JC Block C - Emergency Medicine (I) Flashcards
Outline the primary survey for resuscitation
Airway (top priority) Breathing (top priority) Circulation Disability Exposure
Common causes of emergency airway obstruction
S/S of airway obstruction
Causes of airway obstruction:
Unconscious patient – posterior displacement of tongue in supine position (commonest)
Foreign body obstruction, e.g. choking, oral secretion, vomitus
Facial injury
Inhalation injury
Recognizing airway obstruction: Noisy breathing/ stridor Snoring Breathing difficulty No sound if the airway Is totally blocked
Outline maneuvers for airway patency
A. Triple airway maneuvers (to open the airway):
Head tilt + chin lift + Jaw thrust (without head extension)
B. Positioning (to maintain airway patency):
Recovery position, or
HAINES (high arm in endangered spine)
C. Airway adjuncts (equipment):
Oropharyngeal airway (OPA)
Nasopharyngeal airway (NPA)
Laryngeal mask airway
Triple airway maneuvers
Describe procedure
Positioning (to maintain airway patency)
Describe procedure
3 parts of an oropharyngeal airway device and function
Function: Holds the tongue away from the posterior wall of the pharynx
Structure = J-shaped, curved, single-use disposable plastic device
Straight section/ bite block prevents clenching of the teeth
Distal, semicircular section conforms to the curvature of the tongue and pharynx
The flange prevents swallowing or the over-insertion of the airway
Oropharyngeal airway device
Indication
Contraindication
Sizing
Indication: Unconscious patient with no gag reflex
Contra- indication: Cough/ gag reflex (may induce vomiting and aspiration in victims with gag reflex)
Correct size: Measure the device from the side of the patient’s face: from incisor to the angle of mandible (flange)
Oropharyngeal airway device
Placement procedure
Open the mouth (do not insert fingers between the teeth to avoid accidentally being bitten)
Insert OPA in an inverted position (tip of OPA pointing up*) along the victim’s hard palate. When the OPA is well into the mouth, rotate it by 180o
(so that the tip now points down the throat and curve follows the tongue); or
For paediatrics: depress the tongue with a tongue depressor.
Advance the OPA into the oropharynx. (Better because rotation may cause abrasion or bleeding in oral cavity)
Then, push the OPA the remainder of the way in so that the flange (the flat end) rests on the person’s lips. Oxygen will be given if necessary.
Nasopharyngeal airway device
- Sizing
- Indication
- Contraindication
Sizing: 24 to 36 French
Measure from the external portion of the nostril (flange) to the tragus of ear* (tip)
The diameter of the NPA should not be bigger than the nostril (nasal passage)*
Indication: Semi-conscious patient with intact gag reflex
Contraindication: Facial/ head trauma* (esp skull base fracture: raccoon eyes, CSF rhinorrhoea/ otorrhoea, haemotympanum, Battle’s sign (late))
Nasopharyngeal airway device
Insertion
1) Assess the nasal passage for any obvious airway obstruction
2) Apply water-soluble lubricant to the NPA before insertion
3) Go perpendicular to avoid damaging cribriform plate and going into brain tissue
4) Lift up the tip of the nose
5) Apply a continuous moderate pressure and a gentle spiral movement along the floor of the nose until the flared-out base (flange) rests against the nostril*
6) If you sense an obstruction during insertion, gently withdraw a centimeter or so, rotate it, and direct it medially, and gently attempt to insert it again
7) If you encounter resistance, withdraw the airway completely and attempt to insert an airway into the other nostril
8) Give oxygen if necessary
Laryngeal mask airway
Insertion procedure
1) Deflate the cuff before insertion
2) Lubricate the posterior surface of the cuff
3) Insert the LMA with the posterior tip pressed against the hard palate and into the oropharynx till resistance is met
4) Inflate the cuff with air
When properly placed, the cuffed mask seals the glottis
Look, Listen and Adjunct measures for Breathing assessment
Measures of oxygen supplementation
