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CE oct 12 airway key Presentation Transcript

  • 1. Continuing Education October 2012 AirwayOxygenation & Ventilation Diana Neubecker RN BSN PM EMS System In-Field Coordinator ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 2. ObjectiveAirway Management, Respiration, and Artificial Ventilation Paramedic Education StandardIntegrate complex knowledge of anatomy,physiology, and pathophysiology into assessmentto develop and implement a treatment planwith the goal of assuring a patent airway,adequate mechanical ventilation, and respirationfor pts of all ages. ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 3. ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 4. ProblemKing LTSD• Does not protect airway, from secretions, as well as ETT• Pts should be preoxygenated prior to advanced airway, which often requires BVM use• BVM ventilation often results in gastric distention……• 18 fr soft suction catheter is too short to reach the stomach ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 5. SOLUTION: KLTSD has “gastric access lumen”©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 6. NEW: Salem-Sump NGT LeaveNGT = nasogastric tube OpenSalem-Sump dual lumen NGT1. Secondary lumen (blue pigtail, smaller) open to atmosphere – Vents large lumen – Keeps suction @ gastric openings low to prevent mucosal irritation2. Drainage lumen (larger) Connect To Suction ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS. Openings
  • 7. Salem-Sump NGT & KLTSD• Indications when KLTSD in place – Vomiting – Gastric distention – Prolonged BVM ventilation prior• Contraindications Same as KLTSD• NOTE: Insert AFTER placement & verification of KLTSD ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 8. Salem-Sump NGT & KLTSD Procedure1. Measure for insertion depth (Nose Ear Xyphoid)2. Lubricate3. Insert into proximal lumen & gently advance – If resistance felt – abort procedure4. If concern about proper placement – Attach capnography (should have no persistent ETCO2) – Inject 60mL air & auscultation over epigastrium – Insert end into cup of water & observe for bubbling5. Connect to suction – continuous 30-40 mmHg – Intermittent up to 120 mmHg PRN ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 9. Salem-Sump & KLTSDHow far to insert tube? Measure from: tip of nose around ear down to xyphoid process ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 10. Review QuestionWhich is the correct order of steps for KLTSD insertion? A B C D EInsert Insert Insert Insert InflateVentilate Withdraw Withdraw Inflate InsertAuscultate Ventilate Inflate Auscultate VentilateInflate Auscultate Ventilate Ventilate AuscultateWithdraw Inflate Auscultate Withdraw WithdrawInsert NGT after above steps completed ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 11. ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 12. Airway, Oxygenation, & Ventilation• Without an airway, nothing else matters……• However, airway management requires careful risk – benefit analysis.• Paramedics are expected to assess and manage pts, beyond using an inflexible algorithm, and use critical thinking skills, evidence based practice, and focus on outcomes-based management. ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 13. Research1. Review assigned abstract.2. Prepare 1-2 sentence summary (< 20 words), that you can verbally report in <1 minute. ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 14. Airway, Oxygenation, & Ventilation No Resp Resp Resp CardiacDistress Distress Failure Arrest Arrest Goals: 1. prevent from getting worse 2. improve status ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 15. EMS TreatmentPriority:1. Obtain airway2. Oxygenate3. Ventilate ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 16. ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 17. AssessmentAirway & breathing are assessed on all pts:• UNconscious – after circulation (CAB)• Conscious – before circulation (ABC) ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 18. Review QuestionWhen approaching an UNconscious pt,with a pulse, how should an EMS providerfirst determine the airway is patient?Are they breathing? ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 19. Review QuestionWhen approaching a conscious pt,how should an EMS providerdetermine the airway is patent?– Can they speakWhat else can above assessment determine?– Respiratory distress • Sound – is voice hoarse/raspy? • How many words can pt speak? ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 20. Respiratorydysfunction/obstructioncan beupper orlower airway ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 21. AirwayThe “classic” upper airway dysfunctionoften thought of is – the person chokingFar more common….upper airway obstructionis the tongue, often dueto altered mental statusWhy does this happen? ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 22. AirwayPt w/ AMS lying supine, muscle tone of jawallows heavy tongue to fall back & obstruct airway ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 23. Review QuestionWhat are s/s of tongue obstructing airway?ApneaSnoring ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 24. Review QuestionList other causes of upper airway disorders?– Laryngeal edema due to allergic reaction– Epiglottitis– Tonsillar abscess ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 25. Noisy breathing is Obstructed breathing©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 26. Review QuestionEMS crew arrives on scene of a pt who is notbreathing, but has a radial pulse. In preparingto ventilate, which is the LEAST critical piece ofequipment to use during the first few breaths?– Mask– Oxygen tank– Bag-valve device– Oral/nasal airway ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 27. Review QuestionWhy is an OP/NPA so important?