Paramedic Care Principles & Practice, Volume 2: Paramedicine Fundamentals (Pearson New International Edition)

411 Pages·2013·73.596 MB·English

by  Bryan E. Bledsoe, Robert S. Porter, Richard A. Cherry

P
a
r
a
m
e
d
i
c

C
a
r
e

B
l
e
d
s
o
e

P
o
r
t
e
r

C
h
Paramedic Care: Principles & Practice
e
r
r Volume 2, Paramedicine Fundamentals
y

Bledsoe Porter Cherry

F Fourth Edition
o
u
r
t
h

E
d
i
t
i
o
n
ISBN 978-1-29202-138-6
9 781292 021386
Paramedic Care: Principles & Practice
Volume 2, Paramedicine Fundamentals
Bledsoe Porter Cherry
Fourth Edition
ISBN 10: 1-292-02138-1
ISBN 13: 978-1-292-02138-6
Pearson Education Limited
Edinburgh Gate
Harlow
Essex CM20 2JE
England and Associated Companies throughout the world
Visit us on the World Wide Web at: www.pearsoned.co.uk
© Pearson Education Limited 2014
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the
prior written permission of the publisher or a licence permitting restricted copying in the United Kingdom
issued by the Copyright Licensing Agency Ltd, Saffron House, 6–10 Kirby Street, London EC1N 8TS.
All trademarks used herein are the property of their respective owners. The use of any trademark
in this text does not vest in the author or publisher any trademark ownership rights in such
trademarks, nor does the use of such trademarks imply any affi liation with or endorsement of this
book by such owners.
ISBN 10: 1-292-02138-1
ISBN 13: 978-1-292-02138-6
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Printed in the United States of America
133992911377
P E A R S O N C U S T O M L I B R AR Y
Table of Contents
1. Airway Management and Ventilation
Bryan E. Bledsoe/Robert S. Porter/Richard A. Cherry 1
2. Emergency Pharmacology
Bryan E. Bledsoe/Robert S. Porter/Richard A. Cherry 97
3. Pathophysiology
Bryan E. Bledsoe/Robert S. Porter/Richard A. Cherry 191
4. Intravenous Access and Medication Administration
Bryan E. Bledsoe/Robert S. Porter/Richard A. Cherry 323
Index 397
I
II
Airway Management
and Ventilation
From Chapter 5 of Paramedic Care: Principles & Practice, Volume 2, Fourth Edition. Bryan Bledsoe,
Robert Porter, and Richard Cherry. Copyright © 2013 by Pearson Education, Inc. All rights reserved.
1
Airway Management and Ventilation
Airway Management
and Ventilation
bryan bledsoe, do, FaCep, Faaem, emt-p
W. e. Gandy, jd, nremtp
Standard darren braude, md, mpH, FaCep
Airway Management, Respiration, and Artificial Ventilation
CompetenCy
Integrates comprehensive knowledge of anatomy, physiology, and pathophysiology into the
assessment to develop and implement a treatment plan with the goal of ensuring a patent
airway, adequate mechanical ventilation, and respiration for patients of all ages.
objeCtiveS
Terminal Performance Objective
After reading this chapter you should be able to apply principles of airway management
and ventilation to the assessment and management of patients.
Enabling Objectives
To accomplish the terminal performance objective, you should be able to:
1. Define key terms introduced in this chapter.
2. Explain the importance of immediate recognition and management of problems with
a patient’s airway, breathing, or oxygenation.
3. Explain the importance of nonlinear thinking and action in assessment and manage-
ment of problems with the airway and ventilation.
4. Describe the legal liability associated with poor assessment and management of
airway and ventilation.
5. Recognize the anatomical structures of the upper and lower airway.
6. Describe the functions of the upper and lower airway structures.
7. Apply knowledge of differences in pediatric airway and respiratory anatomy to
managing a pediatric patient’s airway and ventilation.
8. Explain the physiology of respiration and ventilation.
9. Describe the etiologies and pathophysiology of the upper airway and inadequate
ventilation.
10. Recognize the signs and symptoms of upper airway obstruction and inadequate
ventilation.
11. Demonstrate management of upper airway obstruction and inadequate ventilation.
12. Identify problems with the airway, breathing, and oxygenation through primary and
secondary patient assessment and noninvasive respiratory monitoring.
13. Differentiate between patients for whom supplemental oxygen administration is
indicated and those for whom it is not indicated.
14. Describe the risks and benefits of supplemental oxygen administration.
2
C/M/Y/K S4DcESIGaN SrERVlICiESS OlF e
Short / Normal Publishing Services
15. Recognize the indications and contraindications for basic airway interventions,
including the following:
a. various positioning techniques
b. administering supplemental oxygen by a variety of devices
c. manual airway maneuvers
