CPR, FBAO, Airway

Week 5

CPR

Performed when patient is VSA and for children with < 60bpm

Chain of Survival

1. Early recognition and call for help (prevent cardiac arrest)

2. Early CPR (buying time)

3. Early Defibrillation (restart the heart)

4. Post Resuscitation Care (most important! restore quality of life)

CPR (Adult)

• Depth: Min 5cm (2in)

• Rate: 100-120 per min (full recoil, lock elbows, use heel of palm)

• Ventilations: See chest rise, over-inflation causes gastric insufflation

• Ratio: 30:2 (change compressors every 2 mins)

CPR (Infant/Pediatric > 24hrs - puberty)

• Depth: 1/3 of patient’s chest

• Rate: 100-120 per min (use one hand, 2 fingers or thumbs)

• Ventilations: See chest rise, over-inflation causes gastric insufflation

• Ratio: 2 people (15:2), 1 person (30:2)

CPR (Newborn < 24hrs)

• Depth: 1/3 of patient’s chest

• Rate: 100-120 per min (2 fingers or thumbs)

• Ventilations: See chest rise, over-inflation can cause trauma to lungs

• Ratio: 3:1

CPR (pregnancy)

• Caval Compression (vena cava is compressed by gravid uterus, impaired venous return from lower body)

• Left Lateral Tilt: Place blanket under right hip or move uterus to left

AED

• Stops everything, resets, hopes that heart goes back to normal

• Only used for resolving irregular electrical impulses in the heart

• All patients > 24hrs

• Stop CPR only for analyses or shocks

Ventricular Fibrillation

Misfires everywhere, shaking like jello (shockable)

Pulseless Ventricular Tachycardia

Can’t maintain cardiac output, rapid ineffective contractions (shockable)

Asystole

No electrical activity (non-shockable)

Pulseless Electrical Activity

Normal ECG, electrical is good and physically not good (non-shockable)

Defibrillation Pads: Apex-Base

Apex: Right of chest

Base: Left under chest

Defibrillation Pads: Anterior-Posterior

Anterior: Front of heart (slightly left of sternum)

Posterior: Back of heart (slightly left of spine)

AED Safety and Tips

• Water and electricity don’t mix

• Avoid metal surfaces

• Flammable (O2 - BVM)

• Shave chest for good pad contact

• Make sure EVERYONE is clear before shocking

5 P’s

1. Pacemakers: Ensure pad at least 1” away

2. Patches: Reduces effectiveness, take it off

3. Piercings: Burns, avoid placing directly over

4. Pendants: Move away from pads

5. Perspiration: Dry the chest, ensure electricity isn’t conducted across surface of skin 

Post-Resuscitation Care

• Get full set of vitals (every 15 mins)

• Further interventions (ventilation or blood pressure)

• 12-Lead ECG (heart no bueno inaccurate, wait 5-10 mins post ROSC)

• Let them exist before moving, BP can survive more

• ETCO2 spikes, heart is more bueno (let it drop naturally, too quickly causes cerebral vasoconstriction)

• Only life head if BP is normotensive, prevents ICP (if hypotensive can cause cerebral perfusion)

• Oxygen sits at 94-98% (too much causes more swelling due to ROS)

Return of Spontaneous Circulation (ROSC)

Palpable pulses and return and maintenance of increased consciousness

Types of Airway Obstruction

Anatomical: Tongue, swelling, airway positioning

Foreign Body (FBAO): Fluid, fucking anything)

Anatomical Airway Obstruction

Positioning: Head lift/chin lift or jaw thrust

Airway Adjuncts: OPA or NPA

If you can’t manage an airway, rapid transport!

Foreign Body (FBAO)

Partial: Stridor and encourage forceful coughs

Complete: Silence means intervene early

FBAO: Conscious Adult/Child

• Alternate between 5 back blows (put your foot in front of theirs) and 5 abdominal thrusts

• Consider chest thrusts for pregnant or obese patients or smaller children

• Continue until foreign body dislodges, patient can breathe/cough or patient becomes unresponsive

FBAO: Unconscious Adult/Child/Infant

• Lay supine on floor, ABCs (reassess when condition changes)

• Head tilt and open mouth (if see something, remove it)

• Ventilate patient x2 (if unsuccessful, reposition)

• 30 chest thrusts

• Repeat

• Apply defib pads

FBAO: Conscious Infant

• Note stridor - high pitched wheeze

• Visualize airway

• Support jaw and lay body on forearm

• Turn baby over for chest thrusts (2 fingers)

Airway Management

• Primary function is respiration and oxygenation

• Least invasive to most invasive techniques

Basic Airway Anatomy

Upper Airway (all structures above glottis): Protection and filtration

Lower Airway (all structures below glottis): Gas exchange

Nasal Cavity

• External Nares (nostril)

