paramedic update part 1

TOPIC

Workforce Safety andWellness

1

Introduction

• Now more than ever, paramedics must employ multiple strategies to ensure their safety:

– Disease transmission

– Recognition of a dangerous scene

– Personal safety

– Health and wellness

Actual Safety Threats

• The leading cause of death to EMS providers is being involved in a motor vehicle crash.

• EMS providers are as likely to die from a heart attack as to be murdered.

• Leading causes of injury in the EMS workplace include back injuries and exposures to bloodborne pathogens.

Responding to the Actual Threats –Wellness and Injury Prevention

• Motor Vehicle Crashes

– Account for nearly 80 percent of EMS line-of-duty deaths

– It is imperative to safely operate the ambulance.

– Seatbelts save lives.

– Seatbelts worn inside the ambulance can protect the EMS providers.

Responding to the Actual Threats –Wellness and Injury Prevention

• Back injuries

– Most common cause of lost work and long-term disability among EMS providers

– Proper lifting and moving techniques should be used in order to prevent injury

Responding to the Actual Threats –Wellness and Injury Prevention

• Key Elements of Proper Lifting

– Anticipate a career of lifting

– Know your limitations and request assistance when needed

– Lift using the proper power-lift technique

– Pay attention to minor injuries

Responding to the Actual Threats –Wellness and Injury Prevention

• Key Elements of Proper Lifting– You must set the example and help

build a culture in which lift assistance is the norm, rather than the exception.

– Know when your capabilities are outmatched by the weight of your patient.

– Attempting a lift without proper capabilities is unsafe to both you and to your patient.

Infection Control

• Prevent high-risk exposures by using appropriate personal protective equipment and using simple strategies such as:

– Washing your hands

– Handling sharps safely

– Using Standard Precautions

Standard Precautions

• Decide what precautions are needed as you consider the circumstances.

– Gloves and hand washing are a minimum.

– Face, gowns, and respiratory precautions as needed.

Standard Precautions

• Decide what precautions are needed as you consider the circumstances.

– Modalities such as IV catheterization, advanced airway placement, or medication administration require additional attention to Standard Precautions.

Standard Precautions

• Re-evaluate and choose the appropriate level of personal protective equipment accordingly.

• As a paramedic, your decisions will be setting the example for others.

• It is necessary for a paramedic to handle sharps safely.

Wellness

• Leading a healthy lifestyle can benefit paramedics.

• Concepts to incorporate into a wellness plan include:– Regular exercise

– Healthy diet

– Rest

– Routine and regular medical care

– Stress management

Stress Management

• Stress can damage your health and well-being.

• Types of stress reactions include:

– Acute stress reaction

– Delayed stress reaction

– Cumulative stress reaction

• Employ strategies to minimize stress.

Summary

• Self-protection is an imperative part of safely going home at the end of the day.

• The paramedic must remain vigilant to all threats to their well-being.

• Paramedics should take steps to prevent injury and stay safe and well.

TOPIC

Patient Safety

2

Introduction

• Many patients die every year as a result of preventable medical errors.

• As paramedics, you are entrusted to treat your patients and do no harm.

• Your responsibilities include preventing medical errors and ensuring the safety of your patient.

• Improper actions or treatments can result in harm or death to your patient.

Recognizing Risks

• Scene assessment and situational awareness can help identify and avoid problems.

• Patient transfer and handoffs account for the single largest situation associated with patient errors.

Patient Transfer and Handoff

You arrive at a busy ED at a time when your shift has three priority 1 calls holding. Your suspected stroke patient seems stable enough, but you are obviously concerned about the overall outcome. En route you give a radio report; on arrival, you recognize the triage nurse as the person with the voice you spoke to on the radio.

Patient Transfer and Handoff

She says, “Go ahead and put him in the hall bed; we will be right there.” In the meantime, dispatch radios you for the fourth time and asks if you are available. Having been acknowledged by the nurse, you and your partner transfer the patient and leave for the next call.

Patient Transfer and Handoff

• What risks have you exposed the patient to?

