بسم الله الرحمن الرحيم -...
TRANSCRIPT
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بسم اهلل الرحمن الرحيم
Airway Management
and Ventilation
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an و املستعمل وهو الشكل البدائي لجهاز أمب-املصادر الغربية ترد فضل استعمال املنفاخ
ردام أوال جمعية انعاش األشخاص الغرقى في أمست)إلى -حالًيا في اإلنعاش التنفس ي
.1771في إنجلترا عام ( الجمعية اإلنسانية امللكية)ومن ثم استعمل في
ليزية منه والنسخة اإلنج( ابن أبي أصيبعة)الواقعة املختصرة التالية مأخوذة من كتاب
(طبقات األطباء)والعربية Classes of Physicians: بعنوان
كتب في القرن الثالث عشر
.م.1270املؤلف عاش بصورة رئيسية في القاهرة ومات عام
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أن طبيب هارون الرشيد جاء في سيرة صالح بن بهلة : )يروي ابن أبي أصيبعة
الة جاءه ليخبره أن به رمق ينقض ي وقت ص, والذى كان يعالج ابن عمه إبراهيم
. العشاء
في الطب يا أمير املؤمنين إن صالح بن بهلة عالم: وهنا تدخل جعفر بن يحيى وقال
ويحسن إحضاره
. عمهفأمر الرشيد بإحضار صالح وتوجيهه إليه ورده بعد منصرفه من عند ابن
ففعل ذلك جعفر
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فقال . موقد التمس صالح بن بهلة أن يقابل الرشيد بالذات ليخبره عن حال ابن عمه إبراهي
وأشهد على نفس ي من حضرك أن ابن عمك. أنا أشهدك يا أمير املؤمنين: صالح للرشيد
لي فصدقة على وكل مال, فإن كل دابة لي فحبيس في سبيل هللا, إبراهيم إن توفي في هذه الليلة
. ولم أقل ما قلت إال بعلم, املساكين
ح بن فأخذ يكيل اللوم لصال, جاء نعي إبراهيم ابن عم الرشيد, وملا كان وقت صالة العشاء
, ر املؤمنينهللا هللا يا أمي: صاح عند ذلك صالح, فلم يناطقه إلى أن سطعت روائح املجامر, بهلة
. ذلكفأذن له ب, فوهللا ما مات فأطلق لي الدخول عليه وحدي ثانية, أن تدفن ابن عمك حًيا
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ة وأتى صالح بمنفخ
ي من الخزانة ونفخ ف
أنف إبراهيم مقدار
ثلث ساعة
اضطرب بعدها
بدنه وجلس أمام
.الرشيد
وعاش إبراهيم بعد
ثم تزوج, ذلك دهًرا
العباسة بنت
املهدي وولي مصر
.وفلسطين
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FactsIS AIRWAY MANAGEMENT IS IMPORTANT?
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CPR Facts
About 75 percent to 80 percent of all out‐of
hospital cardiac arrests happen at home
So being trained to perform (CPR) can mean the difference
between life and death for a loved one.”AHA Guidelines
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anIntroduction
Establishing and maintaining a patent
airway and ensuring effective oxygenation
and ventilation are vital to patient care.
The human body needs a constant supply of
oxygen to carry out the physiologic
processes necessary to sustain life; the
airway is where it all begins.
To preserve life, the airway must remain
patent at all times—regardless of the
situation.
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Introduction
Respiratory systemBrings in oxygen
Eliminates carbon dioxide
Vital organs will not function properly if process is interrupted.
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Introduction
Failure to manage the airway is a major cause of
preventable death in the prehospital setting.
Understand the importance of:
Early detection of airway problems
Rapid and effective intervention
Continual reassessment
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The airway management techniques are
among the most crucial skills for you as a
paramedic.
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Introduction
Appropriate airway management
Open, maintain patent airway
Recognize, treat obstructions
Assess ventilation, oxygenation status
Administer oxygen.
Provide ventilatory assistance.
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anAnatomy
Oxygenation and ventilation
Assessment &Obstruction
Airway management
Oxygen therapy
Ventilatory support
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Anatomy
To effectively manage a patient’s airway, you must identify key
anatomic structures and
understand how those structures
may need to be manipulated
when inserting various airway
devices.
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Anatomy of
the Upper
Airway
all structures above the glottic opening
(glottis), or the space between the
vocal cords.
