Introduction to Emergency Medical Care 1 Advance Preparation Prepare anatomy models for demonstration. Research related multimedia links for illustration purposes. Prepare airway manikins for psychomotor sessions. Prepare airway equipment for demonstration and psychomotor sessions. Invite assistant instructors to assist with psychomotor sessions.

State Standard 21) Identify and perform skills to manage life threatening illnesses based on assessment findings of a pediatric, adult, and geriatric patient with medical emergencies, utilizing rubrics from textbooks, National HOSA guidelines, or clinical standards of practice in the following areas k. Respiratory distress/Asthma 22) Use assessment information to recognize shock, respiratory failure or arrest, and cardiac arrest based on assessment findings. Demonstrate the ability to manage the situation while awaiting additional emergency response.

Objectives Students will be able to… Identify common ventilation devices Demonstrate proper procedure for applying ventilation devices.

Patient Assessment: Signs of Respiratory Failure Signs of failed oxygenation and/or removal of CO2 Altered mental status Cyanosis Talking Points: Altered mental status occurs as hypoxia and hypercapnea set in. Mental status is a key finding in identifying respiratory failure. Cyanosis also indicates profound hypoxia. Discussion Topic: Define respiratory failure. Discuss the changes that occur when compensation fails. Knowledge Application: Compare and contrast respiratory distress with respiratory failure (inadequate breathing) in the following areas: lung sounds, respiratory rate, skin color, mental status.

Patient Assessment: Signs of Decompensation No or poor air movement Diminished or absent breath sounds Breathing rate too rapid, too slow, or irregular Patient unable to speak Unusual noises (wheezing, crowing, stridor, snoring, gurgling, gasping) Talking Points: Look for signs that the steps of compensation have failed. Decompensation is another key finding of respiratory failure.

Signs of Respiratory Failure: Pediatric Note In addition to other signs, look for retractions and nasal flaring Talking Points: Both of these signs are common findings of respiratory failure in pediatric patients.

Think About It What signs might identify the need to intervene in a breathing patient? Talking Points: Any signs of respiratory failure. Altered mental status, slow or irregular respirations, continued cyanosis, or any of the other signs previously discussed could indicate the need for immediate intervention.

Positive Pressure Ventilation Teaching Time: 30 minutes

Positive Pressure Ventilation Forcing air or oxygen into lungs when a patient has stopped breathing or has inadequate breathing Uses force exactly opposite of how the body normally draws air into the lungs Points to Emphasize: Artificial ventilation utilizes positive pressure to move air into the lungs. The body normally uses negative pressure to pull air in. As these are very different processes, positive pressure has negative side effects. Cricoid pressure can minimize gastric distention during artificial ventilation. Talking Points: Positive pressure ventilation (PPV) is also called artificial ventilation. Under normal circumstances, the respiratory system would create a negative pressure within the chest cavity to pull in air. With artificial ventilation, positive pressure is used to push air in. This difference has negative side effects.

Negative Side Effects of Positive Pressure Ventilation Decreasing cardiac output/dropping blood pressure Gastric distention Hyperventilation Talking Points: Negative pressure ventilation assists the filling of the heart. Positive pressure defeats this filling assistance. Gastric distention is the filling of the stomach with air that occurs when air is pushed through the esophagus during positive pressure ventilation. The esophagus is a larger opening than the trachea and air is frequently diverted there during PPV. Side effects include vomiting and restriction of the diaphragm. Hyperventilation causes too much CO2 to be blown off. This causes a vasoconstriction in the body and can limit blood flow to the brain. Discussion Topic: Discuss the negative impact of poor artificial ventilation technique. Consider the outcome of the following problems: rate too fast; too much volume; inadequate mask seal.

Key Concerns with PPV Do not ventilate patient who is vomiting or has vomitus in airway—PPV will force vomitus into patient’s lungs Watch chest rise and fall with each ventilation Ensure rate of ventilation is sufficient Talking Points: Make sure the patient is not actively vomiting and suction any vomitus from the airway before ventilating. Ventilation rates: 10–12 per minute in adults; 20 per minute in children; minimum of 20 per minute in infants. Knowledge Applications: Discuss scenarios with the class. Ask the class to determine the need for artificial ventilation. Discuss the decision-making process. Divide the class into two groups. Use a scenario to review the cost-benefit analysis of a “ventilate vs. not ventilate” decision. Have students debate both arguments. Discuss.

Ventilating a Breathing Patient Explain procedure to patient After sealing mask on patient’s face, squeeze bag with patient’s inhalation Point to Emphasize: Ventilating a breathing patient may be difficult. The goal is not necessarily to take over breathing, but rather to increase tidal volume. Talking Points: Calm reassurance and a simple explanation such as, “I’m going to help you breathe,” are essential in the conscious patient. When ventilating, watch as the patient’s chest begins to rise and deliver the ventilation with the start of the patient’s own inhalation. The goal will be to increase the volume of the breaths you deliver. Over the next several breaths, adjust the rate so you are ventilating fewer times per minute but with greater volume per breath (increasing the minute volume).