• Nasal Conchae (nasal turbinates): Inferior, middle and superior nasal concha

• Internal Nares

• Extends from external nares to internal nares

Oral Cavity

Lips, teeth, tongue and hard palate (extends from lips to junction of hard/soft palate)

Pharynx

• Funnel-shaped tube (13cm/5in)

• Extends from internal nares to cricoid cartilage (larynx)

• 3 sections: Nasopharynx, Oropharynx and Hypopharynx (Laryngopharynx)

Larynx

• Lies in midline of neck (C4-C6)

• 9 pieces of cartilage (3 unpaired: thyroid, epiglottis, cricoid) (3 paired: arytenoid, corniculate, cuneiform)

• Paired cartilages support vocal cords

Head Tilt/Chin Lift

• Lifts tongue away from back of throat

• Pros: Simple, non-invasive, no equipment

• Cons: Not self-maintained, movement in neck (SMR)

Jaw Thrust

• Lifts tongue away from back of throat

• Pros: Simple, non-invasive, no equipment, protects c-spine

• Cons: Not self-maintained

Tongue-Jaw Lift

Only for suctioning oropharynx or visual inspection

Oropharynx Airway (OPA)

• Physically scoops tongue forward, maintains patent airway

• Flange stops over insertion and reinforced bite block

• Pros: Self-maintained, quick and easy, non-invasive, unlikely to cause damage and can support BVM ventilation

• Cons: Can’t be used with active gag reflex, major oral trauma or in trismus (jaw clenched closed), can cause vomiting laryngospasm and no protection from aspiration

• Invert-Insert-Rotate

Nasopharynx Airway (NPA)

• Moves behind tongue, follows pharynx

• Pros: Easy, non-invasive, supports BVM, used with gag reflex, oral trauma and trismus and self-maintained

• Cons: Can’t be used with nasofacial trauma, nasal polyps, caution with those who suffer with epistaxis, no protection from aspiration

• Lubricate, Invert-Insert-Rotate

Supraglottic Airway (SGA)

iGel, Laryngeal Mask Airway, King LT

iGel

• Bite block, non-inflating cuff with epiglottis blocker, BVM ventilation is difficult with OPA/NPA, ET intubation is not possible/required

• Pros: No cuff inflation problems and ‘masks’ the laryngeal opening - blocks the oesophagus – some protection from aspiration

• Cons: Airway compromise beyond laryngeal entrance, active gag reflex, trismus, seal can fail if high pressure ventilation required, not fully protected from aspiration

King LT

• Inflatable cuffs (oesophageal and hypopharynx)

• Size marked by weight, remove loose dentures

Cricoid Pressure/BURP

Cricoid Pressure: Apply pressure to cricoid cartilage to compress esophagus

BURP: Backward, upward and rightward pressure to thyroid cartilage

Emergency Cricothyroidotomy

Surgical Cricothyroidotomy: Incision made with scalpel and ET tube insertion

Needle Cricothyroidotomy: Large bore IV cannula inserted through cricothyroid membrane (last ditch)

Tracheostomy

• Permanent/semi-permanent (opening called stoma)

• Can become blocked, may be called to clean, suction or re-insert

• Preferably new trach tube over clean old one

• Paramedics are only allowed to reinsert if original trach is removed, patient is in respiratory distress, not able to ventilate adequately and paramedics have a trach for the patient. 

Tracheostomy Tubes

Cuffed: Inflatable cuff at distal end to prevent air leakage and aspiration (usually unable to speak)

Uncuffed: Used in neonates and in those who can control their own secretions (may be able to speak with lots of airflow)

Fenestrated Tubes: Opening over vocal cords to allow speech

Others may speak if they cover trach opening

Suction Units

Manual (fucking sucks), Portable and Wall-mounted

Suction Catheters

Closed (in-line) suction, Wide-bore, Yankaeur and Soft/Flexible/French

Oropharyngeal Suction

• Attach catheter and tubing (sealed)

• PPE

• Set vacuum settings and turn unit on

• Only suction WHAT YOU SEE

• Apply suction as you withdraw catheter (adult: 15 secs, paed: 10 secs, infant: 5 secs)

• Allow for breathing between attempts

Oropharyngeal Suction Settings

Adult: <500 mmHg

Paed: <200 mmHg

Infant: 80-100 mmHg

Neonate: 60-80 mmHg

(settings change when ett/trach suctioning)

Tracheostomy/ETT Suction Settings

> 12 yrs: 100-150 mmHg

> 1yr: 100-120 mmHg

< 1yr: 60-100 mmHg

Sizing: French catheter ½ id of tube (lubricate with water/saline)

10 secs of suction and 1 min between attempts

Hypoxia

Low levels of oxygen in tissues

Hypoxaemia

Low levels of oxygen in the blood

Ischemia

Blood flow (and oxygen) restricted in part of the body causing tissue damage

Infarction

Tissue death as a result of inadequate blood and oxygen supply

Dyspnea

Difficulty breathing/sensation of difficulty breathing

Hypo/Hyperventilation

Not breathing enough/breathing too much

Respiratory Distress

Observable difficulty with breathing

Work of Breathing (WOB)

