Airway and respiratory

[tniuqs]

'DwayneEMTP'

NICE I LIKE IT !

Agreed .. a good thread ... bhwaa haa ha "cast iron ovaries"

Again Agreed realistic advice.

Dwayne

This post deserves a

I would like to add, if an NPA is within scope of practice, this is a most excellent tool to use as a suction guide. Then instillation and deep Tracheal Suction (watching for Bradycardia) many COPDers crash directly due to inadequate hydration, increased insensitive water loss and serious mucus plugging ... just my 2 cents.

cheers

[Floridastudent]

DwayneEMTP - Okay, I'll bite!

"You are dispatched to the local nursing home for an older man who is "difficult to wake". You arrive at the nursing home about five minutes after the initial call and find the patient to be lying supine in bed with oxygen flowing at 2 l/min via nasal cannula. THe nurse states that the patient was fine last evening but they were unable to wake him this morning. They state he has a history of COPD and recent pneumonia. The patient has shallow gurgling respirations at a rate of about 8 breaths per minute. You also note cyanosis around the lips. WHile you are assembling your suction unit, your partner is placing the patient on a pulse oximeter.

Book question - How would you manage this patient's airway and breathing? Would you change the position of this patient?

My guess - insert oropharyngeal airway if he doesn't have a gag reflex (nasopharyngeal airway if he does), suction the patient for up to 15 seconds, then 100 percent high flow oxygen via bag valve mask, squeezing every 3 to 5 seconds. Ventilate for up to 2 minutes, then suction again if needed."

DwayneEMTP - Can you rethink this and see if you can explain why this isn't the most logical order of events? (Note, you won't find this answer in your book.)

Unfortunately, at this point while I'm struggling to keep my grades up - they're varying between 90 and 95 percent depending on how well I did on the most recent test or quiz - all I can do is memorize and recite back what I've been told. Once I pass the NREMTB I can start thinking for myself and paying attention to what actually works in the field. (Well, okay, once I start doing clinicals and ridealongs and talk to real EMTs I can do a little thinking for myself, but honestly - I'm cramming so much rote-memorized stuff into my head - I don't have much room for anything else.

Okay - what would I do differently for the nursing home patient in the example above? From the info the book gave me - the patient is breathing but his breathing is clearly inadequate. He is gurgling. In the book it says, if the patient is gurgling - suction!

Should I have tilted his head back first before I put in the airway, to see if the cause of the gurgling was his tongue?

Edited February 14, 2010 by Floridastudent

[JPINFV]

Book vs. street - Tell me about it! I start ridealongs next month. From what I gather - in class we need to memorize and mindlessly parrot back the book when we take quizzes and tests. In the field we need to do what makes sense, as long as we follow our local protocols.

I'm a CNA and what we learned in class doesn't have much to do with what they tell me to do when I go cover nursing home shifts.

The volume only gets bigger the higher up the food chain you go. However hopefully some of the why's are sticking when memorizing information. After all, just because you can use tools like Epocrates in the field doesn't mean you can use it on a licensing exam.

[DwayneEMTP]

DwayneEMTP - Okay, I'll bite!

Unfortunately, at this point while I'm struggling to keep my grades up - they're varying between 90 and 95 percent depending on how well I did on the most recent test or quiz - all I can do is memorize and recite back what I've been told...

I disagree, for two reasons. First and foremost, your posts make it clear that you're sharp as a tack (For non Americans that means quick witted and intelligent). Second, you not only have room for both, but memorization will be much easier if you attach those things to 'context hooks.' Imagine the pt and imagine your steps as you memorize the facts. The 'what' becomes almost ridiculously easy when you attach it to a 'why.'

Okay - what would I do differently for the nursing home patient in the example above? From the info the book gave me - the patient is breathing but his breathing is clearly inadequate. He is gurgling. In the book it says, if the patient is gurgling - suction!

What have you gained by putting your OPA in place before you suction? What has this done to your visual field as well as your ability to maneuver your suction tip? You had all of the steps, and knowing your attention to detail I'll bet this is the order that the book gave, but doesn't it make more sense to suction first and then put in your OPA?

If possible I'm not going to bag this pt before I suction him as I don't want to actively blow more yucky stuff down his lungs than absolutely necessary. Now, I may have little choice, depending on his condition, but he'll need to be bucking and choking for me to decide to bag for the 3-4 seconds it will take me to begin to suction.

Also, you should have had your suction unit assembled before you needed it, unless this is an issue somewhere that I'm not used to. Now, again, let's go back to your pt, back to you pt, back to your pt...(That was my attempt at making that echo in your head.) It always goes back to the pt....

A couple more questions, beings you have the CAOs to play...

You're assembling your suction. What is your partner doing?