Nasal cannula (1-6L/min)
Venturi mask (6-10L/min)
Non-rebreathing mask (valve controls airflow; FiO2 70%)
Methods of assisted breathing
Disadvantages of each method
Mouth-to-mouth ventilation (for CPR) - Possible risk of infection
Bag-valve mask (BVM) ventilation - Over-aggressive ventilation can:
Damage lungs (barotrauma)
Cause vomiting (gastric inflation), aspiration
Mouth-to-mouth ventilation
Procedure
(Exhaled breath contains enough oxygen for ventilation)
1) Hold the victim’s airway open by head-tilt, chin-lift: pinch the nose, and make a seal with your mouth over the victim’s mouth
2) Ensure adequate pocket mask-face seal
3) Give slow breaths over 2 seconds*
4) Check for visible chest rise*
5) If no chest rise, reposition airway*
6) Rate of ventilation: 10- 12/min*
Bag-valve mask (BVM) ventilation
Procedure
1) If oxygen is available, connect it to the bag – but do not delay BVM to wait for oxygen
2) Assemble the BVM*
3) Position yourself directly above the victim’s head
4) Place the mask on the victim’s face, using the bridge of the nose as a guide
5) Use the EC clamp* to maintain good mask-face seal
6) Use the thumb and index finger on one hand to make a “C” to press the edges of the mask to the face, the remaining three fingers to form an “E” to tilt the head back, lift the angle of the jaw and open the airway*
7) Make sure you squeeze the mask with your thumb and index finger while lifting the jaw to achieve an air-tight seal between the mask and the face
8) Squeeze the bag with your other hand or push it against your leg or body
9) Observe chest rise* when you squeeze the bag
a. If no chest rise, reposition airway; consider OPA/ NPA
10) Rate: ~12/min
11) Volume of ventilation: 400-500mL
Choking
- Assessment in adult and child to indicate resuscitation
Maneuvers for choking resuscitation
Abdominal thrust (Heimlich maneuver)
‘five-and- five’ approach: give 5 back blows + give 5 abdominal thrusts
chest thrusts (for obese or pregnant women)
back blows & chest thrusts (for infants)
Procedure for infant choking resuscitation
If mild obstruction (cough effort present): stay with the infant and keep them calm
If severe obstruction (cannot cry/ speak/ cough) - back blows & chest thrusts:
1) Hold the infant facedown, head lower than their chest but supported (fingers over both cheeks), forearm on your thigh
2) Give up to 5 back blows with the heel of your idle hand to the interscapular region
3) Using both hands and arms, turn infant face up so they are resting on your other arm; this arm should now be resting on your thigh
4) Look for foreign body in mouth; finger- sweep only if object is seen
5) Give up to 5 quick downward chest thrusts over the lower half of the breastbone: use 2 fingers of your idle hand to push on the chest
6) Repeat giving up to 5 back slaps and up to 5 chest thrusts until the infant can breathe/ cough/ cry/ stops responding
7) Call for help
Next steps in management if choking person stops responding
Yell for help
Check breathing
Lay him flat on floor, face up, and start CPR and call for help – give sets of 30 compressions and 2 breaths, checking the mouth for objects after each set of compressions (remove object if seen)
After 5 sets, phone 911 (and get an AED for adult & child)
If you do not see the object, then continue CPR until the person starts to respond or EMS takes over
Basic life support by CPR
- Purpose of CPR
- MoA
improve chance of survival from out-of-hospital cardiac arrest and reduce permanent brain injury
MoA:
Cardiac pump: direct compression forces blood out
Thoracic pump:
Compression - positive pressure: creates cardiac output, expels air, increases ICP (reduces cerebral perfusion)
Decompression - negative pressure (vacuum): fills heart (preload), pulls air in, creates coronary artery blood flow, lowers ICP
Explain why normal CPR only provides limited blood flow
Reduce chest wall expansion and negative intrathoracic pressure»_space; Reduces preload and cardiac output
Quality of CPR:
- Hyperventilation diminishes preload, increases ICP
- Compressing too slow (<100/min) generates insufficient pressure
