3 training scenarios for suctioning the upper airway
With a range of techniques and tools for upper airway suction in the prehospital environment, it’s important to assess the patient and choose the right approach
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By Tim Nowak for EMS1 BrandFocus
Gurgling … one of the sounds an EMS provider may hear upon approaching their patient that immediately sets them into a mode of airway management.
What caused this patient to have an airway obstruction? Was it trauma? Intoxication? How about a reaction of some sort?
Case 1: Trauma
You’re dispatched to a motorcycle accident involving one patient that was ejected off of a motorcycle after colliding into the back of another car. You find your non-helmeted patient prone on the pavement with blood noted around him. As you maintain spinal motion restriction and roll your patient to a supine position, audible gurgling sounds are present due to blood in his upper airway.
It’s not likely that you brought your battery-operated suction device with you to assess your patient, so what other options do you have available in your trauma or primary response bag to handle suctioning blood in the patient’s airway?
How about a simple hand-pump suction device? A few pumps on this device may be all that you need to rapidly clear your patient’s airway from blood or other secretions. These tools are a compact, disposable and inexpensive option that can be stored in a number of locations throughout your cache of equipment.
Blood obstructing the airway can have a lot of obvious negative effects, including clotting, promoting emesis if swallowed and by simply occluding air flow due to accumulation in the oropharynx.
Case 2: Intoxication
As you transport your semi-responsive (to a loud verbal stimulus) suspected alcohol intoxication patient to the emergency department, he shifts out of his comfortable lateral position and into a supine position on your cot. While completing your phone report to the receiving hospital, you hear the patient begin to retch … and then you notice him vomit.
You hang up your call and briskly sit the patient upright. Wiping away his first round of emesis, the patient proceeds into round two and continues to vomit for what feels like eternity. Repositioning him to a high-Fowler’s position has helped, but it has not solved the new airway problem that you’re facing, which is how to prevent aspiration and obstruction on your altered, but not unconscious, patient.
Attempting to turn your patient back onto his side (recovery position), you contemplate your airway suction options. Assuming that he has an intact gag reflex, inserting any sort of tube into his mouth will not result in a positive reaction. So, gravity seems to be your best option for the time being.
Trying to avoid a significant bodily fluid exposure in your ambulance, you frantically reach for the emesis bags hanging conveniently right behind you. Luckily, you’re able to avoid a significant mess both on your floor and cot, but also on yourself as well.
Case 3: Medication Reaction
You respond to a patient experiencing an excited delirium event and arrive to find him agitated, hallucinating, ranting and hyperthermic. After administering an appropriate dose of ketamine via the intramuscular route to your patient, you secure him to your cot and begin transport to the hospital with an additional rider for physical support.
Within a few minutes of beginning your transport, your patient remains dissociated and begins to show signs of hypersalivation. While most of the saliva can be wiped away from the outside of his mouth, you notice excessive amounts of saliva still inside his mouth. Prior to attempting to reposition your patient into a lateral position, he begins to gag.
Luckily, repositioning him allows you to clear his airway to make it patent. As you reflect on the events of this call, you think about your process for oral suctioning. You note the location of your wall-mounted suction device, as well as your portable unit. You think about intubation and the challenge that you had with your last secretion-filled airway, and how imperative suctioning was to clear the way for advanced airway placement.
You recall where your flexible suction catheters are located for each of your endotracheal tubes and supraglottic airway devices, as well as the location of your hard suction catheters. You even think about the one time you used your meconium aspirator to clear the excessive pulmonary edema secretions from your prior CHF patient’s airway. She was beyond the point of airway management via CPAP, so an advanced airway was the next progressive step.
Luckily, this call didn’t require any of these interventions, but you sure feel more prepared for it now because of your prior experiences and equipment familiarization.
Takeaways: Prepare and train with the right tools
Each one of these case scenarios presents its own lessons to be learned. Some are as simple as patient positioning, while others require more active and invasive suctioning procedures. Knowing where your equipment is located, as well as where its backup is located, is a key element to deploying suctioning techniques in a rapid fashion.
Being prepared for airway compromise, especially for instances where suctioning is needed, is a crucial part of both BLS and ALS airway management. Your experience from your initial training, combined with your own field experience and the shared experience of some of your mentors, has increased your confidence in airway management in the field.
Having the right tools for the job plays a key part in this. After all, performing suctioning without the right tools is like immobilizing an injury without a splint. You may be able to MacGyver things all you want, but there’s typically no substitute for the right tools and knowledge in your arsenal.
About the Author
Tim Nowak, AAS, BS, NRP, CCEMT-P, SEMSO, is the founder and CEO of Emergency Medical Solutions, LLC, an independent EMS training and consulting company that he developed in 2010. He's been involved in EMS and emergency services since 2002, and has worked as an EMT, paramedic and critical care paramedic in a variety of urban, suburban, rural and hospital settings. He’s also been involved as an EMS educator, consultant, item writer, clinical preceptor, board member, reference product developer, firefighter and HazMat technician throughout his career.
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