bledsoe et al., essentials of paramedic care: division 1 2006 by pearson education, inc. upper...
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Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Topics Respiratory Problems Respiratory System Assessment Airway ManagementTRANSCRIPT
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Division 1Introduction to Advanced
Prehospital Care
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 8Airway Management
and Ventilation
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Respiratory ProblemsRespiratory System AssessmentAirway Management
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Respiratory Problems
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Airway Obstruction
The tongue is the most common cause of airway obstruction.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The tongue as an airway obstruction
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inadequate minute volume respirations can compromise adequate oxygen intake and
carbon dioxide removal.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Other Causes of Airway Obstruction
Foreign bodiesTraumaLaryngeal spasm and edemaAspiration
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Respiratory System Assessment
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Initial Assessment
Is the airway patent?Is breathing adequate?Look, listen, and feel.If patient is not breathing, open the airway and assist ventilations as necessary.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Feel for air movement.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Look for chest movement.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Listen for air movement.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bag-valve-mask ventilation
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Focused History
OnsetSymptom developmentAssociated symptomsPast medical historyRecent historyDoes anything make symptomsbetter or worse?
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Physical Examination
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inspection
Skin colorPatient’s positionDyspneaModified forms of respirationRatePatternMentation
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abnormal Respiratory Patterns (1 of 3)
Kussmaul’s respirations– Deep, slow or rapid, gasping; common in
diabetic ketoacidosis
Cheyne-Stokes respirations– Progressively deeper, faster breathing
alternating gradually with shallow, slower breathing, indicating brain stem injury
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abnormal Respiratory Patterns (2 of 3)
Biot’s respirations– Irregular pattern of rate and depth with
sudden, periodic episodes of apnea, indicating increased intracranial pressure
Central neurogenic hyperventilation– Deep, rapid respirations, indicating
increased intracranial pressure
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abnormal Respiratory Patterns (3 of 3)
Agonal respirations– Shallow, slow, or infrequent breathing,
indicating brain anoxia
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Auscultation
Listen at the mouth and nose for adequate air movement.Listen with a stethoscope for normal or abnormal air movement.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Positions for auscultating breath sounds
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Airway SoundsAirflow
CompromiseGas Exchange Compromise
Snoring
Stridor
Wheezing
Quiet
Gurgling
Crackles
Rhonchi
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Palpation
Palpate chest wall for tenderness, symmetry, abnormal motion, crepitus, and subcutaneous emphysema.Assess compliance of lungs.
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Noninvasive Respiratory Monitoring
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Pulse oximeter
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Colorimetric End-Tidal CO2 Detector
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Electronic End-Tidal CO2 Detector
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Manual Airway Maneuvers
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Head-tilt/chin-lift
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Modified jaw-thrust in trauma
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Jaw-thrust maneuver
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Jaw-lift maneuver
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Airway before applying Sellick’s
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Sellick’s maneuver(cricoid pressure)
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Airway with Sellick’s applied (note compression on the esophagus)
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Basic Mechanical Airways
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Nasopharyngeal airway
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Nasopharyngeal airway, inserted
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Insert oropharyngeal airway with tip facing palate.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Rotate airway 180° into position.
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Improper placement of oropharyngeal airway
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Advanced Airway Management
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Endotracheal intubation is clearly the preferred method
of advanced airway management in prehospital emergency care.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Engaging laryngoscope blade and handle
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Activating laryngoscope light source
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Laryngoscope blades
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Placement of Macintosh blade into vallecula
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Placement of Miller blade under epiglottis
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETT and syringe
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotrol ETT
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETT, stylet, and syringe, unassembled
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETT, stylet, and syringe, assembled for intubation
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation Indicators
Respiratory or cardiac arrestUnconsciousnessRisk of aspirationObstruction due to foreign bodies, trauma, burns, or anaphylaxisRespiratory extremis due to diseasePneumothorax, hemothorax, hemopneumothorax with respiratory difficulty
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Advantages of Endotracheal Intubation
Isolates trachea and permitscomplete control of airwayImpedes gastric distentionEliminates need to maintain a mask sealOffers direct route for suctioningPermits administration of some medications
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Disadvantages of Endotracheal Intubation
Requires considerable training and experienceRequires specialized equipmentRequires direct visualization of vocal cordsBypasses upper airway’s functionsof warming, filtering, and humidifying the inhaled air
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Complications ofEndotracheal Intubation
Equipment malfunctionTeeth breakage and soft tissue lacerationsHypoxiaEsophageal intubationEndobronchial intubationTension pneumothorax
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Personal protective equipment
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hyperventilate patient.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Prepare equipment.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Apply Sellick’s maneuver and insert laryngoscope.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Visualize larynx and insert the ETT.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Glottis visualized through laryngoscopy
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Inflate cuff, ventilate, and auscultate.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Confirm placement with an ETCO2 detector.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Esophageal detector device, bulb style
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
If the bulb does not refill, the tube is improperly placed.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Attach device to endotracheal tube and squeeze the detector.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
If bulb refills easily upon release, it indicates correct placement.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Secure tube.
