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Introduction to Emergency Airway Management and Ventilation

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Objectives (1 of 2)

  Explain the primary objective of airway maintenance.   Identify commonly neglected prehospital skills related to airway.   Explain the risk of infection to EMS providers associated with ventilation.

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Objectives (2 of 2)

  Defend the need to oxygenate and ventilate a patient.   Defend the necessity of establishing and/or maintaining patency of a patient’s airway.   Comply with standard precautions to defend against infectious and communicable diseases.

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Importance of Airway Management (1 of 2)

  Airway management and ventilation are the highest priorities in patient management.   Compromise of either are among the most rapid causes of disability and death.   The primary goal of airway management is to ensure a free and clear passageway for airflow.

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Importance of Airway Management (2 of 2)

  The primary goal of ventilation is to ensure a constant movement of air in and out of the lungs.   Every second without oxygen causes death to millions of cells. Permanent brain damage begins after 6 minutes of oxygen deprivation.   Providers must understand the importance of early detection, rapid and effective intervention, and continual reassessment of airway and ventilatory threats.

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Airway Management in Controlled Settings (1 of 2)

  The most common situation demanding diligent airway management occurs during surgery, when the patient is under general anesthesia.   There are tens of thousands of surgical cases every day.   Anesthesiologists and anesthetists manage airway and ventilation conditions during surgery.

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Airway Management in Controlled Settings (2 of 2)

  Advantages of airway management during surgery – Surgical patients undergo extensive medical

evaluation before going under anesthesia. – Patients do not eat or drink for 12 hours

before surgery. – Patients are positioned at waist level on a

table in ideal position. – Environment is well lit and climate controlled.

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Emergency Airway Management

  Surgical airway management and emergency airway management differ fundamentally.   Prehospital environment is unpredictable, with variable lighting, temperature, and noise levels.   Paramedics have less experience than anesthesiologists and therefore require different techniques, approaches, and considerations.

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Disadvantages of Emergency Airway Management (1 of 2)

  Frequency varies, a few times a week or month   Rarely obtain detailed history before intervention   All patients are assumed to have eaten.

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Disadvantages of Emergency Airway Management (2 of 2)

  Often trauma is involved.   Environment and location of patient are variable and often less than ideal.   Equipment and backup may not be present if a problem arises.

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Technical Skills vs. Critical Thinking

  Anyone can learn how to intubate a patient, but learning how to make the critical decisions about why to intubate, when to intubate, and the best way to intubate in a given situation, as well as evaluating whether the intubation is successful, are much more difficult.

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Key Concepts

  Airway management and ventilation involve manipulative skills that require technical proficiency.   These skills require a high degree of decision making and critical thinking.   Paramedics must have both good technical skills and clinical judgment to be effective.

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Definitions: Airway Management (1 of 4)

  Airway Management – The process of ensuring that the

passageways remain open and free from obstruction, or patent

  Management involves a combination of patient positioning, manual techniques, removing foreign objects, and inserting devices to minimize threats to the patency of the airway.

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Definitions: Airway Management (2 of 4)

  Airway – A system of

passageways through which air must travel to enable gas exchange

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Definitions: Airway Management (3 of 4)

– The airway includes all the structures from the lips and the tip of the nose to the alveoli.

– Interference with the free passage of air in and out of the lungs is an immediate life threat.

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Definitions: Airway Management (4 of 4)

  Patent – Free from obstruction

  Obstructions can be – Anatomic: tongue, epiglottis – Objects or fluids: food, blood, saliva,

broken teeth, dentures – Anatomic/pathological abnormalities:

abscesses or tumors

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Definitions: Ventilation (1 of 4)

  Ventilation – The process of moving air or some other

gas(es) in and out of the lungs – It cannot occur without proper airway

management. – Involves contraction and relaxation of

the diaphragm and intercostal muscles in a process known as negative pressure ventilation

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Definitions: Ventilation (2 of 4)

  In negative pressure ventilation, air is pulled into the lungs.   All forms of artificial ventilation used in emergency airway management use positive pressure ventilation, which pushes air into the lungs.

