1. Your general impression should focus on three main areas that can be remembered by the mnemonic ABC: A ppearance, (work of) Breathing, and Circulation. As you finish forming your general impression, you will have a good idea if the patient is sick (ie, unstable) or not sick (ie, stable). Begin the primary survey by assessing responsiveness. Start by asking, “ Are you all right?” or “Can you hear me?” If there is no response, then gently tap or squeeze the patient ’s shoulder while repeating verbal cues.
OBJ: Discuss a systematic approach to the initial emergency care of an unresponsive patient.
2. Call for help and ask someone to get an automated external defibrillator (AED) or defibrillator.
Look at the chest for movement while simultaneously feeling for a pulse for 5 to 10 seconds.
OBJ: Discuss a systematic approach to the initial emergency care of an unresponsive patient.
3. If the patient had no pulse, you would direct your team to start chest compressions and attach an AED to the patient. In this situation, chest compressions are not indicated because a pulse is present.
Open the airway and begin rescue breathing.
OBJ: Discuss a systematic approach to the initial emergency care of an unresponsive patient.
4. Because there is no evidence of trauma, open the patient ’s airway using a head tilt – chin lift. If there was anything that suggested trauma in this situation, you would open the airway with a jaw thrust without neck extension maneuver. Look in the mouth for blood, broken teeth or loose dentures,
gastric contents, and foreign objects.
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.
5. Ask a team memberto suction the patient ’s upper airway. Suction should be applied as the catheter is withdrawn and should not be applied for more than 10 seconds to avoid hypoxia.
OBJ: Describe and demonstrate the procedure for suctioning the upper airway, and discuss pos-sible complications associated with this procedure.
6. Proper oral airway size is determined by holding the device against the side of the patient ’s face and selecting an airway that extends from the corner of the mouth to the tip of the earlobe or to the angle of the jaw. To prevent inaccurate measurements for patients who experience facial drooping after a stroke, some experts recommend measuring from the first incisor or from the center of the lips to the tip of the earlobe or to the angle of the jaw.
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.
7. The use of an oral airway is contraindicated in responsive patients who have an intact gag reflex. An oral airway should only be used in unresponsive patients who have no gag reflex because it may stim-ulate vomiting or laryngospasm in responsive or semiresponsive patients.
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.
8. Begin positive pressure ventilation with a BMD connected to 100% oxygen. Ideally, two team mem-bers should be assigned this task. Ask one team member to open and maintain the airway while creating a good seal with the mask. Ask the other team member to squeeze the bag at an age-appropriate rate. Ask a team member to assess baseline breath sounds while the patient is being ventilated.
OBJ: Describe and demonstrate how to ventilate a patient with a BMD and two rescuers.
9. The E-C clamp technique can be used when performing mouth-to-mask or BMV. The rescuer ’s thumb and index finger form a “C” around the mask and the remaining fingers form an “E” on the inferior portion of the patient ’s mandible. If the rescuer is alone, one hand is used to form the E-C clamp while the other is used to squeeze the bag. If a second rescuer is present, the first rescuer uses both hands to form the E-C clamp while the second rescuer squeezes the bag. When the TE method of ventilation is used, the TEs of both hands are used to hold the mask in place and the rescuer ’s fingers are positioned under the angle of the patient ’s mandible to pull the jaw upward toward the mask. A second rescuer is needed to squeeze the BMD.
OBJ: Describe and demonstrate how to ventilate a patient with a BMD and two rescuers.
10. The most frequent problems with BMV are the inability to deliver adequate ventilatory volumes and gastric inflation. The delivery of an inadequate ventilatory volume may be the result of difficulty with providing a leak-proof seal to the face while simultaneously maintaining an open airway, incomplete bag compression, or both. Gastric inflation may result if excessive force and volume are used during ventilation.
OBJ: Recognize the signs of adequate and inadequate BMV.
11. If the chest does not rise and fall with BMV, your first action should be to reposition the patient ’s head and try to ventilate again.
OBJ: Recognize the signs of adequate and inadequate BMV.
