气道通气的识别和评估.ppt

Assessment&RecognitionofAirway&VentilatoryCompromise,HistoryOnsetsuddenvsgradualKnowncause?DurationConstantRecurrentProvocation/Palliation,Assessment&RecognitionofAirway&VentilatoryCompromise,ExacerbationAssociatedSigns/SymptomsCough,chestpain,feverInterventionspastevals/admitsmedseverintubatedbefore?,Assessment&RecognitionofAirway&VentilatoryCompromise,RespiratoryPatternsCheyne-StokesbrainstemKussmaulacidosisBiotsincreasedICP,RespiratoryPatternsCentralNeurogenicHyperventilationincreasedICPAgonalbrainanoxia,Assessment&RecognitionofAirway&VentilatoryCompromise,InadequateVentilationbodycannotcompensateforincreasedoxygendemandormaintainbalanceCausesinfectiontraumabrainsteminjurytoxicinhalationrenalfailure,Airway&VentilationMethods:BLS,SupplementalOxygenincreasedFiO2increasesavailableoxygenobjectiveistomaximizehemoglobinsaturation,Airway&VentilationMethods:BLS,OxygensourcecompressedgasliquidoxygenRegulatorsHumidifier,DeliveryDevicesnasalcannulapartialrebreathermasknon-rebreathermaskventurimasksmallvolumenebulizer,Airway&VentilationMethods:BLS,AirwayManeuversHead-tilt/Chin-liftJawthrustSellicksmaneuverOtherTypestracheostomywithtubetracheostomywithstoma,AirwayDevicesOropharyngealairwayNasopharyngealairway,Airway&VentilationMethods:BLS,MouthtoMouthMouthtoNoseMouthtoMaskOnepersonBVMTwopersonBVMThreepersonBVMFlowrestrictedpoweredventilatorTransportventilator,OnePersonBVMdifficulttomastermasksealofteninadequatemayresultininadequatetidalvolgastricdistentionriskventilateonlyuntilseechestrise,Airway&VentilationMethods:BLS,TwopersonBVMmostefficientmethodUsefulinC-spineinjimprovedmasksealandtidalvolume,ThreepersonBVMlessutilizedusedwhendifficultywithmasksealcrowded,Airway&VentilationMethods:BLS,Flow-restricted,poweredventilatorCardiacsphincteropensat30cmH2Ohighvolume/highconcnotrecommendedforchildren,noncompliantorpoortidalvolumeoxygendeliveredoninspiratoryeffortmaycausebarotrauma,Airway&VentilationMethods:BLS,AutomatictransportventilatorsNotlikea“real”ventilatorUsuallyonlycontrolsVolumeandrateUsefulduringprolongedventilationtimesNotusefulinobstructedairwayorincreasedairwayresistanceFreespersonnelCannotdetectchanges,Airway&VentilationMethods:BLS,PediatricconsiderationsmasksealforcemayobstructairwaybestifusedwithjawthrustBVMsizes:neonate&infant=450ml+Children8yoarequireadultBVMjustenoughvolumetoseechestriseSqueeze-Release-Release,Airway&VentilationMethods:BLS,StomapatientsexposestomapocketmaskBVMSealaroundstomasitesealmouthandnoseifairleakisevident,Airway&VentilationMethods:BLS,AirwayObstructionTechniquesPositioningOPA/NPAHeimlichmaneuverFingersweepwithcautionChestThrustsChestthrustandbackblowsforinfantsSuctioningDirectlaryngoscopy,Airway&VentilationMethods:BLS,SuctioningManualorPowereddevicesSuctioncathetersrigidsoftTracheobronchialsuctioninglubricatecatheter3-5ccsterilewaterorsalineinsertcatheteruntilresistanceisfelt,Airway&VentilationMethods:BLS,GastricDistentionCommonwhenventilatingwithoutintubationpressureondiaphragmresistancetoBVMventilationincreasetimeofBVMventilation,AirwayManagement:Part2,EMSProfessionsTempleCollege,Airway&VentilationMethods:ALS,GastricTubesnasogastriccautionwithesophagealdiseaseorfacialtraumatoleratedbyawakepatientsbutisuncomfortablepatientcanspeakinterfereswithBVMsealorogastricusuallyusedinunresponsivepatientslargertubemaybeusedsafeinfacialtrauma,Airway&VentilationMethods:ALS,NasogastricTubeInsertionSelectsize(french)MeasurelengthnosetoeartoxiphoidLubricateendoftubewatersolubleMaintainaseptictechniquePositionpatientsittingupifpossible,Airway&VentilationMethods:ALS,NasogastricTubeInsertion(cont)InsertintonaretowardsbaseAdvancegraduallybutsteadilytomeasuredlengthHavepatientswallowAssessplacement&secureInstillair&ausculateaspirategastriccontentsMayconnecttolowvacuum(80-100mmHg),Airway&VentilationMethods:ALS,OrogastricTubeInsertionSelectsize(french)MeasurelengthLubricateendoftubeMaintainaseptictechniquePositionpatient(usuallysupine)InsertintomouthAdvancegraduallybutsteadily,Airway&VentilationMethods:ALS,OrogastricTubeInsertion(cont)Assessplacement&secureinstillairoraspirateEvacuatecontentsasneeded,Airway&VentilationMethods:ALS,EndotrachealIntubationTubeintothetracheatoprovideventilationsusingBVMorventilatorSizedbaseduponinsidediameterinmmLengthsincreasewithincreasedIDcmmarkingsalonglengthCuffedvsUncuffed,Airway&VentilationMethods:ALS,EndotrachealIntubationIndicationspresentorimpendingrespiratoryfailureapneaunabletoprotectownairwayAdvantagessecuresairwayrouteforafewmedicationsoptimizesventilationandoxygenation,Airway&VentilationMethods:ALS,TheseareNOTIndicationsBecauseIcanintubateBecausetheyareunresponsiveBecauseIcantshowupatthehospitalwithoutit,Airway&VentilationMethods:ALS,ComplicationsofendotrachealintubationBleedingordentalinjuryLaryngealedemaLaryngospasmVocalcordinjuryBarotraumaHypoxiaAspirationDislodgedtubeoresophagealintubationRightorLeftmainstemintubation,Airway&VentilationMethods:ALS,TechniquesofInsertionOrotrachealIntubationbydirectlaryngoscopyBlindNasotrachealIntubationDigitalIntubationRetrogradeIntubationTransilluminationtechniques,Airway&VentilationMethods:ALS,OrotrachealIntubationbydirectlaryngoscopyPosition&VentilatepatientMonitorpatientECGPulseoximeterAssesspatientsairwayfordifficultyAssemble&checkequipment(suction)Hyperventilatepatient(30-120sec),Airway&VentilationMethods:ALS,OrotrachealIntubationbydirectlaryngoscopy(cont)PositionpatientOpenmouth&insertlaryngoscopebladeAttempttosweeptongue(straightblade)IdentifyanatomicallandmarksAdvancelaryngoscopebladeValleculaforcurved(Miller)bladeUnderepiglottisforstraight(Miller)blade,Airway&VentilationMethods:ALS,OrotrachealIntubationbydirectlaryngoscopy(cont)ElevateepiglottisDirectlywithstraight(miller)bladeIndirectlywithcurved(macintosh)bladeVisualizethevocalcords&glotticopeningEnterthemouthwiththetubefromcornerofmouth,Airway&VentilationMethods:ALS,OrotrachealIntubationbydirectlaryngoscopy(cont)Advanceintoglotticopeningapprox.1/2inchpastvocalcordsContinuetoholdtube¬elocationInflatecuffuntilfirm(approx10cc)Ventilate&Auscultateepigastriumleftandrightchest,Airway&VentilationMethods:ALS,OrotrachealIntubationbydirectlaryngoscopy(cont)SecuretubeReassessVentilationEffectivenessauscultationclinicalsignsend-tidalCO2Esophagealdetectiondevice,Airway&VentilationMethods:ALS,EquipmentLaryngoscopeHandle(lighte