Prior to applying a nonrebreathing mask on a patient with difficulty breathing, you should:!

Transcription

1 An elderly woman with COPD presents with a decreased level of consciousness, cyanosis to her face and neck, and labored respirations. Her pulse is rapid and weak and her oxygen saturation is 76%. You should: A: apply oxygen via nasal cannula and reassess her respiratory status. B: insert a nasal airway and give her oxygen via a nonrebreathing mask. C: assist her ventilations with a bag-mask device and high-flow oxygen. D: avoid high-flow oxygen because this may cause her to stop breathing. The correct answer is C; Reason: The patient in this scenario is experiencing an exacerbation (worsening) of her COPD. Her decreased level of consciousness; cyanosis; weak, rapid pulse; low oxygen saturation (SpO2); and labored breathing clearly indicate that she is not breathing adequately. Therefore, you should assist her ventilations with a bag-mask device and high-flow oxygen; if you don t, she will continue to deteriorate, possibly to the point of cardiac arrest. If needed, insert a nasal airway adjunct to help keep her airway open. Regardless of the patient s history of COPD, you must NOT withhold oxygen from her. Respiratory depression in COPD patients who receive high-flow oxygen is highly uncommon. Death due to hypoxia, however, is very common. ================================== Prior to applying a nonrebreathing mask on a patient with difficulty breathing, you should: A: insert a nasopharyngeal airway to maintain airway patency. B: perform a complete exam to assess the degree of hypoxia. C: prefill the reservoir bag to ensure delivery of 100% oxygen. D: set the flow rate to no more than 10 liters per minute. The correct answer is C; Reason: After attaching the nonrebreathing mask to the oxygen source, the flowmeter should be set to between 12 and 15 L/min. The reservoir bag is then prefilled with oxygen, which will allow the delivery of high-flow oxygen. Unless the patient has a decreased level of consciousness, a nasopharyngeal airway is not required before applying a nonrebreathing mask. The need for supplemental oxygen should be determined early in your assessment; do not perform an indepth exam before deciding to administer oxygen. ================================== While ventilating an apneic patient with a bag-mask device, you note minimal rise of the chest each time you squeeze the bag. You should: A: evaluate the mask-to-face seal and the position of the patient's head. B: ensure that the reservoir is properly attached to the bag-mask device. C: suction the patient s mouth for 15 seconds and reattempt ventilations. D: squeeze the bag harder to ensure delivery of adequate tidal volume.

2 Reason: The correct answer is A; If the patient's chest rises minimally or not at all when you are ventilating him or her with the bag-mask device, you should first reevaluate the mask-to-face seal and make sure that the patient's head is properly positioned. The most common complication associated with bag-mask ventilation is difficulty in maintaining an adequate mask-to-face seal. If repositioning the head does not correct the problem, you should ensure that you are squeezing the bag hard enough to deliver adequate tidal volume. Caution must be used, however, when ventilating a patient; breaths that are delivered too forcefully or too fast (hyperventilation) may cause an increase in intrathoracic pressure, thus impeding blood return to the heart and decreasing cardiac output. Forceful ventilations may also cause significant gastric distention. Therefore, you should deliver each breath over a period of one second just enough to produce visible chest rise. The patient's mouth should be suctioned only if it contains blood or other secretions. ================================== An unresponsive apneic patient s chest fails to rise after two ventilation attempts. You should: A: immediately proceed to chest compressions. B: reposition the head and reattempt to ventilate. C: attempt to ventilate again using more volume. D: suction the airway and reattempt ventilations. The correct answer is A; Reason: If your initial attempt to ventilate an apneic patient is unsuccessful (that is, you meet resistance or the chest fails to visibly rise), reposition the patient s head and reattempt to ventilate. If the second ventilation is unsuccessful, you should proceed under the assumption that the patient has a severe (complete) airway obstruction. Perform 30 chest compressions, open the airway, and visualize the mouth (remove an object only if you can see it). If you are able to remove the foreign object, attempt to ventilate. If you are not, continue chest compressions. Continue this sequence until the obstruction is relieved or an advanced life support (ALS) ambulance arrives. If ALS response will be delayed, transport, continuing your attempts to relieve the obstruction en route, and coordinate a rendezvous with the ALS unit. ================================== While managing a patient with acute shortness of breath, you attempt to apply a nonrebreathing mask set at 12 L/min. The patient pulls the mask away from his face, stating that it is smothering him. You should: A: increase the oxygen flow and reapply the mask. B: inform the patient that refusing oxygen may result in his death. C: reassure the patient and apply a nasal cannula instead. D: securely tape the oxygen mask to the patient s face. The correct answer is C;

