2007 Recertification Session

Airway review

Level of awareness:

This is similar to the AVPU, the GCS is performed laterVerbal, loud verbal, or pain stimulus.If pain stimulus, consider a trapezeussqueeze over a sternal rub as it does not create ‘chest pain’.In a trauma patient do not perform a trapezeus squeeze as the patient may turn their head which, obviously, is unwanted in trauma.

Airway: Patency

Maintain the head tilt with your hand on the head and the chin lift with your hand on the jaw.Look into the airway to determine patency – Is it clear of any obstructions such as secretions,

vomitus, or blood.If patent, proceed to assess the respiratory effort.If not patent, clear the airway.

Suctioning the Oropharynx:

Yankaeur catheter with a suctioning pressure of:– Adults: 500 – 550 mmHg– Children: 200 – 220 mmHg– Infants: 80 – 100 mmHg

Adult CPR is a 30:2 ratio, but once they are intubated is continous

Suctioning the Oropharynx:

How long do we suction the oropharynx? 2, 5, 10, or 15 sec.?

Once given a patent airway, we can then assess the respiratory effort of the patient, the adequacy of their effort & the need for PPV.Exceptions?

Suctioning the Oropharynx:

If the patient is actively vomiting, they need to be rolled onto their side, preferably their left side, for drainage and the prevention of possible aspiration.

If the patient is on the backboard, they should have their body strapped to the backboard first, and then their head, in case they should begin to vomit.

Yankaeur:

Shape designed to follow the natural curvature of the oropharynx.How to insert properly.Follow the inside of the cheek.How far to insert.Suction until clear

After Suctioning...Next?

Reassess the Primary Survey.

Once the airway is patent, then we can proceed to assessing the respiratory effort.

TOTE-L VAC SUCTION

Prior to use: – Inspect for damage to case and

components.Battery rotation.Perform suction pressure Test:– Suction should be at least 550mmHg.– Not in use, return to lowest suction setting.

Problem-solving:

As with most portable electric suction units:Cease to function properly if laid on their side.Valve occludes porthole & lose pressure.The machine still sounds like it’s operating.To rectify this problem...

Breathing: Respiratory Effort

Head tilt/chin lift in a medical patient.Modified jaw thrust in the trauma patient.Continue to maintain the head tilt. ( in the Medical patient )Assess the respiratory effort by:– looking for chest rise, – listening & feeling for any movement of

air.

Given a patent airway...

If the patient is hypoventilating due to a decreased Minute Ventilation: – consider PPV via a BVM.

You must know the appropriate normal ranges for each age group: – adults, children and infants.

BVM

Choose proper BVM.Appropriately sized airway mask.Remember PPE And the Hygrofilter.With both hands, lift the jaw up into the mask.Create a good seal.

Assisting Ventilations

Once you have taken over control of the respiratory effort of the patient by assisting their ventilations, you must now assess yourself as you did the patient initially.

You must serially assess your actions now for airway patency and respiratory effort – Positioning, suctioning prn, airway adjuncts.– Your ventilation rate and tidal volume.– Chest rise, compliance/resistance to bagging.

Resistance ≠ Compliance

Differentiate between:Resistance:– Obstruction to the flow of air.

Compliance:– Distensibility of a hollow organ ( lung ).

...and potential causes of each.

Tidal Volume

How much tidal volume?5 – 7 ml/kg.So, for an 80 kg patient that would be 5 X 80 = 400 ml 7 X 80 = 560 ml

With a 1,500 ml ventilation bag, that would be about 1/3 of the bag.

Also consider the time you deliver this volume and the peak inspiratorypressures.

How do you hold a BVM:

Through the handle.

For the paediatric population consider moving up towards the neck of the BVM.

How do you ventilate a spontaneously breathing patient, especially in the winter with heavy clothing on them?

Paediatric BVM: Blow-off Valve

Set for 40 cmH2ORespiratory values are usually measured in cmH2O.Some of these now have a clip on them that can be opened or closed.Risks and Benefits ?

Hypoventilation ( ? )

Not simply low respiratory rates or tidal volumes.Harder to assess with faster respiratory rates.

What are your Clinical Markers to consider PPV for your patient?

Oro- & Naso-Pharyngeal Airway Adjuncts

This is exactly what they are:– Airway adjuncts.

Do not provide a patent airway alone.You must still maintain proper head positioning of the patient.Can stimulate a gag reflex.

Oropharyngeal airway adjunct:

Proper measurement.Proper insertion technique.

Should the patient gag or begin to vomit, the airway adjunct must be withdrawn and the airway managed appropriately, e.g. roll the patient onto their side and suction prn.

Nasopharyngeal airway adjunct:

Proper measurement.

Properly lubricated with a water-based soluble lubricant.

Proper insertion technique.

Proper insertion technique: NP A/W

Look to see which nare is larger, straighter, & has no defects.If you choose the Right nare:Straighten the airway adjunct:Insert it into the nare straight and along the floorof the nasal passageway so as to avoid the turbinates.Continue to insert it straight and along the floor Once past this region, fully insert the airway adjunct.What if you meet resistance at any time?Never force these airway adjuncts in.

Proper insertion technique: NP A/W

If you choose the Left nare:

The insertion follows the same procedure.

Don’t invert the airway adjunct and then attempt to insert it.– The concern here is that it has a natural

curvature to direct itself up into the turbinates.

Helpful Hint:

Use the ‘Pig’s Nose’ method.Gently tug up on the cartilage at the tip of the nose to create what looks like a ‘Pig’s nose’ effect.Makes it easier to insert and advance along the floor of the nasal cavity.

Challenges

‘Standard’ Positioning

Improved ‘sniffing’ Positioning

Elevation of the head and torso.

Pediatric Airway

© 2000 AAP/AHA© 2000 AAP/AHA© 2000 AAP/AHA

Questions????