What are the late signs of breathing compromise?
- Tracheal deviation
- JVD
What are signs of ineffective breathing?
- AMS
- Cyanosis, especially around the mouth
- Asymmetric expansion of chest wall
- Paradoxical movement of the chest wall during inspiration and expiration
- Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing
- Sucking chest wounds
- Absent or diminished breath sounds
- Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated
- Anticipate definitive airway management to support ventilation.
Upon initial assessment, what type of oxygen should be used for a pt. breathing effectively?
- A tight-fitting nonrebreather mask at 12-15 lap.
What intervention should be done if a pt. presents with effective circulation?
- Insert 2 large caliber IV's
- Administer warmed isotonic crystalloid solution at an appropriate rate
What are signs of ineffective circulation?
- Tachycardia
- AMS
- Uncontrolled external bleeding
- Pale, cool, moist skin
- Distended or abnormally flattened external jugular veins
- Distant heart sounds
What are the interventions for Effective/Ineffective Circulation?
- Control any uncontrolled external bleeding by:
- Applying direct pressure over bleeding site
- Elevating bleeding extremity
- Applying pressure over arterial pressure points
- Using tourniquet (last resort).
- Cingulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution
- Use warmed solution
- Use pressure bags to increase speed of IVF infusion
- Use blood administration tubing for possible administration of blood
- Use rapid infusion device based on protocol
- Use NS 0.9% in same tubing as blood product
- IV = surgical cut-down, central line, or both.
, - Blood sample to determine ABO and Rh group
- IO in sternum, legs, arms or pelvis
- Administer blood products
- PASG (without interfering with fluid resuscitation)
What are factors that contribute to ineffective ventilation?
- AMS
- LOC
- Neurologic injury
- Spinal Cord Injury
- Intracranial Injury
- Blunt trauma
- Pain caused by rib fractures
- Penetrating Trauma
- Preexisting hex of respiratory diseases
- Increased age
What medications are used during intubation?
LOAD Mnemonic:
L = Lidocaine
O = Opioids
A = Atropine
D = Defasiculating agents
What are the Rapid Sequence Intubation Steps?
- PREPARATION:
- gather equipment, staffing, etc.
PREOXYGENATION:
- Use 100% O2 (prevent risk of aspiration).
PRETREATMENT:
- Decrease S/E's of intubation
PARALYSIS WITH INDUCTION:
- Pt. has LOC, then administer neuromuscular blocking agent
PROTECTION AND POSITIONING:
- Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration
PLACEMENT WITH PROOF
- Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt. 30-60
seconds between attempts.
- After intubation, inflate the cuff
- Confirm tube placement w/exhaled CO2 detector.
POSTINTUBATION MANAGEMENT:
- Secure ET tube
- Set ventilator settings
- Obtain Chest x-ray
- Continue to medicate
- Recheck VS and pulse optometry
What is a Comb tube?
, - A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to
establish an airway. If inadvertently placed into trachea, it can be used as a temporary
ET tube. There are only two sizes: small adult and larger adult.
What is a Laryngeal Mask Airway?
- Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar
at the distal end. It is designed to cover the supraglottic area.
ILMA, does not require laryngoscopy and visualization of the chords.
What is Needle Cricothyrotomy?
- Percutaneous Tran’s tracheal ventilation. (Temporary)
Complications include:
- inadequate ventilation causing hypoxia
- hematoma formation
- esophageal perforation
- aspiration
- thyroid perforation
- subcutaneous emphysema
What is Surgical Cricothyrotomy?
- Making an incision in cricothyroid membrane and placing a cuffed endow or trash tube
into trachea. This is indicated when other methods of airway management have failed
and pt. cannot be adequately ventilated and oxygenated.
Complications include:
- Aspiration
- Hemorrhage or hematoma formation or both
- Lac to trachea or esophagus
- Creation of a false passage
- Laryngeal stenosis
How do you confirm ET Tube/Alternative Airway Placement?
- Visualization of the chords
- Using bronchoscope to confirm placement
- Listening to breath sounds over the epigastrium and chest walls while ventilating the
pt.
- CO2 detector
- Esophageal detection device
- Chest x-ray
How do you inspect the chest for adequate ventilation?
- Observe:
- mental status
- RR and pattern
- chest wall symmetry
- any injuries
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