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ECG MADE EASY

ECG MADE EASY

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  • 1. Case 1RespiratoryEmergencies© 2001 American Heart Association 1 1
  • 2. Case PresentationPatient = 69-year-old man,smoker (4 packs/day) PMHx = severe COPD CC = severe shortness of breath; “hungry for air!” VS = not obtained; patient suddenly becomes unresponsive 2
  • 3. Learning and Skills ObjectivesDescribe ACLS Approach (Primary andSecondary ABCD Surveys) in CPRDescribe and demonstrate the “airway hierarchy”: • Supplemental oxygen: – Nasal cannulae – Face masks • Noninvasive airway devices: – Nasopharyngeal airway – Oropharyngeal airway 3
  • 4. Learning and Skills ObjectivesThe airway hierarchy (cont’d) • Recommended invasive airway devices: – Laryngeal mask airway (LMA) – Esophageal-tracheal (Combitube) tube – Tracheal tube • Primary/secondary confirmation of tracheal tube placement: – Physical exam criteria – End-tidal CO2 detection – Devices to detect esophageal placement • Devices to prevent TT dislodgment 4
  • 5. Primary ABCD SurveyFocus: Basic CPR and Defibrillation • Check responsiveness • Activate emergency response system • Call for defibrillator A = Airway: open the airway B = Breathing: check breathing, provide positive-pressure ventilations C = Circulation: check circulation, give chest compressions D = Defibrillation: assess for and shock VF/pulseless VT 5
  • 6. Secondary ABCD SurveyA = Airway: insert advanced airway device as soon as able (new: 3 types)B = Breathing: confirm placement by PE (primary tube confirmation) PLUSB = Breathing: confirm placement with esophageal detector device or end-tidal CO2 detector or both (secondary tube confirmation)B = Breathing: use a commercial tube holder to prevent dislodgmentB = Breathing: confirm effective oxygenation/ventilation by 02 sat, CO2 levels, pH 6
  • 7. Anatomy of Airway 7
  • 8. Airway ObstructionMost common cause: tongue and/or epiglottis 8
  • 9. Opening the AirwayJaw thrust Head tilt–chin lift 9
  • 10. The Oropharyngeal Airway 10
  • 11. Malposition ofOropharyngeal Airway Too short 11
  • 12. Nasopharyngeal Airway Insertion technique 12
  • 13. Barrier DevicesOral airway: inserts in patient 13
  • 14. Pocket-Mask Devices 1-way valve Port to attach O2 source 14
  • 15. Mouth-to-Mask VentilationAdvantages • Eliminates direct contact • Enables positive-pressure ventilation • Oxygenates well if O2 attached • Easier to perform than bag-mask ventilation • 1-rescuer technique; performed from side • Rescuer slides over for chest • Best for small-handed compressions rescuers • Fingers: head tilt–chin lift 15
  • 16. Mouth-to-Mask VentilationFingers: jaw thrust upward Fingers: head tilt–chin lift 16
  • 17. Bag-Mask VentilationKey—ventilation volume: “enough to produceobvious chest rise” 1-Person: 2-Person: difficult, less effective easier, more effective 17
  • 18. Cricoid Pressure Thyroid Cartilage Cricoid 18
  • 19. Bag-Mask VentilationAdvantages • Provides immediate ventilation and oxygenation • Operator gets sense of compliance and airway resistance • May provide excellent short-term support of ventilation • High oxygen concentrations are possible • Can be used to assist spontaneous respirationsPotential complications • Hypoventilation • Gastric inflation 19
  • 20. Airway Adjunct Devices Nasal cannula Face mask with O2 reservoir,24%-44% O2 concentration 60%-100% O2 concentration 20
  • 21. Types of Portable SuctionCourtesy of Laerdal Medical Corporation, Armonk, NY 21
  • 22. Equipment for IntubationLaryngoscope withseveral bladesTracheal tubesMalleable stylet10-mL syringeMagill forcepsWater-soluble lubricantSuction unit, catheters, and tubing 22
  • 23. Curved Blade Attaches to Laryngoscope Handle 23
  • 24. Curved Blade Attached to Laryngoscope Handle 24
  • 25. Curved Blade Laryngoscope Inserted Against Epiglottis 25
  • 26. Straight-Blade Laryngoscope 26
  • 27. Straight-Blade Laryngoscope Inserted Past Epiglottis 27
  • 28. Cricothyroid Membrane WithHorizontal Cricothyrotomy Incision 28
  • 29. Aligning Axes of Upper Airway Mouth A A B B C CPharynx Trachea Extend-the-head-on-neck (“look up”): aligns axis A relative to B Flex-the-neck-on-shoulders (“look down”): aligns axis B relative to C 29
  • 30. Visualization of Vocal Cords Anatomy Tongue Vallecula Epiglottis Vocal cord Glottic Arytenoid opening cartilage 30
  • 31. Tracheal IntubationAdvantages • Protects airway from aspiration of foreign material • Facilitates ventilation and oxygenation • Facilitates suctioning of trachea and bronchi • Provides route for drug administration • Prevents gastric inflation if used with cuff • Allows faster chest compressions 31
  • 32. Tracheal IntubationIndications • Inability to ventilate the unconscious patient • After insertion of pharyngeal airway • Inability of patient to protect own airway (coma, areflexia, or cardiac arrest) • Need for prolonged mechanical ventilation 32
  • 33. Tracheal IntubationRecommendations • Intubate as soon as possible after ventilation and oxygenation in cardiac arrest • Intubation should be done by most experienced person • Do not take longer than 30 seconds per attempt • Auscultate the thorax and epigastrium after intubation 33
  • 34. Tracheal IntubationComplications • Trauma—teeth, lips, tongue, mucosa, vocal cords, trachea • Esophageal intubation • Vomiting and aspiration • Hypertension and arrhythmias 34
  • 35. Esophageal-Tracheal Combitube A = esophageal obturator; ventilation into trachea through side openings = B E C = tracheal tube; ventilation through open end if proximal end inserted in trachea D = pharyngeal cuff; inflated through catheter = E Distal End F = esophageal cuff; inflated through catheter = G H = teeth marker; blindly insert Combitube until marker is at level of teeth A C H Proximal End B D F G 35
  • 36. Esophageal-Tracheal Combitube Inserted in Esophagus A H D D B FA = esophageal obturator; ventilation into trachea through side openings = BD = pharyngeal cuff (inflated)F = inflated esophageal/tracheal cuffH = teeth markers; insert until marker lines at level of teeth 36
  • 37. Laryngeal Mask Airway (LMA)The LMA is an adjunctive airway that consists of a tubewith a cuffed mask-like projection at distal end. 37
  • 38. LMA Introduced Through Mouth Into Pharynx 38
  • 39. LMA in PositionOnce the LMA is in position, a clear, secure airway is present. 39
  • 40. Anatomic Detail 40
  • 41. Esophageal Detector Device (Bulb-Type) 41
  • 42. Confirmation:Tracheal Tube Placement End-tidal colorimetric CO2 indicators 42
  • 43. Tracheal Tube Holders: Adult and Infant 43
  • 44. Qualitative End-Tidal CO2 DetectorWhat should the operator’s next action be? 44