Emergency Care Textbook Professional Responders-part-6 PDF

Key Content Respiratory Pathophysiology.................. Airway Obstruction................ Respiratory Conditions........... Assisted Ventilation................ Resuscitation Devices............. Resuscitation Masks............. Bag-Valve-Mask (BVM) Resuscitators..................... Supplemental Oxygen............ Airway Adjuncts...................... Oropharyngeal Airways....... Nasopharyngeal Airways..... Supraglottic Airways............ Suction..................................... Care for Respiratory Distress................................. Care for Respiratory Arrest.... Introduction In this chapter, you will learn how to manage a patient’s airway and how to care for respiratory emergencies. Because oxygen is vital to life, you must always ensure that the patient has an open airway and is breathing effectively. Airway and respiratory problems should be apparent when you check the patient’s ABCs during your primary assessment. A respiratory emergency can occur in two ways: Respiration becomes difficult or ineffective, or respiration stops entirely. A patient who is having difficulty breathing (dyspnea) is in respiratory distress. A patient who has stopped breathing is in respiratory arrest. Airway management and ventilation can contribute significantly to the survival and recovery of a seriously ill or injured patient. A number of devices can help you maintain 106 107 115 119 121 121 123 124 131 131 134 135 136 138 138 AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES 6 Airway Management and Respiratory Emergencies 105 an open airway, perform ventilations, and/or increase the oxygen concentration in a patient’s bloodstream. In addition, some of these devices limit the potential for infection. system fails to adequately circulate oxygen-rich blood to all cells of the body. It can also be the result of cardiac arrest (often the result of a heart attack), which occurs when the heart stops functioning as a pump. RESPIRATORY PATHOPHYSIOLOGY Sometimes the rate or depth of respiration is inadequate, leading to an insufficient volume of air moving into and out of the lungs. Respiration may be ineffective due to unresponsiveness, an altered level of responsiveness, an injury to the chest, an overdose, poisoning, or diseases such as chronic obstructive pulmonary disease (COPD) or emphysema. Normal respiration uses ambient (surrounding) air, which usually contains all the necessary gases for normal respiration. For respiration to occur, there must be an open passage to the lungs, the lungs must be provided with sufficient oxygen, gas exchange must occur (providing oxygen to the circulatory system), and the lungs must inflate and deflate with an effective rhythm. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Respiratory emergencies can have many causes: Damage to the respiratory system can be caused by trauma or inhaled toxins, a lowoxygen environment can deprive the body’s system of oxygen, an airway obstruction can physically prevent inhalation and exhalation, and neurological injuries or conditions can prevent the lungs from functioning properly. 106 Other causes of respiratory emergencies include poor circulation, infection of the lungs, and excess fluid in the lungs or between the lungs and the blood vessels. In addition, illnesses like asthma can narrow the airway and cause wheezing. If an insufficient amount of oxygen is delivered to the cells, this is referred to as hypoxia, and it may result from an obstructed airway, shock, inadequate breathing, drowning, strangulation, choking, suffocation, cardiac arrest, head trauma, carbon monoxide poisoning, or complications of general anesthesia. Signs and Symptoms of Respiratory Emergencies The signs and symptoms of respiratory emergencies are usually obvious. Patients who are experiencing dyspnea may appear as if they cannot catch their breath, or they may gasp for air (Figure 6–1). Their respiration may be unusually fast, slow, deep, or shallow. They may make unusual noises, such as wheezing, gurgling, or shrill high-pitched sounds. Breathing difficulties may also develop due to upper-airway problems caused by swelling, foreign bodies, or trauma. Swelling of the upper airway can occur due to anaphylaxis (a severe allergic reaction), asthma, or inhalation of hot gases (e.g., in a fire). An airway obstruction (choking) is one of the most common causes of respiratory emergencies. Trauma can occur due to a blow to the upper chest, a puncture, or a crush injury. Breathing problems may also develop because of ineffective circulation. This can be the result of shock, an acute condition in which the circulatory Figure 6–1: Patients with respiratory emergencies may look as if they cannot catch their breath, or they may gasp for air. Because the circulatory system and respiratory system are interconnected, signs of circulatory impairment can indicate a respiratory emergency as well. For example, the patient may feel dizzy or lightheaded, or experience chest pain or tingling in the hands and feet. The patient may also be apprehensive or fearful. Any of these symptoms can indicate a respiratory emergency (Figure 6–2). Table 6–1 lists the signs and symptoms of respiratory emergencies. TABLE 6–1: SIGNS AND SYMPTOMS OF RESPIRATORY EMERGENCIES EXAMPLE Dyspnea Patient has laboured breathing, struggles to breathe, or gasps for breath Abnormal breathing sounds Patient is wheezing, gurgling, or making high-pitched noises Abnormal respiratory rate Patient’s respiration is too fast or too slow Abnormal skin characteristics Skin is unusually moist and/or has an unusual tone Emotional effects Patient is restless or anxious Neurological effects Patient is dizzy or lightheaded and/or experiences pain or tingling in the extremities Patient position Patient is in an unusual position (e.g., tripod position) Figure 6–2: There are many signs and symptoms of respiratory emergencies. AIRWAY OBSTRUCTION There are two types of airway obstruction: 1. Anatomical airway obstruction 2. Foreign-body airway obstruction If you determine that an unresponsive patient has a pulse but is not breathing, this could indicate one of two situations: Either the patient’s airway is completely obstructed, or the patient’s airway is clear but he or she is in respiratory arrest. To determine whether the airway is obstructed, open the airway and attempt to ventilate. If your ventilation goes in, the patient’s airway is clear. Give a second ventilation and begin care for respiratory arrest. Anatomical obstructions occur when the airway is blocked by an anatomical structure, such as the tongue or swollen tissues of the mouth and throat. This type of obstruction may result from injury to the neck or a medical emergency such as anaphylaxis. The most common obstruction in an unresponsive patient is the tongue, which may drop to the back of the throat and block the airway. This occurs because muscles, including the tongue, relax when deprived of oxygen. If the patient’s chest does not rise after the first ventilation, tilt the head back farther to ensure that the airway is not occluded, and attempt to give another ventilation. If the second ventilation does not enter the lungs, this indicates that the airway is completely obstructed. Foreign-body airway obstructions (FBAO) occur when the airway is blocked by a foreign object, such as a piece of food or small toy, or by fluids such as vomit, blood, mucus, or saliva. This may also be referred to as a mechanical obstruction. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES TYPE 107 Common causes of FBAO include: Trying to swallow large pieces of poorly chewed food. Drinking alcohol before or during meals (alcohol dulls the nerves that aid swallowing, making choking on food more likely). Wearing dentures (dentures make it difficult to sense whether food has been fully chewed before swallowing). Laughing or talking while eating. Eating too quickly. Walking, playing, or running with food or objects in the mouth. An airway obstruction can be either partial or complete. As a natural reaction to choking, the patient may clutch at the throat with one or both hands. Partial Airway Obstruction AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES A patient with a partial airway obstruction can still have good air entry. The amount of air entering the lungs depends on the severity of the obstruction. This air allows the patient to cough in an attempt to dislodge the object. The narrowed airway may cause a wheezing sound as air moves in and out of the lungs. 108 Have the patient cough forcefully. Usually the patient’s coughing will clear the object without the need for interventions. Coughing is usually more effective when the patient is in a seated position and leaning forward slightly. Sitting down also reduces the risk of injury if the patient becomes unresponsive. Partial choking can cause a great deal of anxiety, which can aggravate an underlying condition such as angina or asthma. Monitor the patient closely. Complete Airway Obstruction A partial airway obstruction can quickly progress to a complete airway obstruction. A patient with a completely obstructed airway is unable to speak, breathe, or cough effectively, though he or she may cough weakly or make high-pitched noises. A complete airway obstruction essentially prevents respiration. The patient will not be able to breathe, cough, or speak, and will quickly lose responsiveness and asphyxiate without intervention. You must be able to recognize that the airway is obstructed and provide immediate interventions. This is why checking the airway comes first in the ABCs of the primary assessment. Although a complete airway obstruction may be caused by either a foreign body or the patient’s own anatomy, this can be difficult to determine. The interventions for both responsive and unresponsive patients with airway obstructions are primarily effective for FBAO, but these interventions should be attempted even if you are unsure whether the obstruction is anatomical or FBAO. There are fewer interventions available for anatomical obstructions. In some cases, tilting the patient’s head back farther can be sufficient to clear the occlusion from the airway (e.g., the tongue). Other anatomical obstructions (such as swelling in the airway) typically require you to request additional resources, such as personnel trained in advanced life-support. Foreign Body Airway Obstruction Intervention If the patient has a complete FBAO, you must try to open the airway as quickly as possible. This is done by creating pressure in the thoracic cavity to push the obstruction up and out of the airway. The specific interventions you use depend on whether the patient is responsive or unresponsive and can also be affected by other factors (if the patient is pregnant, for example). There are also some variations necessary when you are providing care for an infant. CARE FOR A FOREIGN-BODY AIRWAY OBSTRUCTION—RESPONSIVE ADULT OR CHILD There are three interventions appropriate for removing a foreign body airway obstruction in a responsive adult or child: back blows, abdominal thrusts, and chest thrusts. More than one of these methods is usually necessary, and all three have proven to be effective. You should alternate between at least two of these options, choosing the methods that seem most suitable for the situation (Figure 