• Failure to use an OP/NPA will require an increased amount of force/pressure to ventilate past obstruction of tongue• Increased force/pressure opens esophageal sphincter and allows gastric distention ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 28. Pressure<15 cm H2O rarely causes distention>25 cm H2O often causes gastric distention Br J Anaesth 1987;59:315 ACTA Anaesth Scand 1961;5:107 ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 29. Priority of CareAirway before Breathing ALWAYS*insert an oral/nasal airway prior to BVM ventilation *unless contraindicated ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 30. Review QuestionWhen using an oral/nasal airway, howimportant is it to use the correct size?– Critical– Too small is worse than no airway ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 31. Review QuestionHow should an oral airway be sized? ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 32. Oral Airway Sizing©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 33. Review QuestionIs this OPA• too large?• too small?• the right size? ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 34. Review QuestionHow should an oral airway be inserted? ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 35. Review QuestionHow should an nasal airway be sized? ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 36. Review QuestionHow should an nasal airway be inserted? ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 37. Review QuestionHow can the use ofOP/NPA’s be optimized? “Ortinau Airway Method” NPA - bilateral with OPA ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 38. ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 39. Review QuestionWhen assessing breathing what are theFIRST 2 things that should be determined?A. Respiratory rate & lung soundsB. Respiratory rate & depthC. Breath sounds & O2 satD. O2 sat & ETCO2 ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 40. Review QuestionWhat can help an EMS provider determineif respiratory depth is adequate?Breath sounds ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 41. Review QuestionWhen doing a quick check of breath sounds(e.g., to determine they are present bilat)where is the first place you should listen?A. Over tracheaB. Anteriorly above 1st ribsC. Mid-axillary line (under armpits)D. Upper lobes on posterior chest wall Why? ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 42. Quick Breath SoundsLateral chest• Peripheral lung fields• Less risk sound transmission ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 43. Auscultation Sites©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 44. Review QuestionWhat are the 2 major goals of breathing?1. Oxygenation2. VentilationHow are they different?– Oxygenation: taking in and using oxygen– Ventilation: elimination of carbon dioxide ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 45. Review QuestionWhat are signs of inadequate oxygenation?– Low O2 satWhat are signs of inadequate ventilation?– High ETCO2 ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 46. Assisted Ventilation©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 47. ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 48. Why is head elevation recommended?Bring oral (OA), pharyngeal (PA), laryngeal (LA)axis in alignment ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 49. Alternate to “E-C” Mask Hold©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 50. 2 Hand – Mask Seal©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 51. What’s wrong with this picture?©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 52. What’s wrong with this picture?©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 53. Review QuestionAt what rate should adult pts be ventilated?10-12/m prior to advanced airway8-10/m after advanced airway6-8/m if PMH asthma/COPD ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 54. Review Question• How much volume should be delivered? ~400 – 600 mL• Why are bag-valve devices so large (hold 1200-1500 mL of air)? Designed so only one hand is needed to squeeze bag to deliver a sufficient tidal volume ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 55. Review QuestionWhy is hyperventilation harmful? (list 7 causes):1. Gastric distention diaphragm elevation & impaired lung expansion2. Gastric distention vomiting & aspiration3. Decreased venous return cardiac output4. Alkalosis5. Constriction of cerebral vessels6. Constriction of coronary arteries7. Barotrauma tension pneumothorax ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 56. Review QuestionWhat can help EMS providers avoidhyperventilating pts?capnography ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 57. Review QuestionWhat will happen to EtCO2 w/ hyperventilation? Will decreaseWhy? Ventilating pt faster than making CO2 ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 58. Review QuestionWhat else can cause low ETCO2 levels? – Perfusion • Hypotension (shock, cardiac arrest) • Pulmonary Embolus – Metabolism • Hypothermia ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 59. BVM Ventilation Pitfalls1. Failure to use OP/NPA2. Inadequate pt positioning3. Improper mask holding4. Occluding nostrils w/ mask5. Poor positioning of ventilator6. Hyperventilation ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 60. Review QuestionWhat are examples of lower airway disorders? – Asthma/COPD – Pulmonary edema due to HF – Pulmonary embolus – Pneumonia ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 61. Airway, Oxygenation, & Ventilation No Resp Resp Resp CardiacDistress Distress Failure Arrest Arrest Goals: 1. prevent from getting worse 2. improve status ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 62. Review QuestionWhat normally happens when a ptexperiences respiratory distress?