1
NCTI Paramedic Final
Respiratory
Epiglottitis
Causes the epiglottis and supraglottic tissues to swell, partially or completely occludes glottis
opening.
Presentation & Symptoms:
● Sudden onset with severe sore throat
● Drooling due to inability to swallow.
● Work of breathing increased (Tripod/Sniffing Position), pallor or cyanosis.
● Stridor heard over neck, muffled voice and hypoxia are signs of airway obstruction.
Treatment:
• Goal is to get the child with epiglottis to an appropriate hospital with a maintainable airway, risk
for acute airway obstruction and respiratory arrest, minimize your on-scene time.
Gold standard for ET tube confirmation
Gold Standard is Waveform capnography provides continuous monitoring of exhaled carbon dioxide
(ETCO2), allowing the provider to ensure proper tube placement in the trachea and not in the esophagus
.
This method measures the level of CO2 in exhaled air and displays it as a waveform, which is crucial for
confirming correct placement and for monitoring the patient's ventilation status throughout care.
Capnography is considered more reliable than other methods, such as auscultation or observing chest
rise, because it provides continuous feedback and a more definitive confirmation of successful intubation.
Any movement while patient is intubated, reconfirm placement of tube.
Managing the airway (repositioning head)
● Manual Maneuvers:
○ Head tilt–chin lift: The simplest method to open the airway for patients without
suspected cervical spine injury.
○ Jaw-thrust maneuver: Used for patients with suspected spinal injury to open the airway
without moving the neck.
● Suctioning:
○ Critical for clearing the airway of vomitus, blood, or secretions to prevent aspiration.
● Airway Adjuncts:
○ Oropharyngeal Airway (OPA): Unresponsive patient who have no gag reflex.
○ Nasopharyngeal Airway (NPA): indicated for unresponsive patients or AMS with intact
gag reflex.
● Endotracheal Intubation:
○ The definitive method for securing an airway.
○ Confirmed by waveform capnography, the gold standard for verifying tube placement.
, 2
● Supraglottic Airway Devices:
○ Used when endotracheal intubation is not feasible or successful. Examples include the
King LT and Laryngeal Mask Airway (LMA).
● Oxygenation and Ventilation:
○ Bag-valve-mask (BVM) ventilation is vital for patients who are not breathing or are
inadequately ventilating.
● Needle Cricothyrotomy
○ 14G or 16G IV catheter inserted through cricothyroid membrane and into the trachea.
○ Adequate and ventilation are achieved by attaching a high-pressure jet ventilator to the
hub of the catheter.
○ Indications:
■ Inability to ventilate with less invasive techniques
■ Massive maxillofacial trauma
■ Inability to open patient's mouth
■ Uncontrolled oropharyngeal bleeding
○ Over inflation of the lungs can cause barotrauma.
○ Under inflation of the lungs can result in hypoventilation.
Pulse Ox Reading (Treat patient not the monitor) (Look at the whole picture)
Normally perfused person should have an SPO2 reading greater than 95% at room air.
Less than 95% nonsmoker suggests hypoxemia.
Less than 90% signals the need for aggressive oxygen therapy.
Does not measure ventilation – It cannot detect elevated CO2 levels (hypercapnia).
Delayed response – There may be a lag in showing drops in oxygenation.
Inaccurate in poor perfusion – Shock, hypothermia, or cardiac arrest can cause unreliable readings.
Affected by motion – Patient movement can create false readings.
Nail polish/external factors – Dark nail polish, artificial nails, and ambient light can interfere with
accuracy.
Carboxyhemoglobin/methemoglobin – Cannot distinguish between oxygen and altered forms of
hemoglobin (e.g., in carbon monoxide poisoning), leading to false high readings.
Respiratory Acidosis vs. Alkalosis
Respiratory Acidosis: Breathing slow, high CO2, low pH.
● Cause: Respiratory acidosis occurs when there is hypoventilation, meaning the body is not
expelling enough carbon dioxide (CO2). This results in CO2 buildup in the blood, which forms
carbonic acid, leading to a decrease in blood pH (acidosis).
● Conditions: Common causes include COPD, asthma, drug overdose, or any condition causing
respiratory depression.
● Presentation: Patients often present with confusion, lethargy, and cyanosis due to decreased
oxygenation and CO2 retention. In severe cases, it can lead to coma or respiratory arrest.
● Treatment: Focuses on improving ventilation, such as assisted ventilation (e.g., BVM or
intubation) or addressing the underlying cause, like bronchodilators for asthma or naloxone for
opioid overdose.
, 3
Respiratory Alkalosis: Breathing fast, low CO2, high pH.
● Cause: Respiratory alkalosis results from hyperventilation, where excessive CO2 is exhaled,
reducing CO2 levels in the blood and causing an increase in blood pH (alkalosis).
● Conditions: It is often seen in cases of anxiety, panic attacks, pain, or any condition causing
rapid breathing.