3 Reason: Some adults cannot tolerate the oppressive feeling of an oxygen mask over their face; children are typically less tolerant than adults. You should provide reassurance to the patient and apply a nasal cannula at 2 to 6 L/min, which will likely be better tolerated. Do not force an oxygen mask on a patient's face; doing so will only increase his or her anxiety, which will increase his or her body's oxygen consumption and demand. ================================== Which of the following signs or symptoms is indicative of cerebral hypoxia? A: Heart rate greater than 120 beats/min B: Decreased level of consciousness C: Diffuse wheezing on exhalation D: Chief complaint of dyspnea The correct answer is B; Reason: Dyspnea, a feeling of shortness of breath, is a symptom of a condition that can cause cerebral hypoxia (eg, CHF, COPD); however, dyspnea itself does not indicate cerebral hypoxia. Wheezing, a whistling sound that indicates bronchospasm, is a sign; like dyspnea, it indicates the presence of a condition that can cause cerebral hypoxia (eg, asthma). Tachycardia can occur for many reasons; cerebral hypoxia is but one. Of the choices listed, a decreased level of consciousness is most indicative of cerebral hypoxia. As oxygen levels in the brain decrease and carbon dioxide levels increase, the patient's mental status deteriorates. ================================== Shallow respirations are an indication of: A: increased oxygen intake. B: increased carbon dioxide removal. C: increased minute volume. D: decreased tidal volume. The correct answer is D; Reason: Shallow respirations are an indication of decreased tidal volume. Tidal volume is the amount of air (in milliliters [ml]) breathed into or out of the lungs in a single breath. Adequate tidal volume is needed to bring in adequate amounts of oxygen and eliminate adequate amounts of carbon dioxide. Patients with shallow breathing often need some form of positive-pressure ventilation assistance (eg, bag-mask or pocket face mask device), especially if they have a decreased mental status. Minute volume is the volume of air that is moved through the lungs per minute; it is a product of tidal volume multiplied by the respiratory rate. If tidal volume is reduced, minute volume will be reduced as well unless there is a compensatory increase in the respiratory rate.

4 ================================== After an initial attempt to ventilate an unresponsive apneic patient fails, you reposition the patient's head and reattempt ventilation without success. You should next: A: turn the patient onto his side and deliver 5 to 10 back slaps. B: administer 5 to 10 abdominal thrusts and reattempt to ventilate. C: perform chest compressions, open the airway, and look in the mouth. D: perform continuous chest compressions until ALS personnel arrive. The correct answer is C; Reason: If you are unable to ventilate an unresponsive, apneic patient after two attempts, you should assume that he or she has a severe (complete) foreign body airway obstruction. Immediately perform 30 chest compressions (15 compressions if two EMTs are present and the patient is an infant or child). Next, open the patient's airway and look inside the mouth. If you can see the object, attempt to remove it with your finger (never perform blind finger sweeps of the mouth). If you cannot see the object, continue chest compressions. If you are able to remove the object, reattempt to ventilate. Unless paramedics are nearby, begin transport while continuing chest compressions, opening the airway and looking in the mouth, and attempting to ventilate (if you can remove the object). Abdominal thrusts are indicated for responsive children and adults with a severe airway obstruction. Back slaps are indicated for a responsive infant with a severe airway obstruction. ================================== Which of the following airway sounds indicates a lower airway obstruction? A: Wheezing B: Stridor C: Gurgling D: Crowing The correct answer is A; Reason: Wheezing is a whistling sound that results from narrowing and/or inflammation of the bronchioles in the lungs and is an indicator of a lower airway disease (ie, asthma, bronchiolitis). Crowing and stridor are both high-pitched sounds that indicate an upper airway disease or obstruction (ie, croup, epiglottitis, foreign body obstruction), and gurgling indicates secretions in the oropharynx. ================================== As you begin ventilating an unresponsive apneic man, you hear gurgling in his upper airway. Your MOST immediate action should be to:

5 A: suction the patient s airway for no longer than 15 seconds. B: reposition the patient s airway and continue ventilations. C: squeeze the bag-mask device with less force and reassess. D: quickly turn the patient onto his side so secretions can drain. The correct answer is D; Reason: Gurgling in the airway indicates the presence of vomitus or other secretions. If this is noted, you should immediately turn the patient onto his side to allow the secretions to drain. After placing the patient on his side, suction his airway for no longer than 15 seconds. To continue ventilating a patient whose airway is full of vomitus or secretions will force the secretions into the trachea, resulting in aspiration. Aspiration significantly increases mortality ================================== A 56-year-old man has labored, shallow breathing at a rate of 28 breaths/min. He is responsive to pain only. You should: A: ventilate him with a bag-mask device at a rate of 30 breaths/min. B: suction his mouth for 15 seconds and insert an oropharyngeal airway. C: insert a nasopharyngeal airway and begin assisting his ventilations. D: place him on his side and administer oxygen via nonrebreathing mask. The correct answer is C; Reason: This patient in this scenario is not breathing adequately. He is responsive to pain only, and his respirations are rapid, labored, and shallow. You should insert a nasopharyngeal airway, which is usually well-tolerated in patients who are semiconscious and have a gag reflex, and assist his ventilations with a bag-mask device. When assisting a patient's breathing, you should squeeze the bag-mask device to ensure that he or she receives 10 to 12 adequate breaths per minute. Do not hyperventilate the patient as this increases the risks of vomiting and aspiration. Hyperventilation also increases intrathoracic pressure, which may impair venous return to the heart (preload) and cause a decrease in cardiac output. Oxygen via nonrebreathing mask is appropriate for patients who are breathing adequately, but are suspected of being hypoxic. The recovery position (patient is placed on his or her side) is appropriate for unresponsive, uninjured patients with adequate breathing. ================================== A: Combative; respiratory rate of 24 breaths/min and deep B: Restless; respiratory rate of 12 breaths/min with adequate tidal volume C: Responsive to pain only; respiratory rate of 8 breaths/min and shallow D: Semiconscious; respiratory rate of 14 breaths/min and good chest rise The correct answer is C; Which of the following patients obviously needs positive-pressure ventilation assistance?