– The body attempts to compensateWhat signals the body to compensate?– Increasing CO2– Decreasing O2 ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 63. Review QuestionWhat are signs of compensation forrespiratory distress?– Increasing respiratory rate– Accessory muscle use, tripod positioning– Tachycardia, due to SNS stimulation ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 64. Review QuestionWhat are accessory muscles?– Neck– Chest– Abdomen ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 65. Review QuestionHow is respiratory failure different fromresp distress? In respiratory failure, compensatory mechanisms have failed ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 66. Review QuestionHow can respiratory failure be differentiatedfrom respiratory distress?In addition to resp distress s/s may have:– Altered mental status (anxiety, combative, somnolence, unconscious)– Hypoxia (despite O2 administration)– Hypercarbia (increased ETCO2)– Resp rate slowing, irregular, or gasping ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 67. Prompt Tx to STOP the Progression• QI finding: Treatment not begun where pt found (or on-scene) and pt deteriorating while moving to amb (or while transporting to hospital).• Respiratory DISTRESS should be treated to prevent respiratory FAILURE• Respiratory FAILURE should be treated to prevent respiratory ARREST• Respiratory ARREST should be treated to prevent CARDIAC arrest ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 68. Advanced Airways & Intubation CombiTube LMA iGel©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 69. What are complications of intubation?1. Vagal stimulation bradycardia & hypotension2. SNS stimulation tachycardia3. Hypoxia from inadequate preoxygention4. Hypoxia from prolonged/multiple attempts5. Infection from contamination of ET tube6. Trauma to airway7. Unrecognized esophageal intubation8. Hyperventilation induced – Hypotension – Vasoconstriction of cerebral & coronary arteries – Gastric distention, vomiting & aspiration – Alkalosis – Barotrauma (tension pneumo) ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 70. ETI procedureIf not in cardiac arrest, what should assistantto intubator be doing? (list 4)1. Watch monitor – HR (for changes)2. Watch monitor – O2 sat (for desat)3. Watch clock – elapsed time4. Provide assistance as needed ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 71. ETI procedurePre-Oxygenation CriticalHow long should pts be preoxygenated?3 minutes ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 72. ETI procedure How long is allowed for an attempt? 30 seconds In severe hypovolemic shock, pts may desaturate as quickly as 30 secondsAnes Analgesia 2009;109:303-305 ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 73. ETI procedure• Infection in intubated pt can be life-threatening• Contaminated ET tube – Can lead to pneumonia, sepsis, & death – Keep in pkg until scope in hand & ready to visualize – Treat ET tube w/ same sterile technique as IV cath ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 74. ETI procedureUnrecognized esophageal intubation• Multiple confirmation techniques• Redundancy to prevent deadly complication ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 75. Hypo/Hyperoxia• Know hypoxia kills• Learning just how harmful hyperoxia is• Oxygen (~21%) is present in the environment – However, in higher concentrations it becomes a “drug”• Like all drugs, dose should be considered• Prehospital, because ABG (arterial blood gas) is not available, we rely on other methods to assess oxygenation• Pulse oximetry is one method ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 76. Hyperoxia• When a pt has an O2 sat of 100%, it is unknown if arterial oxygen level is 100 or 600 – While 100 may be fine, 600 could be harmful• Thus, oxygen administration should be titrated based on specific SOP ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 77. Breathing• Under normal breathing, what type of pressure do we use used to bring air into our lungs? – Negative pressure• When ventilating w/ BVM, what type of pressure is used? – Positive pressure ventilation (PPV) ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 78. Breathing• PPV disrupts normal function, esp. filling of heart• Leads to venous return & cardiac output/BP• In hypotensive pts, cardiac output can be lethal• How can the risks of PPV be minimized? – Ventilate at prescribed rate, avoid ventilating too fast – Avoid too much tidal volume or ventilating too deeply ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 79. Critical Thinking & Outcomes-Based Management Which pt is at greatest risk of developing a tension pneumothorax, requiring a pleural decompression?A. Breathing pt with an open pneumothoraxB. Any pt receiving assisted ventilationC. Spontaneous pneumothorax in breathing ptD. Simple/closed pneumothorax in breathing pt ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 80. Negative vs Positive Pressure Breathing• Intrapulmonary (inside lung) pressure = atmospheric pressure – Lung open to outside, so same pressure• Positive pressure breathing: pressure greater than atmospheric - increases risk of pneumothorax leading to tension pneumo ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 81. Tension Pneumothorax©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 82. Critical Thinking & Outcomes-Based ManagementCalled to restaurant for a choking pt. Uponarrival, unresponsive adult male, not breathing,slow, weak radial pulse.