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CHAPTER 2 Airway Management
REFERENCES
Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey, D. E., Jr., Ganiats, T. G., Holmes, D. ,R.Jr., et al. (2014).
2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. J Am Coll Cardiol , 64 (24), e139 – e228.
Anders, J., Brown, K., Simpson, J., & Gausche-Hill, M. (2014). Evidence and controversies in pe diatric prehospital airway management. Clin Pediatr Emerg Med , 15 (1), 28 – 37.
Aufderheide, T. P., Sigurdsson, G., Pirrallo, R. G., Yannopoulos, D., McKnite, S., von Briesen, C,.et al. (2004).
Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation, 109(16), 1960 – 1965.
Barnes, T. A. (2013). Emergency cardiovascular life support. In R. M. Kacmarek, J. K. Stoller, & A. J. Heuer (Eds.), Egan’ s fundamentals of respiratory care (10th ed., pp. 787 – 817). St. Louis: Mosby.
Cantineau, J. P., Merckx, P., Lambert, Y., Sorkine, M., Bertrand, C., & Duvaldestin, P. (1994). Effect of epineph-rine on end-tidal carbon dioxide pressure during prehospital cardiopulmonary resuscitation. Am J Emerg Med , 12 (3), 267 – 270.
Casserly, B., & Rounds, S. (2010). Essentials in critical care medicine. In T. E. Andreoli, I. J. Benjamin, R.
C. Griggs, & E. J. Wing (Eds.), Andreoli and Carpenter ’ s Cecil essentials of medicine (8th ed., pp. 259 – 265).
Philadelphia: Saunders.
Douce, H. F. (2009). Pulmonary function testing. In R. L. Wilkins, J. K. Stoller, & R. M. Kacmarek Egan’ s fun-damentals of respiratory care (9th ed., pp. 415 – 418). St. Louis: Mosby.
Gerstein, N. S., Carey, M. C., Braude, D. A., Tawil, I., Petersen, T. R., Deriy, L,.et al. (2013). Efficacy of facemask ventilation techniques in novice providers. J Clin Anesth, 25 (3), 193 – 197.
Hess, D. R. (2013). Noninvasive ventilation for acute respiratory failure. Respir Care , 58 (6), 950 – 972.
Heuer, A. J. (2013). Medical gas therapy. In R. M. Kacmarek, J. K. Stoller, & A. J. Heuer (Eds.), Egan’ s funda-mentals of respiratory care (10th ed., pp. 909 – 944). St. Louis: Mosby.
Keenan, S. P., Sinuff, T., Burns, K. E., Muscedere, J., Kutsogiannis, J., Mehta, S,.et al. (2011). Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ , 183(3), e195 – e214.
Kleinman, M. E., Brennan, E. E., Goldberger, Z. D., Swor, R. A., Terry, M., Bobrow, B. J.,et al. (2015, Oct). 2015 American Heart Association guidelines for CPR & ECC . In Web-based integrated guidelines for cardiopulmonary 12. The rhythm is a sinus bradycardia. Ask a qualified team member to prepare to intubate the patient.
Ask another team member to start an IV with normal saline. Order a 12-lead electrocardiogram (ECG) and portable chest radiograph and perform a focused physical examination. Resist the temp-tation to treat the patient ’s bradycardia with atropine. The most likely cause of the patient ’s brady-cardia is hypoxia. Make sure the patient is adequately oxygenated and ventilated before considering other possible causes of the patient ’s respiratory arrest or the use of atropine.
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.
13. Attach a ventilation device to the ETT and ventilate the patient. Confirm proper placement of the tube by visualizing the passage of the tracheal tube between the vocal cords. Next, auscultate over the epigastrium (should be silent) and then in the midaxillary and anterior chest line on the right and left sides of the patient ’s chest. Observe the patient ’s chest for adequate chest rise with ventilation. After confirming proper tube position with the use of capnography, note the cm markings on the tracheal tube and then secure the tube in place with a commercial tube holder or tape. Waveform capnogra-phy is recommended for the continuous monitoring of proper tube placement. After securing the tube, recheck and record the tube depth at the patient ’s teeth. This value is typically between the 19 and 23 cm marks on the tube at the front teeth. Average tube depth in men is 23 cm at the lips, 22 cm at the teeth; average tube depth in women is 22 cm at the lips, 21 cm at the teeth.
