Transcript Patient Data Evaluation and Recommendations

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
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Common ACLS IV medications
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Medications that can be instilled through ET tube
 Monitoring and Assessment
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Periodic pulse / respiration checks
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ECG
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Pulse oximetry
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End-tidal CO2
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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
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Transport team must communicate with team at receiving location
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Before transport, receiving location confirms readiness to receive patient
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Members of health care team notified of timing of transport and needed equipment
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Documentation includes physician’s order, indications for transport, and patient status throughout.
Personnel
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At least two persons must accompany critically ill patients
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Usually a critical care nurse and respiratory therapist
Equipment
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BP monitor, pulse oximeter, cardiac monitor/defibrillator
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Airway management and secretion clearance, oxygen, BVM or ventilator
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Basic resuscitation drugs, sedation /narcotic analgesics
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IV fluids, medications, fully charged battery-operated infusion pump
Monitoring
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Duplicate as much as possible monitoring provided in originating unit
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Continuous ECG monitoring
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Continuous pulse oximetry
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Periodic measurement of blood pressure, pulse rate, and respiratory rate
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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
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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
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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
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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 dropletproducing 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