PLATINUM FINAL EXAM EMTP 3.3 REVIEW 2023 QUESTIONS AND ANSWERS COMPLETE

PLATINUM FINAL EXAM EMTP 3.3 REVIEW 2023 QUESTIONS AND ANSWERS COMPLETE What is the best airway device to use for smoke inhalation? Endotracheal intubation is frequently needed for supportive therapy in the management of inhalation injury. Most pertinent piece of information in evaluating a patient's ventilatory status? Ventilation is the movement of air in and out of the lungs through a patent airway. The majority of observations regarding ventilation focus on the movements of the chest. SIGNS OF ADEQUATE VENTILATION: In most patients, your assessment of ventilation will be based on observing their respiratory rate (normal 12 to 20) and listening for clear breathing sounds in the left and right chest. Auditory confirmation of breathing sounds is the strongest sign of adequate ventilation. In patients on ventilators or bag-valve-mask, this does not change. Most pertinent piece of information in evaluating a patient's oxygenation status? Oxygenation is the delivery of oxygen to the tissues of the body, poor ventilation or respiration will generally lead to poor oxygenation. Loss of oxygenation is the ultimate result of ventilatory or respiratory failure. You need to observe the patient's mental status, skin color, oral mucosa, and check a pulse oximeter. Mental status is either normal or abnormal, assessing mental status is based on asking questions about who the person is, what time/date it is, where they are, and why they are here. Skin and mucosal color are important indicators of oxygenation. Just as with poor respiration, cyanosis, pallor, or mottling are signs of decreased oxygen delivery. Pulse oximetry level is the most objective measure of oxygenation, it reads the saturation of hemoglobin (reported as SPO2), note that a pulse oximeter is not foolproof. A patient with poor oxygenation in the limbs may have sufficient oxygenation to their core or vise-versa. Pulse oximeters can also be fooled by specific toxic gases. Always ensure that you match up your pulse oximetry readings with physical findings and ensure they support one another. Pulse oximeters are imperfect and are not a real-time measure of O2 saturation Most important assessment in evaluating a patient's oxygen delivery to the brain? Prior to applying supplemental oxygen, objective data regarding patient status should quickly be obtained such as airway patency, respiratory rate, pulse oximetry, and lung sounds. Signs of cyanosis in the skin or nail bed assessment should also be noted. What is the next step to take if a patient's breathing does not improve with an NRB? BVM What is the next step to take after opening the airway of an unresponsive patient with slow, shallow respirations? After manually opening an unconscious patient's airway, you should: check the mouth for secretions, foreign bodies, or dentures. If clear, then started manually ventilating! Know your ventilation rates Adult: 12-20/minute Child: 15-30/minute Infant: 25-50/minute Flow rates for 02 devices: Nasal Cannula - 2-6L/min Nebulizer - 6-8L/min Non-ReBreather - 10-15L/min BMV - 15L/min EndoTracheal Tube - 15L/min King LTS-D - 15L/min CPAP - 25L/min (oxygen port) When to use what airway device given a scenario / When to use what ventilation device given a scenario: ET Tube One intubation attempt with the definitive airway on patients in cardiac arrest before a provider can attempt placement of a supraglottic airway (King Airway). If the first attempt fails, the provider may attempt at intubation again, or elect to place the King Airway or return to the BLS airway (BVM). When to use what airway device given a scenario / When to use what ventilation device given a scenario: King LT These devices are best used when the ET Tube does not work. When to use what airway device given a scenario / When to use what ventilation device given a scenario: LMA / iGel It is secured in the throat via the inflation cuff, although the seal of the LMA is not as effective as that of an ETT. An iGel works the same way, and does not have an inflatable cuff. These devices are best used when the ET Tube does not work. When to use what airway device given a scenario / When to use what ventilation device given a scenario: CPAP Used for patients with CHF, or drowning victims. Used to help get fluid out of the lungs that is signified by crackles or rales. Must meet requirements of blood pressure and consciousness to be used. Can have a nebulizer connected if the situation requires it. When to use what airway device given a scenario / When to use what ventilation device given a scenario: Nasal Cannula Used for minimal oxygen for patients that have a lower SPO2 than 95% When to use what airway device given a scenario / When to use what ventilation device given a scenario: Non-Rebreather Used for patients that require more than 6L of oxygen, and can be used with a nebulizer for maximum efficiency. When to use what airway device given a scenario / When to use what ventilation device given a scenario: BVM BLS airway that is used initially before an advanced airway, and connected to one if one is placed. TX of a patient in anaphylaxis when epinephrine has failed to improve the patient's condition and he/she is deteriorating If 0.3mg IM 1:1000 Epi does not work, peripheral