6–3, a-b). Regardless of the methods you choose, you should perform the first method up to five times, checking after each one to see whether the object has been dislodged. If the obstruction is not cleared after five attempts, switch to the other selected method and try it up to five times, checking after each attempt. Continue to alternate until either the foreign body is dislodged and the patient begins to cough or breathe or the patient becomes unresponsive. For example, you might perform five back blows, then five chest thrusts, then five back blows, and so on. a If the patient becomes unresponsive, he or she will collapse to the ground. Attempting to support the patient’s full weight unexpectedly can result in injury to you, so focus instead on protecting the head and neck as much as possible as the patient collapses. Begin care for an unresponsive patient. If the patient is in a wheelchair, lock the wheels before providing care. Giving back blows creates pressure in the thoracic cavity that can help to dislodge an obstruction. To perform a back blow, stand behind the patient and ensure that your stance is stable. Standing slightly to one side can make your blows more effective. Wrap one arm around the patient’s chest and bend the patient forward at the waist until the upper airway is at least parallel to the ground. If the patient is a small child, it can be more effective to kneel on the floor with one knee raised and bend the child across your raised knee. With the heel of your other hand, deliver 5 firm blows between the shoulder blades, checking after each one to see if the obstruction has cleared. b Figure 6–3, a-b: To care for a responsive choking adult, alternate between two methods—for example: a, abdominal thrusts; and b, back blows—until the obstruction has cleared. Abdominal Thrusts Abdominal thrusts compress the patient’s abdomen, increasing pressure in the lungs and airway. This simulates a cough, forcing trapped air in the lungs to dislodge the object from the airway. Abdominal thrusts are a good default choice for most patients, but they may be difficult with bariatric (obese) patients. They are not suitable for pregnant women. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Back Blows 109 To perform an abdominal thrust, stand behind the patient and ensure that your stance is stable. If the patient is significantly shorter than you are, it may be more effective to kneel. Make a fist and place it thumb-side-in against the patient’s abdomen, just above the navel and well below the lower tip of the sternum. Grasp your fist with your other hand and give up to 5 quick upward thrusts into the abdomen, checking after each one to see if the obstruction has been cleared. Chest Thrusts Chest thrusts are similar to abdominal thrusts except that they compress the chest rather than the abdomen to create pressure in the lungs and airway. They are recommended for pregnant women. They can also be useful in situations where you cannot effectively reach around a patient’s abdomen. To perform a chest thrust, stand behind the patient and ensure that your stance is stable. Make a fist and place it thumb-side-in against the patient’s sternum. Grasp your fist with your other hand and perform up to 5 quick thrusts, pulling directly back towards you with each one and checking after each thrust to see if the object has been dislodged. If your initial thrusts are ineffective, pull more sharply and deeply. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES CARE FOR A FOREIGN-BODY AIRWAY OBSTRUCTION—UNRESPONSIVE ADULT OR CHILD 110 The methods used to remove a foreign-body airway obstruction from a responsive patient are not effective for an unresponsive patient. Instead, you must perform sets of 30 chest compressions as in the CPR procedure (Figure 6–4). Figure 6–4: Chest compressions for an unresponsive choking adult or child are done just as they are in CPR. your first breath does not go in, reposition the head and attempt to give a second breath. If it does not go in, resume the CPR sequence, starting with 30 chest compressions. Tilting the patient’s head back farther is only necessary on your initial attempt: On consecutive cycles, simply attempt one breath and then resume compressions if it does not go in. Repeat this sequence until either the airway is clear or you transfer care of the patient to appropriately qualified personnel. If your ventilations cause the chest to rise, the obstruction is clear. The patient may still be in respiratory distress or arrest, so reassess and provide care according to what you find. After performing each set of 30 chest compressions, look inside the patient’s mouth. If you see an object, carefully remove it. To do so, grasp the tongue and lower jaw and lift, then sweep the object out using a finger sweep (Figure 6–5). Place your finger only as far into the patient’s airway as you can see. After looking in the mouth, or after removing an object, open the airway and attempt to ventilate. If your breath goes in, give a second breath. If Figure 6–5: To do a finger sweep, grasp the tongue and lower jaw and lift, then sweep the object out. The procedure for caring for an unresponsive patient with absent breathing is represented in Figure 6–6. CARE FOR A FOREIGN-BODY AIRWAY OBSTRUCTION—RESPONSIVE INFANT Care for a responsive infant with a foreign-body airway obstruction consists of alternating sets of back blows and modified chest thrusts. It is preferable to sit or kneel with the infant while performing these interventions, but the technique presented here can be performed while standing if necessary. Position the infant’s body supine on your forearm with the head supported in your hand. Place your other forearm over the infant’s midline, sandwiching the infant between your forearms. Place the thumb of your top hand at the angle of the infant’s lower jaw, and one or two fingers from the same hand at the same point on the opposite side of the infant’s jaw. Be careful not to compress the soft tissues under the chin. Next, turn the infant over so that he or she is prone, and position the infant across your thigh so that the head is lower than the chest (Figure 6–7, a). This allows gravity to assist in dislodging the foreign body. Give up to 5 firm back blows with the heel of your hand (Figure 6–7, b). The blows should be delivered directly between the shoulder blades and should not glance off. Check after each blow whether the foreign body has been dislodged: Your goal is to dislodge the object with the smallest number of blows. Continue to support the head and neck as you deliver the blows by holding the infant’s jaw firmly between your thumb and forefinger. Unresponsive Patient with Absent Breathing Primary Assessment (ABCs) CARDIAC ARREST Respiration absent Pulse present Respiration absent Pulse absent Begin CPR/AED protocol, starting with compressions Attempt 2 ventilations (If 1st doesn’t enter, reposition the head) RESPIRATORY ARREST Begin care (continue airway management and monitor pulse) Ventilation unsuccessful AIRWAY OBSTRUCTION Perform one set of CPR chest compressions, then check for object in mouth. If object is found, carefully remove, and visually confirm that mouth is clear. Attempt 1 ventilation Ventilation successful Give 2nd ventilation Respiration absent Reassess patient’s ABCs (simultaneously) Respiration present Pulse absent UNRESPONSIVENESS Continuously monitor patient and provide ongoing patient care Consider causes of unresponsiveness Figure 6–6: Care for a foreign-body airway obstruction—unresponsive adult or child. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Ventilation successful 111 If you have given five back blows and the airway is still obstructed, you will need to turn the infant supine and deliver up to 5 chest thrusts. Sandwich the infant between your hands and forearms as before. Continue to support the head between your thumb and fingers from the front while you cradle the back of the head with your other hand. a Keep alternating between back blows and chest thrusts until either the object is dislodged and the infant begins to breathe, cough, or cry, or the infant becomes unresponsive. Even if the infant seems to be breathing well, he or she should be examined by more advanced medical personnel. CARE FOR A FOREIGN-BODY AIRWAY OBSTRUCTION—UNRESPONSIVE INFANT Begin by performing 30 chest compressions, as in the CPR protocol. Next, visually inspect the mouth: Open the infant’s mouth using the hand that is nearer to the infant’s feet (Figure 6–9). Place your thumb on the lower teeth and gently open the mouth. If you can see an object, try to remove it by picking it out with your little finger and thumb (Figure 6–10). Because infants’ soft palates are very susceptible to injury, you must use caution to avoid causing damage. Do not use a finger sweep to remove an object from an infant’s mouth. Open the airway and attempt to ventilate. If your breath goes in, give a second breath. If the infant’s chest does not rise after the first breath, reposition the head to adjust the airway and attempt to give another breath. If you still cannot breathe air into the infant’s lungs, repeat the set of compressions, then look inside the infant’s mouth for a foreign object. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES b 112 Figure 6–7, a-b: To care for a responsive choking infant: Sandwich the infant between your forearms; a, turn the infant prone along your forearm on your lap; and b, give up to 5 firm back blows with the heel of your hand between the shoulder blades. Repeat this sequence until either the airway is clear or you transfer care of the patient to appropriately qualified personnel. Turn the infant supine. The head should be lower than the chest. Locate the correct place to give chest thrusts by placing two fingers on the sternum just below the nipple line. Use the pads of these two fingers to compress the sternum to approximately one-third the depth of the chest, and then let it return to its normal position. Keep your fingers in contact with the infant’s sternum (allowing full recoil after each compression). Compress up to 5 times, checking after each compression whether the foreign body has been removed (Figure 6–8). Figure 6–8: After giving 5 back blows, turn the infant supine, lower your arm onto your thigh, and give up to 5 chest thrusts. WHEN THE OBSTRUCTION IS CLEARED Once the airway is clear, reassess the patient’s ABCs. The patient may require additional interventions for conditions such as respiratory distress or cardiac arrest. In addition to injuries caused by the foreign body itself, interventions that clear the airway, such as back blows and chest thrusts, can result in trauma. Therefore, any patient who has received interventions for an obstructed airway should be referred to a physician for examination as soon as possible. Anaphylaxis Figure 6–10: If you see an object, carefully pick it out with your thumb and little finger. Anaphylaxis, also known as anaphylactic shock, is a life-threatening allergic reaction that causes the air passages to constrict. Anaphylaxis is caused by an extreme allergy to a substance such as a particular food, medication, or insect venom. A person may have an anaphylactic reaction to a substance on one occasion and a mild allergic reaction on another. Anaphylaxis usually occurs suddenly, within seconds or minutes of contact with the substance, though it may occur 30 minutes or more after exposure. Parts of the body that come into contact with the substance usually swell and redden (Figure 6–12). The patient may also feel dizzy, confused, distressed, or faint. Other signs and symptoms include hives, itching, rash, weakness, After you have repositioned the head and attempted to give a second breath once, you do not need to repeat the repositioning step between chest-compression cycles. OBSTRUCTED AIRWAY SELF-RESCUE If you are alone and you are choking, dial EMS/9-1-1 and leave the phone off the hook. This will tell the dispatcher to send help. If there are people nearby, move to a place where they will notice you. Try to dislodge the obstruction by performing abdominal thrusts on a safe object with no sharp edges or corners, such as the back of a chair (Figure 6–11). Figure 6–11: To give yourself abdominal thrusts, press your abdomen onto a firm object, such as the back of a chair. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Figure 6–9: Place your thumb on the lower teeth and gently open the infant’s mouth. 113 If the patient has an epinephrine auto-injector, assist him or her in using it. If it is within your scope of practice, or covered by medical direction, you may be able to administer the epinephrine yourself after checking the Six Rights of Medication as described in Chapter 22. Because epinephrine does not correct the underlying condition, any patient experiencing anaphylaxis requires immediate transport to a medical facility, even if he or she injects epinephrine. HOW TO USE AN EPINEPHRINE AUTO-INJECTOR Figure 6–12: A patient in anaphylaxis may have many signs and symptoms, including swelling of the face. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES nausea, vomiting, and respiratory difficulties, such as coughing, wheezing, and tightness in the chest and throat. These respiratory issues can progress to an obstructed airway as the tongue and throat swell. 114 If an unusual inflammation or rash is noticeable after contact with a possible allergen, it could be an allergic reaction. Assess the patient’s airway and breathing. If the patient is experiencing respiratory distress or complains that his or her throat is closing, you should suspect anaphylaxis. Help the patient into the most comfortable position for breathing. Monitor the ABCs and try to keep the patient calm. Patients who know they are extremely allergic to certain substances usually try to avoid them, although this is sometimes impossible. Some patients may carry an epinephrine auto-injector in case they have a severe allergic reaction (Figure 6–13). The injector contains the drug epinephrine hydrochloride, which slows the harmful effects of anaphylactic reactions by constricting blood vessels (reducing swelling) and increasing heart rate (reducing the risk of cardiovascular collapse). It can also prevent the release of additional histamines, reducing the effects of the allergen on the body. After checking the Six Rights of Medications (Chapter 22), remove the safety cap from the injector (being careful to avoid needle injuries). Position the injection tip against the patient’s quadriceps muscle in the centre of the outer thigh, and push it firmly against the thigh with a quick motion. You should hear a click. Hold the auto-injector in place as directed, usually for approximately 10 seconds, to allow the complete dose to be administered. Remove the auto-injector and rub the injection site for approximately 30 seconds to help with medication absorption. Ensure that the used epinephrine auto-injector is transported with the patient to the hospital in a rigid sharps container. If a patient does not improve within 5 minutes of the initial dose of epinephrine, a second dose may be indicated. Remember that epinephrine auto-injectors are needles: Follow your sharps protocol to avoid injury or infection. Oral antihistamines can also help to counteract the effects of the reaction, especially if taken soon after the onset of symptoms. Figure 6–13: An epinephrine auto-injector. Chronic Obstructive Pulmonary Disease Chronic obstructive pulmonary disease (COPD) is a condition of the airways that is characterized by a loss of lung function. This disease affects both men and women. The average Canadian with COPD is 65 years old and has a long history of smoking. However, the disease has also been diagnosed in individuals as young as 40 years of age. The general term COPD encompasses three clinical conditions: Emphysema Chronic bronchitis Bronchospasm A person with COPD may have all of these conditions, but in each particular patient, one of the three is usually most evident. Patients diagnosed with COPD may get colds or the flu more frequently, and they also experience shortness of breath under conditions that do not tax most healthy people. Signs and symptoms of COPD include: Shortness of breath, gasping for air with sudden onset. Sitting upright, leaning forward. A barrel-chested appearance. Coarse rattling sounds in the lungs. Distended neck veins. Cyanosis. Prolonged exhalation through pursed lips. The presence of an oxygen system in a patient’s residence. EMPHYSEMA Emphysema is a disease in which the alveoli lose their elasticity and become distended with trapped air. This results in the lungs losing their ability to efficiently exchange carbon dioxide and oxygen. Emphysema is often caused by smoking and usually develops over many years. Emphysema can worsen over time. Patients with emphysema suffer from shortness of breath. As the total number of functional alveoli decreases, breathing becomes more difficult. Exhalations are often more difficult than inhalations. Patients may cough and may have cyanosis or fever. In advanced cases, patients may become restless, confused, and weak, and can go into respiratory or cardiac arrest. CHRONIC BRONCHITIS Bronchitis is the general term for inflammation of the bronchial tubes. The inflammation results in excessive mucous secretions in the bronchial tubes, constricting smaller air passageways and making respiration more difficult. Patients with bronchitis suffer from shortness of breath and the presence of a cough with sputum. Bronchitis can be either acute or chronic. Acute bronchitis is most often the result of infection and usually improves in a few days without any chronic effects. Chronic bronchitis is often caused by prolonged exposure to irritants (most commonly, cigarette smoke). Chronic bronchitis is characterized by a productive cough that has persisted for at least 3 months per year over 2 consecutive years. There may also be narrowing of bronchi and bronchioles, making it more difficult for air to move in and out of the lungs. BRONCHOSPASM Bronchospasm is a condition that affects the terminal bronchioles, the portion immediately before the alveoli. In a patient with chronic bronchospasm, these small airways can swell and become filled with fluid, and the muscles surrounding the tubes can contract, further narrowing the respiratory passages. Patients with bronchospasm present primarily with shortness of breath and wheezing. Patients with COPD may eventually develop a hypoxic drive to breathe. In healthy individuals, the drive to breathe is determined by the amount of carbon dioxide in the blood: When carbon dioxide levels rise, the brain tells the body to take in more oxygen to compensate. Patients with AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES RESPIRATORY CONDITIONS 115 COPD can maintain high levels of carbon dioxide in the blood for extended periods of time. Due to these consistently high levels, the body looks to the oxygen levels instead to determine the need to breathe. If oxygen levels are low, the respiratory rate increases. Patients with COPD who are not acutely short of breath are usually receiving low concentrations of oxygen from a home oxygen unit. In a patient with COPD who has a true hypoxic drive, increased levels of oxygen could signal the body to slow down or stop breathing entirely. However, this is rarely encountered in the field because EMS is usually called for a patient who is acutely short of breath. If you do encounter this, you should administer high-flow oxygen to the patient. Acute Respiratory Distress Syndrome AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Acute respiratory distress syndrome (ARDS) is a serious lung disease caused by a variety of direct and indirect conditions. It often occurs in patients with other serious illnesses of the lungs or who have suffered significant chest trauma. 116 ARDS occurs when the quantity of fluid between the alveolar membrane and the surrounding pulmonary capillaries increases, causing a decrease in the amount of oxygen that the red blood cells can absorb. Patients with a history of injury or illness involving the lungs are at a higher risk of ARDS. When caused by trauma, ARDS can develop within hours or days of the injury. Signs and symptoms of ARDS include: Rapid breathing (tachypnea). Shortness of breath. Cyanosis (mottled, bluish skin). Possible pulmonary edema. Asthma Asthma is a condition that narrows the air passages and makes breathing difficult. During an asthma attack, the air passages become constricted or narrowed by a spasm of the muscles lining the bronchi or by a swelling of the bronchi themselves. People may become anxious or frightened because breathing is difficult. Asthma is most common in children and young adults. It may be triggered by an allergic reaction to food, pollen, a drug, or an insect sting. It may also be triggered by emotional distress, cold weather, or physical activity. Normally, patients with asthma are able to easily control their attacks with medication. These medications stop the muscles from spasming, opening the airway and making respiration easier. A characteristic sign of asthma is wheezing during exhalations. This is due to the constriction of the air passages, which also traps air in the lungs. This trapped air may also make the patient’s chest appear larger than normal, particularly in small children. If the patient has a prescription for a metereddose inhaler (puffer), you can provide assistance. A metered-dose inhaler may or may not be used with a spacer and/or a mask (Figure 6–14). HOW TO HELP SOMEONE USE A METERED-DOSE INHALER When assisting a patient, follow these steps: 1. Check the Six Rights of Medication before proceeding. 2. Tell the patient to shake the inhaler three or four times. 3. Help the patient remove the cap from the inhaler. 4. Tell the patient to breathe out, away from the inhaler. 5. Have the person bring the inhaler to the mouth. Help to put the mouthpiece between the patient’s teeth and then tell patient to close his or her lips around it. 6. Tell the patient to press the top of the inhaler once while taking one slow, full breath in. If the patient is unable to press the top, you may do it instead if the patient asks you to. 7. Have the patient hold the breath for as long as comfortable (up to 10 seconds) and then exhale. HOW TO HELP SOMEONE USE A METERED-DOSE INHALER WITH A SPACER When assisting a patient, follow these steps: 1. Check the Six Rights of Medication before proceeding. 2. Tell the patient to shake the inhaler three or four times. 3. Have the patient remove the cap from the inhaler (and spacer, if applicable). 4. Have the patient put the inhaler into the spacer. 