Emergency Care CHAPTER. Airway Management THIRTEENTH EDITION. Emergency Care, 13e Daniel Limmer Michael F. O'Keefe

Transcription

1 Emergency Care THIRTEENTH EDITION CHAPTER 9 Airway Management

2 Multimedia Directory Slide 22 Slide 73 Responding to an Adult with an Obstructed Airway Video Suctioning Oral Pharyngeal Video

3 Topics Airway Physiology Airway Pathophysiology Opening the Airway Airway Adjuncts Suctioning Keeping an Airway Open: Definitive Care Special Considerations

4 Airway Physiology

5 Airway Physiology Upper airway Begins at mouth and nose Air is warmed and humidified in nasal turbinates. Pharynx Oropharynx, nasopharynx, and laryngopharynx Ends at glottic opening

6 Airway Physiology The upper airway.

7 Airway Physiology Lower airway Begins below the larynx Composed of: Trachea Bronchial passages Alveoli

8 Airway Physiology The lower airway. (A) The bronchial tree.

9 Airway Physiology Alveoli Tiny sacs in grapelike bunches at the end of the airway Surrounded by pulmonary capillaries Oxygen and carbon dioxide diffuse through pulmonary capillary membranes.

10 Airway Physiology The lower airway. (B) The alveolar sacs (clusters of individual alveoli).

11 Airway Pathophysiology

12 Airway Pathophysiology Variety of obstructions interfere with air flow Foreign bodies Food, small toys Liquids Blood, vomit Obstruction may also result from poor muscle tone caused by altered mental status. continued on next slide

13 Airway Pathophysiology Obstructions can be acute or chronic. Providers must initially evaluate airway and monitor patency over time. continued on next slide

14 Airway Pathophysiology Airway obstructions Acute Foreign bodies Vomit Blood Occurring over time Edema from burns, trauma, or infection Decreasing mental status continued on next slide

15 Airway Pathophysiology Airway obstructions Bronchoconstriction Disorder of lower airway Smooth muscle constricts internal diameter of airway.

16 Patient Assessment Addressed in primary assessment Two questions must be answered. Is airway open? Will airway stay open?

17 Is the Airway Open? In most patients, can be determined by simply saying hello "Sniffing position" seen when swelling obstructs airflow through upper airway continued on next slide

18 Is the Airway Open? Findings indicating breathing problems Inability to speak Unusual raspy quality to voice Stridor Snoring Gurgling

19 Will the Airway Stay Open? Airway assessment is not just a moment in time. Must give constant consideration

20 Signs of an Inadequate Airway No signs of breathing or air movement Evidence of foreign bodies in airway No air felt or heard Inability or difficulty speaking Unusual hoarse or raspy voice Absent, minimal, or uneven chest movement continued on next slide

21 Signs of an Inadequate Airway Abdominal breathing Diminished or absent breath sounds Abnormal noises such as wheezing, crowing, stridor, snoring, gurgling, or gasping during breathing In children and infants, nasal flaring In children, retractions above the clavicles

22 Responding to an Adult with an Obstructed Airway Video Click on the screenshot to view a video on the subject of obstructed airway in an adult. Back to Directory

23 Opening the Airway

24 Patient Care The airway When primary assessment indicates inadequate airway, a life-threatening condition exists. Take prompt action to open and the maintain airway

25 Opening the Airway If airway is not open, use position to open it. Indications of head, neck, spinal injury Mechanism of injury known to cause such injuries Any injury at or above the level of the shoulders Family or bystanders give information leading you to suspect it. continued on next slide

26 Opening the Airway Head-tilt, chin-lift maneuver and jawthrust maneuver move airway structures into position allowing air movement.

27 Head-Tilt, Chin-Lift Maneuver Head-tilt, chin-lift maneuver, side view. Right image shows EMT s fingertips under the bony area at the center of the patient s lower jaw.

28 Head-Tilt, Chin-Lift Maneuver 1. Place one hand on patient's forehead and fingertips of other hand at the center of patient's lower jaw. 2. Tilt head. 3. Lift chin. 4. Do not allow mouth to close.

29 Jaw-Thrust Maneuver Jaw-thrust maneuver, side view. Inset shows EMT s finger position at angle of the jaw just below the ears.