• What consequences can occur because of your actions?

• How could this have been avoided?

Communication Difficulties

• Miscommunication or communication difficulties can lead to patient errors.

• Communication difficulties may put the patient at risk.

• As a paramedic, it is imperative that you communicate well with others.

Medication Issues

• Incorrect medication administration can potentially result in disastrous consequences.

• Ever-changing medication lists, packaging, and dosage calculations can all pose potential problems.

• Use the “five Rights” to help reduce medication errors.

Airway Issues

• Mishandled airways have proven to be both prevalent and disastrous.

• Misplaced endotracheal intubations continue to be a serious problem in the world of EMS.

• Paramedics must incorporate good airway decision-making skills into the assessment and management of each patient.

Patient Movement

• Patients are at risk whenever they are moved.

• Dropping a patient can lead to injury and possible legal and civil liabilities.

• Utilize the appropriate resources and/or technology for safely moving patients.

Ambulance Crashes

• Ambulance crashes remain the largest cause of lawsuits against EMS providers.

• They account for the majority of injuries to patients by providers.

• Safe ambulance operation is a responsibility of the paramedic.

Spinal Immobilization

• Proper spinal immobilization is designed to prevent secondary injuries.

• When performed inappropriately or not applied when necessary, it can present a disastrous risk to the patient.

How Errors Happen

• Types of errors

– Skill-Based errors

– Knowledge errors

– Rule-based failure

• Each category is potentially dangerous and can be prevented.

Preventing Errors

• The two main approaches to preventing errors are systemic strategies and individual tactics.

• Know your own limitations and capabilities.

• Seek help when needed.

• Learn from your mistakes.

• Embrace quality improvement and continuing education.

TOPIC

Legal Issues in EMS

3

Introduction

• Legal issues impact every patient contact.

• Laws are designed to protect both the patient and the care provider.

• If paramedics do not adhere to the legislation that they must operate within, severe legal punishments may result.

Legal Terms

• Scope of practice

• Negligence

• Intentional torts

• Duty to act

• Ethical behavior

• Medical direction

• Good Samaritan laws

• Sovereign immunity

• Statute of limitations

• Standard of care

Figure 3–1 A paramedic may be required to testify in court in a variety of legal settings.

Ethics

• Branch of philosophy directed toward the study of morals or concepts such as right or wrong.

• NAEMT has issued a Code of Ethics.

• Ethical decision making should guide the choices paramedics make everyday.

Patients’ Rights

• Every patient that summons EMS has certain “rights.” These include:

– Privacy and confidentiality

– Access to emergency care

– Consent

– Ability to refuse care

Patients’ Rights

• Every patient that summons EMS has certain “rights.” These include:

– Advance directives

– Organ donation

– Transport

– Privacy

– Refusal

Special Reporting Situations

• EMS providers are legally bound to report certain types of emergencies.

• These mandatory reporting points may vary from state to state.

• Paramedics should remain abreast of what their state requires and learn the reporting system used.

Summary

• So long as there is EMS, there will be laws governing EMS.

• The paramedic is solely responsible for staying abreast of laws that apply in his state.

• The paramedic should always behave ethically and act in the best interest of the patient.

Summary

• The best defense for preventing a lawsuit is to provide conscientious care to the patient, maintain the standard of care, follow state guidelines, and provide quality documentation on the patient care report.

TOPIC

Cellular Environment and Metabolism

6

Introduction

• Understand how changes in the patient are due to changes in cellular integrity.

• The basic intention of emergency medical care is to keep the cells alive.

• Cellular integrity must be the core of a paramedic’s assessment and treatment.

Figure 6–1 The cell.

Physiology

• Metabolism

– Metabolism refers to the sum total of chemical reactions taking place in the body.

– Many metabolic activities build upon each other.

– Disturbances can lead to cellular death, which in turn ultimately leads to death of the organism.