When you perform skills such as
endotracheal (ET) intubation, you must
identify the upper airway anatomy
Larynx
Divides upper and lower airways
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Anatomy of
the Upper
Airway
the tongue is the first—and largest—
anatomic structure that must be
manipulated when managing a
patient’s airway
The Tongue is the most common cause of Airway Obstruction
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Anatomy of
the Upper
Airway
At the base of the tongue, the uvula
extends from the soft palate in the
posterior oral cavity; manipulation of the
uvula is usually unnecessary, although the
uvula is an important anatomic landmark
to identify as you proceed to the posterior
pharynx.
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Anatomy of
the Upper
Airway
The pharynx is a muscular tube that extends from the nose and mouth to
the level of the esophagus and trachea;
it is composed of the
nasopharynx,
oropharynx, and
the laryngopharynx (hypopharynx).
Anatomy of the Upper Airway
Anatomy
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Anatomy of the
Lower Airway
Exchanges oxygen and carbon dioxide
from the glottis to the pulmonary capillary
membrane.
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Larynx
Marks where the upper airway ends and lower airway begins
The thyroid cartilage is a shield-shaped structure palpable on the anterior neck.
The laryngeal prominence, known as the Adam’s apple, is immediately inferior to the thyroid notch.
The Adam’s apple is more prominent in men than in women, and it can also be difficult to palpate in patients with obesity or patients with short necks.
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Larynx
Cricoid cartilage (cricoid ring)
• lies inferior to the thyroid cartilage;
• it forms the lowest portion of the larynx
• the only circumferential ring of the trachea(the other tracheal rings are semicircular).
• The cricoid ring is more prominent in females than it is in males.
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Larynx
Cricothyroid membrane: ligament between the thyroid and cricoid cartilage
• Site for emergency surgical and nonsurgical access to the airway (cricothyrotomy)
• it is bordered laterally and inferiorly by the highly vascular thyroid gland, you must locate the anatomic landmarks carefully when accessing the airway via the cricothyroid membrane.
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GlottisSPACE BETWEEN THE VOCAL
CORDS
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The epiglottis
(a leaf-shaped cartilaginous structure that
closes over the trachea during swallowing) is
located at the superior border of the glottis.
When you perform ET intubation, you must
visualize the epiglottis, glottis, and vocal cords
before inserting the ET tube
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Vallecula
Pocket between base of tongue and
epiglottis
Important landmark for ET
intubation
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Trachea
Conduit for air entry into the lungs
•Begins below the cricoid cartilage
•Descends down the midline of the neck and chest to the fifth or sixth thoracic vertebra
Esophagus lies posterior to the trachea
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Structures of the
Lower Airway
Tracheobronchial tree
…..Trachea—trunk of tree
Carries air to the lungs
Extends from the larynx to the
mainstem bronchi
The point at which the tracheal
cartilage bifurcates is called the
carina.
The carina is at roughly the level
of the fifth intercostal space.
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Structures of the
Lower Airway
In adults, the right mainstem bronchus
typically branches at a less acute angle than
the left. This explains why an endotracheal
(ET) tube that is advanced too far almost
always goes into the right mainstem bronchus
in an adult.
Similarly, aspirated foreign bodies often end
up in the right mainstem bronchus.
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anStructures of
the Lower
Airway
Tracheobronchial tree (cont’d)
Mainstem bronchi branch into:
Lobar bronchi
Segmental bronchi
Subsegmental bronchi
Bronchioles
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Structures of the Lower Airway
Bronchi and bronchioles are lined with cilia.
Inset photo: © Dr. Kessel &
Dr. Kardon/Tissue &
Organs/Visuals Unlimited.
© Dr. Kessel & Dr.
Kardon/Tissue &
Organs/Visuals Unlimited
Inset photo: © Dr. Kessel &
Dr. Kardon/Tissue &
Organs/Visuals Unlimited.
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Structures of the
Lower Airway
Bronchioles
Significant amount of gas
exchange
The terminal bronchioles are thin
and have little cellular structure
This anatomic design is helpful for
gas exchange, but it also means
the bronchioles lack cilia, have no
protective blanket of mucus, and are not shielded by smooth
muscle or more rigid structures.
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LungsCONSIST OF SMALLER BRONCHI,
BRONCHIOLES, AND ALVEOLI
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anLungs
Alveoli
Functional site for the exchange of oxygen
and carbon dioxide
Increase surface area of the lungs
Lined with a phospholipid compound
(surfactant)
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وءاخر دعوانا أن الحمد هلل رب العالمين وصل اللهم على سيدنا محمد وعلى اله وصحبه كلما ذكره الذاكرون
وغفل عن ذكره الغافلون
شكرهللا لكم
Tarik Saber Sarhan
(tssicu)
www.tssicu.tk
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Physiology and
Pathophysiology
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Physiology of Breathing
•Bring oxygen and nutrients to cells
•Remove waste
Respiratory and cardiovascular systems work
together.
