Skills - Procedures Flashcards
Anatomy of the mouth and throat
See slides for image Main points include - Soft palate - Vocal cords - Trachea - Nasopharynx - Oropharynx - Epiglottis - Laryngopharynx - Esophagus
Anatomy of the Lungs
- Path of airway to lungs
- Lobes of lung
- Lymph nodes
- Pleural space
- Mediastinum
See slides for image
Main points include
- Trachea into right and left Bronchus to bronchioles to alveolar where gas exchange occurs within the capillaries of pulmonary system
- Left lung has two lobes, right lung has three
- Lymph nodes (filters that prevent illness and infection)
- Pleural space (space between lungs and chest wall - lined on both sides by pleura)
- Mediastinum (space between the two lungs that holds the heart)
Auscultation Procedure
- Systematic approach
- Specific points to remember
- Parts of stethoscope
Systematic approach starting with upper left moving to upper right then middle right and left to lower left to lower right
Posterior is preferred due to less muscle and adipose tissue interference
Ideally have stethoscope on skin
Auscultate before palpating or percussion
Stethoscope includes diaphragm (hear high pitched sounds) and bell (hear low pitched sounds)
Breathing sounds (lung assessment)
Normal breathing sounds - Vesicular (lung tissue) - Bronchovesicular (near bronchi) - Bronchi (lower part of trachea) - Tracheal (upper part of trachea) No breathing sounds - due to no air movement (obstructed or presence of air/fluid preventing sound conduction)
Heart sounds assessment
Patient sit at 45 degrees
Normal sounds
- S1 (mitral and tricuspid valves closing at start of ventricular contraction or systole)
- S2 (closing of aortic and pulmonary valves at end of systole)
Added sounds
- S3 (rapid ventricular filling as soon as mitral and tricuspid valves open - common in children and young adults but otherwise indicates left ventricular failure, fibrosis ventricle or constructive pericarditis)
- S4 (atrial contraction inducing ventricular filling towards end of diastole - older individuals indicates hypertensive cardiovascular disorder, coronary artery disease, aortic stenosis, myocardial ischemia, infarction or congestive heart failure)
Mummurs
- Turbulent blood flow
- Pericardial friction rub (high pitched noise heard most in systole due to inflamed pericardial sac)
4 Quadrants of the Abdomen
4 quadrants include
- Right upper (liver, gallbladder, head of pancreas, right kidney, large intestine, small intestine)
- Right lower (appendix, right ovary, large intestine, small intestine)
- Left upper (stomach, spleen, body of pancreas, left kidney, large intestine, small intestine)
- Left lower (left ovary, large intestine, small intestine)
Abdomen sound assessment
Examine patient lying flat with pillow under head and knees slightly bent
Listen for 10-15 sec but up to 7 min (Normal bowel sounds occur every 5-20 sec)
Hyperactive sounds - loud tinkling sound and indicate diarrhea or early bowel obstruction as well as indicating increased peristalsis)
Hypoactive sounds - signify decreased motility of bowel and indicate inflammation or late bowel obstruction
Absent bowel sounds - indicate paralytic ileum
Double Airway Maneuver
Jaw thrust upwards
Mouth pushed open by both thumbs
Used when C spine injury is suspected
Triple Airway Maneuver
Jaw thrust upwards
Mouth pushed open by both thumbs
Head tilt
Bag Valve Mask (BVM)
- Sizes
- Complications
- Procedure
Sizes include 240, 500, 1600 mL bags for infants, children and adults
Complications include
- Hyperventilation due to limited ability to gauge tidal volumes
- Gastric distention
- Aspiration (exhaled secretions in mask)
- Claustrophobia
- Risk of barotrauma
Procedure
- Single operator (C and E grip with one hand and bag with other)
- Double operator (C and E grip of two hands and other operator bags)
- Ventilation provided at tidal volume in adults of ~500mL at rate of 10-12 ventilations/min
Suction
Suction is used to clear airway before adding airway adjunct
Commonly removes following - vomit, saliva, blood, food, foreign objects
Oropharyngeal Airway
- Function
- Sizes
- Procedure