30 Jaw-Thrust Maneuver 1. Keep patient's head, neck, and spine aligned, moving patient as a unit into the supine position. 2. Kneel at the top of patient's head. 3. Place one hand on each side of patient's lower jaw, at angles of jaw below ears. 4. Stabilize patient's head with your forearms. continued on next slide

31 Performing Jaw-Thrust Maneuver 5. Using index fingers, push angles of patient's lower jaw forward. 6. You may need to retract patient's lower lip with your thumb to keep the mouth open. 7. Do not tilt or rotate patient's head.

32 Airway Management After airway has been opened, position must be maintained to keep airway open. Airway must be cleared of secretions and other obstructions.

33 Airway Adjuncts

34 Airway Adjuncts Airway position and maneuvers are short-term solutions. Airway adjunct provides longer term air channel. Two most common airway adjuncts Oropharyngeal airway (OPA) Nasopharyngeal airway (NPA)

35 Rules for Using Airway Adjuncts Use OPA only on patients not exhibiting gag reflex. Open patient's airway manually before using adjunct device. When inserting airway, take care not to push patient's tongue into pharynx. continued on next slide

36 Rules for Using Airway Adjuncts Have suction ready prior to inserting any airway. Do not continue inserting airway if patient gags. Maintain head position after adjunct insertion and monitor airway. continued on next slide

37 Rules for Using Airway Adjuncts Continue to be ready to provide suction if fluid or blood obstructs the airway. If patient regains consciousness or develops a gag reflect, remove the airway immediately. Use infection control practices while maintaining airway.

38 Oropharyngeal Airway Device used to move tongue forward as it curves back to pharynx Sizes Infant to large adult

39 Oropharyngeal Airway Oropharyngeal airways.

40 Sizing Oropharyngeal Airways Ensure the oropharyngeal airway is the correct size by checking to make sure it either extends from the center of the mouth to the angle of the jaw or

41 Sizing Oropharyngeal Airways Measure from the corner of the patient's mouth to the tip of the earlobe.

42 Oropharyngeal Airway Inserting OPA 1. Place patient on his back, and use appropriate method to open the airway 2. Open mouth with crossed-finger technique 3. Position airway with tip pointing toward roof of mouth

43 Inserting OPA Use the crossed-fingers technique to open the patient's mouth.

44 Oropharyngeal Airway Inserting OPA 4. Insert device along roof of mouth 5. Gently rotate airway 180 degrees so tip is pointing down into patient's pharynx 6. Position patient 7. Check that flange of airway is against patient's lips 8. Monitor patient closely continued on next slide

45 Inserting OPA Insert the airway with the tip pointing to the roof of the patient's mouth.

46 Oropharyngeal Airway Inserting OPA Use tongue depressor or rigid suction tip and insert OPA directly

47 Nasopharyngeal Airway Soft, flexible tube inserted through nostril and into hypopharynx Moves tongue and soft tissue forward to provide a channel for air continued on next slide

48 Nasopharyngeal Airway Can be used in patients with intact gag reflex or clenched jaw Contraindicated if clear (cerebrospinal) fluid coming from nose or ears continued on next slide

49 Nasopharyngeal Airway Come in various sizes Must be measured Typical adult sizes 34, 32, 30, and 28 French

50 Inserting NPA Inserting NPA 1. Measure for correct size 2. Lubricate outside of tube with waterbased lubricant before insertion

51 Inserting NPA Measure the nasopharyngeal airway from the patient's nostril to the tip of the earlobe or to the angle of the jaw.

52 Inserting NPA Apply a water-based lubricant before insertion.

53 Inserting NPA Inserting NPA 3. Push tip of nose upward; keep head in neutral position 4. Insert into nostril; advance until flange rests firmly against nostril

54 Inserting NPA Gently push the tip of the nose upward, and insert the airway with the beveled side toward the base of the nostril or toward the septum (wall that separates the nostrils). Insert the airway, advancing it until the flange rests against the nostril.

55 Suctioning

56 Suctioning Obvious liquids (blood, secretions, vomitus) must be removed from airway to prevent aspiration into lungs. Use vacuum device to remove liquids from airway.

