bledsoe et al., essentials of paramedic care: division 1 2006 by pearson education, inc. upper...
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Bledsoe et al., Essentials of Paramedic Care: Division 1 © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Topics Respiratory Problems Respiratory System Assessment Airway ManagementTRANSCRIPT
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Division 1Introduction to Advanced
Prehospital Care
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 8Airway Management
and Ventilation
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Respiratory ProblemsRespiratory System AssessmentAirway Management
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Respiratory Problems
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Airway Obstruction
The tongue is the most common cause of airway obstruction.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The tongue as an airway obstruction
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inadequate minute volume respirations can compromise adequate oxygen intake and
carbon dioxide removal.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Other Causes of Airway Obstruction
Foreign bodiesTraumaLaryngeal spasm and edemaAspiration
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Respiratory System Assessment
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Initial Assessment
Is the airway patent?Is breathing adequate?Look, listen, and feel.If patient is not breathing, open the airway and assist ventilations as necessary.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Feel for air movement.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Look for chest movement.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Listen for air movement.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bag-valve-mask ventilation
© Scott Metcalfe
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Focused History
OnsetSymptom developmentAssociated symptomsPast medical historyRecent historyDoes anything make symptomsbetter or worse?
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Physical Examination
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inspection
Skin colorPatient’s positionDyspneaModified forms of respirationRatePatternMentation
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abnormal Respiratory Patterns (1 of 3)
Kussmaul’s respirations– Deep, slow or rapid, gasping; common in
diabetic ketoacidosis
Cheyne-Stokes respirations– Progressively deeper, faster breathing
alternating gradually with shallow, slower breathing, indicating brain stem injury
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abnormal Respiratory Patterns (2 of 3)
Biot’s respirations– Irregular pattern of rate and depth with
sudden, periodic episodes of apnea, indicating increased intracranial pressure
Central neurogenic hyperventilation– Deep, rapid respirations, indicating
increased intracranial pressure
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abnormal Respiratory Patterns (3 of 3)
Agonal respirations– Shallow, slow, or infrequent breathing,
indicating brain anoxia
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Auscultation
Listen at the mouth and nose for adequate air movement.Listen with a stethoscope for normal or abnormal air movement.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Positions for auscultating breath sounds
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Airway SoundsAirflow
CompromiseGas Exchange Compromise
Snoring
Stridor
Wheezing
Quiet
Gurgling
Crackles
Rhonchi
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Palpation
Palpate chest wall for tenderness, symmetry, abnormal motion, crepitus, and subcutaneous emphysema.Assess compliance of lungs.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Noninvasive Respiratory Monitoring
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pulse oximeter
© Scott Metcalfe
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Colorimetric End-Tidal CO2 Detector
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Electronic End-Tidal CO2 Detector
© Scott Metcalfe
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Manual Airway Maneuvers
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Head-tilt/chin-lift
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Modified jaw-thrust in trauma
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Jaw-thrust maneuver
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Jaw-lift maneuver
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Airway before applying Sellick’s
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Sellick’s maneuver(cricoid pressure)
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Airway with Sellick’s applied (note compression on the esophagus)
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Basic Mechanical Airways
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Nasopharyngeal airway
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Nasopharyngeal airway, inserted
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert oropharyngeal airway with tip facing palate.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Rotate airway 180° into position.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Improper placement of oropharyngeal airway
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Advanced Airway Management
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal intubation is clearly the preferred method
of advanced airway management in prehospital emergency care.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Engaging laryngoscope blade and handle
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Activating laryngoscope light source
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Laryngoscope blades
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Placement of Macintosh blade into vallecula
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Placement of Miller blade under epiglottis
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETT and syringe
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotrol ETT
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETT, stylet, and syringe, unassembled
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETT, stylet, and syringe, assembled for intubation
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation Indicators
Respiratory or cardiac arrestUnconsciousnessRisk of aspirationObstruction due to foreign bodies, trauma, burns, or anaphylaxisRespiratory extremis due to diseasePneumothorax, hemothorax, hemopneumothorax with respiratory difficulty
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Advantages of Endotracheal Intubation
Isolates trachea and permitscomplete control of airwayImpedes gastric distentionEliminates need to maintain a mask sealOffers direct route for suctioningPermits administration of some medications
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Disadvantages of Endotracheal Intubation
Requires considerable training and experienceRequires specialized equipmentRequires direct visualization of vocal cordsBypasses upper airway’s functionsof warming, filtering, and humidifying the inhaled air
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Complications ofEndotracheal Intubation
Equipment malfunctionTeeth breakage and soft tissue lacerationsHypoxiaEsophageal intubationEndobronchial intubationTension pneumothorax
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Personal protective equipment
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hyperventilate patient.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Prepare equipment.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Apply Sellick’s maneuver and insert laryngoscope.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Visualize larynx and insert the ETT.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Glottis visualized through laryngoscopy
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inflate cuff, ventilate, and auscultate.