Physiology

• Anabolism

– Creation of larger structures from smaller molecules

– Requires energy

• Catabolism

– Process that breaks down large molecules into smaller ones

– Requires enzymes and water, and produces energy in the process

Physiology

• Cellular Respiration

– Process of transferring energy from a glucose molecule to a cell.

– Oxidation is necessary for energy production and heat.

– Glucose is the building block of cellular energy.

– ATP is the primary energy-carrying molecule.

Physiology

• Aerobic Cellular Metabolism

– Glycolysis

– Citric acid cycle (Krebs cycle)

– Electron transport chain

Figure 6–2 Aerobic metabolism. Glucose broken down in the presence of oxygen produces a large amount of

energy (ATP).

Physiology

• Anaerobic Cellular Metabolism

– Without oxygen, cellular production of ATP is very low.

– Glycolysis still occurs.

– Hydrogen molecules build up, increasing lactic acidosis.

– The cell fails and dies.

Figure 6–3 Anaerobic metabolism. Glucose broken down without the presence of oxygen produces pyruvic acid, which converts to lactic acid and only a small amount of energy (ATP). A lack of glucose and oxygen will create a disturbance to cellular metabolism and may lead to dysfunction and eventual cell death. Cell dysfunction and death lead to organ dysfunction. When a critical mass of cells dies within an organ, the organ itself then dies

Physiology

• Sodium/Potassium Pump

– Maintains normal levels of Na+ and K+

on either side of the cellular wall.

– Exchanges three sodium molecules for two potassium molecules.

– The pump requires ATP to operate.

– If ATP is lacking (anaerobic metabolism), the pump fails and the cell ruptures.

Summary

• Understanding the need for normal cellular function underlies all branches of medicine.

• Although we tend to treat the obvious (airway, breathing, circulation), doing so ultimately treats the ability to maintain cellular integrity.

Summary

• Once cells start dying, the syndrome progresses rapidly and may be irreversible.

• The paramedic should always consider how their treatment will impact cellular activity.

TOPIC

Anatomy and Physiology: The Blood

7

Introduction

• The blood is the body’s transport mechanism.

• Understanding the composition and role of the blood can help the paramedic understand perfusion, shock, and the circulatory system in general.

Composition of the Blood

• Formed elements (45%)

– RBC

– WBC

– Platelets

• Plasma (55%)

– 91 percent water

– Albumin, antibodies, clotting factors

Blood Plasma

• Plasma is the yellow-colored liquid medium of the blood

– 91 percent water

– -9 percent plasma proteins

• Albumin (maintains the fluid balance in the blood)

• Antibodies (defence against infectious)

• Clotting factors (key in coagulation)

Erythrocytes

• Created during erythropoiesis.

• Eliminated during eryptosis.

• Cytoplasm contains hemoglobin.

• Genesis and elimination of RBCs provide for maintaining adequate oxygen-carrying capabilities.

Leukocytes

• Protect the body against infection and eliminate dead and injured cells and debris.

• Types of leukocytes– Neutrophils destruction and removal of bacterial – Eosinophils deal’swith invaders to the body &

inflamation– Basophile releases histamine– Lymphocytes respond to and destroy foreign

invaders– Monocytes assist antibodies with identifying

unwanted invaders

Thrombocytes

• Platelets are fragments that play a major role in hemostasis.

• Adhere to each other to form clots and stop bleeding.

Hemostasis

• Hemostasis is the process of protecting the circulatory system from blood loss.

• Phases of hemostasis:

– Vasoconstriction

– Platelet plugging

– Coagulation

Coagulation Cascade

• During coagulation, fibrin is introduced.

• Fibrin is regulated by chemical factors and proteins,

• Factor X is activated and initiates a series of events which cause coagulation.

Coagulation Cascade

• Prothrombin is converted to thrombin.

• Thrombin converts fibrinogen to fibrin fibers which envelope platelet plug and stabilize the clot.

The Complete Blood Count

• The complete blood count is a test performed on a sample of blood

• Used to determine the presence of key elements of blood composition.