How hard the patient is working in order to breathe (includes accessory muscle use, pursed lips breathing, etc)

Oxygen (D)

• 21% oxygen in room air, 16% oxygen in expired air

• Cylinder Constant: 0.16

Oxygen (E)

• 21% oxygen in room air, 16% oxygen in expired air

• Cylinder Constant: 0.28

Oxygen (M)

• 21% oxygen in room air, 16% oxygen in expired air

• Cylinder Constant: 1.56

Oxygen Tanks

• Tanks consists of a cylinder and regulator (small tanks have removable regulator)

• Regulator displayed PSI in tank (filled to 2000PSI, changed before 200PSI)

• Cylinder Constant: Used to measure remaining time of oxygen delivery

Oxygen Regulator

• Delivers O2 at reasonable flow rate

• Flowmeter allows for adjustments to lpm (0.5-25lmp)

• Pressure compensated (upright, float ball in calibrated tube, gas flow controlled by needle valve)

• Bourdon-Gauge (Not affected by gravity)

Cylinder Preparation

Ensure tank is closed and purged of remaining pressure before removing regulator

Oxygen Math

[Current tank pressure - 200] x CC (cylinder constant) / Flow rate (lpm)

Nasal Cannulae

• Two prongs into nares

• Flow Rate: 1-6lpm (higher irritates and dries nasal mucus)

• Oxygen Concentration: 24-44%

• Some have ETCO2 built in

Non-Rebreather Mask (NRB)

• Flow Rate: 10-15lpm

• Oxygen Concentration: 90-100%

• One-way valve leading to reservoir bag (must be inflated)

• Pt inhales from reservoir, valve prevents air mixing back into reservoir

Filtered Non-Rebreather Mask (Tavish/Hi-Ox)

• Modified NRB

• Flow Rate: 10-15lpm

• Oxygen Concentration: 90-100%

• One-way valve leading to reservoir bag

• Exhaled air forced through high efficiency filters (airborne diseases)

Partial Rebreather

• Similar to NRB but no one way valve (air mixes in reservoir)

• Flow Rate: 6-10lpm

• Oxygen Concentration: 45-60%

• Ambulances don’t carry these

Simple Face Mask

• No reservoir

• Flow Rate: 6-10lpm

• Oxygen Concentration: 40-60%

• Draws in room air from side ports

Venturi Mask

• No reservoir

• Draws in room air from side ports

• Oxygen concentration depends on adapter used (24, 28, 35, 40 or 50%)

• Used in hospitals for COPD patients

• Ambulances don’t carry these

Nebulizer Mask

• Used to deliver aerosolized medications

• 2.5-5ml (If drug less than 2.5 need to make up to 2.5ml with water/saline)

• Flow Rate: 6-8lpm

Bag Valve Mask (BVM)

• Deliver artificial ventilation (apnea or ventilatory assistance)

• Reservoir bag with valve to prevent air mixing

• Pressure release valve to prevent barotrauma (stops you from going too fast but not from overinflating)

• Used with provided mask or attached to SGA or ETT

• PEEP and HEPA filtration attachment options

• Flow Rate: 15-25lpm

• Oxygen Concentration: 100%

• Use single hand C-E grip or double hand grip

Assisted/Artificial Ventilations

• Less than 8 - ventilate (not always true, hard to ventilate conscious pt)

• Observe pt and vs for ineffective ventilatory effort (low SPO2, laboured breathing, not moving much air, hypoxia/low perfusion)

BVM Ventilation Rates

Adult: 10 breaths per min (1 every 5-6 secs)

Paediatric: 20-30 breaths per min (1 every 2-3 secs)

Newborn: 40-60 breaths per min (1 every 1-1.5 secs)

Unless otherwise directed in BLS PCS

Positive End-Expiratory Pressure (PEEP)

• Keeps lungs inflated – splints open and stops them from sticking together (atelectasis)

• Forces fluid OUT of alveoli

• Reduces pre-load and increases intrapulmonary pressure (increased RV afterload)

• Used in patients required ventilation and wet patients (drowning, aspiration, pulmonary edema)

• Not used when asthma attacks, trauma to lungs, hypovolaemic (blood loss), cardiogenic shock (heart muscle can’t pump properly)

• Start at 5cm H2O, increase as need to max 20cm H2O

Continuous Positive Airway Pressure (CPAP)

• High concentrations, high pressure of O2 forced into pts lungs

• Hospitals also use BiPAP (Biphasic Positive Airway Pressure), more common

Oxygen Administration Decisions

Standard BLS Care (maintain): 92-96%

COPD maintain: 88-92%

ROSC maintain: 94-98%

Start low and work upwards!