Mouth to Mask Ventilation Performed using a pocket face mask Point to Emphasize: A variety of methods are used to artificially ventilate a patient. EMTs should be familiar with the tools and techniques available to them. Talking Points: The pocket face mask is made of soft, collapsible material and can be carried in your pocket, jacket, or purse. Most pocket masks have one-way valves that allow ventilations to enter but prevent the patient’s exhaled air from coming back through the valve.

Performing Mouth to Mask Ventilation Open airway Connect oxygen and run at 15 Lpm Position mask on patient’s face Apex over bridge of nose Base between lower lip and prominence of chin Talking Points: It may be necessary to clear the airway of obstructions. If necessary, insert an oropharyngeal airway to help keep the patient’s airway open. continued

Performing Mouth to Mask Ventilation Hold mask firmly in place; maintain head tilt Exhale into mask port Allow passive exhalation Talking Points: Each ventilation should be delivered over 1 second and be of just enough volume to make the chest rise. Once the chest rises, remove your mouth from the port and allow for passive exhalation.

Achieving Tight Mask Seal Position thumbs over top of mask, index fingers over bottom of mask, and remaining fingers under patient’s jaw Position thumbs along side of mask and remaining fingers under patient’s jaw Discussion Topic: Discuss the procedure for ventilating a patient with a pocket mask.

Bag-Valve Mask (BVM) Handheld ventilation device Used to ventilate nonbreathing patient and/or patient in respiratory failure Talking Points: BVM may also be referred to as a bag-valve-mask unit, system, device, or resuscitator. Using a BVM in the field is often referred to as “bagging” the patient.

Standard Features of BVM Self-refilling shell that is easily cleaned and sterilized Non-jam valve that allows an oxygen inlet flow of 15 Lpm Nonrebreathing valve Point to Emphasize: A good mask seal is an important and often difficult element of bag-valve-mask ventilation. Talking Points: Some BVM units are designed for a single use only. continued

Standard Features of BVM

Mechanics of BVM Supply of 15 Lpm O2 attached and enters reservoir When squeezed, air inlet closed and oxygen delivered to patient When released, passive expiration by patient occurs

Two-Rescuer BVM Ventilation Strongly recommended by AHA Most difficult part of BVM ventilation is obtaining adequate mask seal Hard to maintain seal while squeezing bag One rescuer squeezes bag; other rescuer maintains seal Talking Points: The most difficult part of delivering BVM artificial ventilations is obtaining an adequate mask seal so that air does not leak out around the edges of the mask. It is difficult to maintain the seal with one hand while squeezing the bag with the other, and one-rescuer BVM operation is often unsuccessful or inadequate for this reason. In two-rescuer BVM ventilation, one rescuer is assigned to squeeze the bag while the other rescuer uses two hands to maintain a mask seal.

Two-Rescuer BVM Ventilation: No Trauma Suspected Open airway with head-tilt, chin-lift maneuver Select correct bag-valve mask size Kneel at patient’s head; position thumbs over top half of mask, index fingers over bottom half Talking Points: When opening the airway either a head-tilt, chin-lift or a jaw-thrust maneuver may be used, depending on the threat of spinal injury. continued

Two-Rescuer BVM Ventilation: No Trauma Suspected Place apex of triangular mask over bridge of nose; lower mask over mouth and upper chin Talking Points: If the mask has a large, round cuff surrounding a ventilation port, center the port over the patient’s mouth. continued

Two-Rescuer BVM Ventilation: No Trauma Suspected Use middle, ring, and little fingers to bring patient’s jaw up to mask Maintain head-tilt, chin-lift maneuver continued

Two-Rescuer BVM Ventilation: No Trauma Suspected Second rescuer connects and squeezes bag Second rescuer releases bag; patient exhales passively Talking Points: The second rescuer should squeeze the bag once every 5 seconds for an adult, once every 3 seconds for a child or infant.

Two-Rescuer BVM Ventilation: Trauma Suspected Open airway using jaw-thrust maneuver Select correct bag-valve mask size Kneel at patient’s head; place thumb sides of your hands along mask to hold it firmly on patient’s face continued

Two-Rescuer BVM Ventilation: Trauma Suspected Use remaining fingers to bring jaw upward toward mask, without tilting head or neck Class Activities: Distribute clean face masks. Have students choose a partner and practice obtaining good hand position and face seal using a pocket mask or BVM face mask. (Do not ventilate.) Try obtaining the seal in different positions (patient supine, patient sitting up, and so on). Have students choose a partner and find the appropriate finger position for cricoid pressure. Check their locations.

