CASE STUDY 2-1 - ACLS Study Guide

Your patient is an 85-year-old woman who presents with difficulty breathing. She has a long history of COPD and has experienced increasing shortness of breath since yesterday. You have a sufficient number of advanced life support personnel available to assist you and carry out your instructions. Emergency equipment is available.

1. As you approach the patient, you observe that she is supine on a stretcher. Her eyes are closed, her lips are blue, and her skin is pale. You see no signs of breathing. What should be done next?

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2. The patient is unresponsive. What should be done next?

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3. The patient is not breathing but a carotid pulse is present. The rate is slow, weak, and regular. What should be done now?

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4. How will you open the patient ’s airway?

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5. A significant amount of mucus is observed in the patient ’s mouth. How will you remedy this problem?

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6. The patient ’s airway is clear. You have asked a team member to insert an oral airway. How is proper oral airway size determined?

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7. When is the use of an oral airway contraindicated?

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CHAPTER 2 Airway Management

8. An oral airway has been inserted. The patient is still not breathing. What should be done now?

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9. Differentiate between the E-C clamp technique and the TE technique when performing BMV.

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10. What are the most common problems associated with the use of BMV?

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11. The patient ’s chest does not rise despite attempts to ventilate the patient with a BMD. What is the first thing you should do to remedy this problem?

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12. Equal chest rise is now present with BMV. Breath sounds reveal clear upper lobes and diminished sounds in the lower lobes bilaterally. The patient ’s blood pressure is 108/74 mm Hg. She has been placed on the cardiac monitor, which reveals the rhythm shown. What is the rhythm on the monitor?

What should be done now?

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13. Vascular access has been established with normal saline. An ETT has been inserted and the cuff inflated. How will you confirm placement of the ETT?

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14. Waveform capnography confirms the presence of CO2. The ETT has been secured. What should be done now?

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(From Aehlert: ECGs made easy , ed 4, St. Louis, 2011, Mosby.)

CHAPTER QUIZ ANSWERS

1. B. The head tilt – chin liftis thepreferred technique for opening the airway of an unresponsive patient without suspected cervical spine injury. If trauma is suspected, the jaw thrust without neck extension

maneuver should be used. Health care professionals should use the head tilt – chin lift maneuver to open the airway if use of the jaw thrust without neck extension maneuver is unsuccessful.

OBJ: Describe and demonstrate the steps needed to perform the head tilt – chin lift and jaw thrust without neck extension maneuvers and relate the mechanism of injury to the opening of the airway.

2. A. An oral airway should only be used in unresponsive patients who have no cough or gag reflex because it may stimulate vomiting or laryngospasm in responsive or semiresponsive patients. If the airway is too long, it may press the epiglottis against the entrance of the larynx resulting in a complete airway obstruction. If the airway is too short, it will not displace the tongue and may advance out of the mouth. A petroleum-based lubricant should never be used because it may damage the airway device and cause tissue inflammation. A nasal airway (not an oral airway) may inadver-tently enter the cranial vault if it is inserted into the nose of a patient who has sustained a craniofacial injury.

OBJ: Discuss the indications, contraindications, advantages, and disadvantages of oral and nasal airways, and demonstrate how to correctly size and insert each of these airway adjuncts.

3. B. NPPV, mouth-to-mask ventilation, and BMV are examples of methods that may be used to deliver positive pressure ventilation. The remaining devices listed (nasal cannula, simple face mask, and nonrebreather mask) do not deliver a tidal volume; they are oxygen delivery devices and require a spontaneously breathing patient.

OBJ: Describe methods by which positive pressure ventilation is delivered.

4. A. A nasal airway can be used in an unresponsive patient and may be useful in semiresponsive patients who have a gag reflex. It can be placed in either nostril to help maintain an open airway.

To select a nasal airway of proper size, hold the device against the side of the patient ’s face. Select an airway that extends from the tip of the patient ’s nose to the angle of the jaw or the earlobe. When a nasal airway of the proper size is correctly positioned, the tip rests in the back of the throat.

OBJ: Discuss the indications, contraindications, advantages, and disadvantages of oral and nasal airways, and demonstrate how to correctly size and insert each of these airway adjuncts.

