NREMT Correctly Answered Questions 2023!!!

NREMT Correctly Answered Questions 2023!!! Airway management and ventilation are... FIRST and MOST critical steps in assessment of every patient you encounter. Lower airway anatomy trachea (C-shaped rings) bronchi (main stems) bronchioles (bronchiole rings)-have unique property: stimulated by drugs alveoli (perfusion takes place)-surfactant keeps them open lung parenchyma pleura (parietal and visceral) Upper airway anatomy nose nasal cavity para-nasal sinus nasopharynx oropharynx laryngopharynx larynx Pediatric airway is different because... smaller jaw larger tongue cricoid cartilage is narrowest part of airway epiglottis is rounder and floppier respiration is... the exchange of gases between organisms and it's environment ventilation is.... the mechanical process of moving air IN and OUT of the lungs Pulmonary Circulation is... the perfusion of O2 and CO2 Diffusion... movement of gas from an area of HIGHER CONCENTRATION to area of lower concentration Diffusion transfers gases between??? LUNGS and BLOOD and BLOOD and PERIPHERAL TISSUES Normal arterial pressures oxygen(PaO2)=100 torr Carbon dioxide(PaCO2)=35-45 avg.=40 SPO2 and ETCO2 SPO2=94-100 ETCO2=40 Factors affecting O2 concentration in Blood... decreased hemoglobin concentration inadequate alveolar ventilation decreased diffusion across pulmonary membrane, when diffusion distance increases, or pulmonary membrane changes Ventilation/perfusion mismatch occurs when portion of alveoli collapses Factors affecting CO2 concentrations in Blood... Lowers CO2 levels are due to increased respiratory rates or deeper respiration or hyperventilation and Higher CO2 levels are caused by: fever, muscle exertion, shivering, or metabolic processes resulting in the formation of metabolic acids So, a pt. w/ a PaCO2 of 30 will be... ALKALOTIC thus decreasing respiratory rate... Respiratory Rate is INVOLUNTARY however can be VOLUNTARILY controlled. chemical and physical mechanisms provide involuntary impulses to correct breathing irregularities chemoreceptors are located in... carotid bodies arch of the aorta and medulla baroreceptors in carotid artery regulate BP stimulated by decreased PaCO2, increased PaCO2, and decreased PH Cerebrospinal fluid (CSF)pH primary control of respiratory center main respiratory center medulla (neurons in medulla initiate impulses that produce respiration) apneustic center assumes respiratory control if the medulla fails to initiate impluse pneumotaxic center controls respiration Stretch receptors (HERING BREUER REFLEX) prevents over expansion of the lungs Normal respiratory rates: adults: 12-20 pedi: 18-24 infant: 40-60 airway obstruction caused by: foreign bodies trauma laryngeal spasm edema aspiration MOST COMMON OBSTRUCTION: YOUR TONGUE... Respiratory system assessment: is airway patent? is breathing adequate? look, listen, feel respiratory physical exam: inspection (mouth, nose) skin color (flush, pale, blue) pt. position dyspnea modified form of respiration rate, pattern, mentation, auscultation listen at mouth and nose for adequate air movement stethoscope for normal or abnormal air movement auscultation anterior and posterior kussmaul's respirations deep slow or rapid gasping (common in DKA) cheyne-stokes respirations progressively deeper, faster, breathing and alternating gradually with shallow, slower, breathing (indication of brain stem injury) agonal respirations shallow slow or infrequent (indicating brain anoxia) disruption in ventilation caused by nervous system trauma poison over dose disease airway sounds: stridor wheezing rales rhonchi snoring crackles palpate chest wall for: tenderness symmetry abnormal motion crepitus subcutaneous emphysema monitoring devices for airway ETCO2 electronic and colormetric SPO2 esophageal detector device EDD (bulb refills easily upon release indicates correct placement of ET tube) manual airway maneuvers head tilt/chin lift modified jaw thrust (used in trauma b/c C-collar) jaw-thrust maneuver sellick's maneuver (cricoid pressure) jaw lift maneuver basic mechanical airways nasopharyngeal airway (NPA) or oropharyngeal airway (OPA)-tip facing palate & rotate 180 degrees into position advanced airway management Endotracheal intubation is performed if basic airway management is NOT effective Laryngoscope blades: Macintosh blade (vallecula) or Miller blade (lifts up the epiglottis) ET intubation indicators: cardiac arrest, respiratory arrest, unconsciousness risk aspiration or obstruction from foreign bodies trauma, burns, anaphylaxis, respiratory extremis due to disease pneumothorax, hemo-thorax, hemo-pneumothorax w/ respiratory difficulty complications ET intubation: equipment malfunction teeth breakage or soft tissue lacerations hypoxia-esophageal intubation, endo-bronchial intubation, or due to TIME tension pneumothorax advantages of ET intubation: isolates trachea and permits complete control of airway impedes gastric distention eliminates need to maintain mask seal offers direct route suctioning administration of medications disadvantages of ET intubation: considerable training and experience requires special equipment requires direct visual of vocal cords bypasses upper airway functions of warming, filtering and humidifying the air after ETT intubation: Check, Check, Check and check again... don't be a D.O.P.E. DISLODGE Obstruction Pneumo Equipment Foreign body removal with direct visualization... Magill forceps Nasotracheal intubation useful when? possible spinal injury clenched teeth fractured jaw oral injuries or recent oral surgery facial or airway swelling obesity arthritis other advanced airways: esophageal CombiTube laryngeal mask airway pharyngo-tracheal lumen airway exophageal gastric tube esophageal obturator airway (EOA) surgical airway when: inability to establish airway any other way... Jet ventilation w/ cricothrotomy-14G w/ positive pressure air delivery anatomical landmarks for cricothrotomy: between cricoid cartilage and thyroid cartilage make a 1cm horizontal incision through the cricothyroid membrane O2 delivery devices % O2 delivery: N/C- 40% simple face mask- 40%-60% NRB-80%-95% BVM w/ reservoir- 100% BVM w/o reservoir- 21% ventilation methods: mouth to mouth mouth to nose bag valve devise demand valve devise automatic transport ventilator Ventilating a patient proper tidal volume 5-10 cc/kg adult respiratory distress syndrome is what type of lung injury... CHRONIC. CHRONIC. CHRONIC... a lung injury ARDS causes: sepsis, aspiration, pneumonia, pulmonary injury, burns/inhalation injury, drugs, high altitude, hypothermia... pathophysiology of ARDS: affects interstitial fluid, causes INCREASE of fluid in interstitial space, and disrupts diffusion and perfusion.. (high mortality, by multiple organ failure) ARDS assessment: abnormal breath sounds & CRACKLES and RALES Management of ARDS: manage underlying condition, provide O2, support respiratory effort, provide PPV if respiratory failure is imminent. monitor cardiac rhythm, V/S MEDS: corticosteroids Obstructive Lung Disease: emphysema chronic bronchitis asthma (causes: genetic disposition, smoking, allergies, and other risk factors) atelectasis destruction of alveolar wall causing poor perfusion emphysema pathophysiology: exposure to noxious substances, exposure results in destruction of alveoli walls(atelectasis) causing poor perfusion weakens walls of small bronchioles and results in INCREASE RESIDUAL VOLUME loss of elasticity causes increased pressure right sided heart failure RHF failure-Cor Pulmonale Polycythemia Increased infection & Dysrhythmia emphysema assessment: Barrel chest prolonged expiration and rapid rest phase thin, pink, skin due to extra red cell production hypertrophy of accessory muscles EMPHYSEMA PINK PUFFER PUFFER SMOKERS PINK PUFFER PUFF PUFF PUFF Chronic bronchitis pathophysiology result from increase in mucus-secreting cells in respiratory tree alveoli relatively unaffected decreased alveolar ventilation Chronic bronchitis history: frequent infections productive cough smoker HAS BEEN GOING ON FOR YEARS... chronic bronchitis exam: often overweight rhonchi present on auscultation JVD, JVD, JVD ankle edema hepatic congestion "BLUE BLOATER" Bronchitis & Emphysema management: maintain airway, support breathing, monitor SpO2 position of comfort be prepared to ventilate or intubate monitor cardiac rhythm, IV access, MEDS: bronchodilators & corticosteroids asthma pathophysiology chronic inflammatory disorder results in widespread but variable air flow obstruction. airway becomes hyper responsive induced by a trigger, varies by individual trigger causes histamine release causing: bronchoconstriction and bronchial