One-Rescuer BVM Ventilation Open airway Select correct size mask Position mask on patient’s face Squeeze bag Release pressure on bag and let patient exhale passively Talking Points: You should provide ventilations with a one-rescuer BVM procedure only when no other options are available. (Behind use of a pocket face mask with supplemental oxygen, two-rescuer BVM procedure, and use of a flow-restricted, oxygen-powered ventilation device.) Suction and insert an airway adjunct as necessary. To seal the mask with one person form a “C” around the ventilation port with the thumb and index finger. Use middle, ring, and little fingers under the patient’s jaw to hold the jaw to the mask. Squeeze the bag slowly (over one second) once every 5 seconds. For infants and children, squeeze the bag once every 3 seconds. The squeeze should be a full one, causing the patient’s chest to rise.

If Chest Does Not Rise During BVM Ventilation Reposition head Check for escape of air around mask; reposition fingers and mask Check for airway obstruction or obstruction in BVM system Use alternative method Talking Points: Re-suction the patient if necessary. Consider insertion of an airway adjunct if not already done. Alternative methods include a pocket mask or a flow-restricted, oxygen-powered ventilation device. Discussion Topic: Discuss the procedure for ventilating a patient with a bag-valve mask.

Artificial Ventilation of a Stoma Breather Clear mucus plugs or secretions from stoma Leave head and neck in neutral position Talking Points: A stoma is a surgical opening in the neck through which the patient breathes. Patients with stomas who are found to be in severe respiratory distress or respiratory arrest frequently have thick secretions blocking the stoma. It is recommended that you suction the stoma frequently in conjunction with BVM-to-stoma ventilations. It is unnecessary to position the airway prior to ventilations in a stoma breather. continued

Artificial Ventilation of a Stoma Breather Use pediatric-sized mask to establish seal around stoma Ventilate at appropriate rate for patient’s age If unable to artificially ventilate through stoma, seal stoma and attempt artificial ventilation through mouth and nose Talking Points: Ventilating through the mouth and nose may work if the trachea is still connected to the passageways of the mouth, nose, and pharynx. In some cases, however, the trachea has been permanently connected to the neck opening with no remaining connection to the mouth, nose, or pharynx. Discussion Topic: Discuss the procedure for artificially ventilating a stoma patient.

, Oxygen-Powered Ventilation Device Flow-Restricted , Oxygen-Powered Ventilation Device Talking Points: Also called a manually triggered ventilation device. Recommended features of a FROPVD include a peak flow rate of 100 percent oxygen at up to 40 liters per minute, an inspiratory pressure relief valve that opens at approximately 60 cm of water pressure, an audible alarm when the relief valve is activated, a rugged design and construction, and a trigger that enables the rescuer to use both hands to maintain a mask seal while triggering the device.

Using Flow-Restricted, Oxygen-Powered Ventilation Device Use on adults only Follow same procedures for mask seal as for BVM Trigger device until chest rises Talking Points: If the chest does not rise, reposition the head, check the mask seal, check for obstructions, and consider the use of an alternative artificial ventilation procedure. When using the FROPVD on a patient with chest trauma, be especially careful not to over-inflate, as you may actually make the chest injury worse. Discussion Topic: Discuss the procedure for ventilating a patient with a flow-restricted, oxygen-powered ventilation device. continued

Using Flow-Restricted, Oxygen-Powered Ventilation Device

Automatic Transport Ventilator (ATV) Provides automated ventilations Can adjust ventilation rate and volume Provider must assure appropriate respiratory rate and volume for patient’s size and condition Knowledge Application: Describe a variety of patient scenarios. Ask students to choose a method to artificially ventilate the patient in each scenario. Discuss why the chosen method would be appropriate or inappropriate. Critical Thinking: If using a BVM was ineffective at ventilating a patient, what would the next step be? What are the alternatives?

Think About It How would you decide which positive pressure delivery method to use for your patient? Talking Points: Each airway management scenario is slightly different. Factors such as resources, personnel, and even levels of training might impact the choice you make. Generally speaking, it is best to start simply and work to a more complex level only when necessary.

Video Positive Pressure Ventilation https://www.youtube.com/watch?v=L7mj5X71OS4 BVM with a oral/nasal airway https://www.youtube.com/watch?v=VU0sxnIEbz0

Activity ***We have now covered our objectives*** We will now practice proper placement for ventilation devices. You must create a proper seal against the face if using a BVM or facial mask. I will be observing you while placing the devices. Practice placing the devices and maintaining an open airway. Exit ticket: Write a paragraph describing the proper procedure for placing a BVM. When should this be used?