations to to push a little extra air into their lungs. So here is the background mask. Again, we talked about the EC clamp pricing. Hopefully, everyone is at least a little bit familiar with that.

19:51

So that's the idea that The two fingers that are going over the mask are forming a c, and then the three fingers under the mandible is an EC. This is a this is a technique that cannot be practiced enough. Get to make sure you get a nice good seal with the mask. But remember, again, if you have an idea on them, the mask comes off and your bag gets connected directly to the mask and you no longer have to fight the the maintain a seal. One of the big focuses now with back valve mass ventilation or any ventilation is that we don't overinflate the lungs we only inflate the lungs until we see the start of a chest rise.

20:34

That that's adequate volume for the patient. Alright. So assess the breathing. That that's one of the things that's really important. Especially in our setting, we need to make sure that before we even start our assessment of breathing, we need to figure out if there's any consideration for potential c spine compromise because if there is, that's going to determine how you will open the airway.

21:04

If there is an issue with C Spine or a concern of C Spine, you're going to use a jaw thrust. And if not, then then feel free to go ahead with a a head tilt chin lift. You need to figure out is breathing presenter apps. Right? Is it adequate or inadequate?

21:22

So some of those cues that we use beforehand talk about really figuring out if the respirations are adequate is important. And then and tools in the toolbox, you have lots of things available to you if you if you've trained with them. Right? So, obviously, your hands are important for opening the airway airway adjuncts, your OPAs, your NPAs, eyelves, rescue mask, or BBM, and then emergency oxygen. Ideally, any patient and particularly in respiratory arrest that is being ventilated by a BBM, that that mask should that backbone mask should be attached to a 100% oxygen to facilitate as much oxygen delivery to the patient as possible.

22:14

Alright. So our techniques, whatever 5 to 6 seconds for your patient and respiratory arrest, And then the next thing I I indicate here is monitor pulse because if you have someone that is in respiratory arrest, you must be prepared. They're going to move into a full cardiac arrest situation. So just if you're breathing for a patient and providing all of the respirations, whatever 5 to 6 seconds, please keep track of that pulse. Because as soon as that pulse goes away, then you need move to to CPR.

22:52

And then you're gonna use a mask or a VBM. And then don't over reflect the lungs, like I mentioned before. Just nice, smooth, squeeze of that bag to see slight rise and fall of the chest, and then you wanna add oxygen if it is available. And then you have to figure out how is it working. Right?

23:12

So how are you gonna know if what's going on is working in general? You're going to see a rise and fall of chest. The saturation is currently improved, so you wanna make sure that you're keeping a pulse oximeter on your patient while you are working on them. And then typically, their color is going to improve. Like I said, this last patient that we had in respiratory or in cardiac arrest severely cyanotic upon our arrival, could not get an eye gel in them because their jaw is locked.

23:45

Dropped to know an NPA and saturations in color improved dramatically within the first couple of minutes. So just kind of work those through your head as far as what steps you're gonna take in certain situations. And then just concluding, and we'll have some time for questions here, but proper use of airway adjuncts can significantly impact your athlete's outcomes. So I I really strongly believe that as an athletic trainer, we're there to provide emergency services to our patients that we need to be prepared to do so. I will not work in event or anytime when we're working in event, I make sure that I have ready access to a rescue mask.

24:36

And at least an oral faryngeal airway whenever I may have patient contact. And then recognize the need for supplemental oxygen and positive pressure ventilation. That's a that's a critical skill. So you need to recognize that you need to to utilize these tools. And then you just need to be get really good at it because there's nothing that we can really do that's more important to our patients than being able to provide lifesaving measures to them.

25:07

So mastering these skills, find some place to train, connect with your local providers, see what they can My experience is that that if your approach and say, hey, you know, I really like to have upgraded to practice some of this. They will walk in me with open arms because ultimately, it's it's for the patient outcomes. And then it usually makes their life easier if you're doing a nice job when they show up. Alright. I think that's all I have.

25:40

I I hope there's some questions.

25:45

Thanks so much, Mark. Yes. Let's take a look. I know I have questions. Yeah.

25:52

Chris asked you to get a PDF of the slides later. Chris, we we don't share our slides, but you definitely can get an all access pass and get access to this presentation on demand. So if you have any questions for Doctor Hoffman, please put them in the QNA. I'm double checking the chat area to make sure nobody has slipped anything in there. Alright.

26:18

Yeah. Please step him in. I know one question I have, Mark. I know opening an airway is one step, maintaining an airway is really the the core of what you were referring to. OP and MP Airways, they should be in the scope of practice of an athletic trainer or not.

26:36

Oh, absolutely. So they are you know, and one of the things I was really excited about seeing this series is the fact that everything that I have talked about here today is in the current competencies and that we are teaching in our athlete training curriculums. So so OPAs and NPAs at the very least The the challenge with them is that they look a little daunting, but you are not going to hurt your patients in any way by utilizing these devices. If you put an OPA in somebody and they become conscious, they are going to gag and choke and spit it out. So if it needs to come out, you will know it needs to come out.

27:23

They are very, very safe and extremely useful devices.

27:31

So I know you referred to the agile. Talk about the keen tube and your experiences with the 2 as as an advanced stairway?