57 Suction Devices Mounted suction systems Installed near head of stretcher Furnish air intake of at least 30 liters per minute Generate vacuum of no less than 300 mmhg when collecting tube clamped continued on next slide

58 Suction Devices Portable suction units Same requirements as mounted Oxygen- or air-powered or powered by batteries/electricity Manual continued on next slide

59 Suction Devices Tubing, tips, and catheters Tubing Suction tips Suction catheters Collection container Container of clean or sterile water

60 Suction Systems A mounted suction unit installed in the ambulance s patient compartment.

61 Suction Devices Tubing, tips, and catheters Rigid pharyngeal suction tip Also called Yankauer tip Larger bore than flexible catheters

62 Rigid Pharyngeal Tip Place the convex side of the rigid tip against the roof of the mouth. Insert just to the base of the tongue.

63 Suction Devices Tubing, tips, and catheters Rigid pharyngeal suction tip Suction only as far as you can see. Do not lose sight of distal end. Careful insertion helps prevent gag reflex or vagal stimulation. continued on next slide

64 Suction Devices Tubing, tips, and catheters Flexible suction catheters Designed to be used when a rigid tip cannot be used Can be passed through a tube such as the nasopharyngeal or endotracheal tube Can be used for suctioning the nasopharynx continued on next slide

65 Suction Devices Tubing, tips, and catheters Flexible suction catheters Come in various sizes identified by a number "French" Larger the number, larger the catheter continued on next slide

66 Suction Devices Tubing, tips, and catheters Flexible suction catheters Not typically large enough to suction vomitus or thick secretions May kink In event of copious, thick secretions consider removing tip or catheter and using large bore, rigid suction tubing. continued on next slide

67 Suction Devices Tubing, tips, and catheters Flexible suction catheters Measured in similar way as OPA Length of catheter that should be inserted into patient's mouth equals distance between corner of patient's mouth and earlobe.

68 Measuring Flexible Suction Catheter If you are using a flexible catheter, measure it from the patient's earlobe to the corner of the mouth or from the center of the mouth to the angle of the jaw.

69 Techniques of Suctioning Use appropriate infection control practices while suctioning Includes protective eyewear, mask, disposable gloves

70 Suctioning Techniques Position yourself at the patient's head and turn the patient's head or entire body to the side.

71 Techniques of Suctioning Suction no longer than ten seconds at a time. Prolonged suctioning can cause hypoxia and bradycardia. If patient vomits for longer than ten seconds, continue suction. continued on next slide

72 Techniques of Suctioning Place tip or catheter where you want to begin suctioning and suction on the way out.

73 Suctioning Oral Pharyngeal Video Click on the screenshot to view a video on the subject of suctioning. Back to Directory

74 Keeping an Airway Open: Definitive Care

75 Keeping an Airway Open: Definitive Care Keeping the airway open may exceed capabilities of a basic EMT. Medications and/or surgical procedures may be necessary to resolve airway obstruction. continued on next slide

76 Keeping an Airway Open: Definitive Care Rapidly evaluate and treat airway problems. Quickly recognize when more definitive care is necessary. May be Advanced Life Support intercept May be closest hospital

77 Think About It If you were not able to manage an airway at the basic level, what advanced resources might be available to you?

78 Special Considerations

79 Special Considerations Facial injuries Frequently result in severe swelling or bleeding that may block or partially block airway Bleeding may require frequent suctioning or more definitive airway. continued on next slide

80 Special Considerations Obstructions Many suction units are not adequate for removing solid objects. Objects may have to be removed with manual techniques Abdominal thrusts Chest thrusts Finger sweeps continued on next slide

81 Special Considerations Dental appliances Leave in place during airway procedures when possible. Partial dentures may become dislodged during an emergency. Be prepared to remove if airway endangered.

82 Pediatric Note Variety of anatomical differences to consider when managing the airway Anatomic considerations Smaller mouth and nose Larger tongue Narrow, flexible trachea

83 Pediatric Anatomical Considerations Comparison of child and adult respiratory passages.

84 Pediatric Note Management considerations Open airway gently Do not hyperextend neck Consider adjuncts when other measures fail Use rigid tip with adjunct, but do not touch back of airway

85 Chapter Review

86 Chapter Review The airway is the passageway by which air enters the body during respiration, or breathing. A patient cannot survive without an open airway. Airway adjuncts the oropharyngeal and nasopharyngeal airways can help keep the airway open. continued on next slide

87 Chapter Review It may be necessary to suction the airway or to use manual techniques to remove fluids and solids from the airway before, during, or after artificial ventilation.