Table 7–1 Complete Blood Count Normal Values

Blood Types and Rh Factor

• ABO system categorizes blood based on the presence or lack of antigens on red blood cells and antibodies in plasma.

• Blood types: A, B, AB, and O.

• The Rh factor looks for a specific third antigen and is represented as positive or negative

Summary

• Understanding the composition and role of the blood can help the paramedic identify, treat, and manage patients.

• The paramedic should understand how hemostasis is accomplished.

BREAK

TOPIC

The Nervous System

8

Objectives

• Identify the major components of the nervous system.

• Differentiate between the central and peripheral nervous system and their roles in maintaining homeostasis.

• Discuss the clinical application of how the nervous system can affect a patient’s physiological presentation.

Introduction

• The nervous system allows the body to:

– Receive information from the environment

– Transport that information to the brain

– Process and react to the information

Introduction

• Categorized into the central and peripheral nervous systems.

• Thoughts, movements, senses, and reflexes are all results of the actions of the nervous system.

Neurons

• The building blocks of the nervous system.

• The three types of neurons include sensory, motor, and interneurons.

• Nerves transmit impulses to convey information.

• Damage to the nerves can be detrimental to the body’s natural function.

Figure 8–1 The neuron.

Central Nervous System

• Composed of two components.– The brain

– The spinal cord

• Damage can result in the ability to perform even basic functions.

• Sensory pathways of the spinal cord:– Posterior column

– Spinothalamic pathway

– Spinocerebellar pathway

Figure 8–2 The divisions of the brain.

Peripheral Nervous System

• Composed of structures not covered by the central nervous system.

• The PNS is divided into two main sections:

– Somatic division

– Autonomic division

• Sympathetic branch

• Parasympathetic branch

Table 8–1 The Cranial Nerves

Figure 8–3 Spinal nerves.

The Senses

• Allows the body to relay information about the environment to the nervous system.

• Helps prevent the body from sustaining injuries.

The Senses

• The general senses are:

– Pain

– Temperature

– Touch/pressure/position

– Chemical detection

Special Senses

• The special senses have specialized organs which relay information.

• The special senses include:

– Sight

– Smell

– Hearing

– Taste

Reflexes

• Reflexes are physiologic responses from the body to a stimulus.

• Categories of reflexes include:

– Spinal reflexes

– Cranial reflexes

– Somatic

– Autonomic

Summary

• The nervous system is the collector, transporter, and interpreter for the world around us.

• A paramedic should understand that it is vital for maintaining homeostasis and the ability to move, breathe, think, and understand the environment we live in.

TOPIC

Medical Terminology

9

Objectives

• Review the components of a medical term.

• Review a list of common medical terms.

Introduction

• Medical terminology is the language of health care.

• By understanding terms, components, even complex words, can be broken down.

• Understanding and utilizing proper terminology can improve communication between members of the healthcare team.

Medical Terms Origin

• Terms are often derived from Greek and Latin sources.

• Common parts compose the terms.

– Prefixes

– Suffixes

– Combining forms

• Some memorization will be required to get a basic grasp of the language.

Structure of Medical Terms

• Three basic components

– Combining form

• Root

• Combining vowel

– Suffix

– Prefix

How to Define Medical Terms

• Terms can easily be defined by determining the meaning of their parts.

• Read left to right, but define by interpreting the suffix, then the prefix, then the combining form.

prefix combining form suffix

hyper- glyc/o -emia(above or excessive) (sugar) (blood condition)

Use proper medical terminology to communicate with other health care professionals.

Figure 9–1 Sometimes it will be more convenient to use an accepted medical abbreviation or symbol in your

report instead of writing the entire term.