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Definitions: Ventilation (3 of 4)

  Apnea – A condition of not breathing

  Hypoventilation – A condition in which not enough air is

moving in and out of the lungs   Hyperventilation

– A condition in which too much air is moving in and out of the lungs

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Definitions: Ventilation (4 of 4)

  Bradypnea – A condition of abnormally slow breathing

  Tachypnea – A condition of abnormally quick breathing

  Hypopnea – A condition of abnormally shallow

breathing   Hyperpnea

– A condition of abnormally deep breathing

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Definitions: Oxygenation (1 of 2)

  Oxygenation – The process of loading oxygen onto the

hemoglobin and into the plasma for delivery to cells in the body

  Ventilation is necessary for oxygenation to occur.

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Definitions: Oxygenation (2 of 2)

  Every cell in the body requires constant oxygen for conversion of glucose to energy.   One of the strategies to increase oxygenation in cases of hypoventilation is to increase the percentage of oxygen the patient is breathing.

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Definitions: Respiration (1 of 2)

  Respiration – The process of

exchanging oxygen and carbon dioxide

– Oxygenation is required for respiration

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Definitions: Respiration (2 of 2)

  External respiration – The exchange of oxygen and carbon

dioxide between the alveoli and the pulmonary circulatory system

  Internal respiration – The exchange of oxygen and carbon

dioxide between the systemic circulatory system and the cells in the body

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External and Internal Respiration

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The Toolbox Concept (1 of 2)

  Think of airway management and ventilation skills as tools that make up a toolbox.   Having only one or two tools available would limit your ability to solve problems and consider alternatives when one technique does not work.

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The Toolbox Concept (2 of 2)

  This course discusses the advantages, disadvantages, indications, contraindications, and complications of every technique.   Your clinical judgment and problem-solving skills will be necessary to decide which tool is best suited for each situation.

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Notes on Skill Practice

  Most skills in this course are psychomotor skills, which require a cognitive knowledge base to be able to perform a series of discrete, coordinated, and precise actions.   The only way to fully develop and maintain psychomotor skills is through study and practice.

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How Much Practice?

  Studies have shown that it can take between 1,000 and 5,000 repetitions to imprint a skill so that your muscles perform the tasks without thought.   The best paramedics are not those who have the most years of experience but those who perform the skills the most frequently, even if only by practice.

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What kind of practice?

  It is important to work to perfect these skills.   If you are sloppy while practicing, chances are you will be sloppy in a real situation.   You can practice on

– Manikins – Surgical patients

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Practicing on Manikins

  Excellent training manikins have been developed to simulate patients.

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Practicing During Surgery (1 of 3)

  Advantages of practice during surgery – Develop skills in a controlled setting with

direct supervision and backup – Patients are much less likely to vomit

because they have fasted before undergoing anesthesia.

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Practicing During Surgery (2 of 3)

– The hemodynamic and oxygenation status of the patient is known and closely monitored, allowing for longer periods to intubate.

– Secretions are typically reduced by medications.

– The patient is positioned at a good working level.

– The environment is climate-controlled and well lit.

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Practicing During Surgery (3 of 3)

  The only disadvantage of practicing during surgery is the possibility of developing habits that may present a problem in emergency situations. – For example, time limits during

intubation

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Paramedic Safety (1 of 2)

  It is impossible to have access to all of the patient’s medical history and the patient may have a communicable disease.

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Paramedic Safety (2 of 2)

  Therefore, it should be assumed that all body fluids are potentially infectious, and precautions should be used on all patients. – This approach is recommended by the

Centers for Disease Control and Prevention (CDC).

– It is known as taking “universal precautions” or as body substance isolation.

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Body Substance Isolation Precautions (1 of 2)

  You should exercise great caution to avoid contact with all body fluids. – You should wear gloves. – You should wear a mask and eye goggles. – In trauma cases, you should wear a gown

or apron.   Wash your hands thoroughly after removing your gloves.

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Body Substance Isolation Precautions (2 of 2)

  Disinfect equipment with a chemical that kills vegetative organisms, viruses, and bacteria. – Disposable equipment is ideal for

decreasing cleansing, but it must be properly discarded.

– Needles, scalpels, syringes, and other sharps should all be disposed of in proper sharps containers.

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