1 1 case 1 respiratory emergencies © 2001 american heart association
TRANSCRIPT
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Case 1
Respiratory Emergencies© 2001 American Heart Association
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Case PresentationCase Presentation
Patient = 69-year-old man, smoker (4 packs/day) PMHx = severe COPD CC = severe shortness of breath;
“hungry for air!” VS = not obtained; patient suddenly
becomes unresponsive
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Learning and Skills ObjectivesLearning and Skills Objectives
Describe ACLS Approach (Primary and Secondary ABCD Surveys) in CPR
Describe and demonstrate the “airway hierarchy”:• Supplemental oxygen:
– Nasal cannulae– Face masks
• Noninvasive airway devices:– Nasopharyngeal airway– Oropharyngeal airway
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Learning and Skills ObjectivesLearning and Skills Objectives
The airway hierarchy (cont’d)• Recommended invasive airway devices:
– Laryngeal mask airway (LMA)– Esophageal-tracheal (Combitube) tube– Tracheal tube
• Primary/secondary confirmation of tracheal tube placement:– Physical exam criteria– End-tidal CO2 detection– Devices to detect esophageal placement
• Devices to prevent TT dislodgment
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Primary ABCD Survey Primary ABCD Survey
Focus: Basic CPR and Defibrillation• Check responsiveness• Activate emergency response system• Call for defibrillator
A = Airway: open the airwayB = Breathing: check breathing, provide positive-pressure ventilationsC = Circulation: check circulation, give chest compressionsD = Defibrillation: assess for and shock VF/pulseless VT
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Secondary ABCD Survey Secondary ABCD Survey
A = Airway: insert advanced airway device as soon as able(new: 3 types)
B = Breathing: confirm placement by PE (primary tube confirmation)
PLUS
B = Breathing: confirm placement with esophageal detector device or end-tidal CO2 detector or both (secondary tube confirmation)
B = Breathing: use a commercial tube holder to prevent dislodgment
B = Breathing: confirm effective oxygenation/ventilation by 02 sat, CO2 levels, pH
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Anatomy of AirwayAnatomy of Airway
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Airway ObstructionAirway Obstruction
Most common cause: tongue and/or epiglottis
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Opening the AirwayOpening the Airway
Jaw thrust Head tilt–chin lift
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The Oropharyngeal AirwayThe Oropharyngeal Airway
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Malposition of Oropharyngeal Airway
Malposition of Oropharyngeal Airway
Too short
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Nasopharyngeal Airway Nasopharyngeal Airway
Insertion technique
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Barrier DevicesBarrier Devices
Oral airway: inserts in patient
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Pocket-Mask DevicesPocket-Mask Devices
1-way valve
Port to attach O2 source
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Mouth-to-Mask VentilationMouth-to-Mask Ventilation
Advantages
• Eliminates direct contact
• Enables positive-pressure ventilation
• Oxygenates well if O2 attached
• Easier to perform than bag-mask ventilation
• Best for small-handed rescuers
• 1-rescuer technique; performed from side
• Rescuer slides over for chest compressions
• Fingers: head tilt–chin lift
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Mouth-to-Mask VentilationMouth-to-Mask Ventilation
Fingers: jaw thrust upward Fingers: head tilt–chin lift
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Bag-Mask VentilationBag-Mask Ventilation
Key—ventilation volume: “enough to produce obvious chest rise”
1-Person: difficult, less effective
2-Person:easier, more effective
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Cricoid PressureCricoid Pressure
ThyroidCartilage
Cricoid
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Bag-Mask VentilationBag-Mask Ventilation
Advantages
• Provides immediate ventilation and oxygenation
• Operator gets sense of compliance and airway resistance
• May provide excellent short-term support of ventilation
• High oxygen concentrations are possible
• Can be used to assist spontaneous respirations Potential complications
• Hypoventilation
• Gastric inflation
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Airway Adjunct DevicesAirway Adjunct Devices
Nasal cannula24%-44% O2 concentration
Face mask with O2 reservoir,60%-100% O2 concentration
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Types of Portable SuctionTypes of Portable Suction
Courtesy of Laerdal Medical Corporation, Armonk, NY
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Equipment for IntubationEquipment for Intubation