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Ventilation
Process of moving air into and out of lungs: Two phases
Inhalation (inspiration)
Exhalation (expiration)
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Inhalation
Active, muscular part of
breathing
Air enters the mouth and
nose, moves to the trachea.
Diaphragm and intercostal
muscles contract.
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Inhalation
Diaphragm
Specialized skeletal muscle (voluntary and
involuntary)
Lungs
Have no muscle tissue
Depend on movement of the chest and
supporting structures
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Inhalation
The thoracic cage expands
during inhalation and air
pressure within the thorax
decreases.
Negative-pressure ventilation
Inhalation stops when
pressure is equalized.
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Inhalation
Thoracic cage:
like a bell jar in
which balloons
are suspended
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Exhalation
Passive process and does not normally
require muscular effort.
Stretch receptors signal apneustic
center as chest expands
Inhibits respiration
Exhalation occurs
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Oxygenation
Oxygen molecules loaded onto
hemoglobin molecules in the bloodstream
Adequate oxygenation is
required for respiration; however,
it does not guarantee that
respiration is taking place.
Required for ventilation but does
not guarantee it
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Oxygenation
Fraction of inspired oxygen (FIO2)
Percentage of oxygen in inhaled air
Increases with supplemental oxygen
Commonly documented as a decimal number
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Respiration
Respiration: process of exchanging oxygen and carbon dioxide
Involves ventilation, diffusion, and transport of oxygen and carbon
dioxide
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External Respiration
Exchange of O2 and CO2
between alveoli and blood in
pulmonary capillaries
Adequate ventilation is
necessary but does not
guarantee it.
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Internal Respiration
Exchange of O2 and CO2
between the systemic circulation and the cells
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Internal Respiration
Kreb cycle and oxidative phosphorylation
Energy is produced in the form of ATP.
Anaerobic metabolism
Without adequate oxygen, cells do not
completely convert glucose into energy.
Cells will eventually die.
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Internal Respiration
When mitochondria use oxygen to convert glucose to energy,
carbon dioxide accumulates in the cell.
Without oxygen, anaerobic metabolism leads to cell death.
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Pathophysiology of Respiration
Disruption of pulmonary ventilation, oxygenation, and respiration
causes immediate effects.
Must recognize and correct immediately
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Pathophysiology of Respiration
Every cell needs a
constant supply of
oxygen to survive.
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Hypoxia
Tissues and cells do not receive enough oxygen
Varying signs and symptoms, including:
Early signs: restlessness, irritability, tachycardia, and anxiety
Late signs: dyspnea (may be unable to speak in complete sentences),
mental status changes, a weak pulse, and cyanosis
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Ventilation-Perfusion Ratio and
Mismatch
Air and blood flow must be directed to the same place at the same
time.
Ventilation and perfusion must be matched.
If not, V/Q mismatch results.
Blood passes over alveolar membranes without gas exchange.
Carbon dioxide is recirculated into bloodstream.
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Factors Affecting Ventilation
Patent airway is critical for the provision of oxygen to tissues
Intrinsic and extrinsic factors can cause an airway obstruction.
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Factors Affecting Ventilation
Intrinsic factors: infection, allergic reactions, unresponsiveness
The tongue is the most common obstruction in an unresponsive patient.
Factors may not be directly part of the respiratory system.
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Factors Affecting Ventilation
Extrinsic factors: trauma and foreign body airway obstruction
Trauma requires immediate intervention.
Blunt/penetrating trauma and burns can disrupt airflow into the lungs.
Trauma to the chest wall can lead to inadequate pulmonary ventilation.
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Factors Affecting Ventilation
Hypoventilation
Carbon dioxide production exceeds elimination.
Hyperventilation
Carbon dioxide elimination exceeds production.
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Circulatory Compromise
Inadequate perfusion; oxygen demands will not be met.
Obstruction of blood flow is typically related to trauma.
Inhibits gas exchange at the tissue level
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Acid-Base Balance
Can be disrupted by
Hypoventilation
Hyperventilation
Hypoxia
May rapidly lead to deterioration, death
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Acid-Base Balance
Respiratory and renal systems help maintain homeostasis.