Functions to support airway Size measured from patients central incisors to the angle of the jaw 000 - neonate 00 - baby 0 - infant 1 - child 2 - adolescent/small adult 3 - average male/female 4 - large male/female Procedure in Adults - Hold with curve facing upwards - Advance towards hard palate - Rotate 180 degrees over base of tongue and into oropharynx Procedure in paediatric - Hold with curve facing down - Use tongue depressor to displace tongue down and forwards - Insert directly over tongue into oropharynx
Nasopharyngeal airway
- Sizes
- Procedure
Better tolerated in semiconscious patients than OPA
Size measured from tip of nose to ear lobe
Correct size equate approximately with the diameter of patients nostril
Procedure
- Select size
- Identify nasal cannula ith largest diameter (usually right)
- Lubricate and slide into nostril - direct medially and downwards along nasal floor
- Advance airway until flange is on nostril
Foreign body airway obstruction
- Magills (Function and sizes)
- Laryngoscope (Function, sizes, complications and procedure)
Magill’s forceps
- Designed to grab objects lodged in the pharynx
- Sizes (child - 205 mm and adult - 250 mm)
Laryngoscopy
- Optimal visualization of glottis for oral endotracheal tube insertion and removal of foreign bodies
- Sizes (Macintosh size 2 - large child, size 3 - small adult and size 4 - large adult, Miller size 0 - infant, size 1 - small child)
- Complications include laryngospasm, hypoxia due to delays in oxygenation while performing procedure, trauma to mouth/upper airway, exacerbation of underlying c spine injuries, vomiting
- Procedure (position self for visualization, inspect oral cavity, remove dentures, grip handle in left hand, place blade in right side of mouth and gently sweep tongue to left and position blade in midline of mouth, place tip of laryngoscope in vallecula and lift blade upwards and forwards of 45 degree angle to exposed epiglottis
Laryngeal mask airway (LMA)
- Components and design
- When to use
Components of LMA include elliptical mask, tube, connector, pilot balloon
It is designed to provide an oval seal around the laryngeal inlet - lies at crossroad between the digestive and respiratory tracts
Used when concern for airway such as in cardiac arrest, head trauma, GCS impairment, drug/alcohol
Equipment needed to insert an LMA
Equipment for LMA insertion includes
- Correct sized LMA
- Suction
- Oxygen and oxygen tubing
- Bag valve device
- Magills forceps
- Syringe
- Lubricant
- Stethoscope
- Material to secure LMA
Sizes of the LMA
Based on Agex3+7 = weight Do not insert child under ~8 (don't carry correct size) 30-50kg = size 3 (20mL) 50-70kg = size 4 (30mL) 70-100kg = size 5 (40mL)
Cricoid Pressure (Sellick’s maneuver)
- When to use
- Procedure (Adjusted technique for use in visualization of vocal cords)
Recommended during rapid sequence intubation (RSI) but can be considered during BVM
Procedure includes placing thumb and middle finger over cricoid cartilage and apply downward pressure - occludes esophagus against spinal column to prevent gastric inflation and regurgitation
Only use on unconscious patients and only release when technique blocks view of vocal cords
Adjusted technique assist in visualization of vocal cords during intubation via BURP - backwards, upwards, rightwards pressure to manipulate cricoid ring
Procedure of inserting an LMA
- Size LMA
- Deflation and inflation test
- lubricate posterior tip of cuff
- Patient head in sniffing position (if possible)
- Slightly lift patient head with non dominant hand
- Hold LMA behind cuff with index finger and thumb
- Insert into mouth directing upwards to hard palate
- Use middle finger to open jaw and ensure cuff flattened against hard palate
- Use index finger to insert into hypopharynx
- Continue to advance until resistance is felt
- Inflate cuff to create seal
- Observe signs for correct placement and inflation
- Connect resuscitation bag and ventilate
- Secure LMA
Intramuscular Injection
- Equipment
- Complications/ Limitations
- Sites
Equipment includes - Gloves - Alcohol swab - Sharps box - Cotton wool - Tap - Syringe - Needle Complications/Limitations - Infection - Inadvertent IV or subcutaneous injection - Compartment syndrome - Slowed effect in poorly perfused patients - Limited volume can be injected (2mL) Sites - Deltoid (max dose 2mL) - Vastus Lateralis (max 2mL)