● Presentation: Symptoms include dizziness, tingling in extremities, muscle cramps, and
lightheadedness due to decreased calcium ion availability in nerve cells.
, 4
Anaerobic vs. Aerobic Metabolism
Aerobic Metabolism: With oxygen
● Definition: Aerobic metabolism occurs when oxygen is available, allowing cells to efficiently
produce energy (ATP) from glucose.
● Efficiency: This process yields significantly more ATP per glucose molecule compared to
anaerobic metabolism.
● Byproducts: The primary byproducts are carbon dioxide (CO2) and water, which are easily
expelled by the body.
Anaerobic Metabolism: Without oxygen
● Definition: Anaerobic metabolism occurs when oxygen is insufficient, forcing cells to produce
energy without oxygen.
● Efficiency: It is far less efficient, producing only a small amount of ATP.
● Byproducts: The main byproduct is lactic acid, which can lead to acidosis if it accumulates in
the body over time.
Relevance to Airway and Respiratory Emergencies:
● In cases of respiratory distress or failure, when oxygen delivery to tissues is compromised, the
body shifts from aerobic to anaerobic metabolism, leading to the accumulation of lactic acid and
metabolic acidosis.
● This transition highlights the importance of effective airway management and oxygenation to
prevent anaerobic metabolism and its harmful effects.
Landmarks for intubation (Vallecula, vocal cords)
Oropharynx: The intubation process starts by visualizing the oropharynx, ensuring a clear view to
advance the tube.
Epiglottis: Using a laryngoscope, the provider looks for the epiglottis. Proper technique involves lifting
the epiglottis to expose the vocal cords.
Vocal Cords: The vocal cords are the primary landmark, as the endotracheal tube should be passed
between them into the trachea.
Trachea: Successful intubation occurs when the tube is advanced into the trachea beyond the vocal
cords.
Trismus
Definition: Trismus is the involuntary contraction of the jaw muscles, often referred to as "lockjaw,"
making it difficult or impossible to open the mouth fully.
Relevance to Airway Management: Trismus can complicate airway management, particularly during
attempts to perform endotracheal intubation or insert an airway adjunct (like an oropharyngeal airway).
Management: In cases where trismus is present, alternative airway techniques such as a
Nasopharyngeal airway (NPA) or more invasive measures (e.g., surgical airway) may be required.
Sedation and paralysis via RSI can also help relax the jaw muscles to facilitate intubation.
NCTI Paramedic Final
Respiratory
Epiglottitis
Causes the epiglottis and supraglottic tissues to swell, partially or completely occludes glottis
opening.
Presentation & Symptoms:
● Sudden onset with severe sore throat
● Drooling due to inability to swallow.
● Work of breathing increased (Tripod/Sniffing Position), pallor or cyanosis.
● Stridor heard over neck, muffled voice and hypoxia are signs of airway obstruction.
Treatment:
• Goal is to get the child with epiglottis to an appropriate hospital with a maintainable airway, risk
for acute airway obstruction and respiratory arrest, minimize your on-scene time.
Gold standard for ET tube confirmation
Gold Standard is Waveform capnography provides continuous monitoring of exhaled carbon dioxide
(ETCO2), allowing the provider to ensure proper tube placement in the trachea and not in the esophagus
.
This method measures the level of CO2 in exhaled air and displays it as a waveform, which is crucial for
confirming correct placement and for monitoring the patient's ventilation status throughout care.
Capnography is considered more reliable than other methods, such as auscultation or observing chest
rise, because it provides continuous feedback and a more definitive confirmation of successful intubation.
Any movement while patient is intubated, reconfirm placement of tube.
Managing the airway (repositioning head)
● Manual Maneuvers:
○ Head tilt–chin lift: The simplest method to open the airway for patients without
suspected cervical spine injury.
○ Jaw-thrust maneuver: Used for patients with suspected spinal injury to open the airway
without moving the neck.
● Suctioning:
○ Critical for clearing the airway of vomitus, blood, or secretions to prevent aspiration.
● Airway Adjuncts:
○ Oropharyngeal Airway (OPA): Unresponsive patient who have no gag reflex.
○ Nasopharyngeal Airway (NPA): indicated for unresponsive patients or AMS with intact
gag reflex.
● Endotracheal Intubation:
○ The definitive method for securing an airway.
○ Confirmed by waveform capnography, the gold standard for verifying tube placement.
, 2
● Supraglottic Airway Devices:
○ Used when endotracheal intubation is not feasible or successful. Examples include the
King LT and Laryngeal Mask Airway (LMA).
● Oxygenation and Ventilation:
○ Bag-valve-mask (BVM) ventilation is vital for patients who are not breathing or are
inadequately ventilating.
● Needle Cricothyrotomy
○ 14G or 16G IV catheter inserted through cricothyroid membrane and into the trachea.
