. . . here's this person you love more than anything in the world and

59 Pages·2006·1.88 MB·English

. . . here’s this person you love more than anything in the world and you’re looking
into her eyes and all you see is fear, absolute terror. I can’t even imagine what it’s like
to not be able to breathe.
CHAPTER 7 Managing Your Patient’s Airway CHAPTER 8 Module Review and Practice Examination
Managing Your
Patient’s Airway
Numbered objectives are from the U.S.Department of Transportation 1994 EMT-Basic National Standard Curriculum.
COGNITIVE OBJECTIVES
At the completion of this lesson,the EMT-Basic student will be able to:
2-1.1 Name and label the major structures of the respiratory 2-1.13 Describe the signs of adequate artificial ventilation using
system on a diagram.(pp.164–166) the bag-valve mask.(p.197)
2-1.2 List the signs of adequate breathing.(pp.166–167) 2-1.14 Describe the signs of inadequate artificial ventilation
2-1.3 List the signs of inadequate breathing.(pp.167–172) using the bag-valve mask.(p.197)
2-1.4 Describe the steps in performing the head-tilt,chin-lift. 2-1.15 Describe the steps in artificially ventilating a patient with
(p.172) a flow restricted,oxygen-powered ventilation device.
2-1.5 Relate mechanism of injury to opening the airway. (pp.194–195)
(pp.172–173) 2-1.16 List the steps in performing the actions taken when
2-1.6 Describe the steps in performing the jaw thrust. providing mouth-to-mouth and mouth-to-stoma artificial
(pp.172–174) ventilation.(pp.189–190)
2-1.7 State the importance of having a suction unit ready for 2-1.17 Describe how to measure and insert an oropharyngeal
immediate use when providing emergency care. (oral) airway.(pp.181–183)
(pp.176–178) 2-1.18 Describe how to measure and insert a nasopharyngeal
2-1.8 Describe the techniques of suctioning.(pp.178–181) (nasal) airway.(pp.184–186)
2-1.9 Describe how to artificially ventilate a patient with a 2-1.19 Define the components of an oxygen delivery system.
pocket mask.(pp.190–191) (pp.200–208)
2-1.10 Describe the steps in performing the skill of artificially 2-1.20 Identify a nonrebreather face mask and state the oxygen
ventilating a patient with a bag-valve mask while using flow requirements needed for its use.(pp.208–210)
the jaw thrust.(pp.193–194) 2-1.21 Describe the indications for using a nasal cannula versus
2-1.11 List the parts of a bag-valve mask system.(pp.191–194) a nonrebreather face mask.(pp.210–213)
2-1.12 Describe the steps in performing the skill of artificially 2-1.22 Identify a nasal cannula and state the flow requirements
ventilating a patient with a bag-valve mask for one and needed for its use.(pp.210–213)
two rescuers.(pp.191–194)
Chapter 7 Managing Your Patient’s Airway ✱ 163
AFFECTIVE OBJECTIVES
At the completion of this lesson,the EMT-Basic student will be able to:
2-1.23 Explain the rationale for basic life support artificial 2-1.24 Explain the rationale for providing adequate oxygenation
ventilation and airway protective skills taking priority over through high inspired oxygen concentrations to patients
most other basic life support skills.(pp.163,168,176) who,in the past,may have received low concentrations.
(pp.190–191)
PSYCHOMOTOR OBJECTIVES
At the completion of this lesson,the EMT-Basic student will be able to:
2-1.25 Demonstrate the steps in performing the head-tilt,chin- 2-1.34 Demonstrate how to artificially ventilate a patient with a
lift.(pp.172–173) stoma.(p.197)
2-1.26 Demonstrate the steps in performing the jaw thrust. 2-1.35 Demonstrate how to insert an oropharyngeal (oral)
(pp.173–174) airway.(pp.181–183)
2-1.27 Demonstrate the techniques of suctioning.(pp.176–181) 2-1.36 Demonstrate how to insert a nasopharyngeal (nasal)
2-1.28 Demonstrate the steps in providing mouth-to-mouth airway.(pp.184–186)
artificial ventilation with body substance isolation (barrier 2-1.37 Demonstrate the correct operation of oxygen tanks and
shields).(pp.190–191) regulators.(pp.200–207)
2-1.29 Demonstrate how to use a pocket mask to artificially 2-1.38 Demonstrate the use of a nonrebreather face mask and
ventilate a patient.(p.191) state the oxygen flow requirements needed for its use.
