Initiation and Modification of Therapeutic Procedures Initiate, Conduct, or Modify Respiratory Care Techniques in an Emergency Setting

BLS Be able to properly administer BLS to adults and children. NBRC CRT exam will not reflect recent AHA changes – ABC of resuscitation rather than CAB

ACLS Adult Resuscitation Protocols Identify the 4 cardiac arrhythmias that cause most common adult cardiopulmonary emergencies. Medications Common ACLS IV medications Medications that can be instilled through ET tube Monitoring and Assessment Periodic pulse / respiration checks ECG Pulse oximetry End-tidal CO2 ABG

Pediatric and Neonatal Emergencies Pediatric Resuscitation Most likely exam scenario is pulseless arrest Know pediatric doses for medications / defibrillation shock Most common medical emergency with pediatric patients is airway obstruction Neonatal Resuscitation Flaccid, cyanotic, or apneic infants require stimulation and supplemental O2 Manual ventilation required if color, heart rate, breathing not restored within 30 seconds Heart rates below 60 always require chest compressions in neonates.

Treat a Tension Pneumothorax You must be familiar with the common signs and symptoms, as well as emergency treatment, of tension pneumothorax (a potentially life-threatening disorder). Diagnosis Predisposing factors: High airway pressures with mechanical ventilation (> 40-45 cm H2O) Chest trauma Excessively high compliance i.e. advanced emphysema Clinical Manifestations Rapid decline in cardiopulmonary status (hypoxemia, hypotension) Decreased or absent breath sounds on the affected side Hyperresonance when percussing the affected side Possible subcutaneous emphysema Tracheal shift away from affected side Rapid increase in ventilator pressures (if mechanical or manual ventilation in use) Shock and/or PEA in severe, untreated cases. Chest X-ray Confirmation Initial Treatment Emergency decompression of the chest (needle thoracostomy)

Patient Transport NBRC expects you to be competent in transporting critically ill patients. Ensure patient safety Intra-hospital transport as well as land / air external transport AARC guidelines for contraindications to transport are based on any of the following not being reasonably ensured during transport: Provision of adequate oxygenation and ventilation Maintenance of acceptable hemodynamic performance Adequate monitoring of the patient’s cardiopulmonary status Maintenance of airway control

Patient Transport Intra-Hospital Patient Transport Patient transport must address the following: Communication Transport team must communicate with team at receiving location Before transport, receiving location confirms readiness to receive patient Members of health care team notified of timing of transport and needed equipment Documentation includes physician’s order, indications for transport, and patient status throughout. Personnel At least two persons must accompany critically ill patients Usually a critical care nurse and respiratory therapist Equipment BP monitor, pulse oximeter, cardiac monitor/defibrillator Airway management and secretion clearance, oxygen, BVM or ventilator Basic resuscitation drugs, sedation /narcotic analgesics IV fluids, medications, fully charged battery-operated infusion pump Monitoring Duplicate as much as possible monitoring provided in originating unit Continuous ECG monitoring Continuous pulse oximetry Periodic measurement of blood pressure, pulse rate, and respiratory rate Periodic assessment of breath sounds

Patient Transport Air and Land Transport Unique aspects Choosing among ground and air transport modes Managing increased patient movement and stimulation Accommodating the need for special personnel and equipment Addressing the effects of altitude on PaO2 and closed air spaces. Team Physician, respiratory therapist, nurse or paramedic ACLS skills

Medical Emergency Teams Rapid Response Teams ICU nurse, physician or physician assistant, respiratory therapist Criteria for activation for adults Acute change in mental status or overall clinical appearance Heart rate < 40 or > 130, or respiratory rate < 8 or > 30/min Systolic blood pressure < 90 SpO2 < 90%, especially with supplemental O2 Acute change in urinary output to < 50 ml over 4 hours Common interventions performed by RC Airway suctioning Adjusting FiO2 Providing noninvasive ventilation Administering bronchodilators Intubation

Disaster Management NBRC expects you to be prepared for preparedness planning or implementation of triage and decontamination/isolation procedures. Department preparedness plan should consider Patient needs Estimate numbers of patients who may require Ventilatory support Medical gas therapy (O2 or air) Suction Personnel Number of staff required to meet patient needs Staff emergency call-back procedure Enlist non-respiratory personnel to perform manual ventilation Equipment Maintain inventory of available ventilators Maintain adequate number of disposable BVMs to meet needs Determine backup equipment to meet needs Plan to acquire additional backup equipment Plan to transfer patients if backup equipment unavailable. Plan in place for failure of gas supply systmes Estimate quantity of backup required for each gas Estimate ancillary equipment needs (regulators, portable suction, etc.) Deployment plan for distribution/maintaining backup gas sources

Common Errors to Avoid on the Exam Never use an AED on an infant (< 1 year old) Avoid compressions in excess of ½ to 1 inches during infant CPR to help prevent injury to the patient Don’t treat the monitor!! If the monitor shows asystole but the patient appears awake, alert, and in no apparent distress, don’t begin CPR. Never treat a pneumothorax with a needle decompression or a chest tube until the diagnosis has been confirmed by chest x-ray. Never forget a manual resuscitator bag and a mask when you are transporting intubated and ventilated patients so you will be able to ventilate them if they become inadvertently extubated.

More Common Errors to Avoid on the Exam Never use an adult or pediatric manual resuscitator bag/mask to ventilate a neonate. Use the appropriate age-specific equipment. Don’t forget that during air transport, it is often appropriate to increase the FiO2 in order to maintain adequate oxygenation, and it may also be necessary to temporarily adjust tidal volume and artificial airway cuff pressure to ensure the safety of mechanically ventilated patients. Never wait for a physician to arrive to begin assessing a patient as part of a medical emergency team. During management of respiratory epidemics, avoid droplet- producing procedures (e.g., nebulizers, chest physiotherapy on patients with suspected infections).

Exam Sure Bets Always remember the ABCDs (Airway, Breathing, Circulation, Defibrillation) of CPR Always look, listen, and feel before starting CPR; the patient may be simply sleeping. Always give compressions at a depth of 1 1/2 to 2 inches for an adult patient If the chest doesn’t rise with the first breath in CPR, don’t panic – always reposition the head first and try another breath. Always have an appropriate-sized BVM when transporting a critically ill patient.

More Exam Sure Bets Always suspect a tension pneumothorax when a patient is rapidly deteriorating in the presence of any of the following: a unilateral decrease in breath sounds and chest expansion, hyerresonance when percussing the affected side, shifting of the trachea away from affected side, and subcutaneous emphysema. When assisting a physician with a needle thoracostomy for the emergency treatment of a tension pneumothorax, always recommend that the needle be placed over the second rib in the midclavicular line.

More Exam Sure Bets Always apply chest compressions to a neonate whose heart rate is less than 60. When assisting in the transport of a critically ill patient, always ensure that you have an adequate oxygen supply and delivery device, as well as an array of age-appropriate respiratory equipment, including a manual resuscitator bag, transport ventilator/circuits, and intubation equipment. Always practice droplet precautions, in addition to standard precautions, when examining a patient with symptoms of a respiratory infection.

Reference: Certified Respiratory Therapist Exam Review Guide, Craig Scanlon, Albert Heuer, and Louis Sinopoli Jones and Bartlett Publishers