National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Chapter 9 Airway Management

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Objectives 9.1 List the major anatomical structures of the upper airway. 9.2 Describe and demonstrate how to manually open the airway using the following techniques: a.Head tilt-chin lift b.Jaw thrust c.Crossed finger

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Objectives 9.3 Describe how to clear a patient’s airway using the following methods: a.Gravity b.Finger sweep c.Suction 9.4 Describe how to place a patient into the recovery position.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Objectives 9.5 Compare, contrast, and demonstrate the usage of a rigid suction catheter and a flexible suction catheter. 9.6 List the indications of and uses for the following airway adjuncts, and demonstrate the proper methods for choosing the correct size and inserting them: a.Oropharyngeal airway b.Nasopharyngeal airway

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Objectives 9.7 Describe how to calculate the oxygen flow duration rate. 9.8 Describe and demonstrate how to properly set up an oxygen tank for use. 9.9 List four tips for the safe use of oxygen.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Objectives 9.10 Describe and demonstrate how to use the following oxygen delivery and ventilation devices: a.Nasal cannula b.Nonrebreather mask c.Barrier shield d.Pocket mask e.Bag-valve mask

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Objectives 9.11 Describe and demonstrate how to use the following barrier devices: a.Face shield b.Pocket mask

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Topics Airway Anatomy and Physiology Airway Management Oxygen Therapy

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Case Presentation You are called to the scene of an accident where you find a middle-aged ice climber; he is unresponsive to painful stimuli and has shallow respirations. He reportedly fell approximately 20 feet, striking his head and neck on a rocky outcrop. You note minor bleeding from his mouth as well as a deep cut on his chin. His pulse is rapid at 108/minute.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Case Presentation His head and neck appear "crooked" and his left arm appears bent at an unnatural angle.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Anatomy and Physiology Upper Airway ◦ Mouth and nose to the larynx Lower Airway ◦ Trachea, bronchi, and alveoli

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Anatomy and Physiology Anatomy of the upper airway.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Physically ensure that the airway is open and clear. Continued

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Head Tilt-Chin Lift Continued Anatomy of the adult in a neutral position.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Head Tilt-Chin Lift Continued The head tilt-chin lift position; note the open airway.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Head Tilt-Chin Lift Continued The neutral starting position for the head tilt-chin lift maneuver in an adult.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Head Tilt-Chin Lift Continued The final tilted position of the head tilt-chin lift in an adult.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Jaw Thrust The jaw-thrust maneuver is used to open the airway in patients with a suspected spinal injury.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Jaw Thrust The jaw-thrust maneuver is used to open the airway in patients with a suspected spinal injury.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Crossed Finger Method Continued Opening a patient’s mouth using the crossed-finger technique.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Clearing the Airway ◦ Gravity ◦ Finger Sweep ◦ Suction Continued

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Continued A manual suction device.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Continued A portable, battery-operated suction device.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Principles of Suctioning ◦ Pre-oxygenate the patient ◦ Look in the nose/mouth to locate the fluid or object ◦ Insert the tip of the catheter (without suction) Do not insert the catheter farther than you can see Initially, leave the catheter hole on the handle uncovered ◦ Turn on suction or cover the hole on the handle ◦ Suction for no more than seconds No more than 5-10 seconds in a child ◦ Repeat as indicated Continued

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Recovery Position ◦ May be used for conscious or unresponsive patients. ◦ Especially helpful when there is only one rescuer. Continued

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Continued The recovery position (or left lateral recumbent position) is used to prevent aspiration in patients not suspected to have spinal injuries.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Airway adjuncts ◦ Nasopharyngeal Airway (NPA) SSize LLubricate IInsert CCheck Continued

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Continued Two nasopharyngeal (nasal) airways (NPAs).

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Airway adjuncts ◦ Oropharyngeal Airway (OPA) SSize IInsert CCheck Continued

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Continued A set of oropharyngeal (oral) airways (OPAs).

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management What commonly blocks the airway? Which airway maneuver would you use with the fallen ice climber? How long should you apply suction? How far should you insert the suction catheter?