2-1.30 Demonstrate the assembly of a bag-valve mask unit. (pp.201,208–210)
(pp.191–192) 2-1.39 Demonstrate the use of a nasal cannula and state the
2-1.31 Demonstrate the steps in performing the skill of flow requirements needed for its use.(pp.210–213)
artificially ventilating a patient with a bag-valve mask for 2-1.40 Demonstrate how to artificially ventilate the infant and
one and two rescuers.(pp.192–193) child patient.(pp.195–196)
2-1.32 Demonstrate the steps in performing the skill of 2-1.41 Demonstrate oxygen administration for the infant and
artificially ventilating a patient with a bag-valve mask child patient.(pp.195–196)
while using the jaw thrust.(p.194)
2-1.33 Demonstrate artificial ventilation of a patient with a flow
restricted,oxygen-powered ventilation device.
(pp.194–196)
Being successful in EMS means understanding priorities. So far you have learned
that yoursafety and the safety of otherEMS professionals at the scene of an emer-
gency is the top priority. Now that you have learned how to identify and manage
some of the more common hazards at the scene, we will begin discussing issues re-
lating to patient care. We will begin with the single most important priority fol-
lowing personal safety, an open and clear airway for the patient.
Without a clear airway and adequate air exchange, life quickly comes to an
end. We can do without many things for an extended amount of time, such as
food, water, and shelter, but the human body cannot tolerate even short intervals
without oxygen. In this chapter you will learn how to assess the status of a pa-
tient’s airway as well as differentiate between adequate and inadequate respira-
tions. You will also be introduced to many of the tools available to the EMT for
helping maintain an open and clear airway and ensure adequate oxygen.
164 ✱ Chapter 7 Managing Your Patient’s Airway
It is a warm afternoon in late summer and the crew ambulance rolls to a stop.“I tried those ...um ...
of Unit 281 just lit the well-used barbecue at Post abdominal thrusts, you know, where you get behind
when emergency tones chime from the radio. her ...It didn’t seem to work and then she just
“281, 2-8-1, start emergency for Baker Lake, on the passed out.”
east side by the boat ramps,for a 23-year-old female Rob and Mackenzie approach the woman,step-
who is choking.”Mackenzie,an EMT,quickly shuts off ping over the scattered items of a picnic lunch, and
the barbecue’s propane tank and starts the truck as her find her cyanotic and unresponsive.Mackenzie turns
partner, Rob, tosses the uncooked chicken back into to the man as she is opening the airway kit.“What’s
the refrigerator—for the third time today.A quick drive her name and how long has it been since she started
on Baker Parkway brings them to the park entrance by choking?”
the boat ramp, where a man is waving at them and “It’s been about ...I don’t know ...maybe 3 or
pointing toward a woman who is lying on the grass at 4 minutes,”he says.“And her name is Shannon.”
the edge of the lake. “Okay, Shannon,” Rob says as he performs a
“We were eating lunch and talking and ...and head-tilt,chin-lift on the woman.“Hang in there.”
then she just started choking,”the man gasps as the
✱
2-1.1 Name and label the major Before going any further with this chapter, it will be helpful to review the anatomy
structures of the respiratory
and physiology of the respiratory system found back in Chapter 4. You must be
system on a diagram.
able to identify the following anatomical structures on an anatomical chart of the
respiratory system (Figure 7-1A and B):
✱ Nose and mouth
✱ Pharynx
✱ Oropharynx
✱ Nasopharynx
✱ Epiglottis
✱ Trachea
✱ Cricoid cartilage
✱ Larynx
✱ Bronchi and bronchioles
✱ Lungs
✱ Diaphragm
It will also be helpful to review the physiology of the respiratory system including
the process of respiration and how oxygen and carbon dioxide are exchanged at
the alveoli and cellular levels. Also review the differences in anatomy between the
adult and pediatric patient.