88 Remember Always use proper personal protective equipment when managing an airway. Airway assessment must be an ongoing process. Airway status can change over time. Airway management should start simply and become more complicated only if necessary.

89 Questions to Consider Name the main structures of the airway. Explain why care for the airway is the first priority of emergency care. Describe the signs of an inadequate airway. continued on next slide

90 Questions to Consider Explain when the head-tilt, chin-lift maneuver should be used and when the jaw-thrust maneuver should be used to open the airway and why. Explain how airway adjuncts and suctioning help in airway management.

91 Critical Thinking On arrival at the emergency scene, you find an adult female patient with gurgling sounds in the throat and inadequate breathing slowing to almost nothing. How do you proceed to protect the airway? continued on next slide

92 Critical Thinking When evaluating a small child you hear stridor. What does this sound tell you? What are your immediate concerns regarding this sound? continued on next slide

93 Critical Thinking When assessing an unconscious patient, you note snoring respirations. Should you be concerned with this and if so, what steps can you take to correct this situation?

94 Emergency Care THIRTEENTH EDITION CHAPTER 10 Respiration and Artificial Ventilation

95 Multimedia Directory Slide 93 Slide 107 Oxygen Administration via a Non-Rebreather Mask Video In-Hospital Endotracheal Intubation Video

96 Topics Physiology and Pathophysiology Respiration Positive Pressure Ventilation Oxygen Therapy Special Considerations Assisting with Advanced Airway Devices

97 Physiology and Pathophysiology

98 Mechanics of Breathing Ventilation Process of moving air into and out of chest continued on next slide

99 Mechanics of Breathing Inhalation Active process Muscles expand; size of chest increases Negative pressure pulls air into lungs continued on next slide

100 Mechanics of Breathing Exhalation Passive process Muscles relax; size of chest decreases Positive pressure created; air pushed out

101 Respiration Terminology Tidal volume Amount of air moved in one breath Minute volume Amount of air moved into and out of lungs per minute

102 Physiology of Respiration Dead space air Air moved in ventilation not reaching alveoli Alveolar ventilation Air actually reaching alveoli Diffusion Movement of gases from high concentration to low concentration continued on next slide

103 Physiology of Respiration External respiration Diffusion of oxygen and carbon dioxide (exchange of gases) between alveoli and circulating blood Internal respiration Exchange of gases between blood and cells continued on next slide

104 Physiology of Respiration Cellular respiration Oxygen from blood diffused into cell Carbon dioxide diffused from cell into blood

105 Pathophysiology of the Cardiopulmonary System Mechanics of breathing disrupted Gas exchange interrupted Circulation issues

106 Respiration

107 Adequate and Inadequate Breathing Brain and body cells need a steady supply of oxygen. Hypoxia Low oxygen level in cells Carbon dioxide must be continuously removed. Hypercapnea High carbon dioxide level continued on next slide

108 Adequate and Inadequate Breathing Assesses how well cardiopulmonary system is accomplishing oxygenation and carbon dioxide removal continued on next slide

109 Adequate and Inadequate Breathing Compensation for hypoxia or hypercapnea is predictable. Signs Shortness of breath (symptom) Increased respiratory rate and depth Increased heart rate continued on next slide

110 Adequate and Inadequate Breathing Early on, steps of adjustment can meet the needs of the body despite respiratory challenge. Respiratory distress Body compensating for a respiratory challenge and meeting metabolic needs

111 Inadequate Breathing Occurs when challenge are too great for body's compensation mechanisms Also known as respiratory failure Exceptionally important to recognize; often a precursor to respiratory arrest

112 Respiratory Distress Respiratory distress usually involves accessory muscle use and increased work of breathing. Severe or prolonged respiratory distress can proceed to respiratory failure and inadequate ventilation when the body can no longer work so hard to breathe. In this case you will see a reduced level of responsiveness or an appearance of tiring, shallow ventilations, and other signs of inadequate breathing. Dan Limmer

