EMT - Airway, Ventilation, Respiration

• Venturi Mask: 24, 28, 35, or 40% oxygen depending on adaptor
• If cervical/spinal trauma is suspected, the jaw thrust maneuver should be performed.
• Pulse ox, pink skin, moist mucus membrane are unreliable signs of perfusion (CO poisoning).
• Inaccurate pulse ox can be due to dark/metallic nail polish, dirty fingers, CO poisoning, hypovolemia, severe peripheral vasoconstriction, bright ambient light.
• Capillary refill is a good test of circulation in children and should be less than 2-3 seconds.
• Infants should receive back blows and chest thrusts.
• The D-size oxygen cylinder holds 350 L, the Jumbo D-size holds 500 L, the E-size holds 625 L, the M (MM)-size holds 3,000 L, the G-size holds 5,300 L, the H, A (M4), or K-size holds 6,900 L.
• The lower airway is below the vocal cords, including the trachea, bronchi, and lungs.
• The right mainstem bronchi is in a direct line with the trachea, likely for foreign objects.
• The upper airway can be affected by conditions such as flu and sinus infection.
• The lower airway can be affected by conditions such as RSV, bronchiolitis, and pneumonia.
• Burns:

  -stop burning, remove clothing

  -high flow oxygen

  -cover burns with dry sterile dressing, do not use ointment, lotion, antiseptic, or break blisters

  -treat for shock: warm blanket to prevent heat loss and hypothermia

  -transport immediately 
• Pneumothorax: partial or complete accumulation of air in pleural space.
• Spontaneous pneumothorax is not associated with any identifiable cause, but is often seen in individuals with emphysema, asthma, tall thin men, dyspnea, and pleuritic chest pain.
• Tension pneumothorax is caused by blunt trauma or fractured rib that lacerates lung or bronchus, and can lead to chest pain, respiratory distress, decreased lung sounds, tachycardia, signs of shock, and tracheal deviation.
• Pulmonary embolism: blood clot of foreign body/air bubble

  -commonly formed in a vein in leg or pelvis then break off and travel 

  -no O2/Co2 exchange occurs

  -cyanosis and dyspnea, tachycardia, tachypnea, chest pain, hemoptysis
• Intramuscular Epinephrine:

  -signs of localized allergy: sudden pain, swelling, localized heat, urticaria, redness

  -signs of anaphylaxis: bronchospasms, wheezing, chest tightness, coughing, dyspnea, hypotension, anxiety, GI complaints
• Pleural Effusion:

  -collection of fluid outside lung

  -causes: Pulmonary embolism, CHF, cancer
• CHF: 

  -damaged ventricular heart muscle can’t keep up with atria blood flow

  -blood backs up into pulmonary veins 🡪 lung congestion, pulmonary edema

  -tachycardia, hypertension, tachypnea, dyspnea alleviated when sitting upright

  -rales heard

  -distended neck veins, peripheral edema, cyanotic pale sweaty skin

  pink frothy sputum
• Emphysema (type of COPD)

  -loss of elastic material within alveolar air space

  -more common than chronic bronchitis

  -crackles, rhonchi, wheezing

  -dyspnea, chronic coughing, sputum, long expiration
• Pneumonia:

  -fever, tachycardia, hypotension, dyspnea, wheezing/crackles/rhonchi

  -dehydration, chest pain, weight loss, altered mental
• COPD: irreversible airway obstruction (emphysema) + significant inflammation (chronic bronchitis)

  -progressive airflow limitation due to chronic inflammation from noxious gases or particles

  -chronic inflammation causes narrowing of small airways and decreased elastic recoil of the lung

  -increased air trapping, progressive airflow limitation

  -dyspnea, poor exercise tolerance, chronic cough, wheezing, typically have elements of chronic bronchitis and emphysema together

  -most common cause is smoking

  -if experiencing hypoxia, high flow oxygen with NRB, and place in fowler position
• Body temperature:

  -95-93F: shivering, rapid breathing, constricted blood vessels

  -92-89F: loss of coord, muscle stiffness, slow respiration/pulses, confused, lethargic, sleepy