6 Reason: Any patient with a decreased level of consciousness should be assessed for inadequate breathing (eg, fast or slow respiratory rate, reduced tidal volume [shallow breathing]). Of the patients listed, the patient who is responsive to pain only and has shallow respirations of 8 breaths/min clearly needs positive-pressure ventilation assistance. Slow, shallow respirations will not produce the minute volume needed to support adequate oxygenation of the blood. ================================== Snoring respirations in an unresponsive patient are usually the result of: A: swelling of the upper airway structures. B: foreign body airway obstruction. C: upper airway obstruction by the tongue. D: collapse of the trachea during breathing. The correct answer is C; Reason: In an unresponsive patient, the muscles of the tongue, which attach to the mandible, relax and fall back over the posterior pharynx. This makes obstruction by the tongue the most common cause of airway obstruction in the unresponsive patient. Foreign body upper airway obstructions and upper airway swelling typically produce stridor, a high-pitched sound heard during inhalation. Collapsing of the trachea during breathing would likely present with marked respiratory distress. ================================== A 50-year-old man, who fell approximately 20 feet and landed on a hard surface, is semiconscious. You should: A: check for a carotid pulse if the patient is breathing rapidly. B: gently tilt the patient s head back to assess for breathing. C: stabilize his head while performing the jaw-thrust maneuver. D: begin positive-pressure ventilations with a bag-mask device. The correct answer is C; Reason: Because of the significant mechanism of injury (fall of greater than 15 feet), spinal injury should be assumed. The first step in managing this patient is to manually stabilize his head in a neutral position and open his airway with the jaw-thrust maneuver, both of which can be performed simultaneously. After the patient's airway is open, assess the rate and quality of his breathing and treat accordingly. The head tilt-chin lift maneuver should not be used on a patient with a possible spinal injury unless the jaw-thrust maneuver does not adequately open his or her airway. The patient in this scenario is semiconscious; therefore, he has a pulse (pulseless patients are unresponsive). If an uninjured patient is found to be unresponsive, you should

7 quickly assess for breathing by visualizing the chest. If the patient is not breathing or only has agonal gasps, you should check for a carotid pulse. ================================== Occasional, irregular breaths that may be observed in a cardiac arrest patient are called: A: ataxic respirations. B: Biot respirations. C: Cheyne-Stokes respirations. D: agonal gasps. The correct answer is D; Reason: Occasional, irregular breaths, called agonal gasps, may be observed in some patients shortly after their heart stops beating. They occur when the respiratory center in the brain sends stray signals to the respiratory muscles. Agonal gasps are not adequate because they are infrequent and result in negligible tidal volume. Biot respirations are characterized by an irregular pattern, rate, and depth of breathing with intermittent periods of apnea; they are commonly associated with severe brain trauma. Ataxic respirations are ineffective, irregular breaths that may or may not have an identifiable pattern; they are also commonly associated with severe brain trauma. Cheyne-Stokes respirations are characterized by a crescendo-decrescendo pattern of breathing with a period of apnea between each cycle (fast, slow, apnea). Cheyne-Stokes respirations may occur in healthy people during certain phases of the sleep cycle; however, if they are grossly exaggerated or occur in a patient with a head injury, they are an ominous sign. ================================== Which of the following occurs during positive-pressure ventilation? A: The esophagus remains closed B: Blood is drawn back to the heart C: Intrathoracic pressure increases D: Oxygen is pulled into the lungs The correct answer is C; Reason: Negative-pressure ventilation, the act of normal breathing, occurs when the diaphragm and intercostal muscles contract. The actions of these muscles create a vacuum (negative pressure), which pulls oxygen-rich air into the lungs. Because of the negative pressure created in the chest, blood is naturally drawn back to the heart. The esophagus remains closed during normal breathing. In contrast, positive-pressure ventilation involves the forcing of air into the lungs, such as what is provided during rescue breathing. Positive-pressure ventilation causes an increase in intrathoracic pressure, which can impair blood flow back to the heart and cause a decrease in cardiac output. During positive-pressure ventilation, the esophagus is forced open and air enters the stomach (gastric distention); this could result in vomiting and aspiration.

8 ================================== A patient with a mild foreign body airway obstruction: A: has a low oxygen saturation. B: presents with a weak cough. C: is typically not cyanotic. D: has progressive difficulty breathing. The correct answer is C; Reason: Patients with a mild (partial) airway obstruction are able to move adequate amounts of air, but will have varying degrees of respiratory distress. The patient can cough forcefully, although you may hear wheezing in between coughs. Because the patient is able to move air effectively, the level of oxygen in his or her blood remains adequate; therefore, cyanosis is typically absent. By contrast, the patient with a severe (complete) airway obstruction cannot move air effectively and cannot speak. If a cough is present, it is weak and ineffective. As the level of oxygen in the blood falls, cyanosis develops, oxygen saturation falls, and the patient s level of consciousness decreases. A foreign body airway obstruction, mild or severe, is an acute event that presents with an acute onset of difficulty breathing. Progressive (gradually worsening) difficulty breathing is more consistent with diseases such as congestive heart failure and pneumonia. ================================== Which of the following clinical findings is MOST consistent with a chronic respiratory disease? A: A barrel-shaped chest B: Use of accessory muscles C: An irregular pulse D: Altered mental status The correct answer is A; Reason: In certain lung diseases (eg, emphysema, asthma), air is gradually and continuously trapped in the lungs in increasing amounts; this increases the anterior-posterior (front to back) diameter of the chest, causing the chest to assume a barrel shape. A barrel-shaped chest indicates a chronic respiratory disease. Accessory muscle use and an altered mental status in a patient with respiratory distress should be assumed to be acute findings. An irregular pulse could be the result of a primary cardiac problem, or a cardiac problem secondary to chronic hypoxemia in patients with various respiratory diseases. ================================== To obtain the MOST reliable assessment of a patient's tidal volume, you should: A: assess for retractions. B: count the respiratory rate.