113 Patient Assessment Signs of adequate breathing Relatively normal mental status Relatively normal pulse oximetry reading Relatively normal skin color continued on next slide

114 Patient Assessment Signs of inadequate breathing Chest movements are absent, minimal, or uneven Abdominal breathing No air can be felt or heard at the nose or mouth Breath sounds are diminished or absent Wheezing, crowing, stridor, gurgling, or gasping during breathing continued on next slide

115 Patient Assessment Signs of inadequate breathing Rate of breathing is too rapid or too slow Breathing is very shallow, very deep, or appears labored Cyanosis Inspirations or expirations are prolonged Retractions and nasal flaring in children Low oxygen saturation reading (<95%) continued on next slide

116 Patient Assessment Hypoxia Major causes A patient is trapped in a fire. A patient has emphysema. A patient overdoses on a drug that has a depressing effect on the respiratory system. A patient has a heart attack.

117 Patient Care Inadequate breathing Provide artificial ventilation to the nonbreathing patient and the patient with inadequate breathing. Provide supplemental oxygen to the breathing patient. continued on next slide

118 Patient Care When Do I Intervene? Often respiratory failure patients will be breathing and conscious. Identify adequacy of breathing. If breathing is inadequate, immediate intervention is necessary.

119 Think About It What signs might identify the need to intervene in a breathing patient?

120 Positive Pressure Ventilation

121 Positive Pressure Ventilation Forcing air or oxygen into lungs when a patient has stopped breathing or has inadequate breathing Uses force exactly opposite of how the body normally draws air into the lungs continued on next slide

122 Positive Pressure Ventilation Negative side effects of positive pressure ventilation Decreasing cardiac output/dropping blood pressure Gastric distention Hyperventilation

123 Techniques of Artificial Ventilation Do not ventilate patient who is vomiting or has vomitus in airway PPV will force vomitus into patient's lungs Watch chest rise and fall with each ventilation Ensure rate of ventilation is sufficient continued on next slide

124 Techniques of Artificial Ventilation Carefully assess the adequacy of respiration Explain procedure to patient Place the mask over the patient's mouth and nose After sealing mask on patient's face, squeeze bag with patient's inhalation

125 CPAP/BiPAP Form of noninvasive positive pressure ventilation (NPPV) CPAP Continuous positive airway pressure BiPAP Biphasic positive airway pressure

126 Mouth-to-Mask Ventilation Performed using a pocket face mask continued on next slide

127 Mouth-to-Mask Ventilation Pocket face mask. Laerdal Corporation

128 Mouth-to-Mask Ventilation Patient without suspected spine injury EMT at top of patient's head 1. Position yourself directly above the patient's head. 2. Apply the mask to the patient. 3. Place your thumbs over the top of the mask, your index fingers over the bottom of the mask, and the rest of your fingers under the patient's jaw. continued on next slide

129 Performing Mouth-to-Mask Ventilation Patient without suspected spine injury EMT at top of patient's head 4. Lift jaw to the mask as you tilt patient's head backward and place remaining fingers under the angle of the jaw. 5. While lifting the jaw, squeeze the mask with your thumbs to achieve a seal between the mask and patient's face. 6. Give breaths into one-way valve of the mask. Watch for the chest to rise.

130 Performing Mouth-to-Mask Ventilation Use only a pocket mask with a one-way valve.

131 Bag-Valve Mask Handheld ventilation device Used to ventilate nonbreathing patient and/or patient in respiratory failure

132 Bag-Valve Mask Adult, child, and infant bag-valve-mask units.

133 Bag-Valve Mask Standard features Self-refilling shell that is easily cleaned and sterilized Non-jam valve that allows an oxygen inlet flow of 15 liters per minute Nonrebreathing valve continued on next slide

134 Bag-Valve Mask Mechanics of BVM Supply of 15 liters per minute of oxygen attached and enters reservoir When squeezed, air inlet closed and oxygen delivered to patient When released, passive expiration by patient occurs continued on next slide

135 Bag-Valve Mask Two-rescuer BVM ventilation no trauma suspected Strongly recommended by AHA Most difficult part of BVM ventilation is obtaining adequate mask seal Hard to maintain seal while squeezing bag One rescuer squeezes bag; other rescuer maintains seal. continued on next slide