Tendency toward stability in the body
Requires balance between acids and bases
Acid in the body can be expelled as carbon dioxide from the lungs.
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Acid-Base Balance
Acidosis can develop if respiratory function is inhibited.
Alkalosis can develop if the respiratory rate is too high.
Respiratory acidosis/alkalosis
Metabolic acidosis/alkalosis
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Patient Assessment: Airway Evaluation
Quality of care depends on
assessment
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Assessing Airway Patency
An adult who is responsive, alert, and able to speak in complete sentences with a normal voice
has no immediate airway problem. However, because his
or her status can rapidly change, remain watchful.
An unresponsive patient has a compromised airway until that is
ruled out by a careful assessment.
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Signs of airway compromise in an unresponsive patient
snoring : partial obst.
vomitus draining from the mouth,
gurgling sound heard during breathing (secretions)>>> markedly depressed or absent gag reflex >>> significantly increases the risk of aspiration.
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Recognizing adequate Breathing
Rate 12 - 20 breaths/min
Adequate depth (tidal volume),
Regular pattern Clear and equal breath sounds
bilaterally.
Breathing at rest should appear
effortless,
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Normal Respiratory Rate RangesAge Range (breaths/min)
Adults : 12 to 20
Children (ages 1 to 18 years) : 12 to 37
Infants (ages 1 month to 1 year) : 30 to 53
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Recognizing Inadequate Breathing
Breathing rate of less than 12 breaths/min or more
than 20 breaths/min
Shallow breathing Irregular pattern of breathing.
Adventitious (abnormal) breath sounds.
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Recognizing
Inadequate
Breathing
Altered mentation
Cyanosis: indicator of low blood oxygen
Preferential positioning
Upright sniffing (tripod) position
semi-sitting position
Patients experiencing respiratory distress will
avoid a supine position because it will worsen
their breathing difficulties.
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anNote Position and
Determine Degree of Distress
•Prefer sitting positions, such as tripod position
•Lying flat may be a sign of sudden deterioration.
•Ominous sign: head bobbing
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Recognizing Inadequate Breathing
Airway management
steps:
Open the airway.
Clear the airway.
Assess breathing.
Provide appropriate
intervention(s).
Evaluation includes:
Observe
Palpate
Auscultate
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Inadequate Breathing
Note the following:
Position
Orthopnea
Chest rise/fall
Skin
Flared nostrils
Pursed lips
Retractions
Intercostal?
suprasternal notch?
supraclavicular fossa?
Subcostal?
Use of accessory muscles
the sternocleidomastoid (neck muscles),
the pectoralis major muscles,
the abdominal muscles.
Asymmetric chest wall
movement
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Inadequate Breathing
Signs:
Fewer than 12, more
than 20 breaths/min
plus dyspnea
Irregular rhythm
Diminished, absent, or
noisy sounds
Abdominal breathing
Reduced flow
Unequal chest
expansion
Increased effort
Shallow breathing
Pale, clammy skin
Retractions
Staccato speech
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Inadequate Breathing
Feel for air movement.Feel
Observe chest for symmetry.Observe
Note any paradoxical motion.Note
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Inadequate Breathing
Ask about history of present illness
Onset, trigger, duration?
Other symptoms: a productive cough (if yes, then what color is the sputum?), chest pain or pressure, or fever?
Interventions, previous hospitalization?
Medications and overall compliance?
Risk factors? or “trigger” of the event
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Protective
Airway Reflexes
Evaluate protective reflexes.
Coughing, sneezing,
gagging
Gag reflex (eyelash reflex)
Sighing
Hiccupping
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Assessment of
Breath Sounds
Auscultate breath sounds
with stethoscope.
Should be clear and equal
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Assessment of Breath Sounds
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of Breath
Sounds
Duration: length of time for inspiratory and
expiratory phases
Normal I/E ratio: 1:2
Expiration is prolonged with lower airway
obstruction.
Expiration is short with tachypneic patients.
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of Breath
Sounds
Pitch: higher or lower than normal (stridor or
wheezing).
Intensity of sound depends on:
Airflow rate
Constancy of flow throughout inspiration
Patient position
Site selected for auscultation
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Abnormal Breath Sounds
Wheezing:
continuous, high-
pitched
Rhonchi: continuous,
low-pitched
Crackles:
discontinuous
Stridor: loud, high-
pitched, heard during
inspiration
Pleural friction rub:
surfaces of visceral
and parietal pleura
rub together
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Pulse Oximetry
Pulse oximeter
•simple, rapid, safe, and noninvasive
•measure the percentage of hemoglobin with oxygen attached
•Oxygen saturation over 95% = normal
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Pulse Oximetry
Oxygen saturation should match patient’s palpated
heart rate.