9 C: look at the rise of the chest. D: listen for airway noises. The correct answer is C; Reason: Tidal volume is the amount of air, in milliliters, breathed into or out of the lungs in a single breath. The most effective (and practical) way to assess tidal volume is to evaluate the rise of the patient s chest. If the patient's chest rises minimally during inhalation, his or her respirations are shallow; shallow respirations reflect a reduced tidal volume. ================================== A 60-year-old woman presents with acute respiratory distress. She is conscious and alert, but restless. Her respiratory rate is 26 breaths/min with adequate chest expansion, her breath sounds are clear to auscultation bilaterally, and her oxygen saturation is 90%. Which of the following is the MOST appropriate treatment for this patient? A: A nasopharyngeal airway and assisted ventilations B: A nasopharyngeal airway and supplemental oxygen C: A nasal cannula with the flowmeter set at 4 to 6 L/min D: Supplemental oxygen with a nonrebreathing mask The correct answer is D; Reason: Although the patient is restless a sign of hypoxemia she is conscious and alert and able to maintain her own airway; therefore, an airway adjunct is not needed at this point. Furthermore, her respirations, although increased in rate, are producing adequate tidal volume as evidenced by adequate chest expansion. Therefore, she is not in need of assisted ventilation at this point. Considering her oxygen saturation of 90%, the most appropriate treatment would be to administer high-flow oxygen with a nonrebreathing mask and closely monitor her for signs of inadequate breathing (ie, shallow breaths [reduced tidal volume], decreased level of consciousness, cyanosis). An acutely hypoxemic patient requires more oxygen than a nasal cannula can provide. ================================== During your assessment of a trauma patient, you note massive facial injuries, weak radial pulses, and clammy skin. What should be your MOST immediate concern? A: Internal bleeding and severe shock B: Applying 100% supplemental oxygen C: Providing rapid transport to a trauma center D: Potential obstruction of the airway The correct answer is D; Reason:

10 Any trauma patient with severe maxillofacial trauma is at an extremely high risk of airway compromise. The airway can be compromised by either mandibular fractures, in which the tongue may occlude the airway, or severe oral bleeding, in which blood clots can obstruct the airway. Correct ANY airway problems immediately upon discovery, ensure adequate ventilation and oxygenation, assess for and treat other life-threatening injuries, and prepare for rapid transport. ================================== During your assessment of an unresponsive adult female, you determine that she is apneic. You should: A: deliver two rescue breaths. B: assess for a carotid pulse. C: begin chest compressions. D: place an oropharyngeal airway. The correct answer is B; Reason: As soon as you determine that an adult patient is apneic or only has agonal gasps, you should assess for a carotid pulse for at least 5 seconds but no more than 10 seconds. If the patient has a pulse, provide rescue breathing at a rate of 10 to 12 breaths/min (one breath every 5 to 6 seconds). If the patient does not have a pulse, perform 30 chest compressions and then open the airway and deliver 2 rescue breaths. When managing a patient who is in cardiac arrest, it is critical to minimize interruptions in chest compressions and to avoid delays in starting chest compressions. After starting CPR, apply the AED as soon as one is available. An airway adjunct should also be inserted as soon as possible. ================================== You receive a call for a 49-year-old woman who passed out. The patient's husband tells you that they were watching TV when the incident occurred. No trauma was involved. The patient is semiconscious and has cyanosis to her lips. After opening her airway with the head tilt-chin lift maneuver, you should: A: insert an oropharyngeal airway. B: assess her respiratory effort. C: begin ventilation assistance. D: insert a nasopharyngeal airway. The correct answer is D; Reason: In the absence of trauma, open the patient s airway with the head tilt-chin lift maneuver. To help maintain airway patency, a nasopharyngeal airway should be inserted. Your patient is semiconscious, not unconscious, so she will likely gag if you attempt to insert an oropharyngeal airway; this may result in aspiration if she vomits. Remember, you must first open the patient s airway and, if needed, suction any secretions from the mouth. Next, insert an airway adjunct

11 and assess respiratory effort. The method of oxygenation you provide depends on the adequacy of the patient's breathing. Tidal volume is defined as the: ================================== A: volume of air inhaled or exhaled per breath. B: volume of air moved in and out of the lungs each minute. C: total volume of air that the lungs are capable of holding. D: volume of air that remains in the upper airway. The correct answer is A; Reason: Tidal volume (VT) is the amount of air that is inhaled or exhaled per breath; it is normally 500 ml in a healthy adult male. Tidal volume is assessed by noting the depth of a patient's breathing. Shallow breathing, for example, indicates a reduced tidal volume. The volume of air that remains in the upper respiratory tract (eg, larger bronchi, trachea) is called dead space volume (VD); it is approximately 30% of the adult male's tidal volume and does not participate in pulmonary gas exchange. The volume of air that moves in and out of the lungs each minute, and does participate in pulmonary gas exchange, is called alveolar minute volume (VA). It is calculated by multiplying the tidal volume (minus the dead space volume) and the respiratory rate. Therefore, if an adult male has a tidal volume of 500 ml and a respiratory rate of 18 breaths/min, his alveolar minute volume is 6,300 ml (500 ml [VT] ml [VD] 18 [breaths/ min] = 6,300 ml [VA]). The maximum volume of air that the lungs are capable of holding is called the total lung capacity (TLC); it is approximately 6 L in the healthy adult male. ================================== When ventilating an apneic patient, you note decreased ventilatory compliance. This means that: A: the lungs are difficult to ventilate. B: you meet no resistance when ventilating. C: fluid is occupying the alveoli. D: the upper airway is blocked. The correct answer is A; Reason: As it applies to artificial ventilation, compliance is the ability of the lungs to expand during ventilation. Increased ventilatory compliance means that no resistance is met when you ventilate the patient; you can ventilate the lungs with ease. Decreased ventilatory compliance means that significant resistance is met when you ventilate the patient; the lungs are difficult to ventilate. Conditions such as upper airway obstruction, widespread bronchospasm, fluid in the alveoli (eg, pulmonary edema), and COPD can all cause decreased ventilatory compliance. ==================================