  -88-80F: unresponsive, coma, weak pulse, very slow respirations
• Tension pneumothorax: collapsed lung
• Epiglottitis: inflammatory disease of epiglottis, rapid onset of signs and symptoms

  -bacterial infection

  -soft tissue above vocal cords

  -ill, sore throat, high fever, tripod positon
• Endotracheal Intubation: BE MAGIC

  Bag valve mask to pre oxygenate, Evaluate airway, Manipulate patient into proper position, Attempt intubation, GI (use supraglottic airway device if unable to intubate), Confirm placement
• Supraglottic Airway (King LT, LMA, i-Gel)- 

  -Indicated for failed intubation through trachea (endotracheal)

  -contradicted for intact gag reflex or known esophageal disease or caustic substance ingestion

  -Supraglottic airway sits above glottis while allowing advanced airway access

  -Intubation confirmed by attaching end tidal waveform CO2 detector btwn airway and bag used to assist ventilation

  -presence of bilateral breath sounds and absence of gastric or epigastric sounds help confirm appropriate placement
• To alleviate gastric distention in spinal injury patient:

  -roll patient to one side and apply pressure to upper abdomen

  -use spinal motion restriction device to turn patient to one side
• French/whistle tip catheter should be used for stoma, clenched teeth, or nose suctioning

  -Tonsil tip/Yankauer best for infants and children- large diameter, rigid, will not collapse
• Suctioning: at least 300 mmHg vacuum pressure

  -turn head to side if no spine injury

  -no more than 10 seconds

  -prolonged suctioning can obstruct airway, vagal stimulation
• Pediatric Assessment Triangle: Appearance, Work of Breathing, Circulation
• Pediatric Bradycardia: critical hypoxia ischemia

  -ominous sign of respiratory arrest (below 20 for kids under 6 and below 12 for older)
• Normal adult respiratory rates are from 16-20

  school age children (6-12) are 20-30

  infants are initially 40-60 and then drop to 30-40 after the first few minutes
• Cyanide poisoning: dyspnea, respiratory arrest, tachypnea, flushed skin, tachycardia, altered mental, seizures, coma, cardiac arrest
• CO Poisoning:

  flu like symptoms, dizziness, fatigue, headache, impaired judgment, confusion, hallucination, syncope, seizure
• Extended transport or Croup: indication for humidified oxygen 
• NPA:

  indicated for unconscious or semiconscious with intact gag reflex or won't tolerate OPA

  contraindicated for severe head injury, blood draining from nose, fractured nasal bone

  basilar skull fracture: CSF draining from ears

  ecchymosis under eyes (racoon eyes), or behind one ear (Battle sign) are severe head injury
• OPA:

  -to keep tongue from blocking upper airway (will not prevent liquids)

  -contradicted for intact gag reflex, conscious patients, petroleum ingestion 🡪 NPA is an option

  -Peds: measure using length based resuscitation tape (Broselow tape) or place airway next to child’s face with flange at level of central incisors and bite block segment parallel to hard palate, tip should reach angle of the jaw

  -gently remove by following curvature of the mouth

  -rough insertion can cause bleeding

  -after inserted, reassess airway before assisted ventilation or further intervention
• CPAP: provides pressure to keep alveoli open/reverse atelectasis from pulmonary edema 

  -indicated for respiratory distress, pulmonary edema, hypoxia, COPD, recent submersion incident, rapid breathing affecting minute volume, pulse ox below 90

  -contradicted for: respiratory arrest, hypoventilation, can’t speak or protect airway, hypotension (less than 90 systolic BP), chest trauma, pneumothorax, GI bleed or surgery, can’t sit upright, cant tolerate mask/seal, facial trauma

  -complications: claustrophobia, gastric distention, hypotension, decreased blood return/preload
• Pocket mask

  -one way valve prevents backflow of secretions, vomitus, gases

  -supplemental oxygen can be attached to barrier device 🡪 55% oxygen at 15 lpm