d. inserting basic airway adjuncts
16. Demonstrate techniques of basic airway management, including positioning, admin-
istering supplemental oxygen by a variety of devices, manual airway maneuvers, and
inserting basic airway adjuncts.
17. Differentiate between adequate and inadequate breathing in a patient.
18. Recognize the need for artificial ventilation of a patient.
19. Demonstrate techniques of ventilation, including:
a. mouth-to-mouth/mouth-to-nose ventilation (in an apneic patient in the absence
of equipment)
b. mouth-to-mask ventilation
c. bag-valve-mask ventilation
d. use of cricoid pressure in conjunction with techniques of ventilation
e. demand valve device
f. transport ventilator
20. Demonstrate modifications of ventilation techniques for pediatric patients.
21. Describe the indications, contraindications, advantages, disadvantages, complications,
equipment, and techniques for the use of advanced airway devices and techniques,
including various extraglottic airways, endotracheal intubation, and cricothyrotomy.
22. Under the supervision of a lab instructor or clinical preceptor and as allowed in your
scope of practice, demonstrate effective techniques of advanced airway manage-
ment, including the following:
a. insertion of extraglottic airways
b. orotracheal intubation
c. blind nasotracheal intubation
d. digital intubation
e. trauma patient airway management
f. verification of endotracheal tube placement
g. foreign body removal under direct laryngoscopy
h. pediatric intubation
i. needle cricothyrotomy
j. open cricothyrotomy
23. Recognize complications of advanced airway management.
24. Take actions to correct complications of advanced airway management.
25. Discuss management of post-intubation agitation and field extubation.
26. Explain the considerations in medication-assisted intubation.
27. Describe procedures for medication-assisted intubation.
28. Describe the pharmacology of agents commonly used in medication-assisted intubation.
29. Given a variety of scenarios of patients requiring airway management, including pa-
tients with a difficult airway, intervene to establish an effective airway and ventilation
without delay.
30. Recognize predictors of a difficult airway.
31. Defend your decision-making processes in scenarios involving airway management
and ventilation.
3
C/M/Y/K S4DcESIGaN SrERVlICiESS OlF e
Short / Normal Publishing Services
32. Manage airway and ventilation in patients with stomas.
33. Demonstrate effective suctioning of the oropharynx and trachea (in an intubated patient).
34. Take steps to minimize and manage gastric distention.
35. Accurately and completely document relevant information about assessment and
management of the airway, ventilation, and oxygenation in patient care reports.
Key termS
ABCs French oxygen saturation percentage
alveoli gag reflex (SpO )
2
anoxia glottis Pa
apnea hemoglobin (Hgb) PA
arterial oxygen concentration hemoglobin oxygen saturation paradoxical breathing
(CaO ) (SaO ) parenchyma
2 2
aspiration hemothorax partial pressure
atelectasis Hgb pharynx
bag-valve mask (BVM) high-pressure regulator pleura
barotrauma hypercarbia pneumothorax
bilevel positive airway hyperoxia POGO scoring system
pressure (BiPAP) hypoventilation pulmonary embolism
bronchi hypoxemia pulse oximetry
CaO hypoxia pulsus paradoxus
2
capnography hypoxic drive ramped position
carbon dioxide insufflate rapid sequence intubation
compliance intubation (RSI)
continuous positive airway laryngoscope respiration
pressure (CPAP) larynx respiratory rate
Cormack and LeHane grading Lipp maneuver retroglottic airways
system lumen SaO
2
cricoid pressure Magill forceps septum
cricothyroid membrane Mallampati classification sinus
cyanosis system sniffing position
demand-valve device minute volume stenosis
diffusion mucous membrane stoma
dyspnea mucus stylet
ear-to-sternal-notch nare suction
position nasal cannula supraglottic airways
endotracheal tube (ETT) nasolacrimal ducts therapy regulator
endotracheal tube introducer nasopharyngeal airway tidal volume
eustachian tube (NPA) total lung capacity
extraglottic airway (EGA) nasotracheal route trachea
devices needle cricothyrotomy upper airway obstruction
extubation normoxia vallecula
FiO open cricothyrotomy ventilation
2
flail chest oropharyngeal airway (OPA) Venturi mask
free radicals oxygen
CaSe Study
Ellis County Unit 947, along with a Fire Engine, is dispatched to a motor vehicle collision
on rural County Road 664, approximately eight miles from town. This particular stretch
of road is well known to paramedics because of a number of serious crashes over the
last several months. The road contains numerous sharp curves and is under construction