© Scott Metcalfe
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Confirm placement with an ETCO2 detector.
© Scott Metcalfe
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Esophageal detector device, bulb style
© Scott Metcalfe
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
If the bulb does not refill, the tube is improperly placed.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Attach device to endotracheal tube and squeeze the detector.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
If bulb refills easily upon release, it indicates correct placement.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Secure tube.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Lighted stylet for endotracheal intubation
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insertion of lighted stylet/ETT
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Lighted stylet/ETT in position
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Transillumination of a lighted stylet
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Blind orotracheal intubation by digital method
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Digital Intubation (1 of 2)
Insert your middle
and index fingers
into patient’s mouth.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Digital Intubation (2 of 2)
Walk your fingers and palpate the
patient’s epiglottis.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Digital intubation—insertion of the ETT
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation with In-line Stabilization
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hyperventilate patient and apply c-spine stabilization.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Apply Sellick’s maneuver and intubate.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilate patient and confirm placement.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Secure ETT and apply a cervical collar.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Reconfirm placement.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Rapid Sequence Intubation
A patient who needs intubation may be awake. RSI paralyzes the patient to facilitate endotracheal intubation.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation in a Child
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Pediatric Airway
Smaller and more flexible than an adult.Tongue proportionately larger.Epiglottis floppy and round.Glottic opening higher and more anterior.Vocal cords slant upward, and arecloser to the base of the tongue.Narrowest part is the cricoid cartilage.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETT size (mm) = (Age in years + 16)
4
Selecting ETT size according to child’s age
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hyperventilate the child.
© Scott Metcalfe
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Prepare the equipment.
© Scott Metcalfe
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert the laryngoscope.
© Scott Metcalfe
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert ETT and ventilate the child.
© Scott Metcalfe
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Confirm placement and secure ETT.
© Scott Metcalfe
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Reconfirm ETT placement.
© Scott Metcalfe
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilation of Pediatric Patients
Mask seal can be more difficult.Bag size depends on age of child.Ventilate according to current standards.Obtain chest rise and fall with each breath.Assess adequacy of ventilations by observing chest rise, listening to lung sounds, and assessing clinical improvement.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Nasotracheal intubation may be useful in some situations:
Possible spinal injuryClenched teethFractured jaw, oral injuries, or recent oral surgeryFacial or airway swellingObesityArthritis preventing sniffing position
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Advantages ofNasotracheal Intubation
The head and neck can remain in neutral position.It does not produce as much gag response and is better tolerated by the awake patient.It can be secured more easily than an orotracheal tube.The patient cannot bite the ETT.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Disadvantages ofNasotracheal Intubation
More difficult and time-consuming to perform than orotracheal intubation.Potentially more traumatic for patients.Tube may kink or clog more easily than an orally placed tube.Poses a greater risk of infection.Improper placement is more likely when performing blind nasotracheal intubation.Blind nasotracheal intubation requires that the patient be breathing.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Blind nasotracheal intubation
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Other Intubation Devices
Esophageal Tracheal CombiTube (ETC)Pharyngo-tracheal Lumen (PtL)Laryngeal Mask Airway (LMA)Intubating Laryngeal Mask Airway (iLMA)Cobra Perilaryngeal Airway (CobraPLA)Ambu Laryngeal Mask (ALM)Esophageal Gastric Tube Airway (EGTA)Esophageal Obturator Airway (EOA)
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETC airway –esophageal placement
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETC airway – tracheal placement
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pharyngo-tracheal lumen airway
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Laryngeal mask airway
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Intubating laryngeal mask airway
LMA North America
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cobra perilaryngeal airway
Supralaryngeal device designed to be
positioned in the hypopharynx where it abuts the structure of
the laryngeal inlet
Engineered Medical Systems, Inc.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ambu laryngeal mask
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Continuously recheck and reconfirm the placement of
the endotracheal tube.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Foreign body removal with direct visualization and Magill forceps
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Magill forceps
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The only indication for a surgical airway is
the inability to establish an airway by any other method.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Direct visualization of the larynx with a laryngoscope may enable the removal
of an obstructing foreign body.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomical landmarksfor cricothyrotomy
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Locate/palpate cricothyroid membrane.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Proper positioning for cricothyroid puncture
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Advance the catheter with the needle.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cannula properly placed in trachea
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Jet ventilation withneedle cricothyrotomy
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Open Cricothyrotomy
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Locate cricothyroid membrane.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Stabilize larynx and make a 1–2 cm skin incision over cricothyroid membrane.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Make a 1 cm horizontal incision through the cricothyroid membrane.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Using a curved hemostat, spread membrane incision open.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert an ETT (6.0) or Shiley (6.0).
