1、Assessment & Recognition of Airway & Ventilatory Compromise,History Onset sudden vs gradual Known cause? Duration Constant Recurrent Provocation/Palliation,Assessment & Recognition of Airway & Ventilatory Compromise,Exacerbation Associated Signs/Symptoms Cough, chest pain, fever Interventions past e
2、vals/admits meds ever intubated before?,Assessment & Recognition of Airway & Ventilatory Compromise,Respiratory Patterns Cheyne-Stokes brain stem Kussmaul acidosis Biots increased ICP,Respiratory Patterns Central Neurogenic Hyperventilation increased ICP Agonal brain anoxia,Assessment & Recognition
3、of Airway & Ventilatory Compromise,Inadequate Ventilation body cannot compensate for increased oxygen demand or maintain balance Causes infection trauma brainstem injury toxic inhalation renal failure,Airway & Ventilation Methods: BLS,Supplemental Oxygen increased FiO2 increases available oxygen obj
4、ective is to maximize hemoglobin saturation,Airway & Ventilation Methods: BLS,Oxygen source compressed gas liquid oxygen Regulators Humidifier,Delivery Devices nasal cannula partial rebreather mask non-rebreather mask venturi mask small volume nebulizer,Airway & Ventilation Methods: BLS,Airway Maneu
5、vers Head-tilt/Chin-lift Jaw thrust Sellicks maneuver Other Types tracheostomy with tube tracheostomy with stoma,Airway Devices Oropharyngeal airway Nasopharyngeal airway,Airway & Ventilation Methods: BLS,Mouth to Mouth Mouth to Nose Mouth to Mask One person BVM Two person BVM Three person BVM Flow
6、restricted powered ventilator Transport ventilator,One Person BVM difficult to master mask seal often inadequate may result in inadequate tidal vol gastric distention risk ventilate only until see chest rise,Airway & Ventilation Methods: BLS,Two person BVM most efficient method Useful in C-spine inj
7、 improved mask seal and tidal volume,Three person BVM less utilized used when difficulty with mask seal crowded,Airway & Ventilation Methods: BLS,Flow-restricted, powered ventilator Cardiac sphincter opens at 30 cm H2O high volume/high conc not recommended for children, noncompliant or poor tidal vo
8、lume oxygen delivered on inspiratory effort may cause barotrauma,Airway & Ventilation Methods: BLS,Automatic transport ventilators Not like a “real” ventilator Usually only controls Volume and rate Useful during prolonged ventilation times Not useful in obstructed airway or increased airway resistan
9、ce Frees personnel Can not detect changes,Airway & Ventilation Methods: BLS,Pediatric considerations mask seal force may obstruct airway best if used with jaw thrust BVM sizes: neonate & infant=450 ml + Children 8 yoa require adult BVM just enough volume to see chest rise Squeeze - Release - Release
10、,Airway & Ventilation Methods: BLS,Stoma patients expose stoma pocket mask BVM Seal around stoma site seal mouth and nose if air leak is evident,Airway & Ventilation Methods: BLS,Airway Obstruction Techniques Positioning OPA/NPA Heimlich maneuver Finger sweep with caution Chest Thrusts Chest thrust
11、and back blows for infants Suctioning Direct laryngoscopy,Airway & Ventilation Methods: BLS,Suctioning Manual or Powered devices Suction catheters rigid soft Tracheobronchial suctioning lubricate catheter 3-5 cc sterile water or saline insert catheter until resistance is felt,Airway & Ventilation Me
12、thods: BLS,Gastric Distention Common when ventilating without intubation pressure on diaphragm resistance to BVM ventilation increase time of BVM ventilation,Airway Management: Part 2,EMS Professions Temple College,Airway & Ventilation Methods: ALS,Gastric Tubes nasogastric caution with esophageal d
13、isease or facial trauma tolerated by awake patients but is uncomfortable patient can speak interferes with BVM seal orogastric usually used in unresponsive patients larger tube may be used safe in facial trauma,Airway & Ventilation Methods: ALS,Nasogastric Tube Insertion Select size (french) Measure