in several locations. Today, Unit 947 is staffed by paramedic Kathy Mulligan and AEMT
4
C/M/Y/K S4DcESIGaN SrERVlICiESS OlF e
Short / Normal Publishing Services
Airway Management and Ventilation
William Benson. In addition, paramedic student Sharon Rodriquez is assigned to the unit
for her paramedic field internship. There are three volunteer firefighter/EMTs on the engine.
On arrival at the scene, they find one vehicle that has apparently run off the road
and struck a telephone pole. Witnesses to the crash estimate the vehicle was travel-
ing at approximately 45 miles per hour before striking the pole. The lone 24-year-old
male occupant was ejected from the vehicle and lies face down in a ditch approximately
50 feet from the car. After ensuring scene safety and donning the appropriate personal
protective equipment, Kathy assesses the patient. She finds him to be unresponsive.
William, Sharon, and the firefighters help her logroll the patient to a supine position while
applying cervical-spine precautions. Sharon holds in-line cervical spine stabilization
while Kathy opens the airway with the modified jaw-thrust technique.
The patient exhibits agonal respirations. In addition, gurgling noises are heard
with each breath. After suctioning bloody secretions from his mouth, Kathy attempts to
insert an oropharyngeal airway. However, the patient’s teeth are tightly clenched, and
the airway will not pass. Sharon places a nasal airway, and then the entire team provides
three-person ventilatory support with a bag-valve-mask unit and 100-percent oxygen.
The Glasgow Coma Score is 5.
They load the patient into 947 and initiate Code 3 transport to the closest Level 1
Trauma Center 31 minutes away. En route, they obtain a full set of vital signs, keep the
patient warm, and start a large-bore IV. The patient’s blood pressure is 167/92, HR 110,
and oxygen saturation is only 88 percent despite optimal BVM ventilation. Kathy radios to
have another paramedic meet them en route so they can perform rapid sequence intuba-
tion (RSI), as their protocols require that two medics be present for this procedure.
When they meet up with the second paramedic 23 minutes from the hospital, they
are still having trouble maintaining adequate oxygenation, and there is no indication of
tension pneumothorax or other treatable etiology. The two medics agree that RSI is in-
dicated. One of the firefighters maintains in-line cervical stabilization as they remove the
front of the collar. They give the 100-kg patient 30 mg of etomidate and 200 mg of suc-
cinylcholine. Forty-five seconds after succinylcholine was administered, the fasciculations
(muscle twitches) have passed from head to toe, and the patient is flaccid.
Kathy attempts bimanual laryngoscopy but is unable to visualize the glottis or posterior
cartilages. She makes one attempt with an endotracheal tube introducer under the epiglottis,
which is unsuccessful, and the patient’s oxygen saturations are noted to be falling. The two
medics then elect to place an LMA-Supreme airway. They inflate the cuff and begin ventila-
tions with high-concentration supplemental oxygen, using a self-inflating bag. The patient’s
oxygen saturation quickly rebounds, and they decompress the stomach with a gastric tube in-
serted through the dedicated channel on the device. They replace the cervical collar, connect
the LMA-Supreme to the transport ventilator, and monitor capnography and other vitals. They
adjust the ventilator to maintain a normal exhaled CO and administer fentanyl and midazolam
2
to keep the patient comfortable. They arrive at the trauma center 16 minutes later. The pa-
tient’s blood pressure is 147/84, HR is 98, saturation is 93 percent, and exhaled CO is 35.
2
The trauma team leaves the LMA-Supreme in place to obtain initial radiographs and
CT scans that reveal a pulmonary contusion and a large subdural hematoma that requires
emergent surgical drainage. In the operating room, the patient is intubated through the
LMA-Supreme, using fiber-optic guidance. Following surgery, the patient begins to regain con-
sciousness but requires continued intubation for 72 hours because of oxygenation and ventila-
tion issues. On day four, he is successfully extubated and moved to a regular hospital room.
Kathy and her Unit 947 team stop by the hospital to visit after the patient is extu-
bated. He has no recall of the crash at all. The last thing he remembers is looking on the
floor of his car for a CD that he dropped. One week after the crash, he is discharged to
rehabilitation with minimal neurologic deficits.
5
C/M/Y/K S4DcESIGaN SrERVlICiESS OlF e
Short / Normal Publishing Services