136 Bag-Valve Mask Two-rescuer BVM ventilation no trauma suspected 1. Open airway with head-tilt, chin-lift maneuver. 2. Select correct bag-valve mask size. 3. Kneel at patient's head; position thumbs over top half of mask, index fingers over bottom half. continued on next slide

137 Bag-Valve Mask Two-rescuer BVM ventilation no trauma suspected 4. Place apex of triangular mask over bridge of nose; lower mask over mouth and upper chin. 5. Use middle, ring, and little fingers to bring patient's jaw up to mask. Maintain head-tilt, chin-lift maneuver. continued on next slide

138 Bag-Valve Mask Two-rescuer BVM ventilation no trauma suspected 6. Second rescuer connects and squeezes bag. 7. Second rescuer releases bag; patient exhales passively. continued on next slide

139 Bag-Valve Mask Two-rescuer BVM ventilation trauma suspected 1. Open airway using jaw-thrust maneuver. 2. Select correct bag-valve mask size. 3. Kneel at patient's head; place thumb sides of your hands along mask to hold it firmly on patient's face. continued on next slide

140 Bag-Valve Mask Two-rescuer BVM ventilation trauma suspected 4. Use remaining fingers to bring jaw upward toward mask, without tilting head or neck. 5. Second rescuer releases bag; patient exhales passively.

141 Two-Rescuer BVM Ventilation: Trauma Suspected Delivering two-rescuer BVM ventilation while providing manual stabilization of the head and neck when trauma is suspected in the patient.

142 Bag-Valve Mask One-rescuer BVM ventilation 1. Open airway. 2. Select correct size mask. 3. Form a "C" around the ventilation port with thumb and index finger; use middle and little fingers to hold the jaw to mask. continued on next slide

143 Bag-Valve Mask One-rescuer BVM ventilation 4. Squeeze bag. 5. Release pressure on bag and let patient exhale passively. continued on next slide

144 Bag-Valve Mask If the chest does not rise and fall during BVM ventilation, you should: 1. Reposition head 2. Check for escape of air around mask; reposition fingers and mask 3. Check for airway obstruction or obstruction in BVM system 4. Use alternative method continued on next slide

145 Bag-Valve Mask Artificial ventilation of a stoma breather 1. Clear mucus plugs or secretions from stoma 2. Leave head and neck in neutral position 3. Use pediatric-sized mask to establish seal around stoma continued on next slide

146 Bag-Valve Mask Artificial ventilation of a stoma breather 4. Ventilate at appropriate rate for patient's age. 5. If unable to artificially ventilate through stoma, seal stoma and attempt artificial ventilation through mouth and nose.

147 Flow-Restricted, Oxygen-Powered Ventilation Device Also called manually triggered ventilation device Uses oxygen under pressure to deliver artificial ventilations through a mask placed over the patient's face, continued on next slide

148 Flow-Restricted, Oxygen-Powered Ventilation Device Use on adults only. Follow same procedures for mask seal as for BVM. Trigger device until chest rises.

149 Using Flow-Restricted, Oxygen- Powered Ventilation Device Providing ventilations with a flow-restricted, oxygen-powered ventilation device (FROPVD).

150 Automatic Transport Ventilator Provides positive pressure ventilations Can adjust ventilation rate and volume Provider must assure appropriate respiratory rate and volume for patient's size and condition.

151 Automatic Transport Ventilator An automatic transport ventilator. The coin is shown for scale. Edward T. Dickinson, MD

152 Think About It How would you decide which positive pressure delivery method to use for your patient?

153 Oxygen Therapy

154 Importance of Supplemental Oxygen Issues to consider when making decisions about oxygen administration Oxygen is a drug. Oxygen can cause harm. Oxygen should be administered based on your overall evaluation of the patient's presentation and possible underlying conditions.

155 Oxygen Therapy Equipment Portable In the field Lightweight, safe, dependable Installed Inside the ambulance

156 Oxygen Systems For safety, to prevent them from tipping over, oxygen cylinders must be placed in a horizontal position or, if upright, must be securely supported.

