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)
Intramuscular Injection Procedure
- Prepare dose and equipment
- Identify appropriate injection site
- Clean site
- Spread skin taut
- Peirce skin with needle at 90 degree angle using quick dart like technique
- Aspirate by pulling gently back on plunger (if blood appears pull out, dispose and prepare new syringe)
- Hold barrel of syringe firm and inject
- Remove
Subcutaneous Injections Procedure
- Site
- Prep dose
- Recline patient
- Clean site
- Identify injection site
- Pinch 5cm fold of skin between thumb and index and pull fatty tissue away from underlying muscle
- Pierce skin at 90 degree angle using quick dart like technique
- Needle should be completely covered by skin
- Aspirate by gently pulling back on plunger (if blood appears remove and prepare new syringe)
- Hold syringe barrel firmly and inject contents
- Remove needle and dispose of
Site - lower abdomen approx 3cm from umbilicus
Intranasal Drug administration
- Equipment
- Procedure
- Dosage
Aerosol medication administration through nose via Mucosal Atomisation Device directly onto highly vascularised nasal mucosa
Procedure
- Withdraw dose into MAD nasal syringe
- Place tip against nostril aiming slightly upwards and outwards (towards top of ear)
- Briskly compress syringe plunger
Dosage
- Volume between 0.5mL and 2 mL optimize drug absorption by delivering half into each nostril
- Volume above 2 mL should use alternate route of administration
Intranasal Fentanyl
100mcg fentanyl and 10mg of morphine are equipotent
Rapid onset analgesia
used in pediatric
Definition of Pharmacokinetics
Pharmacokinetics refers to the movement of a drug throughout the body
Absorption, distribution, metabolism and excretion
Definition of Bio availability
Bio-availability refers to the amount of drug absorbed through GIT into bloodstream that determines the subsequent plasma levels available from the dose
Definition of Half life
Half life refers to the length of time for the concentration of the drug in the bloodstream to be reduced by half
Definition of pain threshold
Pain threshold refers to the least intense stimulus that will cause pain
Definition of Drug tolerance
Drug tolerance refers to the decreased response to drug dose requiring an increase in dose to provide original effect
Definition of Physical Dependence
Physical dependence is characterized by tolerance to drug causing reduction in effectiveness of analgesia and increase in dose requirements to relieve pain
Definition of Physiological Dependence
Physiological dependence is characterized by craving that influences mood and actions to acquire drug
Definition of Minimum Effective
Minimum effective refers to the lowest concentration of drug in blood required to provide a therapeutic effect
Definition of Titration
Titration refers to the dose adjustment to achieve and maintain the analgesia level within the therapeutic window
Action of opioids to relieve pain
Opioids are natural an synthetic compounds that bind to opioid receptors (mu, delta and kappa) in the brain and spinal cord to achieve satisfactory pain relief while keeping the sedation score under 2.
Opioid - Morphine
- Route and dose of administration
- Adverse effects
Morphine is given via IV receiving 2.5-5mg increments every 5 min until pain is relieved
Adverse effects
- Commonly include nausea, sedation, euphoria, dysphoria, pruritus, constipation and urinary retention
- Serious adverse effects include hypotension and respiratory depression
Opioid - Fentanyl
- Type of opioid and receptor
- Effect on histamine
- Route and dose of administration
- Onset/duration of action
Fentanyl is a short acting pure opioid agonist that binds to mu receptors
- Does not release histamine like morphine does therefore less chance of histamine mediated hypotension
- Delivered intranasally pre-hospital with initial adult dose being 200mg, initial child dose is 2mg/kg and for patients over 60 yrs or weigh less than 60kg a half adult dose should be given
- Onset of action is rapid and duration of action is ~30min
Opioid - Codeine
- Type of opioid
Codeine is a weak opioid pro drug that is metabolized into morphine to have an effect however, up to 10% of the population lack the enzyme (CYP2D6) to allow metabolism to occur
NOT commonly used in emergency setting
Non-opioids:
- Paracetamol MOA, Adverse effects, Daily dose, Metabolism
- Non-steroidal inflammatory drug (NSAIDS) MOA, examples of drugs, when to use
Non opioid are useful in mild to moderate pain however common route of administration is oral therefore not always used in emergency setting Paracetamol
- MOA not known but believed to block pain impulses through prostaglandin inhibitory effect on CNS
- Low therapeutic index
- Few adverse effects
- Daily dose shoul not exceed 400mg for adults
- Metabolized in liver therefore can accumulate in toxic form if overdose occurs leading to acute liver failure
NSAIDS
- MOA causes an anti-inflammatory effect of peripheral tissue by inhibiting prostaglandin synthesis through blocking COX production - COX1 and 2 where NSAIDS are typically non selective
- Examples of NSAIDS drugs include aspirin, diclofenac, ibuprofen, indomethacin, ketoprofen, ketorolac, naproxen, piroxicam, sulfidic, tiaprofenic acid
- NSAIDS are used to treat mild to moderate pain and are a useful adjunct to opioids
Inhalation analgesia
- Nitrous oxide - use, side effect, prolonged use side effects
- Methoxyflurane - use, dose and duration, prolonged use side effects
Nitrous oxide
- Mild analgesic and sedative when given with oxygen
- Safe and few side effects
- If used for more than 6-8hrs it can destroy the enzyme methionine synthase and deplete vitamin B12 stores
Methoxyflurane
- Used as a volatile analgesic to relieve acute pain in emergency setting
- Initial dose is 3mL via disposable inhaler (patient self administration) with the duration of action being ~30min
- Do not provide more than 6mL in 24hrs and 15mL in a week as long term use becomes nephrotoxic and can cause renal failure or impairment