5. A. Pulmonary compliance refers to the resistance of the patient ’s lung tissue to ventilation. The lungs are normally pliable and expand easily. If the lungs feel stiff or inflexible during positive pressure ventilation, lung compliance is said to be poor. Upper airway obstruction, lower airway obstruction, severe bronchospasm, and tension pneumothorax are examples of conditions that can cause poor lung compliance and an inability to ventilate. If at any time you sense poor compliance, reassess the patient to ensure that the airway remains unobstructed and that lung sounds are clear and equal.

Tidal volume is the amount of gas inhaled or exhaled during a normal breath. Respiration is the exchange of oxygen and carbon dioxide during cellular metabolism. Minute volume is the amount of air moved in and out of the respiratory tract in 1 minute.

OBJ: Recognize the signs of adequate and inadequate BMV.

6. D. If not already attached, connect a one-way valve to the ventilation port on the pocket face mask and connect oxygen tubing to the oxygen inlet on the mask. Set the oxygen flow rate at 10 to 12 L/min.

OBJ: Describe the oxygen liter flow per minute and the estimated inspired oxygen concentration delivered with a pocket face mask and a BMD.

7. D. Of the oxygen delivery devices listed, a nonrebreather mask with an oxygen flow rate of 10 L/min will deliver the highest oxygen concentration.

OBJ: Describe the advantages, disadvantages, oxygen liter flow per minute, and estimated oxygen percentage delivered with each of the following devices: nasal cannula, simple face mask, partial non-rebreather mask, and nonnon-rebreather mask.

CHAPTER 2 Airway Management

8. B. A reliable indicator of ventilation adequacy is the rise and fall of the patient ’s chest wall. Gurgling sounds are abnormal and indicate the need for suctioning. If the oxygen reservoir on the BMD col-lapses with each ventilation, it may indicate that the oxygen flow is too low or the ventilation rate is too rapid. If the BMD becomes progressively more difficult to squeeze when ventilating a patient, assess the need to suction, ensure that proper airway opening procedures are in use, suspect that there may be excessive air in the stomach (anticipate vomiting), and suspect a possible pneumothorax.

OBJ: Recognize the signs of adequate and inadequate BMV.

9. B. An ETT is an intraglottic airway device that is placed directly into the trachea. Extraglottic airway devices, formerly called supraglottic airways, are advanced airways that are blindly inserted. Examples of extraglottic airway devices include the esophageal-tracheal Combitube, LMA, air-Q, i-gel, laryn-geal tube, and R €usch EasyTube.

OBJ: Differentiate between extraglottic airways and intraglottic airways.

10. D. The patient has experienced a respiratory arrest. Your best course of action will be to insert an oral airway and begin positive pressure ventilation with a BMD. Chest compressions are not indicated because the patient has a pulse. Although insertion of an advanced airway is appropriate, it must be preceded by another form of ventilation (such as BMV) while preparations are made to insert the airway. Use of a nasal cannula is inappropriate because it can only be used in a spontaneously breath-ing patient.

OBJ: Differentiate among respiratory distress, respiratory failure, and respiratory arrest and implement a treatment plan based on the severity of the patient ’s respiratory compromise.

11. C. Tracheal intubation should be preceded by attempts to ventilate by another method. Tracheal intubation is indicated in situations where the patient is unable to protect his/her own airway. Tra-cheal intubation reduces (but does not eliminate) the risk of aspiration of gastric contents and, when attempted, should be performed in less than 30 seconds.

OBJ: Describe methods that are used to confirm correct ETT placement.

12. B. A BMD that is used without supplemental oxygen will deliver 21% oxygen (ie, room air, not expired air) to the patient. A BMD that is used with supplemental oxygen set at a flow rate of 10 to 15 L/min delivers approximately 40% to 60% oxygen to the patient when a reservoir is not used. A BMD that is used with supplemental oxygen set at a flow rate of 10 to 15 L/min and with an attached reservoir delivers approximately 90% to 100% oxygen to the patient.

OBJ: Describe the oxygen liter flow per minute and the estimated inspired oxygen concentration delivered with a pocket face mask and a BMD.

In document ACLS Study Guide (Page 74-77)