5. Tell the patient to breathe out, away from the spacer. 6. Have the patient bring the spacer to the mouth. 7. Tell the patient to press the top of the inhaler once while taking one slow, full breath in (Figure 6–15). If the patient is unable to press the top, you may do it instead if the patient asks you to. 8. Have the patient hold the breath for as long as comfortable (up to 10 seconds) and then exhale. Figure 6–14: Examples of metered-dose inhalers, spacer, and masks. NEBULIZATION Figure 6–15: An inhaler with a spacer. Typically, bronchodilators are indicated for patients with acute shortness of breath. Bronchodilators relax the bronchial muscles, making them smooth, which improves airflow during inhalation and exhalation. © iStockphoto.com/Gordana Joanovic Because aerosolized medication can travel through the air, additional PPE is required to protect responders from being exposed. In addition to gloves and eye protection, the responder should wear an N95 mask throughout the entire nebulization procedure. Figure 6–16: Nebulizers are common for children under the age of 5. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES A small-volume nebulizer is a special mask designed to administer aerosolized (mist) medication. It allows medication to be delivered to the smaller airways by converting it from a liquid form to an aerosol by forcing oxygen through it at a high velocity. Smaller particles penetrate deeper into the lungs to reach target sites in the smaller airways. Nebulization increases the efficacy of drug delivery even if the patient is not breathing effectively. Nebulizers are common for children under the age of 5, those who have difficulty using inhalers, and those with severe asthma (Figure 6–16). 117 Pneumonia Pneumonia is a term used to describe a group of illnesses characterized by lung infection and fluid- or pus-filled alveoli that results in hypoxia. Pneumonia is usually caused by bacteria or a virus, but it can also be caused by irritants, such as smoke, or aspirated materials, such as vomit. Patients with pneumonia may complain of fever and chills. Signs and symptoms of pneumonia include: Difficulty breathing (dyspnea). Rapid breathing (tachypnea). Pleuritic chest pain, which usually worsens while breathing. Productive cough with pus in the sputum or mucus. Fever, usually exceeding 38°C (100°F). Chills. Patients suffering from pneumonia may also display other symptoms, such as: Nausea. Tiredness. Vomiting. Muscle aches. Headache. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Acute Pulmonary Edema 118 Pulmonary edema can be caused by heart or lung damage. For example, a number of heart disorders (e.g., heart attack, left-sided heart failure, dysrhythmias) can cause fluid to back up in the blood vessels that carry blood away from the lungs to the heart (pulmonary veins). As a result of a buildup of pressure in these veins, excess fluid leaks out into the alveoli. As the fluid builds up in the lungs, the amount of oxygen entering the blood also decreases (Figure 6–17). Congestive heart failure (CHF) is the most common condition to cause pulmonary edema. However, other causes include pneumonia, smoke or toxin inhalation, narcotic overdose, drowning, and high-altitude illness. You may find patients with pulmonary edema sitting upright and leaning forward. If you find a patient lying down, instruct him or her to sit up and dangle his or her legs to encourage fluid to pool in the legs. In some cases, you may need to assist the patient’s ventilations. Figure 6–17: Pulmonary edema is a buildup of fluid in the lungs. Signs and symptoms of pulmonary edema are: Shortness of breath with sudden onset. Rapid, laboured breathing. Cyanosis. Restlessness. Anxiety. Exhaustion. Rapid pulse (tachycardia). Cool, clammy skin. Frothy sputum (in the later stages). Pulmonary Embolism Pulmonary embolism is caused by a blockage (embolus) of a pulmonary artery by a clot or other foreign material that has travelled from another part of the circulatory system (Figure 6–18). It is a common disorder that usually begins as a venous disease. It is most often caused by a blood clot (thrombus) breaking free in the large veins of the lower extremities, but it can also be caused by fat, air, amniotic fluid, or tumour tissue. The embolus flows through the right side of the heart and into a pulmonary artery, obstructing the blood supply to the part of the lung served by the artery. An embolus may range in size from small to massive; therefore, the signs and symptoms vary and depend on the location and size of the blockage. The signs and symptoms of a pulmonary embolism may include: Shortness of breath. Coughing. Pain. ASSISTED VENTILATION Assisted ventilation is a technique for delivering atmospheric air and/or oxygen into a patient’s lungs when his or her breathing is inadequate. When performing assisted ventilation, you are actively pushing air into the patient’s lungs, not just supplying it for the patient to inhale. Anxiety. Fainting (syncope). A sudden reduction in blood pressure (hypotension). Cool, clammy skin. Rapid pulse (tachycardia). Fever. Distended neck vein. If you suspect a patient has a pulmonary embolism, have him or her rest in a comfortable position. Definitive care requires hospitalization and thrombolytic or heparin therapy. Hyperventilation Hyperventilation is a condition in which a person’s respiration rate is significantly higher than usual. This rapid breathing (tachypnea) upsets the body’s balance of oxygen and carbon dioxide. Hyperventilation is often the result of fear or anxiety and is more likely to occur in patients who are tense and nervous. It can also be caused by injuries, such as head trauma, by a hemorrhage, or by conditions such as high fever, heart failure, lung disease, or diabetic emergencies. It can also be triggered by asthma or exercise. The characteristic sign of hyperventilation is shallow, rapid breathing. Despite their efforts, patients often report that they cannot get enough air or that they are suffocating. Therefore, they are often fearful and apprehensive or may appear confused. They may say they feel dizzy or that their fingers and toes feel numb or tingly. The most common devices used for assisted ventilation are the resuscitation mask and the bagvalve-mask (BVM) resuscitator. The best practice is to use supplemental oxygen in conjunction with your ventilation device, though atmospheric air can also be effective if supplemental oxygen is unavailable. While ventilating a patient, maintain an open airway using the head-tilt/chin-lift or jaw thrust manoeuvre. Always provide an appropriate tidal volume for the patient: The amount of air given in each ventilation should be comparable to that of one normal breath. Watch the patient’s chest. You should see it begin to rise with each ventilation (Figure 6–19). If it does not, the patient’s airway may be obstructed. If re-tilting the patient’s head Figure 6–19: When giving assisted ventilation, provide just enough air to make the chest start to rise. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Figure 6–18: Pulmonary embolism is caused by a blockage (embolus) of a pulmonary artery. Assisted ventilation is indicated for patients who are in respiratory arrest or who require assistance regulating their respiratory rates. A respiratory rate lower than 10 breaths per minute or higher than 30 breaths per minute indicates a need for assisted ventilation. 119 does not open the airway, obstructed airway interventions will be necessary before ventilations can be effective. Your goal is to reproduce the natural respiratory rate of the patient. Provide 1 ventilation every 5 to 6 seconds for an adult and every 3 to 5 seconds for a child or an infant. If the patient is breathing too slowly (bradypnea), provide one ventilation as the patient inhales and a second ventilation in between the patient’s breaths, maintaining the natural respiratory rate (every 5 to 6 seconds for an adult and every 3 to 5 seconds for a child or an infant). If the patient is breathing too quickly (tachypnea), provide one ventilation on every second inhalation, trying again to maintain a steady rate that mirrors the patient’s natural respiratory rate. If the patient is responsive, he or she may resist the ventilations or even begin to panic. Try to calm and reassure the person and explain what you are doing. Providing supplemental oxygen can help to reduce anxiety caused by hypoxia. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Because ventilations are given through a mask that covers the patient’s mouth and nose, the procedure is the same even if the patient’s mouth is compromised. Your ventilations will enter the lungs through the nasal passages. 120 In some cases, assisted ventilation will cause a patient to spontaneously resume a normal respiratory rate, even if that patient was initially in respiratory arrest. Otherwise, the ventilations will maintain a steady supply of oxygen to the patient’s lungs until additional interventions can be performed. aspirated (inhaled), impairing breathing and creating the risk of an airway obstruction. If the patient vomits, you must clear the airway immediately (see Suction on page 136). There are several reasons why gastric distension may occur. First, overinflating the lungs by providing too much air in a ventilation may cause the extra air to enter the stomach. Second, ventilations that are given with too much force (aggressive ventilations) can also force air into the stomach. If the patient’s head is not tilted back adequately, the airway will not open completely and the chest may only rise slightly when you ventilate normally. This can lead you to provide ventilations with more force. Third, if your ventilation rate is too high, pressure can build up in the airway and cause air to enter the stomach. To avoid forcing air into the stomach, be sure to keep the patient’s head tilted to an appropriate angle. Give ventilations with just enough volume to make the chest start to rise and maintain a steady rhythm of 1 breath every 5 to 6 seconds (every 3 to 5 seconds for infants and children). MOUTH-TO-STOMA BREATHING Some patients have had an operation to remove all or part of the larynx. They breathe through an opening in the front of the neck called a stoma (Figure 6–20). Air passes directly into the trachea through the stoma instead of through the mouth and nose. Special Considerations for Assisted Ventilation AIR IN THE STOMACH When you perform assisted ventilation, air normally enters the patient’s lungs, but sometimes air may enter the patient’s stomach instead. Air in the stomach is called gastric distension. Gastric distension can be a serious problem because it can cause a patient to vomit. When an unresponsive patient vomits, the stomach contents can be Figure 6–20: A stoma is an opening in the front of the neck that someone breathes through. When assessing the patient’s breathing, put the side of your face over the stoma rather than the mouth and nose. For ventilations, place the mask directly over the stoma and ensure that there is a good seal on the neck. It may be easier to create the seal if you use an infant- or child-sized mask. Otherwise, provide ventilations as usual (Figure 6–21). If the chest does not rise when you give ventilations, this may indicate that the patient has had only part of the larynx removed. This means that some air continues to flow through the