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Airway Management & Ventilation


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True or false: Airway management and ventilation are the second steps in assessment of patients.
False. Airway management and ventilation are the first and most critical steps in the initial assessment of every patient you encounter.
True or false: Deliberate and precise use of simple, basic skills is the key to successful airway management and patient outcome.
Define pneumothorax
The presence of gas or air in the plural cavity
________________ of the airway is an immediate threat to the patients life and a true emergency.
Blockage or obstruction
Define upper airway obstruction
An interference with air movement through the upper airway
What are the five causes of airway obstruction?
Foreign bodies
Laryngeal spasm and edema
The ____________ is the most common airway obstruction.
What is the narrowest part of an adults airway?
The glottis
Since the glottis is the narrowest part of an adults airway, __________ or ____________ of the vocal cords is potentially lethal.
edema, spasm
Define extubation
Removing a tube from a body opening
What is the most common cause of laryngeal spasm?
Overly aggressive intubation
What is the most immediate concern with every patient?
Maintaining a patent airway and adequate oxygenation and ventilation.
What does RSI stand for?
Rapid sequence intubation. Rapid sequence induction describes the classic procedure, but has been modified in the EMS setting. The difference between the two is RSIntubation does not utilize a general anasthetic agent.
What are the indications for RSI?
Impending respiratory failure (pts may be awake, responsive, agitated, or combative)
Acute airway disorder that threatens airway patency
AMS with significant risk of vomiting and aspiration
Significant gag reflex, clinched teeth, or too much airway muscle tone to allow intubation
The basic physiology involved in RSI centers around the ___________________ _______________ - the connection between peripheral nerves and skeletal muscle.
neuromuscular junction
Define faciculations
Generalized involuntary muscle twitching. Caused by stimulation effect from depolarizing agents such as Succinylcholine.
What is the most common depolarizing agent used for RSI?
Define the pathology of depolarizing agents.
Depolarizing agents block acetylcholine at the neuromuscular junctions. This results in relaxation of skeletal muscle and paralysis.
How do depolarizing and nondepolarizing agents differ?
Depolarizing agents block acetycholine at the neuromuscular junction causing relaxation of skeletal muscle, but nondepolarizing agents block the uptake of acetycholine and do not allow stimulation of the muscles; do not cause fasciculations.
Give 3 examples of nondepolarizing nuromuscular agents.
Vecuronium, atracuronium, pancuronium
What is the dose for Sux? (Adult and pediatric)
1.5 mg/kg IV bolus in adults
2 mg/kg IV bolus in children less than 10.
What is the onset of action of Sux?
60-90 seconds
What is the duration of Sux?
3-5 minutes
State several contraindications for Sux.
Penetrating eye injuries, pts with burns greater than 8 hours duration, massive crush injuries, and neurological injuries greater than one week out
________________ is generally the second-line paralytic used when Sux is contraindicated. What is the dose, onset of action, and duration?
Vecuronium (Nocuron). Used because it has fewer cardiac and hypotensive side effects. The dose is 0.15 mg/kg IV bolus (paralyzing) and 0.01 mg/kg IV bolus (priming). Onset is 2-3 minutes and the duration is 45 minutes.
Atracuroium (Tracrium) is useful for pts with _____________ or ____________ disease because these conditions do not prolong its duration.
kidney, liver
Define paradoxical breathing
Assymetrical chest will movement that lessens respiratory efficiency
Define flail chest
Defect in the chest wall that allows a segment to move freely, causing paradoxical motion
When obtaining a history, what information is considered important?
Onset of symptoms
Symptom development
Associated symptoms
Past medical history
Recent history
What makes s/s better or worse
What are things to look for while doing an inspection of the pt?
Modified forms of respiration
Define cyanosis
Bluish discoloration
Define dyspnea
An abnormality of breathing rate, pattern, or effort
Define hypoxia
Oxygen deficiency
Define anoxia
The absence or near absence of oxygen
What are 5 modified forms of respiration?
Explain coughing as a modified form of respiration
Forceful exhalation of a large volume of air from the lungs. Protective function in expelling foreign materials from the lungs.
Define sneezing as a modified form of respiration
A sudden, forceful exhalation from the nose, usually caused by nasal irritation.
Define hiccoughing as a modified form of respiration
Sudded inspiration caused by spasmodic contraction of the diaphragm with spastic closure of the glottis. There is no known physiologic purpose.
Define sighing as a modified form of respiration
Slow, deep, involuntary respiration followed by a prolonged expiration. It hyperinflates the lungs and reexpands the alveoli. Normally occurs once a minute.
Define grunting as a modified form of respiration
A forceful expiration that occurs against a partially closed epiglottis. Usually an indication of respiratory distress.