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inflate the cuff.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Confirm placement.
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Ventilate.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Secure tube, reconfirm placement, evaluate patient.
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Tracheostomy cannulae
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patients with Stoma Sites
Patients who have had a laryngectomy or tracheostomy breathe through a stoma.There are often problems with excess secretions, and a stoma may become plugged.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Suctioning
Anticipating complications when managing an airway is the key for successful outcomes. – Be prepared to suction all airways to
remove blood or other secretions and forthe patient to vomit.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Suctioning Techniques
Wear protective eyewear, gloves, and face mask.Preoxygenate the patient.Determine depth of catheter insertion.With suction off, insert catheter.Turn on suction and suction whileremoving catheter (no more than10 seconds).Hyperventilate the patient.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Tracheostomy suction technique
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Gastric Decompression (1 of 3)
Common problem with ventilating a nonintubated patient is gastric distention.Occurs when the procedure’s high pressures trap air in the stomach.Once patient has gastric distention, you should place a tube in the stomach for gastric decompression, using either the nasogastric or orogastric approach.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Gastric Decompression (2 of 3)
To place a nasogastric or orogastric tube:Prepare patient’s head in neutral position while preoxygenating.Determine length of tube insertion by measuring from the epigastrium to the angle of the jaw, then to the tip of the nares.If patient is awake, suppress the gag reflex with a topical anesthetic applied into the posterior oropharynx or with IV lidocaine.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Gastric Decompression (3 of 3)
Lubricate the distal tip of the gastric tube and gently insert into the nares and along the nasal floor, or into the oral cavity at midline. Advance tube gently, and if patient is awake, encourage swallowing to facilitate tube’s passage.Advance to predetermined mark on tube.Confirm placement.Apply suction and note gastric contents that pass through the tube.Secure the tube in place.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygenation
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Never withholdoxygen fromany patient for whom it is indicated!
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
To calculate how long an oxygen tank will last:
D cylinder tank life in minutes = (tank pressure in psi × 0.16) ÷ liters per minute
E cylinder tank life in minutes = (tank pressure in psi × 0.28) ÷ liters per minute
M cylinder tank life in minutes = (tank pressure in psi × 1.56) ÷ liters per minute
Oxygen Supply and Regulators
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygen Delivery Devices
Device Oxygen Percentage
Nasal cannula
Simple face mask
Nonrebreather mask
Venturi mask
40%
24, 28, 35, or 40%
40 – 60%
80 – 95%
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilation Methods
Mouth-to-mouthMouth-to-noseMouth-to-maskBag-valve deviceDemand valve deviceAutomatic transport ventilator
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bag-valve mask with built-in colorimetric
ETCO2 detector
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilation of Pediatric Patients
Mask seal can be more difficult.Bag size depends on age of child.Ventilate according to current standards.Obtain chest rise and fall witheach breath.Assess adequacy of ventilations by observing chest rise, listening to lung sounds, and assessing clinical improvement.
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Demand valve and mask
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Portable mechanical ventilator
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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
Respiratory ProblemsRespiratory System AssessmentAirway Management