larynx to the lungs during normal breathing. When providing ventilations into the stoma, air may leak through the nose and mouth, diminishing the amount that reaches the lungs. If this occurs, seal the nose and mouth with your hand to prevent air from escaping. PATIENTS WITH DENTURES Dentures help with assisted ventilation by supporting the patient’s mouth and cheeks. If the dentures are loose, the head-tilt/chin-lift may help keep them in place. Remove the dentures only if they become so loose that they obstruct the airway or make it difficult to provide ventilations. Figure 6–21: When giving rescue breaths to a patient with a stoma, breathe directly into the stoma. They are easy to use, especially compared to using a BVM without a partner, and are small enough to be carried on your person. Resuscitation masks can be susceptible to damage: Small parts such as the valves can detach and become lost. If stored for long periods in a collapsed state, the mask can crack or split. RESUSCITATION DEVICES Resuscitation devices are used when providing assisted ventilation for a patient in respiratory distress or arrest. They are also a form of barrier protection, reducing the risk of direct contact between the patient and the responder. An effective resuscitation mask should meet the following criteria (Figure 6–22): It should be made of a transparent, pliable material that allows you to form a tight seal on the patient’s face. It should have a one-way valve for redirecting a patient’s exhaled air. Resuscitation Masks One of the simplest and most readily available ventilation devices is the resuscitation mask. Resuscitation masks are pliable, dome-shaped devices that fit over a patient’s mouth and nose to aid in ventilation. Several types of resuscitation masks are available, varying in size, shape, and features. Resuscitation masks can also be referred to as pocket masks. Resuscitation masks provide a barrier between you and the patient, reducing the risk of infection. Figure 6–22: A resuscitation mask should meet specific criteria. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES SELECTING A RESUSCITATION MASK 121 It should contain a biofilter to keep fluids from entering the valve. It should have an inlet for the delivery of supplemental oxygen. It should work well under a variety of environmental conditions. It should be easy to assemble and use. USING A RESUSCITATION MASK To use a resuscitation mask, begin by expanding the mask and attaching the one-way valve. Next, place the mask so that it covers the patient’s mouth and nose. Position the lower rim of the mask between the patient’s lower lip and chin. The upper end of the mask should cover the nose. Figure 6–23 shows how to position the resuscitation mask. a When using the mask, you must maintain a good seal to prevent air from leaking at the edges of the mask. Use both hands to hold the mask in place, and maintain an open airway by tilting the patient’s head back and lifting the jaw upward into the mask. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Figure 6–24, a-b, shows two methods for using a resuscitation mask. 122 b If you suspect that a patient has a head and/or spinal injury, use the jaw thrust technique to maintain an open airway while holding the mask in position (Figure 6–25). Figure 6–24, a-b: To use a resuscitation mask: a, position yourself behind the patient’s head and hold the two sides tightly against the face; or b, position yourself beside the patient and hold the mask in place. Figure 6–23: A resuscitation mask should be positioned over the mouth and nose, with the lower rim placed between the patient’s lower lip and chin. Figure 6–25: If you suspect a head and/or spinal injury, use the jaw thrust technique and hold the mask to the face without tilting the head. Bag-Valve-Mask (BVM) Resuscitators Using a BVM is a skill that can decline over time without practice. Regular practice is required to maintain proficiency. The device has three main components: a bag, a one-way valve, and a mask. The bag is selfinflating and refills automatically when it is released. The one-way valve allows air to move from the bag to the patient’s airway but prevents exhaled air from entering the bag. The mask is similar to the resuscitation mask. Adult and pediatric mask sizes are available: If possible, use the appropriate size for the patient. An oxygen reservoir bag should be attached to the BVM when supplemental oxygen is administered (Figure 6–26). Figure 6–26: A bag-valve-mask (BVM) resuscitator. A BVM is best used by two responders. A single responder may be able to use a BVM effectively if he or she is proficient. Two-Responder BVM When using a BVM with a partner, the first responder (Responder A) positions the mask and opens the patient’s airway. Responder A should be positioned at the top of the patient’s head, with a view of the patient’s chest. Responder A maintains a tight seal with the mask on the patient’s face with one thumb on each side of the mask, facing the chest (Figure 6–27). The second responder (Responder B) provides ventilations by squeezing the bag (Figure 6–28). The bag should always be squeezed smoothly, not forcefully, giving just enough air to make the The principle of the BVM is simple. By placing the mask on the patient’s face and compressing the bag, you open the one-way valve, forcing air from the bag into the patient’s lungs. When you release the bag, the valve closes and air from the atmosphere refills the bag. At approximately the same time, the patient exhales. This exhaled air is diverted into the atmosphere. USING A BAG-VALVE-MASK RESUSCITATOR When using a BVM on a non-breathing patient, ensure that the patient’s airway is open. Inserting an airway adjunct as soon as possible will assist in maintaining the patient’s airway. Figure 6–27: When using a BVM with a partner, Responder A is positioned by the patient’s head, facing the chest, with one thumb on each side of the mask to maintain a tight seal on the patient’s face. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES A BVM is a hand-held device primarily used to provide assisted ventilation, either to a patient in respiratory arrest or to a patient whose respiratory rate is too low or too high. Because the BVM delivers positive-pressure ventilations, it may be used for either a breathing or non-breathing patient. A BVM can be adapted for use with certain airway adjuncts (e.g., supraglottic airways) and can easily be shared between responders without risk of infection. When used with an oxygen reservoir bag, it can deliver a higher concentration of oxygen than a resuscitation mask. 123 patient’s chest start to rise: This is generally about one-third of the bag’s capacity. This two-person technique allows one responder to maintain an open airway and a tight mask seal while the second responder provides ventilations. Single-Responder BVM If you are using a BVM without a partner, you must maintain the mask seal, monitor the airway, and provide ventilations simultaneously. Position yourself above the patient’s head, facing the chest. Make a “C” with the thumb and index finger of one hand and place it around the mask seal, with the index finger on the chin side. Maintain pressure on the mask to form a tight seal. Place the other three fingers of the same hand along the patient’s cheek, with your fingertips hooked under the patient’s mandible to maintain the angle of the head, protecting the airway (Figure 6–29). SUPPLEMENTAL OXYGEN The normal concentration of oxygen in the air is approximately 21%, which is more than enough to sustain life under normal conditions. However, when serious injury or illness occurs, the body’s tissues may not receive sufficient oxygen from atmospheric air, resulting in hypoxia (a condition in which the body’s cells receive insufficient oxygen). Hypoxia can cause an increase in respiration and heart rate, restlessness, cyanosis, chest pain, and changes in responsiveness. With your other hand, provide ventilations by squeezing the bag. The bag should always be squeezed smoothly, not forcefully, giving just enough air to make the patient’s chest start to rise: This is generally about one-third of the bag’s capacity. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES BVMs FOR CHILDREN AND INFANTS 124 Some BVMs are designed specifically for children and infants. These devices have a smaller mask for a better fit on the face. The bag is designed to hold a smaller volume of air and limit the amount of air that is squeezed into the lungs. A number of these BVMs also include a valve that stops the forced entrance of air once a certain pressure has been reached, avoiding overinflation of the lungs. As always, ventilate until the chest just starts to rise. Figure 6–28: When using a BVM, one responder maintains a tight seal of the mask on the patient’s face, and a second responder provides ventilations. Figure 6–29: Hand placement for single-responder BVM use. Oxygen cylinders may be portable or fixed. An ambulance, for example, typically carries a cylinder with a large supply of oxygen in a secure onboard location. This is connected to an internal system that can interface with multiple devices to provide oxygen when transporting patients. Portable oxygen units are more compact and lightweight. They can be carried to a patient’s location to provide oxygen during care or extrication. If a patient is loaded into an ambulance, the oxygen delivery system you are using can be transferred to draw oxygen from the onboard system instead. Precautions Depending on the environment, supplemental oxygen is not always safe to use. Oxygen supports combustion; therefore, it cannot be used in environments where there is a risk of fire or explosion, or around sparks or flames. You may need to caution bystanders against smoking. The responder needs to remain vigilant of the environment any time oxygen is being administered. When using supplemental oxygen, safety is a primary concern. Remember the following precautions: Do not operate oxygen equipment around an open flame or sparks or in close proximity to an AED. Oxygen causes fire to burn more rapidly. Do not stand oxygen cylinders upright unless they can be well secured. If the cylinder falls, it could damage the regulator or possibly loosen the cylinder valve. Handle oxygen cylinders carefully: Do not drop a cylinder, and never drag or roll a cylinder. Do not use grease, oil, tape, or petroleum products to lubricate any pressure regulator parts. Oxygen does not mix with these products, and a severe chemical reaction could cause an explosion. When disinfecting an oxygen regulator, take care to prevent any material from entering the inlet port (as per the manufacturer’s instructions). Indications for Supplemental Oxygen Supplemental high-flow oxygen is indicated in the following situations: 1. The patient has been exposed to carbon monoxide. 2. The patient is experiencing decompression sickness and/or injury (e.g. SCUBA incidents). 3. The patient is suffering from asphyxiation. 4. The patient is suffering from dyspnea. 5. The patient is hypoxic. 6. The patient’s SpO2 is lower than 95% (hypoxemia). 100% O2w/ reservoir 50% w/O2 16% Rescue Breathing 16% 21% Resuscitation Bag-ValveMask Mask Figure 6–30: Administering supplemental oxygen allows a substantially higher oxygen concentration to be delivered to the patient. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES If a patient is not receiving sufficient oxygen through normal respiration, you must provide additional oxygen to the patient to increase the oxygen saturation in the blood (Figure 6–30). This may be as simple as breathing air into the patient’s lungs or as complex as providing specific quantities of supplemental oxygen from a cylinder. 125 If the patient is already receiving lowflow oxygen (e.g., for COPD), it is usually best to keep the patient on low-flow oxygen unless the patient is suffering from respiratory distress. In order to deliver supplemental oxygen, a responder must have the following equipment: An oxygen cylinder An oxygen regulator A delivery device Figure 6–31 shows an oxygen cylinder, regulator, and flowmeter. Figure 6–31: An oxygen cylinder, regulator, and flowmeter. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Calculating How Long an Oxygen Cylinder Will Last 126 The size of an oxygen cylinder is designated by a letter. If you know the size of your oxygen cylinder and the reading on the pressure gauge, you can calculate how long the supply will last. There are various protocols as to when to change your tank; however, in all cases, 200 psi is known as the safe residual pressure, and the tank should always be changed around this point. Note that this is the oxygen remaining under ideal conditions: The general best practice is to monitor the oxygen supply while it is being administered to ensure that it does not run out unexpectedly. If a patient who is receiving supplemental oxygen is being transported, you must include the extrication and transportation time when calculating how much oxygen will be required and ensure that you are prepared to meet the demands. It is better to have more oxygen than you need than to run out while providing care. The calculation is as follows: Duration of flow = (gauge pressure – 200 psi) x C flow rate (litres per minute (LPM)) Where C = the cylinder constant The constants for each size of cylinder are: D cylinder = 0.16 L/psi E cylinder = 0.28 L/psi M cylinder = 1.56 L/psi Example 1: Duration of a full D cylinder at 2,000 psi, at a flow rate of 10 LPM. Duration of flow = (2000 – 200) x 0.16 10 Duration of flow = approximately 28.8 minutes of flow remaining Example 2: Duration of a full D cylinder at 2,000 psi, at a flow rate of 15 LPM. Duration of flow = (2000 – 200) x 0.16 15 Duration of flow = approximately 19.2 minutes of flow remaining Oxygen cylinders have a distinctive green or white colour and a yellow diamond marking that says “oxidizer.” These cylinders are made of steel, aluminum, or another metal. Depending on their size, those used in the pre-hospital setting typically hold between 350 and 625 litres of oxygen. These cylinders have internal pressures of approximately 2,000 pounds per square inch (psi) (13,790 kPa). Oxygen Regulator The oxygen inside an oxygen cylinder is under tremendous pressure. To safely administer oxygen from the cylinder to a patient, this pressure must be reduced significantly. This is done by attaching an oxygen regulator to the cylinder to reduce the pressure of the oxygen to a safe level. The regulator reduces the pressure from approximately 2,000 psi inside the cylinder to a safe range of 30 to 70 psi. Some oxygen cylinders have an integrated regulator, but these are used in the same way as an independent regulator (Figure 6–32). An oxygen regulator has a gauge that indicates how much pressure is in the cylinder. By checking the gauge, you can determine if a cylinder is full (2,000 psi), nearly empty (200 psi), or somewhere in between. the regulator and the cylinder, a gasket (commonly referred to as an O-ring) must be used. These come in both single-use and multi-use forms. A regulator controls the rate at which oxygen flows through the oxygen delivery device, which is measured in litres per minute (LPM). Regulators normally deliver between 1 and 25 LPM. When working with oxygen cylinders, always: Use pressure gauges and regulators designed for use with oxygen. Ensure that all hardware is in good condition. Use medical-grade (USP) oxygen. Store oxygen in a cool, ventilated room when not in use. Have cylinders hydrostatically tested every 5 years (or per manufacturer’s specifications). Using Oxygen Delivery Devices To deliver oxygen from the cylinder to the patient requires a delivery device. There are a variety of delivery devices available, applicable in different situations. A section of tubing is attached to the device at one end and to the oxygen regulator at the other. NASAL CANNULA An oxygen regulator has two metal prongs that fit into a valve at the top of the oxygen cylinder. Regulators and cylinders are pin indexed, meaning that a regulator will only fit into a cylinder that it was designed for. To ensure a tight seal between A nasal cannula is a plastic tube with two small prongs that are inserted into the patient’s nostrils to deliver oxygen (Figure 6–33). It is commonly used to manage patients with minor respiratory difficulties who do not require high-flow oxygen. It is especially useful in non-trauma situations. Figure 6–32: An oxygen cylinder with an integrated regulator. Figure 6–33: A nasal cannula. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Oxygen Cylinders 127 Because it leaves the mouth clear, it also facilitates communication with the patient. A nasal cannula is only suitable for a breathing patient. The use of a nasal cannula is limited since it is normally used at a flow rate of 1 to 4 LPM. Under these conditions, it delivers a peak oxygen concentration of approximately 36%. Flow rates above 4 LPM are not commonly used because of their tendency to quickly dry out mucous membranes. This can cause epistaxis (nosebleeds) and headaches. After longer periods of use, patients can experience irritation around the nostrils. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES To use a nasal cannula, connect the cannula to an oxygen source and start the oxygen flow. Place the cannula’s prongs into the patient’s nostrils. Hold the prongs in place (or have the patient hold them) while you loop the cannula tubing over the patient’s ears with the excess hanging in front of the patient’s chest. Adjust the collar on the tubing to gather it in front of the patient’s chest and hold the cannula in place. 128 Adding moisture to oxygen by attaching an oxygen humidifier to the regulator can help decrease irritation of the respiratory tract, which can result when a patient receives supplemental oxygen over a long period of time. The humidifier forces oxygen through sterile water, which allows it to pick up moisture before being delivered to the patient. Generally, a humidifier is not used in a pre-hospital setting, although it may be used during a long transfer. A nasal cannula is not appropriate for patients experiencing serious respiratory emergencies, since they need a device that can supply a greater concentration of oxygen. In addition, the nasal cannula can be ineffective if the patient has a nasal airway obstruction, nasal injury, or illness (e.g., a bad cold) causing blocked sinus passages. However, it could be considered if the patient requires low-flow oxygen and cannot tolerate having a mask over his or her face. RESUSCITATION MASK Resuscitation masks may have a port that can be connected to supplemental oxygen. If a breathing patient requires supplemental oxygen and no other delivery device is available, you can connect oxygen directly to the mask and use it as you would use a standard oxygen mask. The oxygen flow rate is 6–10 LPM and can supply an oxygen concentration of approximately 35 to 55%. Some resuscitation masks have elastic straps that can be placed over the patient’s head and tightened to secure the mask in place. If the mask does not have a strap, either you or the patient can hold it in place. STANDARD MASK A standard oxygen mask (also referred to as a simple face mask or standard mask) is an oxygen mask that fits over a patient’s mouth and nose to supply oxygen. It is usually made of a pliable material to increase patient comfort. Oxygen tubing is often an integral part of the mask, so it may not require assembly. Medium-concentration masks are available in both adult and pediatric sizes. The flow rate for a medium-concentration mask is usually 6 to 10 LPM, delivering an oxygen concentration of 40 to 60%. NON-REBREATHER MASK A non-rebreather mask (or partial non-rebreather mask), sometimes referred to as a highconcentration mask, is an oxygen face mask with low-resistance check valves along its sides. It is used with an oxygen cylinder and reservoir bag (usually 750 ml) to provide supplemental oxygen. A non-rebreather mask needs to have a flow rate of 10 LPM or more to ensure the proper reservoir bag inflation. This device allows the patient to inhale air from the reservoir bag and exhale through the check valves (Figure 6–34, a). The nonrebreather mask, when used in conjunction with a pulse oximeter, can be utilized on a patient with SpO2 levels under 95%, with flow rates from 10 to 15 LPM. Monitor the oxygen reservoir bag, and increase the oxygen flow rate as necessary (titrate) to ensure that the bag remains full. a b BAG-VALVE-MASK Administering Oxygen The BVM resuscitator with an oxygen reservoir is capable of supplying an oxygen concentration of 90 to 100%. A flow rate of 15 LPM is sufficient to keep the reservoir full. Begin by checking the cylinder to confirm that it contains medical oxygen (Figure 6–35, a). Next, check the oxygen gauge to ensure that the quantity of oxygen in the cylinder is sufficient. A full cylinder will come with a protective covering over the tank opening. Remove this covering and save the O-ring. While pointing the cylinder’s valve away from yourself and others, and wearing proper ear and eye protection, quickly open the cylinder’s valve (for a maximum of one second) (Figure 6–35, b). This will remove any dirt or debris from the cylinder valve. To deliver oxygen through a BVM, you must first attach an oxygen reservoir bag to the back of the BVM bag (Figure 6–34, b). Next, connect the oxygen cylinder tubing to the BVM through the oxygen port. After setting the oxygen flow rate and opening the cylinder, block the outlet port on the resuscitation mask with your finger or thumb. This will fill the oxygen reservoir. When you compress the BVM bag, the patient will receive close to 100% oxygen. When you release the BVM bag, it will refill with oxygen from the reservoir. Table 6–2 provides an overview of each of the delivery devices. Next, examine the pressure regulator. Ensure that the gasket is positioned properly within the regulator inlet port (Figure 6–36, a). Confirm that the pin index on the regulator corresponds to the oxygen cylinder you are using (Figure 6–36, b). Attach the pressure regulator to the cylinder, seating the prongs inside the holes in the valve TABLE 6–2: OXYGEN DELIVERY DEVICES DEVICE COMMON FLOW RATE OXYGEN CONCENTRATION FUNCTION Nasal cannula 1–4 LPM 24–36% Breathing patients only Resuscitation mask 6+ LPM 35–55% Breathing and non-breathing patients Standard mask 6–10 LPM 40–60% Breathing patients only Non-rebreather mask (w/O2 res.) 10+ LPM 90+% Breathing patients only Bag-valve-mask resuscitator (w/O2 res.) 15 LPM 90+% Breathing and non-breathing patients AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Figure 6–34, a-b: Common oxygen