Define Kussmaul's respirations
Deep, slow or rapid, gasping breathing, commonly found in diabetic ketoacidosis.
Define Cheyne-Stokes respirations
Progressively deeper, faster breathing alternating gradually with shallow, slower breathing indicating brain stem injury
Define Biot's respirations
Irregular pattern of rate and depth with sudden, periodic episodes of apnea, indicating increased intracranial pressure
Define Central Neurogenic Hyperventilation
Deep, rapid respirations indicating increased inreacranial pressure
Define Agonal respirations
Shallow, slow or infrequent breathing, indicating brain anoxia
What is the primary indication of breathing is significant or if significant hypoxia is present?
Altered mentation
Where is the first place you should ascultate after intubation?
Over the epigastrium
What are 5 indications of airflow compromise?
What is 2 indications of inadequate gas exchange?
Crackles or rhonci when ascultating for lung sounds
Snoring is a result of...
partial obstruction of the upper airway
Gurgling results from...
accumulation of blood, vomitus or other secretions in the upper airway
Define stridor
A harsh, high-pitched sound heard on inhalation, associated with laryngeal edema or constriction.
Define wheezing
A musical, squeeking, or whistling sound heard in inspiration and/or expiration, associated with bronchiolar constriction.
Quiet lung sounds, diminished or absent lung sounds, indicate a serious problem with the _____________, _____________ or both.
airway, breathing
Define crackles
A fine, bubbling sound heard on inspiration, associated with fluid in the smaller bronchioles.
What is another term for crackles?
Define rhonchi
A coarse, rattling noise heard on inspiration, associated with inflammation, mucus or fluid in the bronchioles.
True or false: Air movement into the epigastrium may sometimes mimic breath sounds.
Define compliance
The stiffness or flexability of the lung tissue
_____________ __________ abnormalities may suggest respiratory compromise.
Pulse rate
________________ usually acompanies hypoxemia in an adult, while ________________ hints at anoxia with imminent cardiac arrest.
Tachycardia, bradycardia
A ________ in pulse rate in a pt with airway compromise is an ominous finding.
Define pulse oximetry
A measurement of hemoglobin oxygen saturation in the periphreal tissues.
The greater the PaO2, the ____________ will be the oxygen saturation.
Pulse ox readings between ____ and ____% indicate mild hypoxia.
91, 94
What is a normal SaO2 reading?
Between 95% and 99%
Pulse ox readings between ____% and ____% indicate moderate hypoxia and should be given supplemental oxygen.
86, 91
Pulse ox readings ____% and below indicarte sever hypoxia. Pt should be given supplemental oxygen and ventilatory support.
Define capnography
The measurement of exaled carbon dioxide concentration.
In the absence of cervicel spine trauma, what is the best technique for opening the airway in an unresponsive pt who is not protecting his own airway?
Head tilt/chin lift
What are the two manuvers to open a pts airway that can be performed with a c-collar in place?
Jaw thrust w/o head tilt
Modified jaw-thrust
What is the main purpose of the Sellick's maneuver?
To help prevent regurgitation and reduce gastric distention
To perform the Sellick's manuever, you apply gentle pressure ______________ on the anterior _______________ _____________.
posteriorly, cricoid cartilage
True or false: Since they work better, it is best to place a mechanical airway instead of messing with other manuevers.
False. Always attempt any appropriate manual manuever before placing an mechanical airway.
Name 3 advantages to the nasopharyngeal airway
Rapid, blind insertion
It bypasses the tongue, providing a patent airway
May be used in pts with a gag reflex
May be used in pts with oral cavity trauma
Can suction through it
Can be used when pts teeth are clenched
Name 3 disadvantages of nasopharyngeal airway's
Smaller than the OPA
Does not isolate the trachea
Difficult to suction
May cause severe nosebleeds
May cause pressure necrosis of the nasal mucosa
May kink and clog, obstructing the airway
Difficult if nasal trauma is present
May not be used in pts having or suspected of having a basilar skull fx
What are 3 situations in which you would not use a NPA?
Pt who is predisposed to nosebleeds
Nasal obstruction
Suspected basilar skull fx
What are 3 advantages of an OPA?
Easy to use
Air can pass around and through device
Helps prevent obstruction by teeth and lips
Helps manage airway of unconscious pts
Makes suctioning the pharynx easier
Effective bite block
What are 3 disadvantages of an OPA?
Does not isolate the trachea or prevent aspiration
Cannot be inserted when teeth are clenched
May obstruct airway if not inserted properly
Easily dislodged
May produce vomiting if gag returns
Do not use an OPA in _________________ or ___________________ pts who have a gag reflex, as it may cause vomiting or laryngospasm.
conscious, semiconscious
_____________________ intubation is the preferred method of advanced airway management in prehospital emergency care, as it allows the greatest control of the airway.