Chapter 7 Managing Your Patient’s Airway ✱ 165
Sinus
Nasal passage
Nasopharynx
Pharynx
Oropharynx
Epiglottis
Thyroid cartilage
Larynx Cricoid
cartilage
Trachea
Upper lobe Trachea Upper lobe of
Pleura of right lung left lung
Bronchiole
Right main Left main
bronchus bronchus
Middle
Diaphragm
lobe
Lower
lobe
Liver
Bronchiole
Costal
Respiratory bronchiole
cartilage
Alveolar
duct
Alveolus
Alveolar
sac
ALVEOLAR SACS
FIGURE 7-1A The respiratory system.
166 ✱ Chapter 7 Managing Your Patient’s Airway
Nasal cavity
NASOPHARYNX
Hard palate
Soft palate
Tonsil
OROPHARYNX
PHARYNX
Tongue
Vallecula
LARYNGOPHARYNX
Mandible Epiglottis
Hyoid bone
Vocal cords
Thyroid cartilage
(Adam’s apple)
Trachea LARYNX
Cricoid cartilage
Thyroid gland Esophagus
FIGURE 7-1B Anatomy of the upper airway.
2-1.2 List the signs of adequate When Breathing Is Adequate
breathing.
It happens nearly 20 thousand times each day and approximately 58 billion times
✱ respiration in an average lifetime. It is called breathing or respiration. When our respiratory
inhalation and exhalation.May system is functioning normally we hardly even notice it and often take it for
also be called ventilation. granted until something goes wrong.
When we are receiving an adequate supply of oxygen, the primary muscle re-
sponsible for respiration is the diaphragm. It is a flat muscle that acts as a divider
between the chest and abdominal cavities. It moves up and down, causing air to
move in and out of the lungs.
There are three primary characteristics that must be assessed when determin-
ing adequacy of breathing. They are:
✱ Rate—Rate refers to how many times the patient is breathing per minute
and is recorded as a number. Each inspiration(cid:2)expiration(cid:3)1 respiration.
Respiratory rates can be obtained by counting the number of breaths in one
minute. Normal rates for adult, child, and infants are as follows:
• Adult: 12–20/minute
• Child: 15–30/minute
• Infant: 25–50/minute
Depending on the standard practice in your area, there are at least two com-
mon methods for counting respirations. One requires counting the respira-
Chapter 7 Managing Your Patient’s Airway ✱ 167
tions for 30 seconds and multiplying by 2 and the second requires counting
for 15 seconds and multiplying by 4. You must understand that the shorter
your sample the less accurate the total rate. For patients with an irregular
breathing pattern, it may be best to count for a full minute to get the most
accurate rate.
✱ Depth—The depth of respirations is sometimes referred to as tidal volume ✱ tidal volume
and is an assessment of the amount of air the patient is moving in and out the depth of respirations.
with each breath. When a patient is breathing adequately, the tidal volume
is approximately 400 to 600 ml of air and can be seen as moderate chest or
abdominal rise and fall. Depth is commonly recorded as deep, shallow, or
normal, depending on how the patient is breathing. In some areas the term
“good tidal volume” or GTV is used to describe depth that is normal. A low
or inadequate tidal volume may result in an inadequate supply of oxygen
and/or the build up of dangerous levels of carbon dioxide (CO ).
2
✱ Ease—Ease refers to a patient’s work of breathing. Normal respirations re-
quire little to no effort on the part of the patient. Ease can be recorded as
unlabored or labored depending on the situation.
Inadditiontorate,depth,andease,othercharacteristicsthatshouldbe
assessedwithallpatientsarerhythmandsound.Normalrespirationsshould
be steady and regular, much like waves gently crashing on the beach. Irreg-
ularrespirationsarenotnormalandcanbecausedbybothillnessandinjury.
Breath sounds should be assessed on all patients as well. The EMT
should use a stethoscope to listen to both lungs in several places. Normal
lung sounds are described as equal and clear bilaterally (on both sides).
More about assessing lung sounds will be discussed in Chapter 19.
When Breathing Is Inadequate
2-1.3 List the signs of inadequate
breathing.
