1) My goals:
a) Share experiences from prehospital practice that will help you manage airways in confined spaces
b) Help you recognize that you will intubate in confined spaces throughout your career
c) Provide a structural skeleton so that you can improvise and adapt when confronted with a confined space scenario

Ask students what they think of when the hear the phrase "Confined Space"

Not Enough Space
i) hoarder's apartment
ii)A patient down in an elevator or a bathroom.
iii)An airway emergency somewhere other than A-1?

Too Much Stuff
i) Carts, trays, US and other equipment and monitoring all decrease your work space.

Too Many People
i)A-1 during an interesting case
ii) attending breahting down your neck, asking "What do you see?"

Too Much Patient
i)A big patient can make a normal space seem small

Ask: What are some in-hospital scenarios you’ve encountered that have felt confined?

i)BJA Study: 35% of intubations by anesthesia occurring outside the OR involved an adverse event
-a slight change in familiarity can lead to a big spike in complications

Make a plan
a)Hofmeyer: first rule of intubating in a confined space: Don’t.

b)Planning is essential to working in a confined space, you need to ask the right questions.

ie Scene size-up before primary survey

i) How are you getting in?
ii) How are you getting out?
iii) How is the patient getting out?
iv) What will the patient airway needs be in 5 min, 15 min 60 min?

Scene Size-up is a dynamic process

Make a plan (cont.)

c) You have a lot of options in your tool box! Do you really need a definitive airway or can you temporize?

i) An NPA and an NRB can you buy you some time.
ii) A blindly inserted SGA beats a failed intubation every time. You can swap for a tube later.

d) In the truly confined or entrapped patient, you should raise your threshold to intubate, but lower your threshold to cut.

Own the space
a) You to examine the entire space, not just the space between the teeth.

Comfort with manipulate the environment is a hall mark of expertise and higher-order thinking.

i) In Blackhawk down Bowdon writes that whereas Rangers take cover in the streets, Delta Force would kick down doors to take cover in houses.
ii) In simulation of a patient collapsed in a bedroom, novice providers are least likey to manipulate the space to their advantage, experienced will move furniture and flip over beds to clear space to work

Positioning Matters
i) More than just ear to sternal notch
ii) Don’t intubate in a hoarders apartment move them out into the hallway.
iii) Syndey HEMS and London HEMS never intubate in the ambulance. They intubate out side with 360 degrees of access to the patient
iv) Move the surroundings if you can’t move the patient

What else do we need to position?

d) Position yourself
i) May have to kneel or lie prone, but again, don’t attempt DL if you know from the outset you won’t get a good view.

e) Position your equipment
i) Lay it out as you’re going to need it, knowing its in the airway box somewhere is not being prepared

f) Position your team
i) Make sure you’ve got elbow room
ii) You should have the number of people you need, no more no less, you can ask people to step back or leave.

Be ready to improvise
a) Improv comedy is not funny because it’s spontaneous, it’s funny because it is an adaptation of a meticulously rehearsed structure manipulated and adapted by masters of their craft.
i) I’ve heard this applies to good Jazz too, but I don’t know anything about Jazz

b) Mental simulation maintains preparation
i) If the guy in seat 14 f collapsed, would you know what to do?
ii) You open the bathroom door at McDonald and find an Opiate OD face down behind the toilet, what now?


c) You may need to improvise with your team
i) Any bystander can squeeze a bag
ii) Give instructions to ad-hoc team members clearly and succinctly. Closed-loop
(1) “This is called a bougie, this is the tube, when I say pass me the tube, pass me the tube”

c) You may need to improvise with your equipment
i) Sheets can be used to hoist, pull and move patients
ii) A c-collar can be used to maintain the neck inline while moving an intubated patient up or down stairs
iii) PJs in Afghanistan use a bougie to ream the nares of blast victims in order to place an NPA
iv) To record end tidal in an unintubated patient, you can cut the probe an insert it in an NPA
d) Becoming familiar with your equipment and these procedures will allow you to be comfortable when you need to improvise with them.

Review
a) Confined Spaces are everywhere
b) Make a plan
c) Own the space
d) Be ready to improvise
e) Keep thinking, keep learning keep practicing.