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Jan 07 handout Jan 07 handout Document Transcript

  • Respiratory Emergencies Respiratory We are going to cover material for ALL Emergencies levels of training East Region (Washington) OTEP M-7 YOU CAN ONLY PRACTICE AT THE LEVEL YOU HAVE BEEN CERTIFIED Brian Reynolds, MD Deaconess Medical Center Spokane, WA Anatomy of the Upper Airway Topics Anatomy and function of the Respiratory System Patient Assessment Airway Management 1
  • Upper Airway Nasal Cavity Nares Nasal cavity Mucous membranes Oral cavity Sinuses Pharynx Oral Cavity Pharynx Cheeks Nasopharynx Hard palate Soft palate Oropharynx Tongue Gums Laryngopharynx Teeth 2
  • Internal Anatomy of the Upper Airway Larynx Thyroid cartilage Cricoid cartilage Glottic opening Vocal cords Arytenoid cartilage Pyriform fossae Cricothyroid cartilage Anatomy of the Lower Airway Lower Airway Anatomy Trachea Bronchi Alveoli Lung parenchyma Pleura 3
  • Definitions Introduction Atelectasis – collapse of small segments of Ventilation is the mechanical process that brings lung O2 to the lungs, and clears CO2 from the lungs Oxygenation is the diffusion of O2 to the blood Hypoxia – lack of oxygen Perfusion is the flow of blood through the lungs (thus exchanging oxygen and CO2) Hypoxemia – lack of oxygen in arterial Brain stem is the involuntary regulator of blood respirations Respiratory Physiology Pathophysiology Ventilation Disruption in Ventilation Body Structures Upper & Lower Respiratory Tracts Chest Wall Obstruction due to trauma or infectious processes Pleura Diaphragm Chest Wall & Diaphragm Trauma Tidal Volume: Pneumothorax 7ml/kg Hemothorax (Adult 500ml) Flail chest Neuromuscular disease 4
  • Pulmonary Circulation Oxygenation Room air – 21% FiO2 Roughly 3% increase per liter Nasal cannula – 8L max (40%) Mask – 10L (55%) NRB mask – 15L (80%) Respiratory Physiology Pathophysiology Pulmonary Perfusion Disruption in Perfusion Requirements Alteration in systemic blood flow Adequate blood volume Changes in hemoglobin Intact pulmonary capillaries Efficient pumping by the heart Pulmonary shunting Hemoglobin Damaged alveoli Carbon Dioxide 5
  • Respiratory Factors Assessment of the Respiratory Factor Effect System Fever Increases Emotion Increases Scene Assessment Pain Increases Threats to Safety Hypoxia Increases Make sure you are safe first Acidosis Increases Identify rescue environments having Stimulants Increase decreased oxygen levels Depressants Decrease Gases and other chemical or biological Sleep Decreases agents Clues to Patient Information Assessment of the Respiratory Assessment of the Respiratory System System Initial Assessment Airway Proper ventilation cannot take place without an General Impression adequate airway Position Breathing Color Mental status Signs of life-threatening problems Alterations in mental status Ability to speak Severe central cyanosis, pallor, or diaphoresis Respiratory effort Absent or abnormal breath sounds Speaking limited to 1–2 words Tachycardia Use of accessory muscles or intercostal retractions 6
  • Abnormal Respiratory Patterns Abnormal Respiratory Patterns Kussmaul’s respirations: Deep, slow or rapid, gasping; common Agonal respirations: in diabetic ketoacidosis Shallow, slow, or infrequent breathing, Cheyne-Stokes respirations: indicating brain anoxia Progressively deeper, faster breathing alternating gradually with shallow, slower breathing, indication brain stem injury Focused History Focused History & Physical Exam & Physical Exam History Physical Examination SAMPLE History Inspection Look for asymmetry, increased diameter, or Paroxysmal nocturnal dyspnea and orthopnea paradoxical motion Coughing, fever, hemoptysis Palpation Associated chest pain Feel for subcutaneous emphysema or tracheal Smoking history or environmental exposures deviation Similar Past Episodes Percussion Auscultation 7
  • Focused History Focused History & Physical Exam & Physical Exam Auscultation Diagnostic Testing Normal Breath Sounds Pulse Oximetry Bronchial, Bronchovesicular, and Vesicular Inaccurate Readings Abnormal Breath Sounds Snoring Stridor Wheezing Rhonchi Rales/Crackles Pleural friction rub Ausculation Airway Obstruction The tongue is the most common cause of Listen at the mouth and nose for adequate air airway obstruction movement Foreign bodies Listen with a stethoscope for normal or Trauma abnormal air movement Proper listening positions Laryngeal spasm and edema Aspiration 8
  • Congestive Heart Failure Obstructive Lung Disease Wet, crackly lung sounds Types Emphysema Lower extremity edema Chronic Bronchitis Asthma Must sit and sleep upright Causes Genetic Disposition Smoking & Other Risk Factors Frothy, pink sputum Emphysema Chronic Bronchitis Assessment Physical Exam Physical Exam Often overweight Barrel chest Rhonchi present on Prolonged expiration and auscultation rapid rest phase Jugular vein distention Thin Ankle edema Pink skin due to extra red Hepatic congestion cell production “Blue Bloater” Hypertrophy of accessory muscles “Pink Puffers” 9