edema 6-8 hours later immune system cells invade bronchial mucosa and cause additional edema... asthma exam: dyspnea wheezing (in some NOT ALL) cough speech 1-2 consecutive words hyperinflation of chest and accessory muscle use. auscultate breath sounds and measure peak expiratory flow rate. may stop breathing b/c decreased lung capacity asthma management: correct hypoxia, reverse bronchospasm, reduce inflammation maintain airway, support breathing, high flow O2, assist ventilations, monitor cardiac rhythm, IV MEDS: BETA-AGONISTS, IPRATROPIUM BROMIDE, CORTICOSTEROIDS status asthmaticus severe prolonged asthma attack that can NOT be broken by bronchodilators, greatly diminished breath sounds, RECOGNIZE IMMINENT RESPIRATORY ARREST. AGGRESSIVELY MANAGE AIRWAY/BREATHING. transport immediately MEDS: need albuterol continuously Upper respiratory infection URI above the GLOTTIC OPENING URI frequent pt. complaint common pediatric complaint rarely life threatening Worst URI EPIGOLOTITIS Pneumonia pathophysiology infection in lungs, problem in immune suppressed pt. bacterial and viral hospital acquired vs. community acquired infection spread throughout the lungs alveoli may collapse resulting in ventilation disorder pneumonia management maintain airway, support breathing, high flow O2, assist ventilation, monitor V/S, IV access MEDS: AVOID FLUID OVERLOAD, ANTIPYRETICS, BETA-AGONISTS Toxic inhalation pathophysiology heated air, chemical irritants, steam airway obstruction due to edema and laryngospasm due to thermal and chemical burns toxic inhalation assessment: focused history and physical exam SAMPLE/OPQRST determine nature of substance, length of exposure, and LOC toxic inhalation management: SCENE SAFE FIRST... SCENE SAFE... only enter with proper training and equipment. remove pt. from toxic environment. maintain airway, early aggressive management indicated, support breathing, IV access, TRANSPORT PROMPTLY. Carbon Monoxide Inhalation Carbon Monoxide is odorless, colorless gas, results from combustion of carbon-containing compounds. Often builds up to dangerous level in confined spaces. Carbon Monoxide Inhalation pathophysiology: binds to Hemoglobin 200-300 times affinity of oxygen (way sticker) prevents O2 from binding and creates hypoxia on cellular level. Carbon Monoxide Inhalation assessment: focused history and physical exam SAMPLE/OPQRST, length of exposure presence of headache, confusion, agitation, lack of coordination, loss of consciousness, and seizures Carbon Monoxide Inhalation management: SCENE SAFE...SCENE SAFE... only enter if properly trained and with proper equipment, remove pt. from toxic environment, maintain airway, support breathing, high flow O2, assist ventilation, IV access, transport. (hyperbaric chamber) Pulmonary Embolism SpO2 in tank ETCO2 in tank pulmonary Embolism pathophysiology: obstruction pulmonary artery (typically occurs in Right Heart) emboli may be air, thrombus, fat, amniotic, foreign bodies may cause an embolus PE risk factors: recent surgery, long-bone f(x), pregnancy (pregnant or postpartum), oral contraceptive use, tobacco use, IDDM, PE PE assessment: focused history and physical exam, SAMPLE/OPQRST presence of risk factors, unexplained tachycardia, sudden severe dyspnea & pain, pain w/ inhalation and exhalation, cough, cough is often blood tinged PE exam: anxiety syncopy diaphoretic JVD hypotension warm swollen extremities PE management: maintain airway, support breathing, high flow O2, assist ventilations indicated, ETT intubation may be indicated, IV access, monitor V/S, transport to appropriate facility. spontaneous pneumothorax: occurs in the absence of blunt or penetrating trauma spontaneous pneumothorax risk factors: young, tall, skinny, lanky, males spontaneous pneumothorax assessment: focused history and physical exam, SAMPLE/OPQRST presence of risk factors, rapid onset of symptoms, sharp, pleuritic chest or shoulder pain. OFTEN precipitated by COUGH or LIFTING. spontaneous pneumothorax exam: decreased or absent breath sounds on affected side, tachypnea, diaphoresis, and pallor spontaneous pneumothorax management: maintain airway, support breathing, monitor for tension pneumothorax, pleural decompression may be indicated if patient is cyanotic, hypoxic, and difficult to ventilate. JVD and tracheal deviation away from affected side.