Transcript Document
Respiratory Emergencies East Region (Washington) OTEP M-7 Brian Reynolds, MD Deaconess Medical Center Spokane, WA Respiratory Emergencies We are going to cover material for ALL levels of training YOU CAN ONLY PRACTICE AT THE LEVEL YOU HAVE BEEN CERTIFIED Topics Anatomy and function of the Respiratory System Patient Assessment Airway Management Anatomy of the Upper Airway Upper Airway Nasal cavity Oral cavity Pharynx Nasal Cavity Nares Mucous membranes Sinuses Oral Cavity Cheeks Hard palate Soft palate Tongue Gums Teeth Pharynx Nasopharynx Oropharynx Laryngopharynx Larynx Thyroid cartilage Cricoid cartilage Glottic opening Vocal cords Arytenoid cartilage Pyriform fossae Cricothyroid cartilage Internal Anatomy of the Upper Airway Lower Airway Anatomy Trachea Bronchi Alveoli Lung parenchyma Pleura Anatomy of the Lower Airway Definitions Atelectasis – collapse of small segments of lung Hypoxia – lack of oxygen Hypoxemia – blood lack of oxygen in arterial Introduction Ventilation is the mechanical process that brings O2 to the lungs, and clears CO2 from the lungs Oxygenation is the diffusion of O2 to the blood Perfusion is the flow of blood through the lungs (thus exchanging oxygen and CO2) Brain stem is the involuntary regulator of respirations Respiratory Physiology Ventilation Body Structures Chest Wall Pleura Diaphragm Tidal Volume: 7ml/kg (Adult 500ml) Pathophysiology Disruption in Ventilation Upper & Lower Respiratory Tracts Obstruction due to trauma or infectious processes Chest Wall & Diaphragm Trauma Pneumothorax Hemothorax Flail chest Neuromuscular disease Oxygenation air – 21% FiO2 Roughly 3% increase per liter Nasal cannula – 8L max (40%) Mask – 10L (55%) NRB mask – 15L (80%) Room Pulmonary Circulation Respiratory Physiology Pulmonary Perfusion Requirements Adequate blood volume Intact pulmonary capillaries Efficient pumping by the heart Hemoglobin Carbon Dioxide Pathophysiology Disruption in Perfusion Alteration in systemic blood flow Changes in hemoglobin Pulmonary shunting Damaged alveoli Respiratory Factors Factor Fever Emotion Pain Hypoxia Acidosis Effect Increases Increases Increases Increases Increases Stimulants Increase Depressants Decrease Sleep Decreases Assessment of the Respiratory System Scene Assessment Threats to Safety Make sure you are safe first Identify rescue environments having decreased oxygen levels Gases and other chemical or biological agents Clues to Patient Information Assessment of the Respiratory System Initial Assessment General Impression Position Color Mental status Ability to speak Respiratory effort Assessment of the Respiratory System Airway Proper ventilation cannot take place without an adequate airway Breathing Signs of life-threatening problems Alterations in mental status Severe central cyanosis, pallor, or diaphoresis Absent or abnormal breath sounds Speaking limited to 1–2 words Tachycardia Use of accessory muscles or intercostal retractions Abnormal Respiratory Patterns Kussmaul’s respirations: Deep, slow or rapid, gasping; common in diabetic ketoacidosis Cheyne-Stokes respirations: Progressively deeper, faster breathing alternating gradually with shallow, slower breathing, indication brain stem injury Abnormal Respiratory Patterns Agonal respirations: Shallow, slow, or infrequent breathing, indicating brain anoxia Focused History & Physical Exam History SAMPLE History Paroxysmal nocturnal dyspnea and orthopnea Coughing, fever, hemoptysis Associated chest pain Smoking history or environmental exposures Similar Past Episodes Focused History & Physical Exam Physical Examination Inspection Look for asymmetry, increased diameter, or paradoxical motion Palpation Feel for subcutaneous emphysema or tracheal deviation Percussion Auscultation Focused History & Physical Exam Auscultation Normal Breath Sounds Bronchial, Bronchovesicular, and Vesicular Abnormal Breath Sounds Snoring Stridor Wheezing Rhonchi Rales/Crackles Pleural friction rub Focused History & Physical Exam Diagnostic Testing Pulse Oximetry Inaccurate Readings Ausculation Listen at the mouth and nose for adequate air movement Listen with a stethoscope for normal or abnormal air movement Proper listening positions Airway Obstruction The tongue is the most common cause of airway obstruction Foreign bodies Trauma Laryngeal spasm and edema Aspiration Congestive Heart Failure Wet, crackly lung sounds Lower Must extremity edema sit and sleep upright Frothy, pink sputum Obstructive Lung Disease Types Emphysema Chronic Bronchitis Asthma Causes Genetic Disposition Smoking & Other Risk Factors Emphysema Assessment Physical Exam Barrel chest Prolonged expiration and rapid rest phase Thin Pink skin due to