perfusion isn't good enough to circulate the medication! IV EPI: 1:10,000 is the only solution to get the epinephrine to the patient. Know the advantages and disadvantages of a surgical vs needle cricothyrotomy. Which one is the quickest to perform? Once established, surgical cricothyroidotomy has a number of advantages over use of a cannula – provision of a definitive airway (protection by a cuffed tube) being just one. Despite this, the technique is used far less frequently. This may be due to fears about the complication of hemorrhage. Research suggests that needle cricothyroidotomy can provide effective ventilation in the presence of increasing airway obstruction. The failure of the needle systems in the presence of upper airway obstruction results from inadequate exhalation via the narrow 1.5mm lumen of the 13G cannula. Which can lead to: Barotrauma/pneumothorax = from over-inflation* Bleeding Subcutaneous emphysema Survey data from the prehospital and hospital settings show the needle airway to be the most frequently used emergency cricothyroidotomy method, whereas the surgical airway is rarely used. Assessment findings in a patient with a spontaneous pneumothorax Shortness of breath, sudden onset of sharp chest pain, pallor, tachypnea, diaphoresis. Severe symptoms include tachycardia, AMS, cyanosis, decreased breath sounds on the affected side. Best method to protect a patient's airway who vomits each time you try to intubate Inadequate depth of anesthesia or unexpected responses to surgical stimulation may evoke gastrointestinal motor responses, such as gagging or recurrent swallowing, increasing gastric pressure over and above LOS pressure facilitating reflux. In the setting of aspiration, regurgitation occurs three times more commonly than active vomiting. An unprotected airway, excessively light depths of anesthesia, and one or more predisposing risk factors for aspiration combine to significantly increase the risks of aspiration. A summary of the available strategies for reducing aspiration risk: Reducing gastric volume (NRB instead of BVM) Second-generation supra-glottic airway devices Cricoid pressure Rapid sequence induction Position (left lateral, head down or upright) What are the advantages / disadvantages of tracheal intubation vs using an extraglottic airway device? Insertion of a supraglottic airway device is simpler and faster than tracheal intubation, and proficiency requires less training and ongoing practice. Tracheal intubation is a more complex skill than supraglottic airway device insertion and requires 2 practitioners, additional equipment, and good access to the patient's airway The strategy of using a supraglottic airway device first also achieved initial ventilation success more often. Although regurgitation and aspiration occurred with similar frequency overall, regurgitation and aspiration during or after advanced airway management were significantly more common in the supraglottic airway device group. Conversely, patients in the tracheal intubation group were significantly more likely to regurgitate and aspirate before advanced airway management, possibly due to less frequent use of advanced techniques to secure the airway in this group and the increased time required for tracheal intubation compared with insertion of a supraglottic airway device. What would cause a patient's respirations to be shallow after striking his/her head while diving Breathing problems: If the spine is severely compressed, your lungs may not work properly and you can have trouble breathing. Specifically, the C3, C4, and C5 spinal nerves innervate the diaphragm. After a spinal cord injury at or above the C5 level, messages from the brain may not be able to get past the damage, resulting in loss of control over the diaphragm. This causes breathing to be weakened, therefore it’s essential to seek immediate medical attention. With the help of a ventilator, respiratory functions may be restored. First step in treating a patient with a slow pulse, slow respirations, and low BP ABCs -> BVM patient with inadequate ventilations! What is the first assessment you perform for each and every patient? PRIMARY SURVEY/RESUSCITATION: Verbalizes the general impression of the patient Determines responsiveness/level of consciousness (AVPU) Determines chief complaint/apparent life-threats 1-2. Assesses airway and breathing: Assessment Assures adequate ventilation Initiates appropriate oxygen therapy 3. Assesses circulation: Assesses/controls major bleeding Checks pulse Assesses skin [either skin color, temperature or condition] 4. Identifies patient priority and makes treatment/transport decision What to do if a patient cannot tolerate a NRB Switch to a nasal cannula at a max of 6L flow rate. First step in treating a diabetic patient who has overdosed and has slow, shallow respirations Assess and support ABCs: Begin mouth-to-mask rescue breathing. Why would a capnography reading start to decrease in an artificially ventilated patient? Know your ETCO2 values and how it correlates to ventilatory status. If your patient is breathing at a rate above 20 breaths per minute, they’re eliminating a lot more CO2 than average. This excess elimination results in a decreased concentration of carbon dioxide in the body. Which respiratory sound would be most concerning in