Does not differentiate between oxygen or carbon
monoxide molecules
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Pulse Oximetry
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Pulse Oximetry
Used for:
Monitoring oxygenation status during intubation attempt or suctioning
Identifying deterioration in a patient with trauma or cardiac disease
Identifying high-risk patients patients with respiratoryconditions
Assessing vascular status in orthopaedic trauma
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Pulse Oximetry
Erroneous readings
may result from:
Bright ambient light
(cover clip)
Patient motion
Poor perfusion
Nail polish
Venous pulsations
Abnormal hemoglobin
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End-tidal Carbon Dioxide
Assessment
Carbon dioxide can be described as the “smoke of metabolism.”
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End-tidal Carbon Dioxide
Assessment
End-tidal carbon dioxide (etco2) monitors
or detector
•detect the presence of carbon dioxide in exhaled air: 3 types
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End-tidal Carbon Dioxide
Assessment
A colorimetric
carbon dioxide
detector
•indicates whether carbon dioxide is present in reasonable amounts
•between the ET tube and ventilation device.
•After 6-8 positive-pressure the specially-treated paper inside the detector should turn from purple to yellow
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
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End-tidal CO2 Assessment
Colorimetric CO2
detector Limitation
•might give a false-positive reading if the patient has carbon dioxide trapped in the stomach
•sensitive to extremes of temperature and humidity; it may be less reliable if vomitus or other secretions get inside it;
• the paper inside the device degrades over time, resulting in a less reliable reading.
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
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End-tidal CO2 Assessment
Colorimetric CO2
detector Limitation
• is a “spot-check” device;you may use it during initial confirmation of ET tube placement,
• but you should replace it as soon as possible with a more accurate and reliable quantitative device.
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
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End-tidal Carbon Dioxide
Assessment
Capnometer
• provides quantitative information, in real time, by displaying a numeric reading of exhaled carbon dioxide levels.
• It uses a special adapter, which attaches between the advanced airway device and ventilation device
• Because it provides quantitative data, the capnometer is more reliable than the colorimetric co2 detector.
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End-tidal Carbon Dioxide
Assessment
Capnographer
• provides a graphic representation of exhaled carbon dioxide levels.
• It performs the same function and attaches in the same way as the capnometer.
• The two types of capnographers are waveform and digital/waveform.
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Waveform capnography
provides quantitative, real-time information
displays a graphic waveform (Unlike capnometry) .
has many applications in emergency medicine
detection of bronchospasm, hypoventilation, and hyperventilation.
capnography is the recommended method of monitoring initial and
ongoing placement of an advanced airway device.
Capnography can also serve as an indicator of the effectiveness of
chest compressions and to detect return of spontaneous circulation (ROSC).
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LIFEPAK® defibrillator/monitor. Courtesy of Medtronic.
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End-tidal Carbon Dioxide (ETCO2)
Assessment
Phase A–B: initial stage of
exhalation
Phase B–C: expiratory upslope
Phase C–D: expiratory or
alveolar plateau
Phase D–E: inspiratory down
stroke
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Phase I (A-B) : the respiratory baseline, the initial stage of exhalation; the gas sample is dead space gas, free of carbon dioxide.
Phase II (B-C) : the expiratory upslope.
At point B, alveolar gas mixes with dead space gas, resulting in an abrupt rise in carbon dioxide levels.
phase III (C-D): The expiratory or alveolar plateau , the gas sampled is essentially alveolar.
Point D is the maximal etco2 level—the best reflection of the alveolar carbon dioxide level.
The height of the waveform at point D correlates with the numeric value of exhaled carbon dioxide that is also displayed on the cardiac monitor/defibrillator.
phase IV (D-E) : the inspiratory downstroke, causing the waveform to return to the baseline level of carbon dioxide— approximately 0 mm Hg.
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Peak Expiratory Flow
Measured to evaluate
bronchoconstriction
Increasing: patient is
responding to
treatment
Decreasing: patient’s
condition is
deteriorating
Perform three times
and take the best
rate.
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Arterial Blood Gas Analysis
Blood is analyzed for pH,
PaO2, HCO3−, base excess,
and SaO2.
pH, HCO3−: acid-base
status
PaCO2: effectiveness of
ventilation
PaO2 and SaO2:
oxygenation