ABCDE Flashcards
MC reason that airways get obstructed
tongue and submandibular musculature
if you are not conscious that stuff lays on the back of your throat and blocks your airway
when would you use a jaw thrust alone to open airway
if you have not witnessed injury and it could be a C spine injury
review of what airway compramise looks like
- Universal choking sign
- Unconscious, deeply sedated (intoxication or medication)
- Respiratory distress, position preference (you don’t want to lie down)
- Getting sleepy while working to breathe
- Changes in level of consciousness - come in talking - now difficult to arouse •
Sedated + vomiting
- Head trauma, facial trauma
- Infection somewhere along the airway
- Burns - smoke inhalation (get edema from heat/smoke inhalation)
- Face, tongue, neck edema
- Severe bleeding from nose, mouth (flooded your airway)
- Cyanosis, shock
inspiratory stridor indicates
narrowing at the glottis
what can airway trouble sound like
stridor
voice changes- hoarseness and can’t get
words out
gurgling
when would you use a nasopharyngeal airway
for semi-conscious pts with a gagreflex
Nasopharyngeal Airway placement
tip of the nose to the tragus should be the fit
bevel to septum with lube
floor of the nose down until the opening is at the nostril
Oropharyngeal Airway is used for
Use only in unconscious, unarousable patients
NOT IN A PT WITH A GAG REFLEX–> vomit
Oropharyngeal Airway measurement
corner of the mouth to the angle of the jaw
how should you be holding laryngoscopes
with left hand
what should you do before intubating
make sure your balloon inflates but always insert with balloon deflated
Secures the airway by placing a tube in the airway space - secures a lumen
CO2 monitor should turn what color following intubation
Yellow-Yes
purple= poor
laryngoscope with straight blade
Miller
laryngoscope with curved blade
macintosh
indications for intubation
Can’t protect/maintain their own airway:
Alterations in level consciousness
Airway patency threatened
Edema, secretions, blood, infection,
trauma
Breathing indications
Failure to ventilate or oxygenate
Pulmonary, cardiac, systemic problem,
trauma
Preemptive
Threat to airway patency (consciousness), oxygenation, ventilation, aspiration
first thing to do to prop for intubation
Bag Valve Mask – BVM – essential skill
Pre-intubation ventilation – 100% O2
do this right after to before putting them on a ventilator
S.O.A.P M.E checklist
Suction Oxygen Airway equipment Pharmacy Monitoring Equipment
prep for intubation
BVM
SOAPME
Have Plan A, Plan B, Plan C
RSI - Rapid Sequence Intubation
RSI- What are the steps KNOW THIS
Pt is paralyzed to gain control; intubation easier, deals with full stomach - prevents aspiration
ii. The 7 P’s
1. Possibility of success
2. Prepare
3. Pre-oxygenation
4. Pre-treatment
5. Induction/Paralysis
6. Positioning/Protection
7. Pass it, prove it, post procedure tasks
why should you beware of paralyzing a pt
Paralyzed patient = no respiratory effort
You MUST be able to adequately ventilate the patient with bag-valve-mask
Must anticipate a successful intubation or do not paralyze
tubing the goose
don’t pass through the chords, pass into the esophagus
will get a shift CO2 reading
happens witt big pts, looking away
No color change, low pulse ox, no breath sounds.
why do we get a CXR post intubation
to check depth NOT to see if it’s the esophagus
what to do if you can’t see the chords very easily
LMA-Laryngeal Mask Airway
or Bougie
i. Supraglottic airway devices
ii. Designed for blind insertion - goal is esophagus, not trachea
iii. LMA for minor surgery common, good Plan B
Nasotracheal intubation and/or fiber optic guided
All designed to minimize risk of the failed airway-
king tube
goes into the esophagus
inflate giant balloon and
Causes of Inadequate Ventilation-i. Increased airway resistance
- Airway collapse, hyper-reactivity, edema
- Small decreases in diameter significant
- COPD, emphysema, asthma
Causes of Inadequate Ventilation-Decreased airway compliance
- Interstitial edema and alveolar collapse
2. Pulmonary edema, effusion, shock, sepsis, aspiration, drowning, smoke inhalation, ARDS, trauma
Abnormalities of ventilation/perfusion
- Acute left ventricular failure, pneumonia, pulmonary embolus, anemia, ARDS, etc…
Impaired wall mechanics
- Perfused but under-ventilated alveoli
2. Pneumothorax, pneumonia, effusion, neuromuscular problems, rib fx, trauma
Hypoventilation/hyperventilation
- Poisoning, toxic overdoses, intoxication
- Acidosis
- Endocrine disorders
- CNS lesions
Inadequate Ventilation leads to
Leads to Hypoxia… and hypercarbia
Hypoxia causes
- Low arterial O2 tension - alveoli aren’t transferring O2 from lungs to circulation
- Ventilation-perfusion mismatch
Hypercarbia:
- Alveolar hypoventilation
- Increased lung “dead space”
- Acidosis from CO2 retention
- Altered mental status à will cause you to become sleepy and unconsciousness and will affect your breathing
RED FLAGS of respiratory distress
• Can they talk?
• How many word sentences? (<4 NOT GOOD)
• Fighting for each breath - anxiety?