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Lighted stylet for endotracheal intubation
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insertion of lighted stylet/ETT
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Lighted stylet/ETT in position
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Transillumination of a lighted stylet
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Blind orotracheal intubation by digital method
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Digital Intubation (1 of 2)
Insert your middle
and index fingers
into patient’s mouth.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Digital Intubation (2 of 2)
Walk your fingers and palpate the
patient’s epiglottis.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Digital intubation—insertion of the ETT
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation with In-line Stabilization
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Hyperventilate patient and apply c-spine stabilization.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Apply Sellick’s maneuver and intubate.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilate patient and confirm placement.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Secure ETT and apply a cervical collar.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Reconfirm placement.
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Rapid Sequence Intubation
A patient who needs intubation may be awake. RSI paralyzes the patient to facilitate endotracheal intubation.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation in a Child
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Pediatric Airway
Smaller and more flexible than an adult.Tongue proportionately larger.Epiglottis floppy and round.Glottic opening higher and more anterior.Vocal cords slant upward, and arecloser to the base of the tongue.Narrowest part is the cricoid cartilage.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETT size (mm) = (Age in years + 16)
4
Selecting ETT size according to child’s age
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hyperventilate the child.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Prepare the equipment.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert the laryngoscope.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert ETT and ventilate the child.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Confirm placement and secure ETT.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Reconfirm ETT placement.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilation of Pediatric Patients
Mask seal can be more difficult.Bag size depends on age of child.Ventilate according to current standards.Obtain chest rise and fall with each breath.Assess adequacy of ventilations by observing chest rise, listening to lung sounds, and assessing clinical improvement.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Nasotracheal intubation may be useful in some situations:
Possible spinal injuryClenched teethFractured jaw, oral injuries, or recent oral surgeryFacial or airway swellingObesityArthritis preventing sniffing position
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Advantages ofNasotracheal Intubation
The head and neck can remain in neutral position.It does not produce as much gag response and is better tolerated by the awake patient.It can be secured more easily than an orotracheal tube.The patient cannot bite the ETT.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Disadvantages ofNasotracheal Intubation
More difficult and time-consuming to perform than orotracheal intubation.Potentially more traumatic for patients.Tube may kink or clog more easily than an orally placed tube.Poses a greater risk of infection.Improper placement is more likely when performing blind nasotracheal intubation.Blind nasotracheal intubation requires that the patient be breathing.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Blind nasotracheal intubation
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Other Intubation Devices
Esophageal Tracheal CombiTube (ETC)Pharyngo-tracheal Lumen (PtL)Laryngeal Mask Airway (LMA)Intubating Laryngeal Mask Airway (iLMA)Cobra Perilaryngeal Airway (CobraPLA)Ambu Laryngeal Mask (ALM)Esophageal Gastric Tube Airway (EGTA)Esophageal Obturator Airway (EOA)
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ETC airway –esophageal placement
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ETC airway – tracheal placement
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Pharyngo-tracheal lumen airway
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Laryngeal mask airway
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Intubating laryngeal mask airway
LMA North America
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Cobra perilaryngeal airway
Supralaryngeal device designed to be
positioned in the hypopharynx where it abuts the structure of
the laryngeal inlet
Engineered Medical Systems, Inc.