Is this the most productive thing he could be doing to improve this pts status?

What could he be doing instead?

Is there another possibility for maybe helping clear the airway in the short term besides suction? (hint: What would you do if you came across this man unresponsive in the mall?)

Good on you for playing! It's uncommon that we get new students that have the confidence to say, "I don't care if I some people don't think I'm smart, I just want to learn!" We had Lisa O starting a few months ago and I was afraid she'd fulfilled our quota for the year..but it turns out perhaps we'll be setting a new quota for next year.

Dwayne

[CBEMT]

Scenario 2- why are we assuming trauma? Takes about a second and a half to ask bystanders what happened. They'll either tell you, or say nobody saw him go down. It's part of a SAMPLE history, so its not even wrong by the book.

Nobody saw him, ok fine, pretend he's got a 1 in a million unstable cervical spine fracture, and try to maintain a jaw thrust while bagging (not going to happen- effectively- with one person) so we can maintain c-spine stabilization.

Or they say "He just collapsed." In which case I don't think there's a thing wrong with a head tilt/chin lift.

Maybe I didn't answer the question, but I just couldn't let it go.

Scenario 3- x1000 to sitting the patient up. You'd be amazed how many problems it solves. KISS.

[Floridastudent]

Scenario 2- why are we assuming trauma? Takes about a second and a half to ask bystanders what happened. They'll either tell you, or say nobody saw him go down. It's part of a SAMPLE history, so its not even wrong by the book.

Nobody saw him, ok fine, pretend he's got a 1 in a million unstable cervical spine fracture, and try to maintain a jaw thrust while bagging (not going to happen- effectively- with one person) so we can maintain c-spine stabilization.

Or they say "He just collapsed." In which case I don't think there's a thing wrong with a head tilt/chin lift.

Maybe I didn't answer the question, but I just couldn't let it go.

Scenario 3- x1000 to sitting the patient up. You'd be amazed how many problems it solves. KISS.

In the real world, that would be fine, but in the context of this class - our teacher continually tells us to just go by what the question says. Take whatever the question says as being the absolute truth. If the question says that you show up on a crime scene and the scene is safe - don't ask how you know the scene is safe. Don't ask who told you the scene is safe. The Question says so.

In the real world, you'd question bystanders - but in the class - if the question says you don't know the events leading up to the cardiac arrest - you have to assume possible trauma.

I disagree, for two reasons. First and foremost, your posts make it clear that you're sharp as a tack (For non Americans that means quick witted and intelligent). Second, you not only have room for both, but memorization will be much easier if you attach those things to 'context hooks.' Imagine the pt and imagine your steps as you memorize the facts. The 'what' becomes almost ridiculously easy when you attach it to a 'why.'

What have you gained by putting your OPA in place before you suction? What has this done to your visual field as well as your ability to maneuver your suction tip? You had all of the steps, and knowing your attention to detail I'll bet this is the order that the book gave, but doesn't it make more sense to suction first and then put in your OPA?

If possible I'm not going to bag this pt before I suction him as I don't want to actively blow more yucky stuff down his lungs than absolutely necessary. Now, I may have little choice, depending on his condition, but he'll need to be bucking and choking for me to decide to bag for the 3-4 seconds it will take me to begin to suction.

Also, you should have had your suction unit assembled before you needed it, unless this is an issue somewhere that I'm not used to. Now, again, let's go back to your pt, back to you pt, back to your pt...(That was my attempt at making that echo in your head.) It always goes back to the pt....

A couple more questions, beings you have the CAOs to play...

You're assembling your suction. What is your partner doing?

Is this the most productive thing he could be doing to improve this pts status?

What could he be doing instead?

Is there another possibility for maybe helping clear the airway in the short term besides suction? (hint: What would you do if you came across this man unresponsive in the mall?)

Good on you for playing! It's uncommon that we get new students that have the confidence to say, "I don't care if I some people don't think I'm smart, I just want to learn!" We had Lisa O starting a few months ago and I was afraid she'd fulfilled our quota for the year..but it turns out perhaps we'll be setting a new quota for next year.

Dwayne

My partner could be elevating the patient's bed while I'm assembling suction, or he could be trying to manually clear the patient's airway.

Hey, I am DELIGHTED to ask questions on here! There's not always the opportunity in class.

[Floridastudent]

Oh, as to the question why I would use an oropharyngeal airway before suctioning - according to The Book - all hail the almighty book - The two principal purposes of an oropharyngeal airway are: To keep the tongue from blocking the upper airway and to make it easier to suction the oropharynx if necessary.

[tniuqs]

Oh, as to the question why I would use an oropharyngeal airway before suctioning - according to The Book - all hail the almighty book - The two principal purposes of an oropharyngeal airway are: To keep the tongue from blocking the upper airway and to make it easier to suction the oropharynx if necessary.