Laryngoscope with several blades
Tracheal tubes Malleable stylet 10-mL syringe Magill forceps Water-soluble lubricant Suction unit, catheters, and tubing
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Curved Blade Attaches to Laryngoscope Handle
Curved Blade Attaches to Laryngoscope Handle
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Curved Blade Attached to Laryngoscope Handle
Curved Blade Attached to Laryngoscope Handle
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Curved Blade Laryngoscope Inserted Against Epiglottis
Curved Blade Laryngoscope Inserted Against Epiglottis
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Straight-Blade LaryngoscopeStraight-Blade Laryngoscope
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Straight-Blade Laryngoscope Inserted Past Epiglottis
Straight-Blade Laryngoscope Inserted Past Epiglottis
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Cricothyroid Membrane With Horizontal Cricothyrotomy Incision
Cricothyroid Membrane With Horizontal Cricothyrotomy Incision
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Aligning Axes of Upper AirwayAligning Axes of Upper Airway
Extend-the-head-on-neck (“look up”): aligns axis A relative to B
Flex-the-neck-on-shoulders (“look down”): aligns axis B relative to C
C
ABA
B
C
TracheaPharynx
Mouth
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Visualization of Vocal CordsVisualization of Vocal Cords
Glotticopening
Arytenoidcartilage
Tongue
EpiglottisVallecula
Vocalcord
AnatomyAnatomy
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Tracheal IntubationTracheal Intubation
Advantages• Protects airway from aspiration of foreign material • Facilitates ventilation and oxygenation• Facilitates suctioning of trachea and bronchi• Provides route for drug administration• Prevents gastric inflation if used with cuff• Allows faster chest compressions
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Tracheal IntubationTracheal Intubation
Indications• Inability to ventilate the unconscious patient• After insertion of pharyngeal airway• Inability of patient to protect own airway (coma,
areflexia, or cardiac arrest)• Need for prolonged mechanical ventilation
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Tracheal IntubationTracheal Intubation
Recommendations• Intubate as soon as possible after ventilation
and oxygenation in cardiac arrest• Intubation should be done by most
experienced person• Do not take longer than 30 seconds per attempt• Auscultate the thorax and epigastrium
after intubation
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Tracheal IntubationTracheal Intubation
Complications• Trauma—teeth, lips, tongue, mucosa,
vocal cords, trachea• Esophageal intubation• Vomiting and aspiration• Hypertension and arrhythmias
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Esophageal-Tracheal CombitubeEsophageal-Tracheal Combitube
A = esophageal obturator; ventilation into trachea through side openings = B
C = tracheal tube; ventilation through open end if proximal end inserted in trachea
D = pharyngeal cuff; inflated through catheter = E
F = esophageal cuff; inflated through catheter = G
H = teeth marker; blindly insert Combitube until marker is at level of teeth
Distal End
Proximal End
B
C
D
E
F
G
H
A
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Esophageal-Tracheal Combitube Inserted in Esophagus
Esophageal-Tracheal Combitube Inserted in Esophagus
A = esophageal obturator; ventilation into trachea through side openings = B
D = pharyngeal cuff (inflated)
F = inflated esophageal/tracheal cuff
H = teeth markers; insert until marker lines at level of teeth
D
A
DB F
H
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Laryngeal Mask Airway (LMA)
Laryngeal Mask Airway (LMA)
The LMA is an adjunctive airway that consists of a tube with a cuffed mask-like projection at distal end.
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LMA Introduced Through Mouth Into Pharynx
LMA Introduced Through Mouth Into Pharynx
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LMA in PositionLMA in Position
Once the LMA is in position, a clear, secure airway is present.
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Anatomic DetailAnatomic Detail
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Esophageal Detector Device (Bulb-Type)
Esophageal Detector Device (Bulb-Type)
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Confirmation: Tracheal Tube Placement
Confirmation: Tracheal Tube Placement
End-tidal colorimetric CO2 indicators
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Tracheal Tube Holders:Adult and Infant
Tracheal Tube Holders:Adult and Infant
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Qualitative End-Tidal CO2 Detector
Qualitative End-Tidal CO2 Detector
What should the operator’s next action be?