delivery devices include a, a non-rebreather mask; and b, a BVM. 129 a b AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Figure 6–35, a-b: a, An oxygen cylinder is usually green or white, with a yellow diamond indicating oxygen; b, open the cylinder for one second, pointing it away from you. 130 a b c d Figure 6–36, a-d: To attach the pressure regulator to the cylinder: a, insert the gasket into the pressure regulator; b, check to see that the pin index corresponds to the oxygen tank; c, seat the prongs of the regulator inside the cylinder and hand-tighten the screw until the regulator is snug; and d, turn on the oxygen and check how much pressure is in the cylinder. stem (Figure 6–36, c). Hand-tighten the screw until the regulator is snug. To avoid damaging the assembly, do not use a wrench or other tool to tighten the regulator. Using an appropriate oxygen wrench, open the cylinder by giving the valve one full turn, and listen for leaks. Check the gauge to determine how much pressure is in the cylinder (Figure 6–36, d). A full cylinder should have approximately 2,000 psi. Attach the chosen delivery device to the oxygen port on the regulator using the appropriate tubing. Set the regulator to the appropriate flow rate. Listen and feel to make sure that oxygen is flowing into the delivery device. If using a delivery device with a reservoir bag, ensure that it is full (Figure 6–37), and then place the delivery device on the patient. AIRWAY ADJUNCTS An airway adjunct is a tube that is inserted into a patient’s upper airway to assist in keeping it patent (open). It can also facilitate assisted ventilations. Airway adjuncts are especially useful for patients with decreased levels of responsiveness, whose tongues can otherwise become anatomical obstructions. The most common adjuncts are oropharyngeal airways (OPAs) and nasopharyngeal airways (NPAs). A foreign-body airway obstruction must be cleared before any airway adjunct can be inserted. Note that an airway adjunct may not be sufficient to maintain an open airway on its own. Even after inserting an adjunct, you must continue to monitor the patient’s respiration and use manual techniques such as the head-tilt/chin-lift to maintain airway patency. After inserting an airway adjunct for an unresponsive breathing patient, check the patient’s breathing to confirm that the airway has not been obstructed. Oropharyngeal Airways Figure 6–37: Ensure that the reservoir bag is full before placing the delivery device on a patient. Figure 6–38: Oropharyngeal airways (OPAs) come in a variety of sizes. PROPER SIZING AND INSERTION OF AN OPA Measure the device against the side of the patient’s face to ensure that it extends from the earlobe to the corner of the mouth (Figure 6–39). Open the patient’s mouth using the crossed-finger technique (see below), and then insert the OPA by gently sliding the tip along the roof of the mouth (Figure 6–40). When the device is approximately one-half to three-quarters of the way into the patient’s mouth (as the tip approaches the back of the throat), rotate it a half-turn (Figure 6–41). The OPA should drop into the throat without resistance. The flange end should rest on the patient’s lips (Figure 6–42). AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES c An oropharyngeal airway (OPA) is a device that is inserted into the mouth of an unresponsive patient. OPAs come in a variety of sizes (Figure 6–38). The curved design fits the natural contour of the mouth and throat. A properly sized and inserted OPA will not interfere with assisted ventilations or oxygen delivery. 131 Figure 6–39: A properly sized OPA extends from the earlobe to the corner of the mouth. Figure 6–40: To insert the OPA, open the patient’s mouth using the crossed-finger technique. Insert the OPA with the tip along the roof of the mouth. If the patient appears unresponsive but gags when you attempt to insert the device, he or she may be partially responsive. If so, stop your attempt. Maintain an open airway using other methods and continue your assessment of the patient. The patient’s LOR can rapidly decline. Reattempt to insert the OPA frequently: A small change in the patient’s responsiveness may allow you to insert it without triggering the gag reflex. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES OPAs IN CHILDREN AND INFANTS 132 Younger children and infants have delicate airways, so extra caution must be taken to avoid causing injury when inserting an OPA. Also, you must be careful not to hyperextend the patient’s neck, which could close or even damage the airway. When inserting an OPA into a child’s mouth, you should gently slide the tip along the inside of the cheek, and then rotate it 90 degrees to place it into the throat (Figure 6–43). When inserting an OPA for an infant, place some padding (e.g., a towel) under the infant’s shoulders to help maintain the neutral position of the head without hyperextending the neck. Hold the tongue against the bottom of the mouth with a tongue depressor. Place the OPA against the lower lip with the concave side facing down, and slide the OPA smoothly into place without rotating it, following the natural curvature of the mouth and throat. Figure 6–41: As the tip of the device approaches the back of the throat, rotate it a half-turn. Figure 6–42: The flange end of the OPA should rest on the patient’s lips. has experienced facial trauma, use caution when inserting your fingers to avoid injury from sharp edges of broken teeth or dental appliances. THE CROSSED-FINGER TECHNIQUE The crossed-finger technique (Figure 6–44) is the preferred method in most situations: 1. Cross the thumb and index finger of one hand. 2. Place the thumb on the patient’s lower front teeth and the index finger on the upper front teeth. 3. Open the mouth using a scissor motion (sometimes described as a slow-motion snapping motion). THE TONGUE-JAW LIFT TECHNIQUE The tongue-jaw lift (Figure 6–45) can provide a better view of the oral cavity and upper airway than the crossed-finger technique. However, it requires you to place your thumb between the patient’s teeth, so it exposes you to the risk of being bitten. If the patient is fully unresponsive, this risk is mitigated, so this technique may be used interchangeably with the crossed-finger technique. Figure 6–43: You may attempt to insert the OPA by gently sliding the tip along the inside of the cheek, and then rotating it 90 degrees to place it into the throat. REMOVING AN OPA To remove an OPA from a patient of any age, grasp the flange between your thumb and index finger and pull gently outwards and downwards (towards the chin). The OPA will slide out smoothly. Techniques for Opening the Mouth There are two common methods of opening a patient’s mouth to assess the upper airway, insert an OPA, or provide suction. If the patient Figure 6–44: The crossed-finger technique for opening the mouth. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES To perform the tongue-jaw lift: 1. Place your index finger beneath the patient’s chin. 2. Insert the thumb of the same hand into the patient’s mouth and grasp the tongue, pinning it between your thumb and finger. 3. Gently lift the mandible to open the patient’s mouth. 133 Figure 6–45: The tongue-jaw lift technique for opening the mouth. Figure 6–46: Lubricate a nasopharyngeal airway (NPA) with a water-soluble lubricant. Nasopharyngeal Airways A nasopharyngeal (nasal) airway (NPA) is used to assist in maintaining an airway in an unresponsive adult. An NPA may also be used on a responsive adult who needs help keeping the tongue from obstructing the airway. Unlike an OPA, an NPA will not interfere with suctioning a patient’s airway, so it may be preferable in cases where a patient has fluid in the airway. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES INSERTING AN NPA 134 NPAs are available in a variety of sizes. When choosing an NPA, confirm that you have selected the correct size by measuring the device against the patient’s cheek: The NPA should extend from the earlobe to the tip of the nose. Ensure that the diameter of the NPA is no larger than the diameter of the patient’s nostril. Lubricate the NPA with a water-soluble lubricant (Figure 6–46). Insert the NPA into the patient’s right nostril (which tends to be slightly larger than the left), with the bevel towards the septum. Gently advance the airway straight in (not upward) until the flange rests against the patient’s nostril (Figure 6–47, a-b). If you feel even minor resistance, do not attempt to force the NPA into the airway. If the NPA does not pass easily, remove it and try the other nostril. Unlike the OPA, the NPA will not cause a patient to gag. a b Figure 6–47, a-b: a, Advance the airway gently, straight in, not upward; b, the flange end should rest against the nostril. REMOVING AN NPA To remove an NPA, grasp the flange gently between your thumb and index finger and draw it gently out of the patient’s nose. Supraglottic Airways A supraglottic airway (SGA) is used to keep the upper airway open (create a protected airway) and/or to provide unobstructed ventilation. It is used when other airway management is ineffective. A variety of supraglottic airways are commercially available (Figure 6–48), but they all consist of a rigid tube with inflatable cuffs that expand to seal the patient’s airway and hold the SGA in place. Aspiration is a risk with supraglottic airways, especially if the patient has gastric inflation or high airway pressure, and these airways are not suitable for patients with active vomiting. Monitor the patient closely after inserting the airway. Supraglottic airways are not indicated for patients with airway edema or stridor, or in cases where you suspect that the patient has ingested a caustic substance. Figure 6–48: A variety of supraglottic airways are available. INSERTING AN SGA An SGA has a small port that is used to inflate and deflate the cuffs. Before inserting the SGA, deflate the cuffs using a 20 to 30 ml syringe. Lubricate the outer cuff with water-soluble lubricating gel. Position yourself behind the supine patient, standing, sitting, or kneeling behind the patient’s head. Tilt the patient’s head back approximately 15 degrees, ensuring that the head is extended on the neck and that the chin is centred on the midline of the body (without lateral deviation). Still standing or kneeling behind the patient, hold the SGA as you would hold a pen and insert it into the patient’s mouth. Apply enough pressure to direct it back and downwards until it reaches the back of the hypopharynx. Using the syringe, inflate the cuffs (Figure 6–49). The volume of air required depends on the specific model that you are using: Consult the manufacturer’s guidelines to determine the appropriate amount. If necessary, attach the BVM to the tube. Next, confirm that the SGA is in the correct position by observing the chest expansion and auscultating both sides of the chest. You should see and hear good air entry on both sides of the chest. If your level of training and local protocol allow it, consider applying a CO2 detector or endtidal CO2 monitor to confirm that the placement is correct. Figure 6–49: An SGA and a syringe. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES An NPA is not indicated for a patient with a suspected skull fracture, active bleeding from the nose, or facial trauma. Insertion of an NPA may cause nosebleeds (epistaxis), which can cause blood to enter the airway. Monitor the patient and provide interventions as necessary. 135 Secure the SGA’s end with tape or a commercially manufactured device. Most SGAs have an attached string or strap: Attach this at the back of the patient’s neck to further support the SGA. You should not make more than two attempts to insert a supraglottic airway (with an attempt defined as an insertion of the airway into the mouth). REMOVING AN SGA a To remove an SGA, simply reverse the steps for insertion: Detach the tape, string, and/or strap, deflate the cuffs with the syringe, and draw the SGA out of the patient’s airway. Be prepared to support the patient’s airway as you remove the SGA. For example, have a suction device ready in case it is needed. The patient may require an OPA to manage his or her airway once the SGA is removed. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES SUCTION 136 Injury or illness can cause materials such as mucus, vomitus, water, or blood to collect in a patient’s airway. In many cases, these materials can be removed by simply rolling the patient onto his or her side and sweeping the mouth clean with your finger. Because this technique involves moving the patient, it can aggravate existing injuries and therefore may not be appropriate for a person with a suspected spinal injury, for example. It may also not allow you to remove material that is farther back in the airway. A safer and more effective method is to suction the airway clear. Suctioning is the process of removing foreign matter by means of a vacuum. Whenever you are providing assisted ventilations to an unresponsive patient, it is good practice to have the suction unit on standby so you can use it immediately if the patient vomits. A variety of manual and mechanical vacuums are available. Manual suction devices are lightweight and compact (Figure 6–50, a-b). Mechanical suction devices use either battery-powered pumps or oxygen-powered aspirators. These devices are normally found on ambulances. b Figure 6–50, a-b: Manual suction devices are lightweight and compact. Attached to the end of any suction device is a suction tip, also referred to as a catheter. These come in various sizes and shapes. Some are rigid and others are flexible. The two most common are the tonsil tip catheter and the French catheter. The tonsil tip catheter is used for clearing the mouth and throat, whereas a French catheter is used to clear the nose. A bulb syringe is used to provide suction for an infant. Ensure that you deflate the bulb syringe before inserting it into the infant’s airway. Some catheters are disposable and can be attached to a reusable handle or trigger assembly. Suction devices may also have a canister that captures any material that is drawn through the catheter. These canisters may be disposable or reusable. Disposable components should be discarded safely after use, and reusable portions should be disinfected between patients according to the manufacturer’s instructions. Suctioning devices are most effective when removing fluids: The catheter can be clogged by large pieces of material (e.g., pieces of food). If this happens, quickly pull a quantity of sterile water or saline through the device to clear the catheter. If this is not immediately effective, roll the patient carefully and attempt to clear the airway with a finger sweep. If the patient vomits up a large quantity of material, it may exceed the capacity of the unit. If this happens, roll the patient immediately and clear the airway with a finger sweep. If the patient has an OPA inserted that will interfere with suctioning the oral cavity (see Oropharyngeal Airways on page 131), remove the OPA prior to suctioning. If necessary, reinsert the OPA once the airway is clear. Figure 6–51: Measure the distance from the patient’s earlobe to the corner of their mouth to determine the depth of insertion. Whether you are using a manual or mechanical suction device, the basic steps are the same. First, measure the distance of insertion, which is the distance from the patient’s earlobe to the corner of the mouth (Figure 6–51). This indicates how far into the airway the vacuum can be safely inserted. Using suction will draw air from the patient’s airway. After providing suction, give the patient supplemental oxygen to ensure that he or she does not become hypoxic. If a mechanical suction device malfunctions or does not adequately clear the airway, roll the patient onto his or her side immediately and sweep the airway clear. If a patient has a tracheostomy or stoma, suction through the tube or hole, as this is where the patient’s air passes. Do not insert the suction tip more than 5 cm (2 in.) beyond the lower edge of the opening. Figure 6–52: Insert the suction tip into the back of the mouth. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Open the patient’s mouth using the crossed-finger technique or tongue-jaw lift (see page 133). Insert the catheter into the upper airway (Figure 6–52) to the maximum depth measured earlier. Provide rapid suction until the airway is clear. 137 CARE FOR RESPIRATORY DISTRESS CARE FOR RESPIRATORY ARREST Respiratory distress can be life-threatening and can also progress to other serious conditions. For example, respiratory distress could lead to respiratory arrest. It may also aggravate underlying conditions such as asthma. Respiratory arrest is a life-threatening condition in which respiration ceases. It may be caused by illness, injury, or an obstructed airway. During respiratory arrest, the patient’s body is not independently acquiring oxygen. Without oxygen, the heart will quickly stop functioning, which causes the circulatory system to fail. However, you can simulate the function of the patient’s respiratory system with assisted ventilation (page 119). For this reason, it is crucial that you are able to recognize the signs and symptoms of respiratory distress and provide appropriate interventions immediately. Many different respiratory emergencies have similar signs and symptoms, and particular conditions may require specific interventions, but certain general principles can be helpful for most patients with respiratory distress. Have the patient rest in a comfortable position. Sitting upright usually makes respiration easier. Loosen restrictive clothing and help to keep the patient calm: Anxiety can contribute to the patient’s breathing difficulty. If the environment is enclosed or uncomfortable (e.g. too hot or too cold), consider moving the patient to a more suitable location. AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Assist the patient in taking any prescribed medication for the condition, if it is available. For example, a patient experiencing asthma-related dyspnea may require his or her inhaler. 138 If the patient’s breathing is rapid (tachypnea) and you suspect that it is caused by emotion, such as excitement or anxiety, try to calm the patient to slow his or her breathing. Reassurance is often enough to correct hyperventilation, but you can also ask the patient to breathe along with you. Breathe at a normal rate, emphasizing each inhalation and exhalation. If possible, monitor the patient’s pulse as you provide ventilations. After every 2 minutes of assisted ventilation, check whether the patient has begun to breathe spontaneously. You should also recheck the patient’s carotid pulse (for adults and children) or brachial pulse (for infants) to confirm that the heart is still beating. If the patient still has a pulse but is not breathing, continue to provide ventilations. Continue to provide assisted ventilation until one of the following occurs: The patient begins to breathe. The patient’s pulse is absent. In this case, begin CPR (described in Chapter 7). You transfer care to another person with the same or a higher level of qualification. You are too exhausted to continue. The scene becomes unsafe. SUMMARY SIGNS AND SYMPTOMS OF RESPIRATORY EMERGENCIES Type Example Dyspnea Patient has laboured breathing, struggles to breathe, or gasps for breath Abnormal breathing sounds Patient is wheezing, gurgling, or making high-pitched noises Abnormal respiratory rate Patient’s respiration is too fast or too slow Abnormal skin characteristics Skin is unusually moist and/or has an unusual tone Emotional effects Patient is restless or anxious Neurological effects Patient is dizzy or lightheaded, and/or experiences pain or tingling in extremities Patient position Patient is in an unusual position (e.g., tripod position) Unresponsive Patient with Absent Breathing Primary Assessment (ABCs) CARDIAC ARREST Respiration absent Pulse present Respiration absent Pulse absent Begin CPR/AED protocol, starting with compressions Attempt 2 ventilations (If 1st doesn’t enter, reposition the head) RESPIRATORY ARREST Begin care (continue airway management and monitor pulse) Ventilation unsuccessful AIRWAY OBSTRUCTION Perform one set of CPR chest compressions, then check for object in mouth. If object is found, carefully remove, and visually confirm that mouth is clear. Attempt 1 ventilation Ventilation successful Give 2nd ventilation Respiration absent Reassess patient’s ABCs (simultaneously) Respiration present Pulse absent UNRESPONSIVENESS Continuously monitor patient and provide ongoing patient care Consider causes of unresponsiveness AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Ventilation successful 139 SUMMARY Situations in Which High-Flow Supplemental Oxygen Is Indicated 1. 2. 3. 4. 5. 6. Carbon monoxide exposure Decompression sickness/injury Asphyxiation Dyspnea Hypoxia SpO2 < 95% Calculating How Long an O2 Cylinder Will Last Duration of flow = ( gauge pressure - 200 psi) x C flow rate (litres per minute) Where C = the cylinder constant: D cylinder constant = 0.16 L/psi E cylinder constant = 0.28 L/psi M cylinder constant = 1.56 L/psi Administering Oxygen 1. Confirm that cylinder contains medical oxygen. 2. Ensure cylinder contains sufficient oxygen. 3. Remove protective covering (for new cylinders). Save the O-ring. 4. Briefly open valve (maximum one second). 5. Ensure gasket is positioned properly. 6. Confirm that regulator’s index pin corresponds to oxygen cylinder. 7. 8. 9. 10. 11. 12. Attach regulator to cylinder. Hand-tighten screw until regulator is snug. Check cylinder pressure. Attach delivery device to regulator. Set regulator to appropriate flow rate. Confirm that oxygen is flowing. OXYGEN DELIVERY DEVICES Device Nasal cannula AIRWAY MANAGEMENT AND RESPIRATORY EMERGENCIES Patient 1–4 LPM 24–36% Breathing 6+ LPM 35–55% Breathing and non-breathing Standard mask 6–10 LPM 40–60% Breathing Non-rebreather mask (w/O2 res.) 10+ LPM 90+% Breathing Bag-valve-mask resuscitator (w/O2 res.) 15 LPM 90+% Breathing and non-breathing Resuscitation mask 140 Common Flow Rate Oxygen Concentration TECHNIQUES FOR OPENING THE MOUTH The Crossed-Finger Technique The Tongue-Jaw Lift Technique 1. Cross the thumb and index finger of one hand. 2. Place the thumb on the patient’s lower front teeth and the index finger on the upper front teeth. 3. Open the mouth using a scissor motion. 1. Place your index finger beneath the patient’s chin. 2. Insert the thumb of the same hand into the patient’s mouth and grasp the tongue, pinning it between your thumb and finger. 3. Gently lift the mandible to open the patient’s mouth.

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