ECG-Case 01

1,587 views

Published on

ECG MADE EASY

ECG-Case 01

  1. 1. Case 1RespiratoryEmergencies© 2001 American Heart Association 1 1
  2. 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. 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. 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. 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. 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. 7. Anatomy of Airway 7
  8. 8. Airway ObstructionMost common cause: tongue and/or epiglottis 8
  9. 9. Opening the AirwayJaw thrust Head tilt–chin lift 9
  10. 10. The Oropharyngeal Airway 10
  11. 11. Malposition ofOropharyngeal Airway Too short 11
  12. 12. Nasopharyngeal Airway Insertion technique 12
  13. 13. Barrier DevicesOral airway: inserts in patient 13
  14. 14. Pocket-Mask Devices 1-way valve Port to attach O2 source 14
  15. 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. 16. Mouth-to-Mask VentilationFingers: jaw thrust upward Fingers: head tilt–chin lift 16
  17. 17. Bag-Mask VentilationKey—ventilation volume: “enough to produceobvious chest rise” 1-Person: 2-Person: difficult, less effective easier, more effective 17
  18. 18. Cricoid Pressure Thyroid Cartilage Cricoid 18
  19. 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. 20. Airway Adjunct Devices Nasal cannula Face mask with O2 reservoir,24%-44% O2 concentration 60%-100% O2 concentration 20
  21. 21. Types of Portable SuctionCourtesy of Laerdal Medical Corporation, Armonk, NY 21
  22. 22. Equipment for IntubationLaryngoscope withseveral bladesTracheal tubesMalleable stylet10-mL syringeMagill forcepsWater-soluble lubricantSuction unit, catheters, and tubing 22
  23. 23. Curved Blade Attaches to Laryngoscope Handle 23
  24. 24. Curved Blade Attached to Laryngoscope Handle 24
  25. 25. Curved Blade Laryngoscope Inserted Against Epiglottis 25
  26. 26. Straight-Blade Laryngoscope 26
  27. 27. Straight-Blade Laryngoscope Inserted Past Epiglottis 27
  28. 28. Cricothyroid Membrane WithHorizontal Cricothyrotomy Incision 28
  29. 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. 30. Visualization of Vocal Cords Anatomy Tongue Vallecula Epiglottis Vocal cord Glottic Arytenoid opening cartilage 30
  31. 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. 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. 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. 34. Tracheal IntubationComplications • Trauma—teeth, lips, tongue, mucosa, vocal cords, trachea • Esophageal intubation • Vomiting and aspiration • Hypertension and arrhythmias 34
  35. 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. 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. 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. 38. LMA Introduced Through Mouth Into Pharynx 38
  39. 39. LMA in PositionOnce the LMA is in position, a clear, secure airway is present. 39
  40. 40. Anatomic Detail 40
  41. 41. Esophageal Detector Device (Bulb-Type) 41
  42. 42. Confirmation:Tracheal Tube Placement End-tidal colorimetric CO2 indicators 42
  43. 43. Tracheal Tube Holders: Adult and Infant 43
  44. 44. Qualitative End-Tidal CO2 DetectorWhat should the operator’s next action be? 44

×