Table 9–2 Common Prefixes in Medical Terms

Table 9–2 (continued) Common Prefixes in Medical Terms

Table 9–3 Common Suffixes in Medical Terms

Table 9–3 (continued) Common Suffixes in Medical Terms

Table 9–4 Common Combining Forms in Medical Terms

Table 9–4 (continued) Common Combining Forms in Medical Terms

Table 9–4 (continued) Common Combining Forms in Medical Terms

Table 9–4 (continued) Common Combining Forms in Medical Terms

Table 9–4 (continued) Common Combining Forms in Medical Terms

Table 9–4 (continued) Common Combining Forms in Medical Terms

Table 9–4 (continued) Common Combining Forms in Medical Terms

Table 9–4 (continued) Common Combining Forms in Medical Terms

Table 9–4 (continued) Common Combining Forms in Medical Terms

Table 9–4 (continued) Common Combining Forms in Medical Terms

Table 9–4 (continued) Common Combining Forms in Medical Terms

Table 9–4 (continued) Common Combining Forms in Medical Terms

Table 9–4 (continued) Common Combining Forms in Medical Terms

Table 9–4 (continued) Common Combining Forms in Medical Terms

Summary

• The proper use of medical terminology will help ensure clarity in the sharing of information regarding the patient.

• The paramedic should keep abreast of medical terms and abbreviations as they pertain to the practice.

• A paramedic is expected to use proper medical terminology.

TOPIC

Self-Defense Mechanismsand Inflammation

11

Objectives

• Review the inherent mechanisms of cellular self-defense and the inflammatory process.

• Discuss the first-line and second-line defenses of the inflammatory response.

• Understand the local and systemic manifestations of inflammation.

Introduction

• The immune system provides a defense against the challenges faced by the body.

• Native immunity includes natural barriers and inflammation.

• Protective physical, mechanical, and biochemical barriers provide protection against infection.

Figure 11–1 The defense mechanisms of the body.

Figure 11–2 White blood cells form the basis for the phagocytic response.

The Inflammatory Response

• The inflammatory response is a complex sequence of events designed to prevent damage and repair existing damage to cells.

• It is stimulated by any process that can kill cells or damage connective tissue.

Figure 11–3 The process of inflammation.

Manifestations of Inflammation

• Local manifestations of inflammation include:

– Heat

– Redness

– Swelling

– Pain

Manifestations of Inflammation

• Systemic manifestations of acute inflammation include:

– Fever

– Leukocytosis

– Plasma protein synthesis

Manifestations of Inflammation

• Acute

– Short time of activation

• Chronic

– Over two weeks of activation

– Common pathways include:

• Persistent accute inflammation

• Neutrophil degranualation and death

• Lymphocyte activation

• Fibroblast activation

Summary

• The immune system provides a defense against the challenges faced by the body.

• It is important to understand how the body responds to theses challenges, especially at the cellular level.

• Paramedics should understand how inflammation impacts the body.

TOPIC

The CardiovascularSystem

12

Objectives

• Distribution of blood within the vascular compartment and the physiologic determinants that affect movement of fluid into and out of the vascular compartment:

– Hydrostatic pressure.

– Plasma oncotic pressure.

Objectives

• Normal cardiac output, and how certain variables can alter it from normal:

– Changes in heart rate.

– Changes in stroke volume.

• Systemic vascular resistance, and the effects should it become deranged:

– Tissue perfusion.

– Systolic and diastolic blood pressure.

– Pulse pressure.

Objectives

• Microcirculation, and how changes of the aforementioned principles have a positive or negative effect on it.

• Blood pressure, and how it becomes deranged from disturbances in the aforementioned principles.

Objectives

• How the autonomic nervous system (sympathetic and parasympathetic) can alter cellular perfusion through manipulation of the aforementioned principles.

Introduction

• The heart, the blood, and the blood vessels each play an essential role in maintaining adequate tissue perfusion and homeostasis.

• Understanding how the cardiovascular system functions will help the paramedic to recognize critical situations and anticipate further patient deterioration.

Blood Volume

• Blood volume is one of the determinants of adequate blood pressure and perfusion.

• Blood is distributed throughout the cardiovascular system.

• Hydrostatic pressure and plasma oncotic pressure play important roles in maintaining the fluid balance.

