Airway Decisions Module

Gaining control of the airway is an essential goal in caring for patients.

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force3 By Steve Cole, CCEMT-P EMS House of DeFrance By Steve Cole, CCEMT-P

Airway control can be a challenge and it requires solid preparation, staying focused, the right tools and the right decisions.

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force5 Do I have an airway?

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force6 Is the chest rising evenly?

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force7 Is he breathing?

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force8 Are his respirations shallow?

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force9 Are we ventilating?

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force10 What are her breath sounds like?

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force11 Is the Combitube placed correctly? Is the oral airway the right size? Do we need to assist her breathing? What is the respiratory pattern?

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force12 Is this patient in respiratory distress? Shortness of breath Poor skin color Tripod position Irregular breathing Coughing Abdominal breathing Decreased tidal volume Retractions Difficulty speaking Noisy breathing Decreased respiratory rate Increased respiratory rate Increased pulse rate Restlessness Increased work of breathing

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force13 Noisy Breathing  Crowing  Wheezing  Gurgling  Snoring  Stridor

Decision making and airway management are addressed in a separate module.

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force15 Answers are, in part, founded in understanding of anatomy and physiology  Role of CO2  Mechanics of breathing  Aerobic metabolism

Principles of Clinical Decision Making

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force17 Principles of Clinical Decision Making  History  Assessment  Anticipated Outcomes  Complications

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force18 Principles of Clinical Decision Making  History  Assessment  Anticipated Outcomes  Complications Past History (AMPLE) Underlying medical conditions (COPD) Present History Onset Provocation Quality Radiation Severity Time Interventions Trauma? Access? Team airway ability?

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force19 Principles of Clinical Decision Making  History  Assessment  Anticipated Outcomes  Complications Assess for signs of ADEQUATE breathing Reassess often Reassess at any deterioration of patient condition

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force20 Principles of Clinical Decision Making  History  Assessment  Anticipated Outcomes  Complications Experience with similar patients Patient prediction Assessment findings “Charted course” of deterioration History or MOI

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force21 Principles of Clinical Decision Making  History  Assessment  Anticipated Outcomes  Complications What will happen if nothing is done? What are the risks to procedures being considered? What is the likelihood of a poor outcome? Assess for procedural effectiveness

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force22 Decision Making Algorhythm  Patient is:  Responsive/adequate breathing – Oxygen may be indicated

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force23 Decision Making Algorhythm  Patient is:  Responsive/inadequate breathing – Oxygen is indicated – Open airway – Use NPA – Assist ventilations Mouth to mask, BVM, Manually triggered ventilator

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force24 Decision Making Algorhythm  Patient is:  Responsive/inadequate breathing – Oxygen is indicated – Open airway – Use NPA/OPA – Suction as needed – Reassess

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force25 Decision Making Algorhythm  Patient is:  Unresponsive/adequate breathing – Oxygen is indicated – Use NPA – Assist ventilations Mouth to mask, BVM, Manually triggered ventilator – Reassess

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force26 Decision Making Algorhythm  Patient is:  Unresponsive/inadequate or no breathing – Oxygen is indicated – Open the airway – Use NPA/OPA – Suction as needed – Assist ventilations Mouth to mask, BVM, Manually triggered ventilator – Reassess

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force27 Considerations in Difficult Ventilation Situations  Patient positioning  Suctioning  Manual airway maneuvers  Two person mask seal

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force28 Considerations in Difficult Ventilation Situations  Oral and nasopharyngeal airways  ECT/PTL  Agents to treat swollen airways  Verify no obstruction

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force29 Approach to Airway  Trauma  Non Trauma

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force30 Airway Decisions  To oxygenate or not  Trauma versus nontrauma  Ventilate versus oxygenate only  Adjunctive device application  Effectiveness of patients own respiratory efforts OR of care team’s ventilations

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force31 To Oxygenate or Not  Assess for adequate breathing  Consider – History – Assessment – Anticipated Outcomes – Complications

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force32 Trauma versus Nontrauma  Decide early/reconsider throughout care  Assess for force involved  Medical conditions may lead to trauma  Trauma may complicate medical conditions  History  Assessment  Anticipated Outcomes  Complications

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force33 Ventilate versus Oxygenate Only  Reduction in minute volume  Respiratory arrest  Need to eliminate CO2  Reduced tidal volume  History  Assessment  Anticipated Outcomes  Complications

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force34 Adjunctive Device Application Progressive 02 BVM OPA/NPA ECT/PTL  History  Assessment  Anticipated Outcomes  Complications

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force35 Effectiveness of Patients Own Respiratory Efforts OR of Care Team’s Ventilations  Assess for improvement in patient condition  Verify device effectiveness/place ment  Use end tidal C02 detectors  Assess for adequate ventilation  History  Assessment  Anticipated Outcomes  Complications

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force36 Assessment “of our breathing for them”  Effort of breathing  Compliance  Chest rise – Evenness – Depth  Intercostal bulging  Skin Color

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force37 Assessment “of our breathing for them”  CO2 detector  Lung sounds  Epigastric sounds  General condition

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force38 Assessment “of their breathing”  Effort of breathing  Number of ventilations per minute  Pattern of breathing  Frequency of breathing  Plus assessment of items under our breathing for them

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force39 Key Airway Decisions  How bad is he?  Is the patient better or worse?  What can I do to improve the patient’s condition?  Experience and assessment  Compare one assessment to another  Ensure adequacy of airway/ventilation

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force40 Case Number One  A 17 year old female involved in a car accident (see next slide). She is unresponsive and has gurgling respiration on removal from the car. She is immobilized in a supine position on a spine board.

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force41 Case Number One

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force42 Case Number Two A 22 year old male has been stabbed in the throat. First responders tell you he was conscious and could not speak beyond a whisper. He said he felt like his airway was blocked and it was hard to breath. He was struggling to breath. Minutes later, on your arrival he has stopped breathing.

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force43 Case Number Two

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force44 Case Number Three A tractor has rolled over a 54 year old male. He is conscious and complaining of shortness of breath. He has diminished breath sounds on the right side and uneven chest rise. There is no JVD. HR is 150. RR is 28. BP is 148/88. Skin is pink, warm and dry.

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force45 Case Number Four  An 18 year old male was beaten by several men after an argument. His LOC is responsive and breathing is irregular and shallow.

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force46 Case Number Four

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force47 Case Number Five  A 7 year old boy drowned in a backyard pool. There is gurgling on ventilation attempts. He is pulseless and not breathing.

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force48 Case Number Five

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force49 Case Number Six  A 20 year old was holding a firecracker in his mouth when in exploded. He is short of breath. RR is 26. HR is 140. He feels like there is swelling in his throat. He is wheezing and has a history of asthma. He does not have his inhaler.

August 2002 Kansas Airway Supplement Kansas BEMS EMS Educator Task Force50 Case Number Six