N-methyl-D-aspartate (NMDA) receptor antagonists
- MOA
- Ketamine - MOA, Dose, Adverse effects
NMDA receptor antagonists block the NMDA receptors that normally bind to neurotransmitters such as glutamate, glycine and aspartate in postsynaptic interneurons and ascending neurons of spinal cord thus produce analgesic effect
Ketamine
- Anesthetic properties without reducing reflexes or muscle tone
- A sub analgesic levels it produces conscious sedation
- IV dose of 0.3mg/kg
- Increases SNS activity to increase CO and BP therefore reduce risk of hypotension but can lead to increase intraocular and intracranial pressure
- Does not depress respiration like other opioids
- Older patients coming of ketamine can experience hallucinations, agitation and vivid dreams
Non Pharmacological pain management
- Psychological
- Physical
Psychological interventions include - Distraction - Hypnosis - Imagery - Relaxation Physical interventions include - Massage - Application of heat and cold - Transcutaneous electrical nerve stimulation - Acupuncture
Local Anesthesia
- Use
- MOA and intended site of action
- Classifications and specific drugs
Reduce or prevent pain without effective consciousness
MOA
- Block sodium channels and prevent sodium influx to depolarize the cell to stop propagation of AP along neurons
- Intended for neurons of pain stimulation but effects all excitable cell in the area therefore can cause paralysis or paresis
Classifications
- Amides are slowly metabolized by the liver and have a long duration of action (Lignocaine, Bupivacaine, Levobupivacaine and Ropivacaine)
- Esters are metabolized quickly by liver (Procaine, Cocaine, Benzocaine, Amethocaine, Oxybuprocaine and Proxymetacaine)
Local Anesthetic
- Routes of administration
- Topical - applied to mucous membrane, conjunctiva and damaged skin
- Infiltration - sub dermal and subcutaneous injections (may need ultrasound to place needle)
- Epidural - inject into epidural space
- Subarachnoid - administration into CSF at point below third lumbar vertebrae
- Intravenous regional - IV cannula in dorsum of hand for onset of action in 5-10 min
Local Anesthetic
- Advantages
- Disadvantages
Advantages
- Provide pain relief without affecting patient level of consciousness
- Nerve blocks
Disadvantages
- Can affect propagation of AP in other parts of body such as heart and CNS
Nebulisation
- Function
- Nebuliser Mask procedure
- T-Piev
Nebulisers deliver drugs in form of a mist into the lungs
Nebuliser mask procedure
- Position patient
- Unscrew top and place drug in (chamber can hold 10mL) and close
- Attach the oxygen source
- Place nebuliser mask on patient and set oxygen flow rate at 6-8L/min
- Nebulise drug until vapor stops
T-Piece Nebuliser
- Position patient and continue PPV
- Unscrew nebuliser and place drug in chamber then close
- Attach oxygen source
- Place T piece inline
- Set oxygen flow rate to min L/min for nebulisation
- Nebulise until drug vapor stops while continuing to ventilate patient
NOTE - T-piece nebulisation is for CCPs
Factors impacting the site for IV access
- Purpose of IV
- Nature of drug/fluid to be administered
- Rate the drug/fluid needs to be administered
- Perfusion status of patient
- Target organ
- Quality of veins
- Concomitant injuries and medical conditions
- Left or right hand dominant patient
- Practitioner skill/confidence
Note - generally cannulate right hand as its the side accessible in ambulance
Factors preventing a site from being used for cannulation
- Distal to injury
- Limb with arteriovenous fistula present
- When extremity has phlebitis or cellulitis
- When limb has potential or existing lymphoedema
- Whe there exists venous occlusive edema of the limb
Techniques to cause venodilation
- Gravity and tourniquet
- Clenching the fist
- Milking or tapping the vein
- Warmth
Equipment required for cannulation
- Catheter selection size
ABCDEF - Alcohol swab - Bung - Cannula - Dressing - Elastic tourniquet - Flush Other equipment - Gloves - Cotton wool - Syringe - Sharps box - Drawing up needle - Tape - Absorbent sheet - Plastic needle - Clinical waste bin Sizes of cannula - 22-24 gauge (children/adults with small and fragile veins) - 18-20 gauge (medical/surgical patients) 16-20 gauge (blood product administration, surgical admission and trauma) - 14-16 gauge (life threatening situations)
Intravenous Cannulation Procedure
- Apply tourniquet
- Consider best site for cannulation (vein you feel not see)
- Swab area (one swipe)
- Break seal on hub of cannula (twist and move forward)
- Hold cannula on either side of flash chamber with thumb and middle finger
- Pierce skin and vein at angle of ~15-30 degrees
- Observe flashback
- Advance cannula of stylet
- Remove tourniquet and apply pressure with fingers over cannula
- Attach bung
- Flush to ensure placement
- Secure with dressing
- Label with time of access, location of access, size of cannula, fluid/drug infused and total volume of fluid infused at time of handover
Complications of IV cannulation
- Arterial puncture
- Nerve damage
- Extravasation
- Infiltration
- Haematoma
- Air emboli
- Catheter shear
- Haemorrhage
- Infection
- Phlebitis
- Vasovagal syncope
- Tissue/vascular necrosis
Fluid therapy
- Function
- Procedure
The giving set functions to deliver fluid and electrolytes directly into circulatory system via IV
Procedure
- Ensure air vent in giving set is closed
- Reposition flow regulator roller clamp immediately below drip chamber and close flow regulator roller clamp
- Remove and discard safety cap
- Remove and discard giving sets spike protector
- Invert vertically and insert giving set spike downwards into the port
- Hang in upright position
- Gently squeeze and release drip chamber until filled to level that covers filter
- Open roller clamp and slowly prime tubing until fluid drops from patient connection port
- Remove air bubbles from tubing
- Close roller clamp
- Connect giving set to patient cannula
