NUR357 Topic 2 Lecture

• Presentation to Emergency Department

  1. Assessment continues – with the paramedic team handing over to the clinical team

  2. "Hands Off" handover ensures that all staff are listening to the handover as this provides valuable information on the mechanism of injury, treatment that has occurred and any vital signs

  3. IMIST-AMBO provides a structure to ensure everyone remains focused
• Assessment

  • Look, listen and feel
  • If the patient is already intubated, confirm appropriate endotracheal tube (ETT) placement by assessing end-tidal carbon dioxide (EtCO2)
  • Patients intubated prior to arrival at hospital may be moved several times, increasing the potential for ETT displacement
• Life threatening breathing problems

  • Tension pneumothorax
  • Pneumothorax
  • Haemothorax
  • Sucking chest wound
  • Flail chest
  • Full-thickness circumferential burn of thorax
• Review of pathophysiology


  1. Cells need perfusion with oxygen and glucose

  2. Perfusion is provided by blood pressure

  3. Where blood pressure is normal the cell is able to function normally

  4. Mitochondria within the cell produce ATP + H2O + CO2 (Aerobic respiration)

  5. When perfusion fails = shock

  6. Cell switches metabolism to Anaerobic respiration = much less ATP + H2O + CO2 + Lactic acid
• Indications for oxygen therapy

  • Cardiac and respiratory arrest
  • Type I respiratory failure
  • Type II respiratory failure
  • Chest pain or acute coronary syndrome with hypoxia (i.e. SpO2 less than 93%) or evidence of shock
  • Low blood pressure, cardiac output
  • Increased metabolic demands
  • Carbon monoxide poisoning
• Respiratory anatomy


  1. During spontaneous breathing, it is simply the air which is moving into and out of the lungs

  2. The contraction of respiratory muscles causes the thorax to expand; therefore, the air in the atmosphere goes into the lungs

  3. This is how spontaneous breathing occurs

  4. During ventilation with mechanical ventilator, the user must consider the lung condition or the diagnosis of the patient in order to fulfill the best ventilation for the patient
• Oxygen is required for aerobic cellular metabolism and ultimately for human survival, with some cells, such as those in the brain, being more sensitive to hypoxia than others
• Oxygen therapy should be considered for patients with a significant reduction in arterial oxygen levels, irrespective of diagnosis and especially if the patient is drowsy or unconscious
• Mechanical Ventilation


  • The aim is to reduce respiratory distress and reverse acute respiratory failure
  • Non-invasive ventilation (NIV) may not be appropriate
  • Endotracheal intubation is conducted to provide mechanical ventilation for patients who are unable to support their own oxygenation
  • Once intubated, a decision must be made regarding the most appropriate ventilation strategy for the patient
• Preparation for intubation


  • Adequate preparation of the patient, equipment and environment, as well as knowledge of emergency procedures is important to ensure safe and efficient intubation. Not always possible external to the hospital!
  • Up to 50% of patients undergoing endotracheal intubation in the ICU experience complications; around one-third will have a serious complication, including hypoxaemia, circulatory collapse, cardiac arrhythmia, cardiac arrest, oesophageal intubation, aspiration and death
  • Assisted ventilation pre-hospital and initially in the ED is usually achieved with a self-inflating resuscitation bag, which is available in various sizes
• Preparation for Intubation


  1. In a controlled environment (not in an emergency) – consent is required

  2. Staff to have assigned roles, reliable IV access,, monitoring and N/G tube, patient positioned in supine in the 'sniff' position

  3. Equipment and drugs: oxygen supply, suction supply, laryngoscope blades, face mask, manual ventilation, ETT, capnography, ventilator, emergency/resuscitation trolley, gloves, eye protection, sedative and muscle relaxant
• Rapid Sequence Induction (RSI)


  An airway management technique that produces inducing immediate unresponsiveness (induction agent) and muscular relaxation (neuromuscular blocking agent) and is the fastest and most effective means of controlling the emergency airway
• Indications for RSI


  • Lack of airway protection despite patency (swallow, gag, cough, positioning , and tone)
  • Hypoxia
  • Hypoventilation
  • Need for neuroprotection (e.g. target PaCO2 35-40 mmHg)
  • Impending obstruction (e.g. airway burn, penetrating neck injury)
  • Prolonged transfer
  • Combativeness
  • Humane reasons (e.g. major trauma requiring multiple interventions)
  • Cervical spine injury (diaphragmatic paralysis)
• MNEMONICS FOR RSI

  O2 MARBLES: Oxygen, masks, airway adjuncts, RSI drugs, Resus drugs, BVM, Laryngoscopes, ETTs, Suction, State Plan
• RSI INDUCTION AGENT/S


  Sedatives that provide amnesia, reducing sympathetic responses and improve intubation. Examples include Ketamine, Fentanyl, Propofol
• PARALYTIC AGENTS


  Powerful muscle relaxants used to prevent muscle movements, including the diaphragm to allow for mechanical ventilation. Examples include Suxamethonium, Rocuronium, Vecuronium
• Ventilator Modes

  • Describes inspiratory phase variables, how the ventilator controls pressure, volume, and flow during a breath, and how breaths are sequenced
• Importance of ventilation/Nursing management

  • Correct tube placement, maintain cuff inflation, monitor oxygenation and ventilation, maintain tube patency, assess for complications, provide oral care and skin integrity, ensure comfort and communication
• Where does the ETT go?

  Pre-oxygenation, oral intubation is preferred, cricoid pressure is applied, tube is inserted into the mouth, through the vocal cords and into the trachea, 3-5cm above the carina, CO2 detector or end-tidal CO2 monitor is applied to confirm placement, tube is secured with tape, confirmation is by chest x-ray immediately
• Intubation Summary

  • Once intubated this then allows the rest of the algorithm to continue and identify where the patient's problems arise
  • The aim is to reverse the cause or causes of the patient's condition
  • ETT placement needs confirmation
  • Cuff management is to prevent airway contamination
  • Closed suctioning required
  • Goal of mechanical ventilation is to promote gas exchange, minimise lung injury, reduce work of breathing and promote patient comfort