OBJ: Describe methods that are used to confirm correct ETT placement.
14. Repeat the primary survey and obtain another set of vital signs. Order laboratory studies, evaluate the patient ’s 12-lead ECG and chest radiograph results, and attempt to determine possible causes of the patient ’s respiratory arrest. Transfer the patient for continued monitoring and care.
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.
resuscitation and emergency cardiovascular care—part 5: Adult basic life support and cardiopulmonary resusci-tation quality: Eccguidelines.heart.org .
Liesching, T., Kwok, H., & Hill, N. S. (2003). Acute applications of noninvasive positive pressure ventilation.Chest , 124 (2), 699 – 713.
Link, M. S., Berkow, L. C., Kudenchuk, P. J., Halperin, H. R., Hess, E. P., Moitra, V. K,.et al. (2015, Oct). 2015 American Heart Association guidelines for CPR & ECC . In Web-based integrated guidelines for cardiopulmonary resuscitation and emergency cardiovascular care—part 7: Adult advanced cardiovascular life support:
Eccguidelines.heart.org .
Markovitz, G. H., Colthurst, J., Storer, T. W., & Cooper, C. B. (2010). Effective inspired oxygen concentration measured via transtracheal and oral gas analysis. Respir Care , 55 (4), 453 – 459.
McEvoy, M. (2013). How to assess and treat acute respiratory distress. JEMS , 38 (8).
O’Gara, P. T., Kushner, F. G., Ascheim, D. D., Casey, D. E., Jr., Chung, M. K., de Lemos, J. ,A.et al. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol , 61(4),
e78 – e140.
Ornato, J. P., Shipley, J. B., Racht, E. M., Slovis, C. M., Wrenn, K. D., Pepe, P. ,E.et al. (1992). Multicenter study of a portable, hand-size, colorimetric end-tidal carbon dioxide detection device. Ann Emerg Med , 21(5), 518 – 523.
Reardon, R. F., Mason, P. E., & Clinton, J. E. (2014a). Basic airway management and decision making.
In J. R. Roberts, C. B. Custalow, T. W. Thomsen, & J. R. Hedges (Eds.),Roberts and Hedges ’ clinical procedures in emergency medicine (6th ed., pp. 39 – 61). Philadelphia: Saunders.
Reardon, R. F., McGill, J. W., & Clinton, J. E. (2014b). Tracheal intubation. In J. R. Roberts, C. B. Custalow, T. W. Thomsen, & J. R. Hedges (Eds.), Roberts and Hedges ’ clinical procedures in emergency medicine (6th ed.,
pp. 62 – 106). Philadelphia: Saunders.
Rouse, M., & Frakes, M. (2010). Airway management. In R. S. Holleran (Ed.), ASTNA patient transport: Principles and practice (4th ed., pp. 181 – 233). St. Louis: Mosby.
Schutz, S. L. (2011). Oxygen saturation monitoring with pulse oximetry. In D. L.-M. Wiegand (Ed.), AACN procedure manual for critical care (6th ed., pp. 121 – 128). St. Louis: Saunders.
Sum Ping, S. T., Mehta, M. P., & Symreng, T. (1992). Accuracy of the FEF CO2 detector in the assessment of endotracheal tube placement. Anesth Analg , 74 (3), 415 – 419.
Tiffin, N. H., Keim, M. R., & Frewen, T. C. (1990). The effects of variations in flow through an insufflating catheter and endotracheal tube and suction catheter size on test lung pressures. Respir Care , 35 (9), 889 – 897.
Ward, J. J. (2013). High-flow oxygen administration by nasal cannula for adult and perinatal patients. Respir Care , 58 (1), 98 – 122.
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