4 Uses for the OPA

1- An Airway (as stated)

2- As a guide for a suction cath.(type dependent ie Guedel)

3- As a bite block.

4- As a puke scoop (and to prevent the operator from being bitten)

[DwayneEMTP]

Oh, as to the question why I would use an oropharyngeal airway before suctioning - according to The Book - all hail the almighty book - The two principal purposes of an oropharyngeal airway are: To keep the tongue from blocking the upper airway and to make it easier to suction the oropharynx if necessary.

I've never really gotten the idea that it's easier to suction with an OPA in, perhaps I need more practice.

What I was getting at above was this, that this patient needed oxygenation, right?

How do we know that? Because his lips are blue. So if his lips are blue, and this convinces us that he really really needs Os, then what advantage has our pt gained for the time that your partner spent digging out and then applying the SPO2? What information did it give you that you didn't already have simply by looking at your patient?

Does your book insist that you apply a pulse ox on all difficulty breathing patients? If so it's very dangerous to be convinced that the machine will tell you more than your assessment...

Perhaps I'm trying to make these too difficult, but I've lost track of the basic curriculum long ago, so you'll have to help me out...

While you're assembling your suction and your partner is dicking around with the SPO2, couldn't someone simply roll this pt to LLR (Left lateral recumbent) so that some of the drainage would simply drain onto the bedding? That's what I meant by the 'found him in the mall' reference. If he's breathing, slobbery, pukey, I'm just going to roll him LLR and find a fireman to stand by being heroic while they wait for EMS.

The point I was trying to make before, and doing so very poorly, was to try and focus your attention back onto your patient. All of your answers are there, every time and always will be. You need the rest of the educational tools of cours, but too often when we get jammed up we turn to our books which often necessitates turning away from our patients...

I will try and stay more book focused to the best of my ability in the future however..

Good luck girl...

Dwayne

[Kiwiology]

1.) If someone is breathing, but they are breathing inadequately - say, shallow breaths, labored breathing, etc. - am I correct in assuming that I would use assisted ventilation (bag valve mask) rather than a nonrebreathing mask? The nonrebreathing mask would generally be used if breathing is adequate but hypoxia is suspected?

Also - once you start the assisted ventilations via BVM - do you continue with the BVM after breathing becomes adequate, or switch to a nonrebreathing mask? My guess is you would continue the assisted ventilations with the BVM until you arrive at the hospital and transfer care - is that right?

Be careful here; ventilation and oxygenation are not the same thing, a patient can be barely breathing but adequately oxygenated or breathing fine and inadequately oxygenated. The two are very different physiologic processess which most ambo's never pick up on.

If the patient is inadequately oxygenated then its appropriate to use a bag mask however do so at a slow rate; the good old ambo trick of "more is better" is not going to help you.

A cautionary note that there is nothing "magic" about oxygen and it is often given to patients who do not require it or in quantities above what is required. 2-4 litres on a nasal cannula will do for 90% of patients who actually require oxygen.

Should the breathing become adequate then stop bagging them, there's no point in continuing to do something they can do themselves

2.) Scenario in book - you are called to the scene of a cardiac arrest and find that bystanders have initiated CPR. Patient was not breathing for about 3 minutes before they started CPR. Patient has occasional gasping breaths. You decide to open the patient's airway. You have no history of events leading up to the point of cardiac arrest. What is the preferred method of opening the airway? Head tilt chin lift, jaw thrust, nasal airway, none of the above.

I say jaw thrust because you don't know if there was any trauma - am I right?

Do you SEE any evidence of head or spinal trauma? Although it is wise to state the absense of evidence does not indicate evidence of absense I would use a head tilt, chin lift. Most cardiac arrests are primary arrests which are cardiac in origin, traumatic arrests well, there should be some evidence of trauma.

Book question - How would you manage this patient's airway and breathing? Would you change the position of this patient?

My guess - insert oropharyngeal airway if he doesn't have a gag reflex (nasopharyngeal airway if he does), suction the patient for up to 15 seconds, then 100 percent high flow oxygen via bag valve mask, squeezing every 3 to 5 seconds. Ventilate for up to 2 minutes, then suction again if needed.

Change the position of the patient - once they have been suctioned, before putting on the BVM, I would do the head tilt chin thrust maneuver (because no trauma is suspected).

Why are you inserting an NPA if the patient has a gag reflex?

History of COPD is most likely a red herring designed to make you withold oxygen.

Suction the airway and go from there; my guess is the old boy is going to require a lot of suctioning. I'd put him on a non-rebreather mask and see how that works, it may be entirely appropriate to just use that if he is getting good air exchange.