extra red cell production Hypertrophy of accessory muscles “Pink Puffers” Chronic Bronchitis Physical Exam Often overweight Rhonchi present on auscultation Jugular vein distention Ankle edema Hepatic congestion “Blue Bloater” Asthma Physical Exam Presenting signs may include dyspnea, wheezing, cough No wheezing is severe disease Speech may be limited to 1–2 word sentences Look for hyperinflation of the chest and accessory muscle use/feel chest wall for crepitus Carefully auscultate breath sounds and measure peak expiratory flow rate Pneumonia Infection of the Lungs Immune-Suppressed Patients Pathophysiology Bacterial & Viral Infections Hospital-acquired vs. community-acquired Alveoli may collapse, resulting in a ventilation disorder Lung Cancer Pathophysiology General Majority are caused by carcinogens secondary to cigarette smoking or occupational exposure May start elsewhere and spread to lungs High mortality Types Adenocarcinoma Epidermoid, small-cell, and large-cell carcinomas Toxic Inhalation Pathophysiology Includes inhalation of heated air, chemical irritants, and steam Airway obstruction due to edema and laryngospasm due to thermal and chemical burns Assessment Focused History & Physical Exam SAMPLE & OPQRST History Determine nature of substance Length of exposure and loss of consciousness Carbon Monoxide Inhalation Pathophysiology Binds to Hemoglobin Prevents oxygen from binding to RBC’s Room air half life – 6 hrs., HBO – 23 minutes Assessment Focused History and Physical Exam SAMPLE & OPQRST History Determine source and length of exposure Presence of headache, confusion, agitation, lack of coordination, loss of consciousness, and seizures Pulmonary Embolism Pathophysiology Obstruction of a pulmonary artery Emboli may be of air, thrombus, fat, or amniotic fluid Foreign bodies may also cause an embolus Risk Factors Recent surgery, long-bone fractures Pregnant or postpartum Oral contraceptive use, tobacco use Immobility Blood disorders Spontaneous Pneumothorax Pathophysiology Pneumothorax Can occur in the absence of blunt or penetrating trauma Risk factors Assessment Focused history SAMPLE Presence of risk factors Rapid onset of symptoms Sharp, pleuritic chest or shoulder pain Often precipitated by coughing or lifting Hyperventilation Syndrome Assessment Focused History & Physical Exam SAMPLE Fatigue, nervousness, dizziness, dyspnea, chest pain Numbness and tingling in mouth, feet, and both hands Presence of tachypnea and tachycardia Spasms of the fingers and feet Airway Sounds Airflow Compromise Gas Exchange Compromise Snoring Crackles Gurgling Rhonchi Stridor Wheezing Quiet Basic Mechanical Airways Insert oropharyngeal airway with tip facing palate Rotate airway 180º into position Nasopharyngeal Airway (Do not use if significant facial trauma) Advanced Airway Management Advanced Airway Management Endotracheal intubation Combitube CPAP and BiPAP CO2 monitors – measure exhaled CO2 Normal – 5-6% Advantages of Endotracheal Intubation Isolates trachea and permits complete control of airway Maximizes ventilation and oxygenation Impedes gastric distention Eliminates need to maintain a mask seal Offers direct route for suctioning Laryngoscope Blades Placement of Macintosh blade into vallecula Placement of Miller blade under epiglottis Endotrol ETT ETT, stylet, syringe Combitube CPAP Endotracheal Intubation Indicators Respiratory or cardiac arrest Unconsciousness Risk of aspiration Obstruction due to foreign bodies, trauma, burns, or anaphylaxis Respiratory extremis due to disease (Pneumothorax), hemothorax, (hemopneumothorax) with respiratory difficulty Complications of Endotracheal Intubation Equipment malfunction Teeth breakage and soft tissue injury Hypoxia Esophageal intubation Endobronchial intubation Tension pneumothorax Extubation Tracheostomies/Stomas Use patient’s supplies Ambu Treat bag attaches easily as an endotracheal tube Suction Questions 1. Which one is lack of oxygen in the blood? a. Hypoxia b. Hypocarbia c. Hypoxemia d. Hypocarbemia Questions 2. Which one is the best airway? a. Nasal cannula b. Endotracheal tube c. Oral airway d. Combitube Questions 3. Which one is a contraindication to nasal trumpet use? a. Seizure b. Bloody nose c. DNR patient d. Significant facial trauma Questions 4. Which one is the correct tidal volume for a 200 pound patient? a. 500cc b. 600cc c. 700cc d. 800cc Questions 5. Which one is not an indication for endotracheal intubation? a. Respiratory failure b. Cardiac arrest c. GCS of 5 d. Hyperventilation syndrome Now you know everything about respiratory emergencies Questions? Renee Anderson [email protected] Garry Frey [email protected] 509-232-8155 FAX: 509-232-8344 509-242-4263