JC Block C - Emergency Medicine (I)

Question 1

Outline the primary survey for resuscitation

Answer 1

 Airway (top priority)
 Breathing (top priority)
 Circulation
 Disability
 Exposure

Question 2

Common causes of emergency airway obstruction

S/S of airway obstruction

Answer 2

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

Question 3

Outline maneuvers for airway patency

Answer 3

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

Question 4

Triple airway maneuvers

Describe procedure

Answer 4

Question 5

Positioning (to maintain airway patency)

Describe procedure

Answer 5

Question 6

3 parts of an oropharyngeal airway device and function

Answer 6

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

Question 7

Oropharyngeal airway device

Indication
Contraindication
Sizing

Answer 7

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)

Question 8

Oropharyngeal airway device

Placement procedure

Answer 8

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.

Question 9

Nasopharyngeal airway device

• Sizing
• Indication
• Contraindication

Answer 9

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))

Question 10

Nasopharyngeal airway device

Insertion

Answer 10

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

Question 11

Laryngeal mask airway

Insertion procedure

Answer 11

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

Question 12

Look, Listen and Adjunct measures for Breathing assessment

Answer 12

Question 13

Measures of oxygen supplementation

Answer 13

 Nasal cannula (1-6L/min)
 Venturi mask (6-10L/min)
 Non-rebreathing mask (valve controls airflow; FiO2 70%)

Question 14

Methods of assisted breathing

Disadvantages of each method

Answer 14

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

Question 15

Mouth-to-mouth ventilation

Procedure

Answer 15

(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*

Question 16

Bag-valve mask (BVM) ventilation

Procedure

Answer 16

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

Question 17

Choking

• Assessment in adult and child to indicate resuscitation

Answer 17

Question 18

Maneuvers for choking resuscitation

Answer 18

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)

Question 19

Procedure for infant choking resuscitation

Answer 19

 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

Question 20

Next steps in management if choking person stops responding

Answer 20

 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

Question 21

Basic life support by CPR

• Purpose of CPR
• MoA

Answer 21

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

Question 22

Explain why normal CPR only provides limited blood flow

Answer 22

Reduce chest wall expansion and negative intrathoracic pressure&raquo_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

Question 23

Correct CPR techniques ***

Answer 23

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)

2. 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

Question 24

Most critical factor for survival after sudden collapse

Answer 24

Collapse to defibrillation time (10% decrease in survival for every minute of delay)

Question 25

Outline the DRS ABCD resuscitation procedure

Answer 25

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

Question 26

Next step in resuscitation if:

Breathing normal, pulse present

Answer 26

 Monitor until emergency responders arrive

 If single rescuer for paediatrics, activate emergency response system (if not already done)

Question 27

Next step in resuscitation if:

Breathing abnormal, pulse present

Answer 27

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

Question 28

Next step in resuscitation if:

Breathing abnormal, pulse absent

Answer 28

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

Question 29

Compare the chest compression to breath ratio for adults, children and infants

Answer 29

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*

Question 30

Compression- ventilation ratio with advanced airway

Answer 30

 Continuous compressions at a rate of 100-120/min

 Give 1 breath every 6 seconds (10 breaths/min)

Question 31

Compression rate and depth, recoil for resuscitation in adults, children and infants

Answer 31

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

Question 32

Hand placement for CPR on adults, children and infants

Answer 32

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

Question 33

AED

Placement on adult, children

Answer 33

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)

Question 34

AED procedure after placement of pads