What is the name of a curved laryngoscope blade?
What is the name for a straight laryngoscope blade?
What is the size range for laryngoscope blades?
0 for infants to 4 for large adults
The curved blade is designed to fit into the ______________.
The straight blade is designed to fit under the ________________ and lift it out of the way.
What type of blade is better for intubation of infants?
Straight blades because they stabilize the floppier epiglottises and provide greater displacement of their relatively larger tongues. This would also be true for the occasional adult with a floppy epiglottis or large tongue.
ET tubes range from 2.5mm-4.5mm, _____________, and _____mm-_____mm cuffed.
uncuffed, 5.0, 9.0
What is the generally accepted ETT size for both males and females?
7.5 mm
Define stylet
Plastic-covered metal wire used to bend the ETT into a J or hockey-stick shape.
What are 4 indications for ET intubation
Respiratory of cardiac arrest
Unconscious or obtusion w/o gag reflex
Risk of aspiration
Respiratory extremis due to disease
Pneumo, hemothorax or hemopneumothorax with respiratory diffuculty
True or false: Intubation should not be attempted prehospital if epiglotitis is present unless airway failure is imminent.
True. Attempts to manipulate the airway in epiglotitis are likely to result in vigorous laryngospasm.
What are 3 advantages of ET intubation?
Isolation of the trachea and complete control of the airway
Impedes gastric distention
No need to maintain a mask seal
Offers a direct route for suctioning
Permits administration of select meds
What are the drugs that are able to be give down the ETT?
What are 3 disadvantages of ET intubation?
Requires training and experience
Requires special equipment
Requires direct visualization of vocal cords
Bypasses the upper airways function of warming, filtering, and humidifying inhaled air
Name 3 complications of ET intubation
Equipment malfunction
Teeth breakage and soft tissue lacerations
Esophageal intubaion
Endotracheal intubation
Tension pneumothorax
To avoid hypoxia during intubation, limit each intubation attempt to no more than _____ _____________ before reoxygenating the pt.
30 seconds
What are 3 indications of esophageal intubation?
Absence of chest rise and fall
Absence of breath sounds w/mechanical ventilation
Gurgling sounds over the epigastrium
Absence of breath condensation in tube
Persistant air leak
Cyanosis and progressive worstening of pts condition
ETCO2 detector
Falling pulse ox reading
What is the most reliable method for confirming proper placement of an ETT?
Direct visualization of the tube through pts vocal cords
To prevent endobronchial intubation, how far should you advance the distal cuff of an ETT?
No more than 1-2 cm past the vocal cords
If an ETT is misplaced into the right or left mainstem, __________________, such as a pneumothorax, can occur because a BVM insufflates enough air for two lungs, but air flows into only one.
What is the purpose of noting the number marking on the side of the ETT where it emerges from pts teeth, gums, or lips?
It helps indicate if there is any change in tube placement.
Although it will vary, the average ETT depth for an adult woman is _____ cm, and _____ cm for men.
21, 23
What are 3 indications of endobronchial intubation?
Breath sounds are present on one side, but diminished or absent on the other
Poor compliance (resistance to ventilations)
Cyanosis, cardiac dysrhythmias, or other evidence of hypoxia
What should be done if the ETT has been placed in the L or R mainstem?
The cuff should be deflated and the tube withdrawn until ETT breath sounds are present and equal bilaterally.
In addition to mainstem bronchus intubation, what is a cause of tension pneumothorax?
Using too much volume from a BVM on a small adult or child using the full BVM volume against diseased lungs with poor compliance.
What are some indications of a tension pneumothorax?
Progressively worstening compliance
Diminished unilateral breath sounds
Hypoxia and hypotension
Distended neck veins
Trachial deviation away from the side of the pneumo
Decreased cardiac output
What is the most widely used and preferred path for endotracheal intubation?
You know you have misplaced the ETT into the esophagus if you see ____________ in the tube instead of _____________, which you will see with a tracheal intubation.
vomitus, condensation
It is important to verify and document at least 3 indications of proper placement. What are 3 indications?
Visualization of the tube between the cords
Presence of bilateral breath sounds
Absence of breath sounds over the epigastrium
Positive end-tidal CO2 change
Verification by esophageal detector device
Condensation in the tube
Absence of vomit in the tube
Absence of phonation once tube is placed
When confirming tube placement in transillumination intubation, little or no light visible through the anterior neck indicates what?
Possible esophageal intubation
What form of intubation allows you to intubate without directly visualizing the glottic opening?
Transillumination intubation
What is the biggest limitation to transillumination intubation?
Ambient light can make the transillumination to see.
If you see a ________________ ____ ___________ at the pts Adam's apple, the transillumination stylette is correctly placed
circle of light

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