• What should be done? Attempt to ventilate• What if that is not successful? Reposition head, attempt to ventilate• What if that is not successful? Begin CPR Attempt to visualize w/ laryngoscope & remove w/ forceps/suction ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 83. Choking man continued• What if that is not successful? – Attempt to intubate• What if that is unsuccessful? – If unable to intubate or ventilate – perform cricothyrotomy• What if during surgical cric, PM is unable to pass ET tube? – Attempt smaller size ETT ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 84. Critical Thinking & Outcomes-Based ManagementWhat’s the best method to secure airway,oxygenate, & ventilate pts in cardiac arrest? ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 85. Critical Thinking & Outcomes-Based Management1. Does an OP/NPA provide a long-term airway that the pt in cardiac arrest may need?2. Do these pts often require ETI?3. Should compressions be interrupted for ETI?4. What is more important than ETI?5. What are alternatives to ETI?6. Can ETI be performed without interrupting quality compressions? ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 86. Critical Thinking & Outcomes-Based ManagementCalled for infant in cardiac arrest.Should PM’s intubate?• In peds, ETI should be attempted when BVM oxygenation/ventilation is not effective• Peds pts often easier to BVM vent, due to small head, neck mobility, small tidal volumes• Critical to use OP/NPA, due to lg tongue ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 87. Critical Thinking & Outcomes-Based ManagementCalled for pt w/ blunt chest trauma, RR 40, lung soundsdecreased on (R). Despite O2/NRBM, O2 sat is 75%• What should be done? Assist ventilation• At what rate should pt be ventilated (40 or 10)? 10• How can this be done? Ventilate every 4th breath• What is the risk of doing this? Gastric distention• How can that risk be minimized? – Don’t over-ventilate or use too much TV, attempt cricoid pressure, consider benefit/risk ETI ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 88. Critical Thinking & Outcomes-Based ManagementWhat’s the best method to secure airway,oxygenate, & ventilate pt with head injury? ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 89. Critical Thinking & Outcomes-Based ManagementCalled for MVC, adult male w/ obvious head injury,actively vomiting. Breathing (RR ~10) w/ strong radialpulse, responds to pain by withdrawing (GCS 6).– What should be the first priority?– How long should suction attempts be limited to?– What should be done between suctioning attempts?Despite suctioning, pt continues to vomit– How should oxygen be delivered to this pt?– Should this pt be BVM ventilated?– Should this pt be intubated? ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 90. Critical Thinking & Outcomes-Based ManagementCalled for MVC, adult male w/ obvious head injury.P 70, BP 160/80, RR 10, O2 sat 86% RA, ETCO2 45,(+) gag reflex, withdraws to pain (GCS 6).– How should oxygen be delivered to this pt?– Should this pt be BVM ventilated?– Should this pt be intubated? ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 91. Critical Thinking & Outcomes-Based Management70/F w/ difficulty breathing. Sitting upright, lookingscared, not speaking. Family states PMH of COPD,problems breathing x 3 days, worse today. P = 98, Skinpale, cool, moist, BP = 164/92, RR = 48, lungs soundsdiminished w/ wheezing, O2 sat = 64%, ETCO2 = 58sharkfin, GCS 14 confused (not normal), Gluc = 104.• Is she is respiratory distress or failure? – Failure• What treatment would you initiate? – CPAP w/ albuterol-ipratropium neb – Be prepared to intubate if no improvementFamily then tells you she has a history of heart failure.• Will this change your treatment? – Add NTG ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 92. Critical Thinking & Outcomes-Based Management Called for very anxious 35/F sitting upright in sniffing position, c/o difficulty breathing, fever, difficulty speaking & swallowing. States if tries to lie down or lean back it becomes more difficult to breathe. Skin pale, hot, moist, RR 42, drooling, lungs clear, O2 sat 90% RA, ETCO2 48, HR 142, BP 162/92.• What immediate treatment should she receive? – Oxygen and suction w/ rigid tip for oral secretions• What should be considered? – Ideally pt may need intubation, but may be a difficult and best left to more experienced personnel w/ more resources• If ETI unsuccessful, may require surgical cric ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 93. 35/F continued• What should be done if enroute to the hospital the pt stops breathing? – Attempt ventilation w/ BVM• Should intubation be immediately attempted? Why? – No, may be able to ventilate w/ BVM pressure• Under what circumstances should ETI be attempted? – Only if unable to ventilate w/ BVM• Sometimes, the most difficult intervention of all: – Doing nothing ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 94. What you know; Not what you can do• For providers with advanced skills the risk of the “technological imperative” exists.• Just because you can, does not mean you should, perform a skill.• In many cases, the least invasive skill may be the most appropriate to use.• Advanced invasive skills have the highest risk for serious complications; thus, good judgment (critical thinking) is essential. ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 95. Critical Thinking & Outcomes-Based Management FD rescued pt from house fire who not breathing. PM’s unable to effectively ventilate pt w/ BVM. Intubation attempted but unsuccessful.• What is the next step? – King LTSD was inserted and pt successfully oxygenated/ventilated (Good work AHFD)• Start basic and advance as needed• What should PM’s have done if pt was unable to be oxygenated/ventilated using King LTSD? – Cricothyrotomy ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 96. ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.
  • 97. What is themost important thing you learned? ©2012, D. Neubecker, Northwest Community EMS System, These slides are not to be reproduced without permission of NWCEMSS.