157 Oxygen Systems Larger cylinders are used for fixed systems on ambulances.

158 Oxygen Cylinders Come in various sizes D cylinder About 350 liters of oxygen E cylinder About 625 liters of oxygen M cylinder About 3,000 liters of oxygen continued on next slide

159 Oxygen Cylinders Come in various sizes G cylinder About 5,300 liters of oxygen H cylinder About 6,900 liters of oxygen continued on next slide

160 Oxygen Cylinders Use pressure gauges, regulators, and tubing intended for use with oxygen. Use nonferrous wrenches. Ensure valve seat inserts and gaskets are in good condition. Use medical-grade oxygen. continued on next slide

161 Oxygen Cylinders Open the valve of an oxygen cylinder fully then close it half a turn to prevent someone else from thinking the valve is closed and trying to force it open. Store reserve oxygen cylinders in cool, ventilated room, properly secured in place. Have oxygen cylinders hydrostatically tested every five years. continued on next slide

162 Oxygen Cylinders Never drop a cylinder or let it fall against any object. Never leave an oxygen cylinder standing in an upright position without being secured. Never allow smoking around oxygen equipment in use. continued on next slide

163 Oxygen Cylinders Never use oxygen equipment around open flame. Never use grease, oil, or fat-based soaps on devices that will be attached to an oxygen supply cylinder. Never use adhesive tape on a cylinder. Never try to move an oxygen cylinder by dragging it or rolling it on its side or bottom.

164 Pressure Regulators Connected to the oxygen cylinder to provide a safe working pressure of 30 to 70 psi.

165 Flowmeters Allow control of the flow of oxygen in liters per minute Low-pressure flowmeters Pressure-compensated flowmeter Constant flow selector valve High-pressure flowmeters Thumper CPR device Respirators and ventilators such as CPAP and BiPAP devices

166 Flowmeters Low-pressure flowmeters: (Left) A pressure-compensated flowmeter; (Right) a constant flow selector valve.

167 Flowmeters High-pressure flowmeter. High-pressure oxygen is delivered through hoses attached to a threaded connector.

168 Humidifiers Connected to flowmeter Provide moisture to dry oxygen from supply cylinder

169 Humidifier Humidifier in use on board an ambulance.

170 Hazards of Oxygen Therapy Common hazards of oxygen and oxygen equipment If the tank is punctured or a valve breaks off, the supply tank can become a missile. Oxygen supports combustion. Can saturate towels, sheets, clothing Oxygen and oil do not mix under pressure. continued on next slide

171 Hazards of Oxygen Therapy Rare medical situations Oxygen toxicity or air sac collapse Infant eye damage Respiratory depression or respiratory arrest

172 Administering Oxygen Work with your instructor or follow your instructor's directions to understand how to use specific equipment. Various devices available

173 Nonrebreather Mask Best way to deliver high concentrations of oxygen to a breathing patient

174 Delivery Devices: Nonrebreather Mask Nonrebreather mask. Note the round disks flutter valves that allow air exhaled by the patient to escape so it is not rebreathed.

175 Delivery Devices: Nonrebreather Mask Nonrebreather mask. Note the round disks flutter valves that allow air exhaled by the patient to escape so it is not rebreathed.

176 Nonrebreather Mask Provides oxygen concentrations of 80 to 100 percent Optimum flow rate is 12 to 15 liters per minute. A new design feature allows for one emergency port in the mask to the patient can still receive atmospheric air should the oxygen supply fail.

177 Nasal Cannula Best choice for a patient who refuses to wear an oxygen face mask

178 Delivery Devices: Nasal Cannula Nasal cannula.

179 Nasal Cannula Provides oxygen concentrations between 24 and 44 percent Oxygen is delivered to patient by two prongs that rest in patient's nostrils. Should deliver no more than 4 to 6 liters per minute

180 Partial Rebreather Mask Very similar to nonrebreather mask No one-way valve in opening to reservoir bag Delivers 40 to 60 percent oxygen at 9 10 liters per minute

181 Venturi Mask Delivers specific concentrations of oxygen by mixing oxygen with inhaled air Some have set percentage and flow rate; others have adjustable Venturi port.