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Ambu laryngeal mask
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Continuously recheck and reconfirm the placement of
the endotracheal tube.
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Foreign body removal with direct visualization and Magill forceps
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Magill forceps
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The only indication for a surgical airway is
the inability to establish an airway by any other method.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Direct visualization of the larynx with a laryngoscope may enable the removal
of an obstructing foreign body.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomical landmarksfor cricothyrotomy
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Locate/palpate cricothyroid membrane.
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Proper positioning for cricothyroid puncture
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Advance the catheter with the needle.
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Cannula properly placed in trachea
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Jet ventilation withneedle cricothyrotomy
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Open Cricothyrotomy
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Locate cricothyroid membrane.
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Stabilize larynx and make a 1–2 cm skin incision over cricothyroid membrane.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Make a 1 cm horizontal incision through the cricothyroid membrane.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Using a curved hemostat, spread membrane incision open.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert an ETT (6.0) or Shiley (6.0).
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Inflate the cuff.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Confirm placement.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilate.
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Secure tube, reconfirm placement, evaluate patient.
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Tracheostomy cannulae
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Patients with Stoma Sites
Patients who have had a laryngectomy or tracheostomy breathe through a stoma.There are often problems with excess secretions, and a stoma may become plugged.
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Suctioning
Anticipating complications when managing an airway is the key for successful outcomes. – Be prepared to suction all airways to
remove blood or other secretions and forthe patient to vomit.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Suctioning Techniques
Wear protective eyewear, gloves, and face mask.Preoxygenate the patient.Determine depth of catheter insertion.With suction off, insert catheter.Turn on suction and suction whileremoving catheter (no more than10 seconds).Hyperventilate the patient.
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Tracheostomy suction technique
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Gastric Decompression (1 of 3)
Common problem with ventilating a nonintubated patient is gastric distention.Occurs when the procedure’s high pressures trap air in the stomach.Once patient has gastric distention, you should place a tube in the stomach for gastric decompression, using either the nasogastric or orogastric approach.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Gastric Decompression (2 of 3)
To place a nasogastric or orogastric tube:Prepare patient’s head in neutral position while preoxygenating.Determine length of tube insertion by measuring from the epigastrium to the angle of the jaw, then to the tip of the nares.If patient is awake, suppress the gag reflex with a topical anesthetic applied into the posterior oropharynx or with IV lidocaine.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Gastric Decompression (3 of 3)
Lubricate the distal tip of the gastric tube and gently insert into the nares and along the nasal floor, or into the oral cavity at midline. Advance tube gently, and if patient is awake, encourage swallowing to facilitate tube’s passage.Advance to predetermined mark on tube.Confirm placement.Apply suction and note gastric contents that pass through the tube.Secure the tube in place.
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Oxygenation
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Never withholdoxygen fromany patient for whom it is indicated!
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
To calculate how long an oxygen tank will last:
D cylinder tank life in minutes = (tank pressure in psi × 0.16) ÷ liters per minute
E cylinder tank life in minutes = (tank pressure in psi × 0.28) ÷ liters per minute
M cylinder tank life in minutes = (tank pressure in psi × 1.56) ÷ liters per minute
Oxygen Supply and Regulators
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Oxygen Delivery Devices
Device Oxygen Percentage
Nasal cannula
Simple face mask
Nonrebreather mask
Venturi mask
40%
24, 28, 35, or 40%
40 – 60%
80 – 95%
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Ventilation Methods
Mouth-to-mouthMouth-to-noseMouth-to-maskBag-valve deviceDemand valve deviceAutomatic transport ventilator
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Bag-valve mask with built-in colorimetric
ETCO2 detector
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilation of Pediatric Patients
Mask seal can be more difficult.Bag size depends on age of child.Ventilate according to current standards.Obtain chest rise and fall witheach breath.Assess adequacy of ventilations by observing chest rise, listening to lung sounds, and assessing clinical improvement.
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Demand valve and mask
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Portable mechanical ventilator
Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
Respiratory ProblemsRespiratory System AssessmentAirway Management