12 The MOST appropriate treatment for a semiconscious patient with slow, shallow respirations includes: A: an oropharyngeal airway and assisted ventilation with a bag-mask device. B: a nasopharyngeal airway and assisted ventilation with a bag-mask device. C: a nasopharyngeal airway and high-flow oxygen via a nonrebreathing mask. D: an oropharyngeal airway and high-flow oxygen via a nonrebreathing mask. The correct answer is B; Reason: Semiconscious patients are not fully able to protect their own airway and require an airway adjunct. The nasopharyngeal airway is indicated for semiconscious patients because they often have an intact gag reflex; the oropharyngeal airway is contraindicated in any patient with an intact gag reflex. Slow, shallow respirations will not provide the minute volume needed to support adequate oxygenation and should be treated with positive-pressure ventilation assistance (eg, bag-mask device, pocket face mask). ================================== A reduction in tidal volume would MOST likely result from: A: flaring of the nostrils. B: increased minute volume. C: unequal chest expansion. D: accessory muscle use. The correct answer is C; Reason: Unequal (asymmetrical) or minimal expansion of the chest results in a decrease in the amount of air inhaled per breath (tidal volume). Accessory muscle use and nasal flaring are signs of increased work of breathing, which represents an attempt to maintain adequate tidal volume (and therefore, minute volume). An increase in tidal volume, respiratory rate, or both, would result in an increase in minute volume. It should be noted, however, that a markedly fast respiratory rate would cause a natural decrease in tidal volume. For example, a patient breathing at a rate of 40 breaths/min would likely only inhale air into the anatomic dead space before promptly exhaling it. ================================== After an adult cardiac arrest patient has been intubated by a paramedic, you are providing ventilations as your partner performs chest compressions. When ventilating the patient, you should: A: deliver 2 breaths during a brief pause in chest compressions. B: deliver each breath over 2 seconds at a rate of 12 to 15 breaths/min. C: hyperventilate the patient to maximize carbon dioxide elimination.

13 D: deliver each breath over 1 second at a rate of 8 to 10 breaths/min. The correct answer is D; Reason: When ventilating an adult cardiac arrest patient with an advanced airway in place (ie, ET tube, multilumen airway, supraglottic airway), you should deliver each breath over a period of 1 second just enough to produce visible chest rise at a rate of 8 to 10 breaths/min (one breath every 6 to 8 seconds). Do not attempt to synchronize ventilations with chest compressions once the airway has been secured with an advanced device. Hyperventilation should be avoided as it may result in increased intrathoracic pressure, decreased blood return to the heart, and as a result, less effective chest compressions. ================================== Which of the following is the preferred initial method for providing artificial ventilations to an apneic adult? A: Two-person bag-valve-mask technique with 100% oxygen B: Mouth-to-mask technique with supplemental oxygen C: Flow-restricted, oxygen-powered ventilation device D: One-person bag-valve-mask technique with 100% oxygen The correct answer is B; Reason: The preferred initial method for providing artificial ventilations is the mouth-to-mask technique with one-way valve and supplemental oxygen attached. Evidence has show that rescuers who ventilate patients infrequently have difficulty maintaining an adequate seal with a bag-mask device. Because both of the rescuer s hands are freed up when using a pocket face mask, it is easier to maintain an adequate seal, thus providing more effective ventilations. Of course, if two rescuers are available to manage the airway, the two-person bag-mask device technique should be used. The flow-restricted, oxygen-powered ventilation device, also referred to as the manually-triggered ventilator or demand valve, requires an oxygen source to function and would thus not be practical as an initial device for providing artificial ventilations. ================================== You are dispatched to a residence for an elderly female who has possibly suffered a stroke. You find her lying supine in her bed. She is semiconscious; has vomited; and has slow, irregular breathing. You should: A: administer high-flow oxygen and place her on her side. B: perform a head tilt-chin lift and insert an oral airway. C: manually open her airway and suction her oropharynx. D: insert a nasal airway and begin assisting her breathing. The correct answer is C; Reason:

14 This patient s airway is in immediate jeopardy The first step in caring for any semi- or unconscious patient is to manually open the airway (eg, head tilt-chin lift, jaw-thrust) and ensure it is clear of obstructions or secretions. Because the patient has vomited, she likely has vomitus in her mouth, which must be removed with suction before she aspirates it into her lungs. Mortality increases significantly if aspiration occurs. After opening her airway and removing any vomitus or secretions from her oropharynx with suction, you should insert an airway adjunct (a nasal airway in this case; the patient is semiconscious and likely has an intact gag reflex) and begin assisting her breathing with a bag-mask device. Her respiratory effort is inadequate and should be treated with some form of positive-pressure ventilation, not a nonrebreathing mask. Placing a semi- or unconscious patient on his or her side (recovery position) is only appropriate if he or she is breathing adequately; this patient is not. ================================== The lower airway begins at the: A: cricoid cartilage. B: larynx. C: trachea. D: epiglottis. The correct answer is B; Reason: Anatomically, the lower airway begins at the larynx (voice box). The cricoid cartilage is a firm cartilage ring that forms the inferior (lower) part of the larynx. The trachea is connected to the larynx and extends downward to form the left and right mainstem bronchi. The epiglottis is an upper airway structure; it is a leaf-shaped structure above the larynx that prevents food and liquid from entering the trachea during swallowing. ================================== A 60-year-old female is found unresponsive. She is cyanotic, is making a snoring sound while she breathes, and has a slow respiratory rate. You should: A: ventilate her with a bag-mask device. B: insert an airway adjunct. C: suction her airway for 15 seconds. D: manually open her airway. The correct answer is D; Reason: Before you can assess and manage a patient s breathing, you must ensure that his or her airway is open first; this patient s airway is not open Snoring respirations indicate partial blockage of the airway by the tongue. Manually open her airway, using the head tilt-chin lift or jaw-thrust maneuver, and ensure that her airway is clear of secretions. If needed, suction her oropharynx for up to 15 seconds. After manually opening her airway and removing any

15 secretions with suction, insert an airway adjunct (eg, oral or nasal airway) to assist in maintaining airway patency. Slow respirations and cyanosis in an unresponsive patient are obvious signs of inadequate breathing; assist the patient s ventilations with a bag-mask device and high-flow supplemental oxygen. ================================== When ventilating an unresponsive apneic adult with a bag-mask device, you should ensure that: A: an airway adjunct has been inserted. B: ventilations occur at a rate of 20 breaths/min. C: the pop-off relief valve is manually occluded. D: you are positioned alongside the patient. The correct answer is A; Reason: When ventilating an unresponsive apneic patient with a bag-mask device, you should ensure that an oral or nasal airway adjunct is inserted, which will keep the tongue off of the posterior pharynx. When ventilating a patient with a bag-mask device, it is best for you to be positioned at the patient's head to allow for better control of the head. Ventilations in the apneic adult with a pulse (ie, not in cardiac arrest) should be provided at a rate of 10 to 12 breaths/min (one breath every 5 to 6 seconds). Generally, only pediatric sized bag-mask devices have pop-off relief valves, which should NOT be occluded, because they help prevent overinflation of the patient's lungs. ================================== Which of the following injuries or conditions should be managed FIRST? A: A large open abdominal wound B: Fluid drainage from both ears C: Bleeding within the oral cavity D: Bilateral fractures of the femurs The correct answer is C; Reason: Any injury or condition that jeopardizes the airway has priority over all else. If blood or other secretions within the mouth are not suctioned immediately, aspiration may occur; this significantly increases mortality. After securing a patent airway, control any external bleeding. Ideally, you and your partner should treat airway problems and external bleeding at the same time. ================================== Which of the following is the MOST correct technique for ventilating an apneic adult who has a pulse?

16 A: Hyperventilate at a rate between 20 and 24 breaths/min. B: Ventilate at a rate of 15 breaths/min and look for visible chest rise. C: Deliver each breath over 1 second at a rate of 10 to 12 breaths/min. D: Deliver each breath over 1 second at a rate of 8 to 10 breaths/min. The correct answer is C; Reason: When ventilating an apneic adult who has a pulse, deliver each breath over a period of 1 second, at a rate of 10 to 12 breaths/min (one breath every 5 to 6 seconds), while observing for visible chest rise. A ventilation rate of 8 to 10 breaths/min (one breath every 6 to 8 seconds) is appropriate for infants (except newborns), children, and adult patients in cardiac arrest after an advanced airway device (eg, ET tube, multilumen airway, supraglottic airway) has been inserted. Do NOT hyperventilate the patient; doing so may impede blood return to the heart, thus reducing cardiac output, secondary to hyperinflation of the lungs. Hyperventilation also increases the incidence of gastric distention, regurgitation, and aspiration. ================================== Which of the following yields the lowest minute volume? A: Respiratory rate of 14 breaths/min; tidal volume of 300 ml B: Respiratory rate of 10 breaths/min; tidal volume of 500 ml C: Respiratory rate of 16 breaths/min; tidal volume of 400 ml D: Respiratory rate of 12 breaths/min; tidal volume of 500 ml The correct answer is A; Reason: Minute volume is the amount of air moved through the lungs each minute, and is calculated by multiplying tidal volume and respiratory rate. Therefore, a respiratory rate of 14 breaths/min and a tidal volume of 300 ml would yield a minute volume of 4,200 ml (4.2 L), which is less than the sum of any of the other values listed. Minute volume is affected by tidal volume, respiratory rate, or both. An increase in tidal volume, respiratory rate, or both will cause an increase in minute volume. A decrease in tidal volume, respiratory rate, or both will cause a decrease in minute volume. ================================== Signs of inadequate breathing in an unresponsive patient include: A: warm, moist skin. B: cyanotic oral mucosa. C: an irregular pulse. D: symmetrical chest rise. The correct answer is B; Reason:

17 Signs of inadequate breathing in both responsive and unresponsive patients include a respiratory rate that is too slow (less than 12 breaths/min) or too fast (greater than 20 breaths/ min); shallow (reduced tidal volume), irregular, or gasping respirations; asymmetrical (unequal) chest rise; abnormal respiratory sounds, such as wheezing, stridor, or gurgling; and abnormal skin color and condition (ie, cool or cold skin, pallor, diaphoresis, cyanosis). An irregular pulse indicates a cardiac dysrhythmia. ================================== Sonorous respirations are MOST rapidly corrected by: A: correctly positioning the head. B: suctioning the oropharynx. C: inserting an oropharyngeal airway. D: initiating assisted ventilations. The correct answer is A; Reason: Sonorous (snoring) respirations, which most commonly result from partial airway obstruction by the tongue, are most rapidly corrected by simply positioning the head. This involves using either the head tilt-chin lift or the jaw-thrust maneuver if trauma is suspected. To further ensure airway patency, a simple adjunct (oral or nasal airway) may need to be inserted. The patient's airway should be suctioned if a gurgling sound is heard during breathing. ================================== The tidal volume of an unresponsive patient is rapidly assessed by: A: counting the patient's respiratory rate. B: auscultating his or her lung sounds. C: evaluating for the presence of cyanosis. D: observing for chest rise during inhalation. The correct answer is D; Reason: Tidal volume, a measure of the depth of breathing, is the amount of air in milliliters (ml) that is moved into or out of the lungs during a single breath. The average tidal volume for an adult male is approximately 500 ml. The quickest and most effective way to assess a patient s tidal volume is to observe his or her chest during breathing. If the chest rises adequately during inhalation, tidal volume is probably adequate. If the chest rises very little, as with shallow breathing, tidal volume is likely reduced. Auscultating breath sounds can give you an idea as to the patient's tidal volume; bilaterally diminished breath sounds may indicate a reduced tidal volume. It is quicker, however, to simply observe the chest for adequate rise. The presence of cyanosis indicates hypoxemia and is not a direct reflection of tidal volume. ==================================

18 You are performing abdominal thrusts on a 19-year-old male with a severe airway obstruction when he becomes unresponsive. After lowering him to the ground and placing him in a supine position, you should: A: open his airway and look inside his mouth. B: assess for a carotid pulse for up to 10 seconds. C: begin CPR, starting with chest compressions. D: continue abdominal thrusts until ALS arrives. The correct answer is C; Reason: A patient with a severe airway obstruction may initially be responsive and then become unresponsive during treatment. In this case, you know that an airway obstruction is the cause of his or her problem. Therefore, after placing the patient in a supine position, you should begin CPR, starting with chest compressions. Do not check for a pulse before starting chest compressions. After performing 30 chest compressions (15 compressions in infants and children when two EMTs are present), open the airway and look in the mouth. Only remove an object that you can see; do not perform a blind finger sweep in any patient. If you cannot see the object, resume chest compressions. Attempt to ventilate only if you retrieve an object from the mouth. ================================== A nonrebreathing mask is MOST appropriate to use on patients who: A: are breathing less than 12 times per minute. B: are semiconscious and breathing shallowly. C: are cyanotic and have a low oxygen saturation. D: have an adequate rate and depth of breathing. The correct answer is D; Reason: With the oxygen flow rate set at 15 L/min, the nonrebreathing mask can deliver an oxygen concentration of 90% or greater. Unlike the bag-mask or pocket mask devices, which deliver oxygen via positive pressure, the nonrebreathing mask delivers oxygen passively; therefore, the patient must have an adequate rate and depth (tidal volume) of breathing in order to open the one-way valve in the nonrebreathing mask and inhale oxygen from the reservoir bag. Shallow (reduced tidal volume) breathing, bradypnea (slow breathing), cyanosis, a low oxygen saturation, and a decreased level of consciousness are signs of inadequate breathing, and should be treated with some form of positive-pressure ventilation assistance. ================================== A young woman who overdosed on heroin is unresponsive with slow, shallow breathing. As you attempt to insert an oropharyngeal airway, she begins to gag. You should: A: suction the patient s oropharynx as you insert a nasopharyngeal airway.

19 B: remove the oropharyngeal airway and be prepared to suction her mouth. C: make sure you are using the most appropriate size of oropharyngeal airway. D: place her on her side until she stops gagging and then suction her mouth. The correct answer is B; Reason: Although uncommon, an unresponsive patient may have an active gag reflex. If an unresponsive patient begins to gag as you are attempting to insert an oropharyngeal airway, you must remove the airway immediately and be prepared to suction if vomiting should occur. Turn the patient on his or her side to facilitate drainage of secretions. Once the airway has been cleared, a nasopharyngeal airway, which is better tolerated in patients with a gag reflex, should be inserted. ================================== An inaccurate pulse oximetry reading may be caused by: A: heat illnesses, such as heat stroke. B: excessive red blood cell production. C: a heart rate greater than 100 beats/min. D: severe peripheral vasoconstriction. The correct answer is D; Reason: A pulse oximeter measures the percentage of hemoglobin that is saturated with oxygen. Under normal conditions, a patient's oxygen saturation (SpO2) ranges between 95% and 100% while breathing room air. Although no definitive threshold for normal SpO2 values exists, an SpO2 that is less than 95% in a nonsmoker may indicate hypoxemia. Of the factors listed, several peripheral vasoconstriction (ie, hypothermia, cigarette smoking, chronic hypoxia) would be the most likely to produce an inaccurate SpO2 reading. When the peripheral vasculature constricts, blood is shunted to the core of the body; in such cases, the pulse oximeter would likely yield a falsely low reading (or no reading at all). Other factors that can cause inaccurate readings include dark or metallic nail polish, dirty fingers, and abnormal hemoglobin binding (ie, carbon monoxide [CO] poisoning). It is important to note that the pulse oximeter is designed to detect gross abnormalities, not subtle changes, and should be used in conjunction with a thorough clinical assessment of the patient. ================================== A: It can only be used in conjunction with an oropharyngeal airway. B: It should be used in conjunction with an appropriate airway adjunct. C: It is the technique of choice for patients with potential spinal injury. D: It should be used on all unresponsive patients that you encounter. The correct answer is B; Which of the following statements regarding the head tilt-chin lift maneuver is correct?