182 Delivery Devices: Venturi Mask Venturi mask.

183 Delivery Devices: Venturi Mask Venturi mask.

184 Tracheostomy Mask Placed over stoma or tracheostomy tube to provide supplemental oxygen Connected to 8 to 10 liters per minute of oxygen via supply tubing

185 Delivery Devices: Tracheostomy Mask Tracheostomy mask.

186 Oxygen Administration via a Non-Rebreather Mask Video Click on the screenshot to view a video on the topic of oxygen delivery using a simple mask. Back to Directory

187 Special Considerations

188 Special Considerations Facial injuries Bleeding and swelling can disrupt movement of air. Aggressive suction and advanced airway maneuvers may be necessary. continued on next slide

189 Special Considerations Obstructions Foreign bodies can impede ventilation of patients. If unable to ventilate, always consider the possibility of obstruction. continued on next slide

190 Special Considerations Dental appliances Dentures should ordinarily be left in place during airway procedures. Partial dentures may become dislodged during an emergency. Leave a partial denture in place if possible, but be prepared to remove it if it endangers the airway.

191 Pediatric Note Hypoxia often occurs rapidly. Children burn oxygen at twice the rate of adults Accounted for by the many anatomical differences associated with airway continued on next slide

192 Pediatric Note Ventilating pediatric patients Avoid excessive pressure and volume. Use properly sized face masks. Flow-restricted, oxygen-powered ventilation devices contraindicated Use pediatric-sized nonrebreather masks and nasal cannulas. Gastric distention may impair adequate ventilations.

193 Assisting with Advanced Airway Devices

194 Assisting with Advanced Airway Devices Devices requiring direct visualization of the glottic opening (endotracheal intubation) Devices inserted "blindly," meaning without having to look into the airway to insert the device.

195 Types of Advanced Airway Devices In the BURP maneuver, press your thumb and index finger on either side of the throat over the cricoid cartilage and gently direct the throat upward and toward the patient s right. Edward T. Dickinson, MD

196 Preparing the Patient for Intubation Maximize oxygenation prior to procedure. Position patient in sniffing position. Cricoid pressure Confirmation Securing tube in place

197 Ventilating the Intubated Patient Very little movement can displace an endotracheal tube. Pay attention to resistance to ventilations; report changes. If patient is defibrillated, carefully remove bag from tube. Watch for any change in patient's mental status.

198 Assisting with a Trauma Intubation Provide manual in-line stabilization throughout procedure. Position hands to hold stabilization, but allow for movement of jaw.

199 Blind-Insertion Airway Devices Examples King LT airway Laryngeal mask airway (LMA ) Usually do not require head to be placed in sniffing position

200 In-Hospital Endotracheal Intubation Video Click on the screenshot to view a video on the subject of in-hospital endotracheal intubation. Back to Directory

201 Chapter Review

202 Chapter Review Respiratory failure is the result of inadequate breathing, breathing that is insufficient to support life. A patient in respiratory failure or respiratory arrest must receive artificial ventilations. Oxygen can be delivered to the nonbreathing patient as a supplement to artificial ventilation. continued on next slide

203 Chapter Review Oxygen can also be administered as therapy to the breathing patient whose breathing is inadequate or who is cyanotic, cool and clammy, short of breath, suffering chest pain, suffering severe injuries, or displaying an altered mental status.

204 Remember Always use proper personal protective equipment when managing an airway. Assessment of breathing must be an ongoing process. Respiratory status can change over time. Inadequate breathing requires immediate action. continued on next slide

205 Remember Positive pressure ventilations are very different than normal breathing and can have negative side effects. Select the most appropriate method of positive pressure ventilations based upon the needs of the individual. continued on next slide

206 Remember Always use appropriate safety measures when handling oxygen. Select the appropriate delivery device to provide supplemental oxygen.

207 Questions to Consider What are the signs of respiratory distress? What are the signs of respiratory failure? For BVM ventilation, what are recommended variations in technique for one or two rescuers? continued on next slide

208 Questions to Consider How does the way positive pressure ventilation moves air differ from how the body normally moves air? Describe a patient problem that would benefit from administration of oxygen and explain how to decide what oxygen delivery device should be used.

209 Critical Thinking On arrival at the emergency scene, you find an adult female patient who is semiconscious. Her respiratory rate is 7 per minute. She appears pale and slightly blue around her lips continued on next slide

210 Critical Thinking Is this patient in respiratory failure, and if so what signs and symptoms indicate this? Does this patient require artificial ventilations?