Blood Volume

• Hydrostatic pressure—is the “push” force inside the vessel or capillary bed generated by the contraction of the heart and blood pressure

• Plasma oncotic pressure,colloid oncotic pressure, or oncotic pressure—is the “pull” force responsible for keeping fluid inside the vessels

Table 12–1 Distribution of Blood in the Cardiovascular System

Figure 12–1 Hydrostatic pressure pushes water out of the capillary. Plasma oncotic pressure pulls water into

the capillary.

Pump Function of the Myocardium

• The heart must pump effectively to maintain adequate blood pressure and perfusion.

• Cardiac output is the amount of blood ejected by the left ventricle in 1 minute.

Pump Function of the Myocardium

• Systolic blood pressure is a relative indicator of cardiac output.

• Cardiac output = Heart rate × Stroke volume

Systemic Vascular Resistance

• The resistance that is offered to blood flow through a vessel

– Vasodilation typically decreases the pressure.

– Vasoconstriction typically increases the pressure.

Systemic Vascular Resistance

• Diastolic pressure is the basic measure of SVR.

• Pulse pressure is the difference between the systolic and diastolic blood pressure readings.

• Vasoconstriction decreases vessel diameter, increases resistance, and increases blood pressure.

• Vasodilation increases vessel diameter, decreases resistance, and decreases blood pressure

Microcirculation

• Microcirculation is the flow of blood through the arterioles, capillaries, and venules.

• True capillaries are the sites of exchange between the blood and the cells.

Microcirculation

• Capillary blood flow is influenced by:

– Local factors

– Neural factors

– Hormonal factors

Microcirculation

• In a resting state, the local factors predominantly control blood flow through the capillaries.

• When adaptation is necessary, the neuralfactors will change the capillary blood flow.

• Hormones are usually responsible for a sustained effect on the arterioles and capillaries.

Microcirculation is the flow of blood through the smallest blood vessels: arterioles, capillaries, and venules.

Precapillary sphincters control the flow of blood through the capillaries.

Blood Pressure

• Blood pressure (BP) is derived by multiplying two major factors: cardiac output (CO) and systemic vascular resistance (SVR).

• Blood pressure is monitored and regulated by:

– Baroreceptors

– Chemoreceptors

Summary

• Maintaining adequate metabolism and perfusion is essential for the survival of the cells, organs, and the patient.

• Understanding the ways in which the cardiovascular system compensates will help the paramedic not only recognize critical situations, but also anticipate further patient deterioration.

TOPIC

MedicationAdministration

15

Objectives

• Discuss patient safety strategies associated with medication administration.

• Understand the responsibilities of paramedic-level pharmacology.

• Discuss ways to prevent medication errors.

• Review nontraditional medication routes.

Introduction

• Paramedics have access to and provide a wide array of medications to benefit patients.

• With this ability, comes great responsibility.

Introduction

• Paramedics must keep the patient’s safety at the center of care and treatment.

• Paramedics must maintain, improve, and enhance their capabilities to utilize medications.

Patient Safety

• Patient safety is imperative.

• Medication errors can result in fatal consequences to the patient.

• Some medication errors encountered in EMS include those involving:– Dose

– Route

– Rate of administration

– Allergies

Figure 15–1 Check the medication.

The Five Rights

• The five rights of medication administration include:

– Right medicine

– Right dose

– Right time

– Right route

– Right patient

Figure 15–2 Double-check the concentration and expiration date.

Maintaining Competency

• Paramedics must ensure that their knowledge base meets and exceeds the standard of care.

• It is imperative that the paramedic is familiar with the regulations and protocols that guide their practice.

Advances in Medication Administration

• Paramedics have adopted a number of changes associated with the delivery of medications.

– Intraosseous administration for adult and pediatric patients.

– Intranasal administration can allow for rapid medication absorption and a safer needle-free environment.

The EZ-IO (Vida-Care Corporation).

Summary

• Medication administration is an important responsibility of a paramedic and should always be taken seriously.

• The paramedic should always consider the patient’s safety and the “five rights” before administering any medication.

TOPIC

Paramedic Medications

16

Objectives

• Review the paramedic formulary.