  • Asthma Pneumonia Physical Exam Infection of the Lungs Presenting signs may include dyspnea, wheezing, cough Immune-Suppressed Patients No wheezing is severe disease Pathophysiology Speech may be limited to 1–2 word sentences Look for hyperinflation of the chest and accessory Bacterial & Viral Infections muscle use/feel chest wall for crepitus Hospital-acquired vs. community-acquired Carefully auscultate breath sounds and measure Alveoli may collapse, resulting in a ventilation peak expiratory flow rate disorder Lung Cancer Toxic Inhalation Pathophysiology Pathophysiology Includes inhalation of heated air, chemical irritants, General and steam Majority are caused by carcinogens secondary to Airway obstruction due to edema and laryngospasm cigarette smoking or occupational exposure due to thermal and chemical burns May start elsewhere and spread to lungs Assessment High mortality Focused History & Physical Exam Types SAMPLE & OPQRST History Adenocarcinoma Determine nature of substance Epidermoid, small-cell, and large-cell carcinomas Length of exposure and loss of consciousness 10
  • Carbon Monoxide Inhalation Pulmonary Embolism Pathophysiology Pathophysiology Binds to Hemoglobin Obstruction of a pulmonary artery Prevents oxygen from binding to RBC’s Emboli may be of air, thrombus, fat, or amniotic Room air half life – 6 hrs., HBO – 23 minutes fluid Assessment Foreign bodies may also cause an embolus Focused History and Physical Exam Risk Factors SAMPLE & OPQRST History Recent surgery, long-bone fractures Determine source and length of exposure Pregnant or postpartum Presence of headache, confusion, agitation, lack of Oral contraceptive use, tobacco use coordination, loss of consciousness, and seizures Immobility Blood disorders Spontaneous Pneumothorax Pathophysiology Hyperventilation Syndrome Pneumothorax Assessment Can occur in the absence of blunt or penetrating trauma Focused History & Physical Exam Risk factors SAMPLE Assessment Fatigue, nervousness, dizziness, dyspnea, chest Focused history pain SAMPLE Numbness and tingling in mouth, feet, and both Presence of risk factors hands Rapid onset of symptoms Presence of tachypnea and tachycardia Sharp, pleuritic chest or shoulder pain Spasms of the fingers and feet Often precipitated by coughing or lifting 11
  • Airway Sounds Airflow Compromise Gas Exchange Compromise Basic Mechanical Airways Snoring Crackles Gurgling Rhonchi Stridor Wheezing Quiet Insert oropharyngeal airway Rotate airway 180º into position with tip facing palate 12
  • Nasopharyngeal Airway (Do not use if significant facial trauma) Advanced Airway Management Advanced Airway Management Advantages of Endotracheal Intubation Endotracheal intubation Isolates trachea and permits complete control of airway Combitube Maximizes ventilation and oxygenation CPAP and BiPAP Impedes gastric distention Eliminates need to maintain a mask seal CO2 monitors – measure exhaled CO2 Offers direct route for suctioning Normal – 5-6% 13
  • Placement of Macintosh blade into Laryngoscope Blades vallecula Placement of Miller blade under epiglottis Endotrol ETT 14
  • ETT, stylet, syringe Combitube CPAP Endotracheal Intubation Indicators Respiratory or cardiac arrest Unconsciousness Risk of aspiration Obstruction due to foreign bodies, trauma, burns, or anaphylaxis Respiratory extremis due to disease (Pneumothorax), hemothorax, (hemopneumothorax) with respiratory difficulty 15
  • Complications of Endotracheal Tracheostomies/Stomas Intubation Equipment malfunction Use patient’s supplies Teeth breakage and soft tissue injury Hypoxia Ambu bag attaches easily Esophageal intubation Endobronchial intubation Treat as an endotracheal tube Tension pneumothorax Extubation Suction Questions Questions 1. Which one is lack of oxygen in the blood? 2. Which one is the best airway? a. Hypoxia a. Nasal cannula b. Hypocarbia b. Endotracheal tube c. Hypoxemia c. Oral airway d. Hypocarbemia d. Combitube 16
  • Questions Questions 3. Which one is a contraindication to nasal 4. Which one is the correct tidal volume for a trumpet use? 200 pound patient? a. Seizure a. 500cc b. Bloody nose b. 600cc c. DNR patient c. 700cc d. Significant facial trauma d. 800cc Questions 5. Which one is not an indication for endotracheal intubation? Now you know everything a. Respiratory failure about respiratory emergencies b. Cardiac arrest c. GCS of 5 d. Hyperventilation syndrome 17
  • Questions? Renee Anderson Garry Frey andersr@inhs.org freyg@inhs.org 509-232-8155 509-242-4263 FAX: 509-232-8344 18