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Flashcards in ABCDE Deck (57)
1

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

2

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

3

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

4

inspiratory stridor indicates

narrowing at the glottis

5

what can airway trouble sound like

stridor

voice changes- hoarseness and can't get
words out

gurgling

6

when would you use a nasopharyngeal airway

for semi-conscious pts with a gagreflex

7

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

8

Oropharyngeal Airway is used for

Use only in unconscious, unarousable patients

NOT IN A PT WITH A GAG REFLEX--> vomit

9

Oropharyngeal Airway measurement

corner of the mouth to the angle of the jaw

10

how should you be holding laryngoscopes

with left hand

11

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

12

CO2 monitor should turn what color following intubation

Yellow-Yes

purple= poor

13

laryngoscope with straight blade

Miller

14

laryngoscope with curved blade

macintosh

15

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

16

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

17

S.O.A.P M.E checklist

Suction
Oxygen
Airway equipment
Pharmacy
Monitoring Equipment

18

prep for intubation

BVM
SOAPME
Have Plan A, Plan B, Plan C
RSI - Rapid Sequence Intubation

19

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

20

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

21

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.

22

why do we get a CXR post intubation

to check depth NOT to see if it's the esophagus

23

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-

24

king tube

goes into the esophagus
inflate giant balloon and

25

Causes of Inadequate Ventilation-i. Increased airway resistance

1. Airway collapse, hyper-reactivity, edema
2. Small decreases in diameter significant
3. COPD, emphysema, asthma

26

Causes of Inadequate Ventilation-Decreased airway compliance

1. Interstitial edema and alveolar collapse
2. Pulmonary edema, effusion, shock, sepsis, aspiration, drowning, smoke inhalation, ARDS, trauma


27

Abnormalities of ventilation/perfusion

1. Acute left ventricular failure, pneumonia, pulmonary embolus, anemia, ARDS, etc…

28

Impaired wall mechanics

1. Perfused but under-ventilated alveoli
2. Pneumothorax, pneumonia, effusion, neuromuscular problems, rib fx, trauma

29

Hypoventilation/hyperventilation

1. Poisoning, toxic overdoses, intoxication
2. Acidosis
3. Endocrine disorders
4. CNS lesions

30

Inadequate Ventilation leads to

Leads to Hypoxia... and hypercarbia

31

Hypoxia causes

1. Low arterial O2 tension - alveoli aren’t transferring O2 from lungs to circulation
2. Ventilation-perfusion mismatch

32

Hypercarbia:

1. Alveolar hypoventilation
2. Increased lung “dead space”
3. Acidosis from CO2 retention
4. Altered mental status à will cause you to become sleepy and unconsciousness and will affect your breathing

33

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?

34

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

35

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 cause

36

placing nasal cannula

tubes down

37

Maybe tachypnec but full sentences, no posturing, 2-4L/min

what type of O2 threapy

ii. Nasal cannula - no/slight distress

38

Moderate distress & O2 deficit, 4-10L/min

iii. Face mask

39

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

40

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?

41

ROS for SOB

rash-allergies
fever
cough
hemoptysis
DOE
CP
orthopnea
edema
trauma
syncope

42

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?

43

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

44

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

45

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

46

a. ED Diagnostics respiratory distress

IV, 02, monitor
triple scan
CXR
EKG

LAB
CBC
CMP
UPREG
UTOX
Lactic acid

47

Case specific - consider:

1. Cardiac enzymes
2. D-Dimer, lower extremity ultrasound
3. ABG/VBG, PT/INR
4. Aspirin level: mixed acid base picture and first sign of aspirin tox is tachypnea
5. BNP?
CHEST CT
NIPPV-

48

Non-invasive Positive Pressure Ventilation

Hypercapnic, hypoxemic respiratory failure

49

d. BiPAP - “bilevel positive airway pressure”

i. Nasal mask
ii. Use to vary inspiratory and expiratory pressures (COPD)

50

c. CPAP - “continuous positive airway pressure”

i. Mask over mouth/nose
ii. Continuous inspiratory/expiratory pressure (CHF)

51

NIPPV can be used for

i. COPD exacerbations, severe asthma
ii. Pulmonary edema/CHF
iii. Obstructive sleep apnea
iv. Post-extubation, chest trauma

52

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

53

CI for NIPPV

1. Pt cannot breathe on own if mask falls off
2. Must be relatively stable, not agitated or unconscious
3. Intact face - avoid subcutaneous air

54

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

55

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

56

43 YO M brought in by ambulance from house fire

preemptively intubate because of worry about edematous

57

lil guy with lip swelling

epinephrine
package for anaphylaxis