• Discuss new approaches with traditional prehospital medications.

• Understand some of the issues surrounding specific prehospital medications.

Introduction

• New research has influenced the medications being administered by paramedics.

• Paramedics should be aware of various debates pertaining to the administration of some medications.

• Paramedics should understand how these debates may impact their protocols.

Oxygen Reconsidered

• Hypoxic patients should still receive oxygen.

• Hyperoxia may be harmful and lead to systemic vasoconstriction and the release of free radicals in the body.

• Oxygen therapy should be titrated based on the monitoring of the oxyhemoglobin saturation to ≥94 percent.

Figure 16–1 Use of supplemental oxygen is being reconsidered.

Acute Pulmonary Edema Medications

• Morphine Sulfate

– Morphine has been found to not possess the vasodilatory property once believed.

– Cardiac toxicity and reduced cardiac output may occur with administration.

– Low-dose benzodiazepines may provide the same anxiolytic effects without the negative side effects.

Acute Pulmonary Edema Medications

• Furosemide (Lasix)– Once believed that the diuresis would

benefit the patient’s hypervolemic state and was often administered in high doses.

– Research studies have found that many patients in APE are not hypervolemic.

– The diuresis in a normovolemic patient can lead to hypovolemia, which must be corrected.

Cardiac Arrest Medications

• The following medications have been recently reviewed by the AHA and have remained a cause of much debate and research with respect to appropriate care of cardiac arrest:

– Atropine (no therapeutic benefit)

– Vasopressin (no better than standard EPI)

– Sodium bicarbonate (no benefit)

Other Controversial Medications

• Thiamine

– Thiamine deficiency is rare and for thiamine to be effective, it should be administered over days.

• Procainamide

– Antidysrhythmic used in the treatment of wide complex tachycardia. But avoid in pt. with a prolonged QT or CHF

Summary (cont'd)

• Paramedics must stay abreast of the changes and understand how they can impact their practice.

TOPIC

Airway Assessment andDecision Making

17

Objectives

• Delineate between respiratory distress and respiratory failure.

• Review the signs and symptoms that illustrate ventilatory adequacy of inadequacy.

Objectives

• Determine when or when not to ventilate a patient.

• Review and integrate the airway treatment options for a patient suffering from a disturbance to the airway.

• Review core treatment interventions for a patient suffering from disturbance to the airway.

Introduction

• Paramedics must be able to properly assess and recognize airway dysfunction.

• Airway management is a process that should be guided by the assessment findings and should be goal oriented.

Introduction

• The paramedic must utilize critical thinking and good decision-making skills in order to provide the best treatment for the patient.

Anatomy of the upper airway.

Pathophysiology

• Upper airway dysfunction

– Obstruction can result from foreign bodies or more commonly as a result of poor muscle tone.

– Structural changes can also impede airflow.

Loss of control of the upper airway may occur, when the muscles of the upperairway relax too much and the epiglottis is allowed to fall back and cover the glottic

opening.

Pathophysiology

• Lower airway dysfunction

– Bronchoconstriction is the most common cause.

– Other disorders can structurally change how gas is exchanged in the alveoli.

Airway Assessment

• The paramedic must ensure and secure the airway.

• Consider the following:

– Mental status, speech, and voice

– Pathophysiology or other findings that may threaten airway

• Ensure breathing is adequate to meet the needs of the body

Patient suffering respiratory distress, indicated by his tripod position.

Respiratory Distress

• Compensation to a respiratory challenge

– Respiratory rate increases

– Accessory muscles are engaged

– Heart beats faster and stronger

• The compensatory efforts are sustaining normal function despite the problem.

Respiratory Failure

• Compensatory mechanisms fail.

– Oxygen may not be distributed

– Carbon dioxide is retained

– Muscles of respiration tire

Respiratory Failure

• The patient will require ventilatory assistance.

• Altered mental status, hypoxia, cyanosis, and irregular respiratory patterns are key findings that indicate respiratory failure.