Inadequate breathing is often the result of inadequate gas exchange (oxygen for
carbon dioxide) and can result in the development of at least two problems for the
patient, an inadequate supply of oxygen and an excessive buildup of carbon diox-
ide (CO ). Regardless of the cause, some of the first responses the body makes to
2
inadequate gas exchange are changes in the way that we breathe and a change in
mental status. Signs of inadequate gas exchange can appear anywhere on a sliding
scale from very mild, to moderate, to severe. In some instances, the buildup of CO
2
can occur even with an adequate supply of oxygen.
Signs of inadequate breathing are not always immediately obvious. They can
be very subtle, perhaps only mild shortness of breath. In these instances, the only
way you would know is by asking the patient, “Do you feel short of breath?”
Sometimes if the patient has been short of breath for awhile, he may also appear
pale. It is good practice to ask any patient who appears pale if he is having any
trouble breathing or if he feels short of breath.
RESPIRATORY DISTRESS
Often the first sign that the patient is not receiving an adequate supply of oxygen
is an increased respiratory rate. This is the body’s way of saying, “If I can’t get
enough oxygen at the normal rate, I had better increase the rate to try and make
up the difference.” If the body is unable to compensate simply by increasing the
rate, other mechanisms begin to kick in, making the respiratory distress more ob-
vious (Table 7-1 on page 168).
168 ✱ Chapter 7 Managing Your Patient’s Airway
TABLE 7-1 SIGNS OF AN INADEQUATE GAS EXCHANGE (RESPIRATORY DISTRESS)
✱ Increased respiratory rate (early sign)
✱ Increased work of breathing (labored)
✱ Decreased tidal volume
✱ Increased use of accessory muscles (neck, chest, and abdominal)
✱ Nasal flaring (most common in pediatric patients)
✱ Retractions (above the clavicles, between the ribs, below the ribs) Mostly
seen in pediatric patients
✱ Pale skin that may be moist
✱ Decreasing mental status
✱ respiratory distress Respiratory distress is the body’s way of attempting to compensate for an in-
the body’s attempts to adequate supply of oxygen (Figure 7-2AandB). In most cases the body does a good
compensate for an inadequate job of compensating and, with the assistance of the EMT, some oxygen, and ap-
supply of oxygen. propriate medications, the patient’s respiratory status may return to normal.
RESPIRATORY FAILURE
When the body’s normal compensatory mechanisms are not able to provide for ad-
equate gas exchange, the patient is in danger of progressing from respiratory dis-
✱ respiratory failure tress to respiratory failure(Figure 7-3). Respiratory failure occurs when the brain
the reduction of breathing to the and vital organs have gone too long without an adequate supply of oxygen and
point where oxygen intake is not can no longer compensate. Some of the first signs of respiratory failure are a de-
sufficient to support life. creased mental status and a decreased respiratory rate (Table 7-2).
Respiratory failure is an extreme emergency, and the EMT must begin pro-
viding assisted ventilations as soon as possible (Figure 7-4on page 170). This will
be discussed in more detail later in this chapter.
TABLE 7-2 SIGNS OF RESPIRATORY FAILURE
✱ Decreased mental status
✱ Decreased respiratory rate (below normal)
✱ Change in breathing rhythm (irregular)
✱ Breath sounds that become diminished (less obvious)
✱ Decreased chest rise and fall (poor tidal volume)
✱ Skin that may be pale or cyanotic (blue) and cool and clammy
✱ In infants, possible “seesaw” breathing where the abdomen and chest
move in opposite directions
✱ Agonal respirations (occasional gasping breaths) that may be seen just
before death
Chapter 7 Managing Your Patient’s Airway ✱ 169
FIGURE 7-2A Patient displaying signs of respiratory distress. FIGURE 7-2B A patient in respiratory distress may
assume the tripod position.
FIGURE 7-3 An unresponsive patient in respiratory failure.
PEDIATRIC DIFFERENCES
As discussed in Chapter 4, there are several differences in anatomy between adult
and pediatric patients. Some of these differences may change the way that you care
for the patient.
In general, all of the structures of the pediatric respiratory system are smaller
and therefore more easily blocked by swelling or foreign material. The tongue