20 Reason: In an unresponsive patient without a suspected spinal injury, the head tilt-chin lift maneuver is the recommended method for opening the airway. To aid in maintaining a patent airway, an appropriate airway adjunct (ie, oral or nasal airway) should be used in conjunction with the head tilt-chin lift maneuver. When inserted properly, the oral or nasal airway will keep the tongue off of the posterior pharynx. You must remember that even once an airway adjunct has been placed, proper positioning of the head must be maintained until the airway is secured more definitively (ie, endotracheal intubation). If you suspect that the unresponsive patient has a spinal injury, the jaw-thrust maneuver should be used; however, if the jaw-thrust maneuver does not adequately open the patient's airway, the head tilt-chin lift maneuver should be used. ================================== An unresponsive 60-year-old male is apneic and has a weak, rapid pulse. His oxygen saturation reads 79%. You should: A: deliver one breath over 1 second every 5 to 6 seconds. B: mildly hyperventilate him until his oxygen saturation improves. C: ventilate at a rate of 8 to 10 breaths/min, ensuring visible chest rise. D: use a pocket face mask to deliver 12 to 20 breaths/min. The correct answer is A; Reason: When ventilating an apneic adult with a pulse, deliver one breath every 5 to 6 seconds (10 to 12 breaths/min). A ventilation rate of 12 to 20 breaths/min (one breath every 3 to 5 seconds) is appropriate for infants and children. Regardless of the patient s age or ventilation device you are using (eg, bag-mask device, pocket face mask), each breath should be delivered over a period of 1 second (enough to produce visible chest rise). Do not hyperventilate any patient, even mildly, as this may cause a decrease in venous return to the heart secondary to hyperinflation of the lungs. Hyperventilation also increases the risks of gastric distention, regurgitation, and aspiration. After an advanced airway device has been inserted (eg, ET tube, multilumen airway, supraglottic airway) in a cardiac arrest patient, you should no longer perform cycles of CPR; the compressor delivers compressions at a rate of at least 100/min and the ventilator delivers 8 to 10 breaths/min (one breath every 6 to 8 seconds). This ventilatory rate during cardiac arrest applies to all age groups, except the newborn. ================================== A: Rotate the device as you insert it into the right nostril. B: Insert the device with the bevel facing the septum. C: Apply firm, gentle pressure if you meet resistance during insertion. D: Insert the device with the bevel facing the lateral part of the nose. The correct answer is B; Reason: Which of the following describes the correct technique for inserting a nasopharyngeal airway?

21 Lubricate the nasopharyngeal airway with a water-soluble gel. Insert it into the larger nostril with the curvature following the floor of the nose. If using the right nostril, the bevel should face the septum. If using the left nostril, insert the device with the tip pointing upward, which will allow the bevel to face the septum. Gently advance the airway. If using the left nostril, insert the device until slight resistance is met, and then rotate it 180 degrees into position. This rotation is not required if using the right nostril. Continue until the flange of the device rests against the nostril. If you feel any resistance or obstruction, remove the device and insert it into the other nostril. Forcing the airway into place may cause trauma to the nasal mucosa and unnecessary bleeding, which the patient could potentially aspirate. ================================== Which of the following would MOST likely occur if an adult patient is breathing at a rate of 45 breaths/min with shallow depth? A: The lungs would become hyperinflated, potentially causing a pneumothorax. B: Alveolar minute volume would increase due to the rapid respiratory rate. C: Most of his or her inhaled air will not go beyond the anatomic dead space. D: The volume of air that reaches the alveoli would increase significantly. The correct answer is C; Reason: Alveolar minute volume, the amount of air that reaches the alveoli per minute and participates in pulmonary respiration, is affected by tidal volume, respiratory rate, or both. If the respiratory rate decreases, tidal volume must increase in order to maintain adequate alveolar minute volume. Conversely, if tidal volume decreases, the respiratory rate must increase accordingly. However, if the respiratory rate is extremely fast, especially if the depth of breathing is shallow (reduced tidal volume), most of the inhaled air will only make it to the anatomic dead space (ie, trachea, larger bronchi) before it is promptly exhaled. As a result, alveolar minute volume would decrease, resulting in inadequate pulmonary respiration and hypoxia. For this reason, patients with rapid, shallow breathing often require ventilation assistance. Pulmonary hyperinflation would not be an issue in a patient with exceedingly fast breathing and reduced tidal volume because very little air is actually reaching the lungs. ================================== Which of the following devices is contraindicated in patients with blunt chest trauma? A: Oxygen-powered ventilator B: Oral airway C: Bag-mask device D: Nasal airway The correct answer is A; Reason: