Airway/Airway/VentilationVentilation

&&ShockShock

Jami Windhorn, RN BSN CPN Jami Windhorn, RN BSN CPN TNCC ENPCTNCC ENPC

ObjectivesObjectives

• Identify Airway and Ventilation Issues in Trauma Patient

• Describe Nursing Assessment and Intervention of the Trauma Patient

• Identify Types of Shock• Describe Signs and Symptoms of

Shock• Discuss Nursing Assessment and

Interventions for Shock

UpperUpperAirway AnatomyAirway Anatomy

• Mouth • Nose• Pharynx• Oropharynx• Nasopharynx• Epiglottis• Trachea

Lower Respiratory AnatomyLower Respiratory Anatomy• Cricoid Cartilage• Larynx• Bronchi• Lungs• Pleura/Pleural

Space• Diaphragm

VentilationVentilation

• Inhalation* Diaphragm moves down, ribs move

up and out, air flows in• Exhalation

* Diaphragm moves up, ribs move down and in, air flows out

• Gas exchange occurs to oxygenate the body

Airway AssessmentAirway Assessment• Obstruction

* Tongue* Loose Teeth* Blood/Vomit* Foreign Body* Edema

Patient HistoryPatient History

• Type of Trauma?• Burn?• Pre-Existing Respiratory Disease?• Drugs? Smoking?• Loss of Consciousness?

Nursing Assessment:Nursing Assessment:AirwayAirway

• Open airway – Head Tilt Chin Lift• Maintain C-Spine • Suction any blood, vomit or objects

from airway• Can the patient talk?• Trauma to airway?

Opening the AirwayOpening the Airway

Airway ManagementAirway Management

• Oral Airway

• Nasopharyngeal Airway

Laryngeal Mask AirwayLaryngeal Mask Airway

CombitubeCombitube

King AirwayKing Airway

IntubationIntubation

• If unable to maintain an open airway and patient is requiring Bag/Mask Ventilation, endotracheal intubation may be necessary

RSI:RSI:Rapid Sequence IntubationRapid Sequence Intubation

• The process of quickly inducing anesthesia (Sedation and Paralytics) in a patient in order to intubate

• Sedation is used to reduce anxiety• Paralytics are used in a patient who

is awake, has a gag reflex and is agitated or combative

RSI StepsRSI Steps

• Preparation: Gather all supplies• Preoxygenation• Pretreatment: Atropine or Fluid Bolus• Paralysis• Protect and Position: Cricoid Pressure• Proof of Placement• Post-Intubation Management

Tube Placement Tube Placement ConfirmationConfirmation

• Auscultate breath sounds

• Equal chest rise and fall

• Exhaled Carbon Dioxide detector

“Gold is Good”

• Chest X-Ray

ContraindicationsContraindicationsto RSIto RSI

• Hypotension• Total upper airway obstruction• Total loss of oropharyngeal

landmarks• Paralytic can mask seizure activity

Inadequate VentilationInadequate Ventilation• Due to:

* Pain* Loss of Consciousness* Spinal Cord Injury* Trauma to Chest causing flail

chest, broken ribs, pneumothorax

• All trauma patients should have on 100% Oxygen via a Non-Rebreather mask to allow for adequate oxygenation

Nursing Assessment:Nursing Assessment:VentilationVentilation

• Trauma to the chest• Dyspnea• Level of Consciousness• Symmetrical chest rise and fall• Listen for Breath sounds• Tracheal Deviation?• Palpate chest for deformities

Nursing AssessmentNursing AssessmentContinuedContinued

• Use of accessory muscles• Agonal respirations• Tachypnea• Bradypnea• Irregular breathing patterns

TensionTensionPneumothoraxPneumothorax

• Symptoms:* Deviated Trachea* Absent breath sounds on one side* Restlessness* Cyanosis

• Prepare for Needle Thoracentesis and chest tube insertion

Ongoing AssessmentOngoing Assessment• Work of Breathing• Pain• Level of Consciousness• Breath Sounds• ABGs• Chest X-Rays• Respiratory Rate• Effectiveness of Interventions

SHOCK

Types of Types of ShockShock

• Cardiogenic

• Hypovolemic

• Distributive

• Obstructive

• Shock is a medical condition arising from poor tissue perfusion that is insufficient to meet the oxygen and nutrient demands of the body causing metabolic activities to slow or stop

Cardiogenic ShockCardiogenic Shock• Cardiac tissue is damaged and

unable to supple sufficient blood flow• Common Causes:

* Acute MI* Dilated Cardiomyopathies* Blunt Cardiac Trauma* Arrhythmias

Cardiogenic ShockCardiogenic ShockSymptomsSymptoms

• Hypotension• Cool, clammy skin• Distended jugular veins• Tachyarrhythmias• Fatigue

Cardiogenic ShockCardiogenic ShockTreatmentsTreatments

• Oxygen• Cardiac Meds – Dopamine,

Epinephrine, Norepinephrine

Hypovolemic ShockHypovolemic Shock

• Condition caused by inadequate blood volume which does not allow the heart to pump enough blood to the body

• Most common form of shock

Hypovolemic ShockHypovolemic ShockSymptomsSymptoms

• Anxiety• Hypotension• Rapid, thready pulse• Hypothermia• Thirst and Dry mouth• Cool, mottled skin

Hypovolemic ShockHypovolemic ShockTreatmentsTreatments

• Control the bleeding• Fluid boluses• Blood Transfusions• Oxygen

Distributive ShockDistributive Shock• Maldistribution of blood volume and

flow results from loss of vasomotor tone causing peripheral vasodilation

• Three types:* Septic Shock* Neurogenic Shock* Anaphylactic Shock

Septic ShockSeptic Shock

• Overwhelming Infection• Seen in patients with Disseminated

Intravascular Coagulation (DIC) and Multiple Organ Dysfunction Syndrome (MODS)

Septic Shock SymptomsSeptic Shock Symptomsand Treatmentsand Treatments

• Symptoms:* Fever* Vasodilation

• Treatments:* Fluid boluses* Oxygen* Antibiotics

Neurogenic ShockNeurogenic Shock

• Caused by a Spinal Cord Injury or any Injury to the central nervous system

Neurogenic Shock Neurogenic Shock Symptoms & TreatmentsSymptoms & Treatments

• Symptoms:* Hypotension* Warm, dry skin

Treatments:* Fluid Boluses* Vasopressors – Norepinephrine* Atropine

Anaphylactic ShockAnaphylactic Shock

• Severe whole body allergic reaction

• Insect bites/stings, horse serum, food allergies and drug allergies

Anaphylactic Shock Anaphylactic Shock Symptoms & TreatmentsSymptoms & Treatments

• Symptoms:* Respiratory Distress* Unconsciousness* Hives* Angioedema

Treatments:* Remove the antigen* Epinephrine* IV Fluids

Pathophysiology of ShockPathophysiology of Shock• 3 stages:

1. Compensated:Compensatory mechanisms are initiated to maintain normal

tissueperfusion and organ functions

Pathophysiology of ShockPathophysiology of Shock2. Progressive:

Compensation begins to fail leading to tissue damage

3. Irreversible:Untreated shock leads to loss of perfusion to the whole body – Vasomotor, cardiac and hepaticfailure

LungsLungs

• Permeability increases• High oxygen

consumption• Respiratory acidosis• Lactate levels increase• Lungs become stiff• Tachypnea

KidneysKidneys

• Vasoconstriction causes acute renalfailure

• Proximal tubules and ascending Loopof Henle are damaged

HeartHeart• Subendocardial

hemorrhages arecommon

• Myocardial cells are clumped

• Damage resembles shock or drowning injuries

• Peripheral Vasoconstriction

BrainBrain

• Altered mental status

• Infarcts• Laminar necrosis

GI TractGI Tract• Infarction of GI Epithelium• Fluid Imbalances• Acidosis• GI tract may appear

bloody and swollen

LiverLiver• Liver

necrosis/ischemia• Elevated Bilirubin• Pancreas may also

have ischemic injury

• Glycogen brokendown into glucose

Nursing AssessmentNursing Assessment• Obvious signs of bleeding• Quality of Respirations• Level of consciousness• Auscultate heart, breath and bowel

sounds• Skin color and temperature• Pain

Nursing CareNursing Care

• Administer oxygen, fluids and pain medicine

• Blood Transfusion• Control external bleeding• Gastric tube? Foley?• Watch for development of

coagulopathies• Collaboration of the team

Questions???