- Compressing too fast (>120/min) doesn’t allow enough time for heart to fill
- Incomplete chest wall recoil diminishes preload
Correct CPR techniques ***
1. Provide correct chest compressions: Rate: 100-120/min Depth: *at least 5cm/ 2 inches Allow complete chest wall recoil Minimize interruptions to <10s* (to maintain cerebral perfusion, only stop when analyzing or defibrillating)
- Provide correct ventilations:
Rate: <12 breaths/min (once every 6s)
Duration: 1 second
Tidal volume: no more than visible chest rise
If unable/ unwilling to deliver rescue breath - chest compression only CPR
Most critical factor for survival after sudden collapse
Collapse to defibrillation time (10% decrease in survival for every minute of delay)
Outline the DRS ABCD resuscitation procedure
1) Dangers and standard precautions (make sure the environment is safe for rescuers and victim)
2) Responsive - assess level of consciousness (LOC)**
3) Send for help** - 2nd rescuer dial 999; get AED** and emergency equipment as well
4) Airway
5) Breathing - Check carotid pulse and breathing for 5- 10s for adults, For small kids: check brachial/ femoral pulse
6) Circulation: CPR
Next step in resuscitation if:
Breathing normal, pulse present
Monitor until emergency responders arrive
If single rescuer for paediatrics, activate emergency response system (if not already done)
Next step in resuscitation if:
Breathing abnormal, pulse present
Provide rescue breathing:
Rate:
1) For adults: 1 breath every 5-6s, or 10-12 breaths/min
2) For paediatrics: 1 breath every 3-5s, or 12-20 breaths/min
For paediatrics, add compressions if pulse remains <60/min with signs of poor perfusion (shock)
After 2 minutes, activate emergency response system (if not already done)
Continue rescue breathing; every 2 minutes, check pulse
If possible opioid overdose, administer naloxone if available per protocol
Next step in resuscitation if:
Breathing abnormal, pulse absent
For adults and adolescents:
If alone with no mobile phone, leave the victim to activate the emergency response system (if not already done) and get the AED/ defibrillator before beginning CPR
Otherwise, send someone and begin CPR immediately
For paediatrics, start CPR
If witnessed collapse: follow steps for adults and adolescents
If unwitnessed collapse: give 2 minutes of CPR, then leave the victim to activate the emergency response system and get the AED; then return to the child/ infant and resume CPR
Compare the chest compression to breath ratio for adults, children and infants
Adults:
- 30 compression: 2 breaths with open airway
Children:
- 30:2 if single rescuer
- 15:2 if two rescuers
Infants:
- 15:2
- Stop inflating air once there is visible chest rise to prevent barotrauma*
Compression- ventilation ratio with advanced airway
Continuous compressions at a rate of 100-120/min
Give 1 breath every 6 seconds (10 breaths/min)
Compression rate and depth, recoil for resuscitation in adults, children and infants
Compression rate: 100-120/ min for ALL
Compression depth:
Adult - >5cm
Children 5cm, at least 1/3 AP diameter of chest
Infant - 4cm, at least 1/3 AP diameter of chest
Chest recoil: Allow full chest recoil*** after each compression; do not lean on the chest after each compression
Hand placement for CPR on adults, children and infants
Adult: 2 hands on the lower half of the sternum
Children: 2 hands or 1 hand (optional for very small child) on the lower half of the sternum
Infant:
If 1 rescuer: 2 fingers in the center of the chest, just below the nipple line
If >2 rescuers: 2 thumbs – encircling hands in the center of the chest, just below the nipple line
AED
Placement on adult, children
8 years of age or older:
use adult pads, place anterolateral (one to the side of the left nipple, another on victim’s upper right chest, directly below the collarbone)
If 1-8 years old or 30kg:
use paediatric attenuated AED pads (lower current to avoid stunning the heart), place anteroposterior
If <1 year old: do not use AED (use manual defibrillation)
AED procedure after placement of pads