27:40

Yeah. That's a that's a great question. So there are there are really 2 the supraglottic airways that are being utilized now across the country. 1 is the king airway and 1 is the Igel. The King Airway in principle is just like the idea.

28:00

Everything is above the glottis. The challenge with the king is that it has some inflatable cups that So once it's placed, you have to inflate a cuff and make sure that it's secure. And it's it's not a difficult path but it is not near as straightforward as the IGL. Here in the Pacific Northwest, almost all of our agencies have transitioned transitions to I gels away from the king. But if you work with the provider or service that uses the king, that's it's a reputable super blunt and care way as well.

28:41

Gotcha. Yeah. I think that's the same here in South Louisiana transitioning from the key tube over to the IJEL. And I know when I began to practice and use the idea. I'm like, oh my goodness.

28:55

This is, like, super simple expecting it to be complicated and was almost as easy as inserting an OP airway in. But the advantage is definitely outweigh any risk that that might come along with inserting airways. So talk just a little bit about and and we'll we'll be wrapping this up. This might be my last question. Unless somebody else comes in here as well, but you referred a little bit to respiratory distress and potentially doing positive pressure ventilation what is the criteria to to quantify or to describe somebody that would qualify an athletic trainer to start positive pressure ventilation even though there seems to be some breathing activity going on.

29:48

What's your criteria to to start bagging down?

29:54

Yeah. That's a that's a great question. I somewhere to know that we slip we we skipped over that slide. But the in general, anybody who is breathing below 8 respirations per minute. These are all guidelines.

30:12

You need to assess them and see how well they are changing gases. And if they are breathing slow, and again, our our guideline is 8, then you just squeeze that mask, squeeze that bag out mask whenever they are breathing in. So you just boost the volume that they're bringing in when they're breathing slowly. That's the easier of the 2. If somebody's breathing real slow, You can just, what we call, track their respirations.

30:42

And then whenever they inhale, you just squeeze the mat the bag and give them a little bit extra. On the other side, if somebody is breathing very quickly, and the number we use is around 20. We see actually a lot of patients that are breathing at 20 and they're doing just fine. But when somebody starts breathing very quickly, you have to start being concerned that they're not moving enough. So if they if their clinical signs are poor, if they're cyanotic, If they have low oxygen saturation and they're breathing very quickly, then you also need to use that bag belt mask to try to assist them.

31:22

And so again, whenever they breathe in, you just need to give them a little bit extra volume. Again, this can be a bit of a challenge because at that quick rate, tracking so many user aspirations, can be difficult. But if you have your bag valve mask connected to an oxygen tank and you're providing a 100% oxygen Any little air that you can get into their lungs when they're breathing that quickly is going to be to to their benefit.

31:54

So the downside, you know, it's kinda it's kinda it's kind of odd to think that somebody is breathing in quite often. We just monitor the breathing and wait on EMS to arrive, but you're saying that athletic trainers should be aggressive and supporting their ventilation with oxygenization as well as positive pressure ventilation. And so the downside of doing this, the the the risk are fairly minimal. Right?

32:24

Oh, absolutely. And I mean oxygen is is really benign. Especially in the patients that we're looking at. And if you have it's all about your patient. We'd like to have devices that give us numbers and things But if your patient looks like they're sick, if they have poor skin color, and if they're showing a low oxygen saturation that that person needs potentially assistance.

32:53

And and, you know, you might try just providing oxygen with a non carburetor mask initially, which might boost their saturations, and that's fine. But If those efforts are working, then then there needs to be aggressive steps to support the patient in their military efforts.

33:16

Excellent. Alright. We we have no other questions, and we're going to begin to do the transition to the next speaker. Mark, are there any final thoughts or comments to wrap this up before we we move on, and we definitely appreciate your time.

33:30

No. Again, it's just that nudge that people need to just be talkable with things that are within your scope. And like I said, the idea of sticking something in somebody's mouth or nose can be a little daunting, but it's they're very simple techniques. Relatively benign and really important for your your patient's outcomes. Yeah.

33:56

And I I just hate having the opportunity to come in chat. And if if folks wanna reach out to me directly, that's that would be great too.

34:05

Let's see. Let's see if we can find one more question in the chat here. Let's see. Ray and I've seen it in the shed, but let me look at it. Okay.

34:15

Here we go. Jason asked some states are limited by practice set because they say that if the AT isn't managed to supplement our auction, you are prescribing. Can you speak to that, Mark?

34:27

Sure. And this is a this is a pretty fine line. I it's my understanding that that and there's a big difference between supplemental and therapeutic oxygen and rescue oxygen. So for the most part, If you're delivering oxygen at 6 liters above for a critically ill patient, will he consider that rescue oxygen as opposed to therapy to got So the most of the laws are related to the use of therapeutic oxygen. As opposed to rescue oxygen?

35:02

That's a great question and an important clarification And I believe if anybody really digs into their state laws, they'll find that there are typically very few restrictions on administration of rescue oxygen.

35:20

Yeah. Very good. Yep. Alright. Once again, I'm pretty confident we're gonna see Doctor Hoffman back again in future educational sessions as we laid the groundwork for developing an incredibly comprehensive library of resources in emergency medicine to support the athletic trainer.

35:42

And so we have a 16 speakers, March number 1. So we're ready to move on to the