14、 length nose to ear to xiphoid Lubricate end of tube water soluble Maintain aseptic technique Position patient sitting up if possible,Airway & Ventilation Methods: ALS,Nasogastric Tube Insertion (cont) Insert into nare towards base Advance gradually but steadily to measured length Have patient swall
15、ow Assess placement & secure Instill air & ausculate aspirate gastric contents May connect to low vacuum (80-100 mm Hg),Airway & Ventilation Methods: ALS,Orogastric Tube Insertion Select size (french) Measure length Lubricate end of tube Maintain aseptic technique Position patient (usually supine) I
16、nsert into mouth Advance gradually but steadily,Airway & Ventilation Methods: ALS,Orogastric Tube Insertion (cont) Assess placement & secure instill air or aspirate Evacuate contents as needed,Airway & Ventilation Methods: ALS,Endotracheal Intubation Tube into the trachea to provide ventilations usi
17、ng BVM or ventilator Sized based upon inside diameter in mm Lengths increase with increased ID cm markings along length Cuffed vs Uncuffed,Airway & Ventilation Methods: ALS,Endotracheal Intubation Indications present or impending respiratory failure apnea unable to protect own airway Advantages secu
18、res airway route for a few medications optimizes ventilation and oxygenation,Airway & Ventilation Methods: ALS,These are NOT Indications Because I can intubate Because they are unresponsive Because I cant show up at the hospital without it,Airway & Ventilation Methods: ALS,Complications of endotrach
19、eal intubation Bleeding or dental injury Laryngeal edema Laryngospasm Vocal cord injury Barotrauma Hypoxia Aspiration Dislodged tube or esophageal intubation Right or Left mainstem intubation,Airway & Ventilation Methods: ALS,Techniques of Insertion Orotracheal Intubation by direct laryngoscopy Blin
20、d Nasotracheal Intubation Digital Intubation Retrograde Intubation Transillumination techniques,Airway & Ventilation Methods: ALS,Orotracheal Intubation by direct laryngoscopy Position & Ventilate patient Monitor patient ECG Pulse oximeter Assess patients airway for difficulty Assemble & check equip
21、ment (suction) Hyperventilate patient (30-120 sec),Airway & Ventilation Methods: ALS,Orotracheal Intubation by direct laryngoscopy (cont) Position patient Open mouth & insert laryngoscope blade Attempt to sweep tongue (straight blade) Identify anatomical landmarks Advance laryngoscope blade Vallecul
22、a for curved (Miller) blade Under epiglottis for straight (Miller) blade,Airway & Ventilation Methods: ALS,Orotracheal Intubation by direct laryngoscopy (cont) Elevate epiglottis Directly with straight (miller) blade Indirectly with curved (macintosh) blade Visualize the vocal cords & glottic openin
23、g Enter the mouth with the tube from corner of mouth,Airway & Ventilation Methods: ALS,Orotracheal Intubation by direct laryngoscopy (cont) Advance into glottic opening approx. 1/2 inch past vocal cords Continue to hold tube & note location Inflate cuff until firm (approx 10 cc) Ventilate & Ausculta
24、te epigastrium left and right chest,Airway & Ventilation Methods: ALS,Orotracheal Intubation by direct laryngoscopy (cont) Secure tube Reassess Ventilation Effectiveness auscultation clinical signs end-tidal CO2 Esophageal detection device,Airway & Ventilation Methods: ALS,Equipment Laryngoscope Han
25、dle (lighted) & Blades Stylet Syringe Magills Lubricant Suction BVM BAAM (BNI),Selection Typical Adult ET Tube Sizes Male - 8.0, 8.5 Female - 7.0, 7.5, 8.0 Blade Mac - 3 or 4 Miller - 3 Tube Depth Usually 20 - 22 cm at the teeth,Equipment Review,From AHA PALS,Airway & Ventilation Methods: ALS,Airway
26、 & Ventilation Methods: ALS,Pediatric Equipment Differences Uncuffed tube 8 yoa Miller blade preferred Tube Size Premie: 2.0, 2.5 Newborn: 3.0, 3.5 1 year: 4 Then: (age/4)+4,Pediatric Differences Anatomic Differences Depth (cm) Tube ID x 3 12 + (age/2) easily dislodged Intubation vs BVM,Airway & Ventilation Methods: ALS,Patient Positioning Goal Align the 3 planes of view, so that The vocal cords are most visible T - trachea P - Pharynx O - Oropharynx,From AHA PALS,