a patient with a possible allergic reaction? Absence of lung sounds (from field experience) S/S of pneumonia Assessment: A patient with bacterial pneumonia will generally appear ill. He may report a recent history of fever and chills. These chills are commonly described as "bed shaking." There is usually a generalized weakness and malaise. The patient will tend to complain of a deep, productive cough and may expel yellow to brown sputum, often streaked with blood. Many cases involve associated pleuritic chest pain. Therefore, pneumonia should be considered in any patient who presents complaining of chest pain, especially if accompanied by fever and /or chills. In pneumonia involving the lower lobes of the lungs, a patient may complain of nothing more than upper abdominal pain. Physical examination will commonly reveal fever, tachypnea, tachycardia, and a cough. Respiratory distress may be present. Auscultation of the chest usually demonstrates crackles (rales) in the involved lung segment, although wheezes or rhonchi may be heard. There usually is decreased air movement in the areas filled with infection. Percussion of the chest may reveal dullness over these areas. Egophony (a change in the spoken "E" sound to an "A" sound on auscultation) may also be noted. In the forms of pneumonia involving viral, fungal, and rare bacterial causes, the typical symptoms as described are not seen. Instead, these patients may report a nonproductive cough with less prominent lung findings. Systemic symptoms such as headache, malaise, fatigue, muscle aches, sore throat, and abdominal complaints including nausea, vomiting, and diarrhea are more prominent. Fever and chills are not as impressive as in bacterial pneumonia. S/S of emphysema Symptoms start gradually and include: -Shortness of breath, even with routine activities of walking, climbing stairs etc -Barrel chest may be a symptom of a related condition. -Long lasting cough which can be dry or with mucus -Wheezing -Fatigue -Frequent respiratory infections -Nails and lips turning blue even with the slightest of exertion How to correct snoring respirations Snoring: caused by the tongue obstructing the airway. Treat by head-tilt chin-lift or jaw thrust and / or insert airway adjunct. TX of a patient with a closed head injury and S/S of ICP. How do we ventilate these patients? Increased ICP results in a lack of oxygen in brain tissue and a restriction of cerebral blood flow in the brain. This is most commonly caused by a head injury, bleeding in the brain (i.e. hematoma or hemorrhage), tumor, infection, stroke, excess cerebrospinal fluid, or swelling of the brain. Increased ICP activates the Cushing reflex, a nervous system response resulting in Cushing’s triad. As the ICP begins to increase, it eventually becomes greater than the mean arterial pressure, which typically must be greater than the ICP in order for the brain tissue to be adequately oxygenated. This difference in pressure causes a decrease in the cerebral perfusion pressure (CPP), or the amount of blood and oxygen the brain is receiving, therefore leading to the brain not receiving enough oxygen (also known as a brain ischemia). To compensate for the lack of oxygen, the sympathetic nervous system is activated, causing an increase in systemic blood pressure and an initial increase in heart rate. The increased blood pressure then signals the carotid and aortic baroreceptors to activate the parasympathetic nervous system, causing the heart rate to decrease. As the pressure in the brain continues to rise, the brain stem may start to dysfunction, resulting in irregular respirations followed by periods where breathing ceases completely. This progression is indicative of a worsening prognosis. Cushing’s triad is characterized by a widened pulse pressure (decreased), bradycardia, and irregular respirations (also known as Cheyne–Stokes respirations). Ventilations Guided by ETCO2 • Target: 35-40 mmHg TBI (rate ~10bpm)* • Target: 30-35 mmHg (suspected herniation) (rate~20)* • Breathing What to do if needle decompression does not correct a tension pneumothorax and patient is deteriorating In some instances, it will be necessary to perform needle chest decompression multiple times on the same casualty, as time allows. Multiple attempts become necessary when the catheter kinks, becomes obstructed by a clot, or in some other way fails to serve its intended purpose. At all reassessments, evaluate your treatments for effectiveness. Check chest seals for suck and blow. Observe whether the needle chest decompression produces a whooshing sound. S/S of Respiratory distress Nasal Flaring (infants), Cyanosis (possible)/ Pale skin color improves with O2, Retractions (see-saw breathing), Noisy Breathing, Mood Change, and Tripod (possibly), Increase Respirations, Increased work of breathing (early signs), Head bobbing. - BN S/S of Respiratory failure Rapid Breathing, bluish-colored skin, lips, and capillary beds (late sign in respiratory failure), tiredness, tachy to bradycardia, deterioration of everything, tachypnea to bradypnea, retraction to agonal - BN TX for epiglottitis Epiglottitis is an acute infection and inflammation of the epiglottis and is potentially life threatening. (Recall that the epiglottis is a flap of cartilage that protects the airway during swallowing.)