• Tachypnec? >30/min?
• Posture - tripod? Won’t lie down? •
Accessory muscles?
• Handling secretions?
• Diaphoretic? Cyanotic?
• Altered? Sleepy?
• Gag reflex?
• Stridor?if your pt is in respiratory distress
Give supplemental O2 now; beta-agonist now if appropriate -->bronchodilators Prepare for definitive airway control Vital signs, Pulse Ox IV access, cardiac monitor Undress Pre-hospital hx, PE, interventions Rapid assessment: <1 min Focused history, PE
treatment goals
Airway control
Reverse hypoxemia
Supplemental O2
Improve ventilatory effort/status
Avoid/treat hypercapnea
Increase effective tidal volume
Improve alveolar ventilation
Find and treat the causeplacing nasal cannula
tubes down
Maybe tachypnec but full sentences, no posturing, 2-4L/min
what type of O2 threapy
ii. Nasal cannula - no/slight distress
Moderate distress & O2 deficit, 4-10L/min
iii. Face mask
Limitations of Pulse Oximetry
Measures % oxygen saturation of hemoglobin in arterial blood (SaO2 measured = SpO2)
Useful only if arterial O2 above 60% Hyperventilation, anemia can give false readings
Pulse Ox tells us very little about adequacy of ventilation
Pulse Ox tells us nothing about CO2/hypercarbia
really important questions for red flags
have you had this before
how long?
what medications are you on and did you run out of them?
associated sxs- rash, fever, cough, hemoptysis, DOE, CP, orthopnea, edema, trauma, syncope
home O2? –> lung issues
ever been intubated?
ROS for SOB
rash-allergies fever cough hemoptysis DOE CP orthopnea edema trauma syncope
vital sign red flags
a. Blood pressure
Often elevated (think cardiac too) – very
common
Hypotension - ominous sign–> intubation
Respiratory rate - tachypnea is sensitive
Pulse - tachycardia common, beta agonists?
Pulse – bradycardia – ominous sign
Temperature - infectious process
Pulse Oximetry – improvement with O2?
PE
look at the bare torso –> accs muscles
listen to breath sounds
Cardiac exam, pulses – rhythm, m/r/g
Check capillary refill time: <2secs normal. >2secs? Think shock!
Abdomen – distention, ascites
Eyes (pallor), mouth (tongue, thrush) neck (JVD, masses, swelling)
Skin – rash, diaphoresis
Extremities – edema, clubbing? Think CHF, DVT, COPD
Neuro – mental status, muscle weakness
Common Pulmonary Causes of respiratory distress
Asthma or COPD exacerbation Pneumonia, infectious Pleural effusion Pneumothorax Pulmonary embolus Malignancy Trauma Rhematologic, connective tissue Dz, Sickle Cell Pulmonary manifestations Aspiration, foreign body
Common Non-Pulmonary Causes
Acute coronary syndrome Sepsis CHF/pulmonary edema (pump problem) Pericardial effusion/pericarditis Anemia Renal and metabolic disturbances Environmental, toxic ingestion Allergy, anaphylaxis Neuromuscular Psychiatric
a. ED Diagnostics respiratory distress
IV, 02, monitor
triple scan
CXR
EKG
LAB CBC CMP UPREG UTOX Lactic acid
Case specific - consider:
- Cardiac enzymes
- D-Dimer, lower extremity ultrasound
- ABG/VBG, PT/INR
- Aspirin level: mixed acid base picture and first sign of aspirin tox is tachypnea
- BNP?
CHEST CT
NIPPV-
Non-invasive Positive Pressure Ventilation
Hypercapnic, hypoxemic respiratory failure
d. BiPAP - “bilevel positive airway pressure”
i. Nasal mask
ii. Use to vary inspiratory and expiratory pressures (COPD)
c. CPAP - “continuous positive airway pressure”
i. Mask over mouth/nose
ii. Continuous inspiratory/expiratory pressure (CHF)
NIPPV can be used for
i. COPD exacerbations, severe asthma
ii. Pulmonary edema/CHF
iii. Obstructive sleep apnea
iv. Post-extubation, chest trauma
Positive Pressure Ventilation-what does it do exactly
i. Reduces the work of breathing
ii. Maintains alveolar inflation, assists ventilation (O2 in, CO2 out)
iii. Improves airway compliance
iv. Reduces preload and afterload
CI for NIPPV
- Pt cannot breathe on own if mask falls off
- Must be relatively stable, not agitated or unconscious
- Intact face - avoid subcutaneous air
21 YR o F partier
cut her hand
resisted going to the ED
sleeping deeply without arousing to shake and shout
ETOH .28
what are your airway issues and options
vomiting
sedated
on her back
could use a nasal trumpet
rescue position on side
suction nearby
will pull it out
could put a nasal cannula
case 2 55 yo M robbed by youths, hit in the face by the bat, can’t speak or open his mouth
can’t speak
jaw is probably broken –> difficult to
suction the hell out of him
reevaluate need for intubation
43 YO M brought in by ambulance from house fire
preemptively intubate because of worry about edematous
lil guy with lip swelling
epinephrine
package for anaphylaxis