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Case Update You immediately perform a jaw-thrust maneuver to open the unresponsive patient’s airway. With an assistant protecting the spine, you carefully roll the patient onto his side to allow blood to flow out of his airway. You perform a finger sweep to remove several broken teeth. Upon arrival of a suction unit, you suction out the airway.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Case Update Although the patient’s pulse is strong, his respirations are becoming increasingly shallow and erratic. His lips are cyanotic.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Barrier devices ◦ Face shields Examples of barrier devices.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Airway Management Barrier devices ◦ Pocket masks Examples of barrier devices.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Possible Indications ◦ Short of breath ◦ Cardiac or respiratory arrest ◦ Cardiac chest pain ◦ Stroke ◦ Signs and symptoms of shock ◦ Decreased LOR ◦ Head injury ◦ Fractures long bone Continued

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Oxygen Cylinders Continued Three oxygen cylinders. Left to right: jumbo D cylinder, D cylinder, and E cylinder.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Set-Up ◦ Inspect the cylinder and regulator ◦ Momentarily “crack” the value ◦ Attach the regulator Align the two smaller pins. Finger-tighten the regulator. Set the flow rate to zero. ◦ Open the oxygen valve Continued

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Safety ◦ Never use near a spark or open flame ◦ No smoking when oxygen is in use ◦ Keep petroleum materials away ◦ Turn off cylinder when not in use ◦ Protect the valve stem from damage Continued

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Safety ◦ Leave protective caps in place ◦ Clear stem before attaching regulator ◦ Do not over tighten regulator Continued

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Delivery Adjuncts ◦ Nasal Cannula Low flow adjunct (1-6 LPM). Prongs concave downward. Delivers 24%-44% oxygen. Well tolerated by patients. Continued

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Continued A nasal cannula.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Delivery Adjuncts ◦ Non-Rebreather Mask High flow adjunct (10-15 LPM). Delivers 80%-90% oxygen. May cause patient anxiety. Continued

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Continued A nonrebreather mask.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Delivery Adjuncts ◦ Bag-Valve Mask (BVM) Patients who are not breathing or who need assisted breathing. Ambient air or supplemented with oxygen. High flow oxygen (12-15 LPM). Delivers 80%-100% oxygen. Continued

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Continued A bag-valve mask unit with an oxygen reservoir.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Bag-Valve Mask (BVM) ◦ Two-Person Technique Continued A two-rescuer breathing assist using a bag-valve mask. Copyright Scott Smith

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Bag-Valve Mask (BVM) ◦ One-Person Technique A one-rescuer breathing assist using a bag-valve mask. Copyright Scott Smith

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Pulse Oximetry ◦ Measures oxygen saturation in blood ◦ Typically 92% or higher Continued

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Continued A mini “finger-sized” pulse oximeter.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Oxygen Therapy Gastric distention: ◦ Caused by stomach filling with air ◦ More common with children ◦ May result in vomiting or aspiration of gastric contents into the lungs ◦ Prevented by reducing ventilatory pressure (gentle breaths over two seconds)

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Case Disposition You insert an OPA and begin providing artificial respirations using a pocket mask. As other providers arrive, you request that another OEC technician assist you in two-rescuer ventilation using a BVM and suction the patient as needed.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Case Disposition You assist in immobilizing the patient and placing him onto a toboggan. He is then transported to a waiting ambulance. You later learn that the patient had a severe head injury. The neurosurgeon credits you and your team for your effective airway management, without which, he states, the patient would have died.

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Chapter Summary Review the structures of the upper and lower airways. Review the two maneuvers to open a patient’s airway. ◦ Which is appropriate for trauma patients? Review the three methods of clearing the airway. Continued

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Chapter Summary Review the principles of suctioning. Review the oxygen setup, adjuncts, and oxygen flow rates. What do SLIC and SIC refer to with NPAs and OPAs?

National Ski Patrol, Outdoor Emergency Care, 5/e ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Chapter Summary What oxygen flow rates are used with: ◦ Nasal Cannula? ◦ Non-Rebreather Mask? ◦ Bag-Valve-Mask?