气道通气的识别和评估（英文）

Assessment & Recognition of Airway & Ventilatory Compromise History Onset sudden vs gradual Known cause? Duration Constant Recurrent Provocation/Palliation Assessment & Recognition of Airway & Ventilatory Compromise Exacerbation Associated Signs/Symptoms Cough, chest pain, fever Interventions past evals/admits meds ever intubated before? Assessment & Recognition of Airway & Ventilatory Compromise Respiratory Patterns Cheyne-Stokes brain stem Kussmaul acidosis Biots increased ICP Respiratory Patterns Central Neurogenic Hyperventilation increased ICP Agonal brain anoxia Assessment & Recognition of Airway & Ventilatory Compromise Inadequate Ventilation body cannot compensate for increased oxygen demand or maintain balance Causes infection trauma brainstem injury toxic inhalation renal failure Airway & Ventilation Methods: BLS Supplemental Oxygen increased FiO2 increases available oxygen objective is to maximize hemoglobin saturation Airway & Ventilation Methods: BLS Oxygen source compressed gas liquid oxygen Regulators Humidifier Delivery Devices nasal cannula partial rebreather mask non-rebreather mask venturi mask small volume nebulizer Airway & Ventilation Methods: BLS Airway Maneuvers Head-tilt/Chin-lift Jaw thrust Sellicks maneuver Other Types tracheostomy with tube tracheostomy with stoma Airway Devices Oropharyngeal airway Nasopharyngeal airway Airway & Ventilation Methods: BLS Mouth to Mouth Mouth to Nose Mouth to Mask One person BVM Two person BVM Three person BVM Flow restricted powered ventilator Transport ventilator One Person BVM difficult to master mask seal often inadequate may result in inadequate tidal vol gastric distention risk ventilate only until see chest rise Airway & Ventilation Methods: BLS Two person BVM most efficient method Useful in C-spine inj improved mask seal and tidal volume Three person BVM less utilized used when difficulty with mask seal crowded Airway & Ventilation Methods: BLS Flow-restricted, powered ventilator Cardiac sphincter opens at 30 cm H2O high volume/high conc not recommended for children, noncompliant or poor tidal volume oxygen delivered on inspiratory effort may cause barotrauma Airway & Ventilation Methods: BLS Automatic transport ventilators Not like a “real” ventilator Usually only controls Volume and rate Useful during prolonged ventilation times Not useful in obstructed airway or increased airway resistance Frees personnel Can not detect changes Airway & Ventilation Methods: BLS Pediatric considerations mask seal force may obstruct airway best if used with jaw thrust BVM sizes: neonate & infant=450 ml + Children 8 yoa require adult BVM just enough volume to see chest rise Squeeze - Release - Release Airway & Ventilation Methods: BLS Stoma patients expose stoma pocket mask BVM Seal around stoma site seal mouth and nose if air leak is evident Airway & Ventilation Methods: BLS Airway Obstruction Techniques Positioning OPA/NPA Heimlich maneuver Finger sweep with caution Chest Thrusts Chest thrust and back blows for infants Suctioning Direct laryngoscopy Airway & Ventilation Methods: BLS Suctioning Manual or Powered devices Suction catheters rigid soft Tracheobronchial suctioning lubricate catheter 3-5 cc sterile water or saline insert catheter until resistance is felt Airway & Ventilation Methods: BLS Gastric Distention Common when ventilating without intubation pressure on diaphragm resistance to BVM ventilation increase time of BVM ventilation Airway Management: Part 2 EMS Professions Temple College Airway & Ventilation Methods: ALS Gastric Tubes nasogastric caution with esophageal disease or facial trauma tolerated by awake patients but is uncomfortable patient can speak interferes with BVM seal orogastric usually used in unresponsive patients larger tube may be used safe in facial trauma Airway & Ventilation Methods: ALS Nasogastric Tube Insertion Select size (french) Measure length nose to ear to xiphoid Lubricate end of tube water soluble Maintain aseptic technique Position patient sitting up if possible Airway & Ventilation Methods: ALS Nasogastric Tube Insertion (cont) Insert into nare towards base Advance gradually but steadily to measured length Have patient swallow Assess placement & secure Instill air & ausculate aspirate gastric contents May connect to low vacuum (80-100 mm Hg) Airway & Ventilation Methods: ALS Orogastric Tube Insertion Select size (french) Measure length Lubricate end of tube Maintain aseptic technique Position patient (usually supine) Insert into mouth Advance gradually but steadily Airway & Ventilation Methods: ALS Orogastric Tube Insertion (cont) Assess placement & secure instill air or aspirate Evacuate contents as needed Airway & Ventilation Methods: ALS Endotracheal Intubation Tube into the trachea to provide ventilations using BVM or ventilator Sized based upon inside diameter in mm Lengths increase with increased ID cm markings along length Cuffed vs Uncuffed Airway & Ventilation Methods: ALS Endotracheal Intubation Indications present or impending respiratory failure apnea unable to protect own airway Advantages secures airway route for a few medications optimizes ventilation and oxygenation Airway & Ventilation Methods: ALS These are NOT Indications Because I can intubate Because they are unresponsive Because I cant show up at the hospital without it Airway & Ventilation Methods: ALS Complications of endotracheal intubation Bleeding or dental injury Laryngeal edema Laryngospasm Vocal cord injury Barotrauma Hypoxia Aspiration Dislodged tube or esophageal intubation Right or Left mainstem intubation Airway & Ventilation Methods: ALS Techniques of Insertion Orotracheal Intubation by direct laryngoscopy Blind Nasotracheal Intubation Digital Intubation Retrograde Intubation Transillumination techniques Airway & Ventilation Methods: ALS Orotracheal Intubation by direct laryngoscopy Position & Ventilate patient Monitor patient ECG Pulse oximeter Assess patients airway for difficulty Assemble & check equipment (suction) Hyperventilate patient (30-120 sec) Airway & Ventilation Methods: ALS Orotracheal Intubation by direct laryngoscopy (cont) Position patient Open mouth & insert laryngoscope blade Attempt to sweep tongue (straight blade) Identify anatomical landmarks Advance laryngoscope blade Vallecula for curved (Miller) blade Under epiglottis for straight (Miller) blade Airway & Ventilation Methods: ALS Orotracheal Intubation by direct laryngoscopy (cont) Elevate epiglottis Directly with straight (miller) blade Indirectly with curved (macintosh) blade Visualize the vocal cords & glottic opening Enter the mouth with the tube from corner of mouth Airway & Ventilation Methods: ALS Orotracheal Intubation by direct laryngoscopy (cont) Advance into glottic opening approx. 1/2 inch past vocal cords Continue to hold tube & note location Inflate cuff until firm (approx 10 cc) Ventilate & Auscultate epigastrium left and right chest Airway & Ventilation Methods: ALS Orotracheal Intubation by direct laryngoscopy (cont) Secure tube Reassess Ventilation Effectiveness auscultation clinical signs end-tidal CO2 Esophageal detection device Airway & Ventilation Methods: AL