The continuum of breathing ranges from normal, adequate breathing to no breathing at all. It is essential to recognize the need for assisted ventilations even before severe respiratory

distress develops.

Using Assessment to Guide Treatment

• Quality assessment allows for recognition of a problem and provides valuable information.

• Critical thinking is a must for using the correct tools in the right circumstance.

• Cost and benefits must be considered.

• Consider the pathophysiology.

Goals of Airway Management

• Assess the ability to move air and exchange oxygen and carbon dioxide.

• Determine weather the patient is in respiratory distress or respiratory failure.

Goals of Airway Management

• Goals of airway management should include:

– Securing and protecting the airway

– Oxygenating the patient

– Ventilating the patient

Outcome-Based Management

• Depends on critical thinking.

• Links assessment findings to desired outcome in order to form a treatment plan.

• Allows for the most appropriate tools for the best patient outcome.

Opening/Securing the Airway

• Basic airway interventions are frequently the most appropriate to open and secure the airway.

• Consider both short-term and long-term airway management.

• Utilize a cost–benefit analysis.

• Consider the nature of the disorder.

Oxygenating and Ventilating

• Ensure adequate oxygenation and ventilation.

• Patients in respiratory failure require positive pressure ventilation.

– Consider the ability to secure the airway

– Consider minute volume

– Consider pharmacologic treatments including oxygen

Oxygenating and Ventilating

• Support compensatory efforts and reverse the challenge for patients in respiratory distress.

– Oxygen therapy

– Pharmacologic treatments

Summary

• The paramedic must be able to assess and promptly treat respiratory failure.

• Airway management should be guided by the assessment findings and should be goal oriented.

• Critical thinking is necessary for the paramedic to choose what is the most appropriate treatment for their patient.

TOPIC

Noninvasive AirwayIntervention

18

Objectives

• Discuss the core interventions for a patient suffering from a disturbance to the airway.

• Review the concepts of oxygen therapy and positive pressure ventilation.

• Discuss the use of continuous positive airway pressure during the management of a patient in respiratory distress.

Introduction

• Paramedics must use assessment and critical thinking to decide which tool is right for a specific patient.

• A wide range of tools are available for managing patients with airway problems.

• It is the responsibility of the paramedic to determine the most appropriate intervention.

Don’t Forget the Basics

• A paramedic must weigh the costs and benefits to determine the best treatment for the patient.

• In many cases, basic interventions are the most valuable and/or appropriate.

• Advanced procedures are important in the right circumstances.

Supplemental Oxygen Revisited

• Oxygen is a drug that must be used correctly.

• Never withhold oxygen from a hypoxic patient.

• Continued high-flow oxygen beyond normal oxygen saturations may cause hyperoxia.

Supplemental Oxygen Revisited

• Oxygen should be titrated to maintain a normal saturation levels of 94 percent to 95 percent

Positive Pressure Revisited

• Positive pressure ventilation is needed to correct respiratory failure.

• Minimize the effect of positive pressure on the heart and cardiac output.

• Keep gastric insufflation in mind.

• Ventilate at age-appropriate rates to avoid hyperventilation.

Bag-Mask Device and Cardiac Arrest

• Intubation interrupts compressions and may negatively affect resuscitation.

• Bag-mask ventilations alone may not be an effective way to move air.

• Blind airway insertion devices should be considered.

• The costs and benefits of moving to a more aggressive airway must be weighed by the paramedic.

Continuous Positive Airway Pressure

• CPAP creates a constant slight flow of air against which the patient will breathe.

• CPAP is most commonly used to treat acute pulmonary edema, but can be used to treat other forms of respiratory distress.

Continuous positive airway pressure (CPAP) is used for the awake and spontaneously breathing patient

who needs ventilatory support.

Summary

• Paramedics must use assessment findings and critical thinking to determine the most appropriate way to manage a patient suffering from an airway disturbance.

Summary

• Many options are available for the paramedic to manage the airway.

• Utilizing noninvasive airways may be the most beneficial for the short-and long-term outcomes for some patients.