○ Adequate and ventilation are achieved by attaching a high-pressure jet ventilator to the
hub of the catheter.
○ Indications:
■ Inability to ventilate with less invasive techniques
■ Massive maxillofacial trauma
■ Inability to open patient's mouth
■ Uncontrolled oropharyngeal bleeding
○ Over inflation of the lungs can cause barotrauma.
○ Under inflation of the lungs can result in hypoventilation.
Pulse Ox Reading (Treat patient not the monitor) (Look at the whole picture)
Normally perfused person should have an SPO2 reading greater than 95% at room air.
Less than 95% nonsmoker suggests hypoxemia.
Less than 90% signals the need for aggressive oxygen therapy.
Does not measure ventilation – It cannot detect elevated CO2 levels (hypercapnia).
Delayed response – There may be a lag in showing drops in oxygenation.
Inaccurate in poor perfusion – Shock, hypothermia, or cardiac arrest can cause unreliable readings.
Affected by motion – Patient movement can create false readings.
Nail polish/external factors – Dark nail polish, artificial nails, and ambient light can interfere with
accuracy.
Carboxyhemoglobin/methemoglobin – Cannot distinguish between oxygen and altered forms of
hemoglobin (e.g., in carbon monoxide poisoning), leading to false high readings.
Respiratory Acidosis vs. Alkalosis
Respiratory Acidosis: Breathing slow, high CO2, low pH.
● Cause: Respiratory acidosis occurs when there is hypoventilation, meaning the body is not
expelling enough carbon dioxide (CO2). This results in CO2 buildup in the blood, which forms
carbonic acid, leading to a decrease in blood pH (acidosis).
● Conditions: Common causes include COPD, asthma, drug overdose, or any condition causing
respiratory depression.
● Presentation: Patients often present with confusion, lethargy, and cyanosis due to decreased
oxygenation and CO2 retention. In severe cases, it can lead to coma or respiratory arrest.
● Treatment: Focuses on improving ventilation, such as assisted ventilation (e.g., BVM or
intubation) or addressing the underlying cause, like bronchodilators for asthma or naloxone for
opioid overdose.
, 3
Respiratory Alkalosis: Breathing fast, low CO2, high pH.
● Cause: Respiratory alkalosis results from hyperventilation, where excessive CO2 is exhaled,
reducing CO2 levels in the blood and causing an increase in blood pH (alkalosis).
● Conditions: It is often seen in cases of anxiety, panic attacks, pain, or any condition causing
rapid breathing.
● Presentation: Symptoms include dizziness, tingling in extremities, muscle cramps, and
lightheadedness due to decreased calcium ion availability in nerve cells.
, 4
Anaerobic vs. Aerobic Metabolism
Aerobic Metabolism: With oxygen
● Definition: Aerobic metabolism occurs when oxygen is available, allowing cells to efficiently
produce energy (ATP) from glucose.
● Efficiency: This process yields significantly more ATP per glucose molecule compared to
anaerobic metabolism.
● Byproducts: The primary byproducts are carbon dioxide (CO2) and water, which are easily
expelled by the body.
Anaerobic Metabolism: Without oxygen
● Definition: Anaerobic metabolism occurs when oxygen is insufficient, forcing cells to produce
energy without oxygen.
● Efficiency: It is far less efficient, producing only a small amount of ATP.
● Byproducts: The main byproduct is lactic acid, which can lead to acidosis if it accumulates in
the body over time.
Relevance to Airway and Respiratory Emergencies:
● In cases of respiratory distress or failure, when oxygen delivery to tissues is compromised, the
body shifts from aerobic to anaerobic metabolism, leading to the accumulation of lactic acid and
metabolic acidosis.
● This transition highlights the importance of effective airway management and oxygenation to
prevent anaerobic metabolism and its harmful effects.
Landmarks for intubation (Vallecula, vocal cords)
Oropharynx: The intubation process starts by visualizing the oropharynx, ensuring a clear view to
advance the tube.
Epiglottis: Using a laryngoscope, the provider looks for the epiglottis. Proper technique involves lifting
the epiglottis to expose the vocal cords.
Vocal Cords: The vocal cords are the primary landmark, as the endotracheal tube should be passed
between them into the trachea.
Trachea: Successful intubation occurs when the tube is advanced into the trachea beyond the vocal
cords.
Trismus
Definition: Trismus is the involuntary contraction of the jaw muscles, often referred to as "lockjaw,"
making it difficult or impossible to open the mouth fully.
Relevance to Airway Management: Trismus can complicate airway management, particularly during
attempts to perform endotracheal intubation or insert an airway adjunct (like an oropharyngeal airway).
Management: In cases where trismus is present, alternative airway techniques such as a
Nasopharyngeal airway (NPA) or more invasive measures (e.g., surgical airway) may be required.
Sedation and paralysis via RSI can also help relax the jaw muscles to facilitate intubation.
