Condensed version.

Transcription

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2 I m Stu

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4 Condensed version

5 Listen 1. Snoring 2. Gurgling 3. Hoarseness 4. Stridor (inspiratory/expiratory) 5. Wheezing 6. Grunting

6 Listen Crackles Wheezing Stridor Absent

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11 Crackles Coarse/Rhonchi Fine/Rales Larger Airways Smaller Airways

12 Wheezing

13 Stridor (stridulous, NOT stridorus) When you hear hoofbeats think of horses, but don t forget the zebras - Some wise dude

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21 A. R. M. Awareness Recognition Management

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27 Absent Breath Sounds

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43 Penetrating injuries to chest, abdomen, head, neck, or groin

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50 # Arrests Age distribution of arrests Age (years)

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58 CPAP

59 CHF/PULMONARY EDEMA

60 CHF/PULMONARY EDEMA When fluid saturates the interstitial spaces it will begin to accumulate in the alveoli

61 In cardiogenic pulmonary edema due to heart failure, PCWP is already maxed out. If greater than 23, cardiac output is dependent on afterload. CPAP increases pressures throughout the thorax, including pressure surrounding the left ventricle (LV). This makes it easier to eject blood out of the heart. Similarly, pressure surrounds the thoracic cavity but not the abdominal aorta, giving the impression of reduced LV afterload outside of the thoracic cavity. This will increase cardiac output unless PEEP levels are too high. High intrathoracic pressures greatly reduce preload to the right heart and will reduce the blood pressure. In a nutshell, the LV can catch up

62 CHF/PULMONARY EDEMA Alveoli collapse with each exhalation Fluid washes out the surfactant Alveoli can not re-expand Pink frothy sputum Acute respiratory distress Rapid deterioration

63 BVM with PEEP & Capnography

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65 Applies positive pressure to the airways throughout the respiratory cycle This keeps the alveoli open during expiration Allows for O2 & CO2 exchange Can rapidly improve pt s condition Frequently prevents intubation CPAP : What it is

66 Why wouldn t we want to intubate? Mandatory ICU admission Prolonged hospital stay & recovery Higher potential for complications Airway trauma possible Infection can occur More invasive & uncomfortable CPAP

67 CPAP : What it isn t CPAP does not maintain the airway CPAP does not allow you to assist your pt with ventilation Pt MUST be able to maintain their own airway Pt MUST be able to clear their own airway

68 CPAP Indications/Inclusions Pulmonary Edema Dyspnea Crackles/wheezes Check history for ; asthma, PE, aspiration, infection At least 18 yrs old Alert with airway intact/maintainable Systolic BP of at least 90 SpO2 less than 94%

69 Age less than 18 AMS BP less than 90 CPAP - Contraindications Need for immediate airway control Unstable airway Acute MI If your pt requires ventilatory assistance with a BVM he is not a candidate for CPAP Altered mental status GCS 8 requires ventilatory assistance, therefore no CPAP

70 CPAP May exclude Uncooperative pt Facial hair making it impossible to obtain seal Pregnancy Morbid obesity Inability to properly fit mask

71 CPAP - Procedure Follow pulmonary edema SOP Prepare equipment Connect oxygen to 15 L Adjust venturi valve to 60 % Have intubation equipment available Position pt sitting up Explain procedure to pt & reassure

72 CPAP - Procedure Hold mask gently to face Slowly adjust PEEP valve to 5 cm After 5 min. lift mask & give next NTG Now gently place head straps on

73 CPAP - Procedure If no improvement in 3 minutes: Increase venturi to 95% & O2 flush Gradually increase PEEP to max of 10 in 2 cm increments to maintain SpO2 at 94% or greater Continuously monitor pt for S/S requiring intubation

74 CPAP D/C in field Inability to tolerate mask (Nobody likes CPAP at first) Need to intubate SBP below 90 ECG instability with evidence of acute ischemia

75 CPAP System is dependent on a good seal Pt MUST remain on O2 & cardiac monitor at ALL times, even when transferring pt care to hospital Continue to give NTG SL every 5 min, just lift mask briefly to administer drug

76 BiPAP (CPAP with an inspiratory pressure)

77 BiPAP A more sophisticated machine is still only as good as the knowledge and abilities of the operator. It also means you have more ways to seriously screw up a patient.

78 BiPAP Modes S (Spontaneous) In spontaneous mode the device triggers IPAP when flow sensors detect spontaneous inspiratory effort and then cycles back to EPAP. T (Timed) In timed mode the IPAP/EPAP cycling is purely machinetriggered, at a set rate, typically expressed in breaths per minute (BPM). S/T (Spontaneous/Timed) Like spontaneous mode, the device triggers to IPAP on patient inspiratory effort. But in spontaneous/timed mode a "backup" rate is also set to ensure that patients still receive a minimum number of breaths per minute if they fail to breathe spontaneously.

79 Indications Dyspnea (moderate to severe, but short of respiratory failure) Tachypnea (>24 breaths/min) Increased work of breathing (accessory muscle use, pursed-lips breathing) Hypercapnic respiratory acidosis (ph range ) Hypoxemia REQUIRED: Patient cooperation (an essential component that excludes agitated, belligerent, or comatose patients)

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82 Indications (cont) After discontinuation of mechanical ventilation (COPD) Pneumonia and COPD Asthma Immunocompromised state Postoperative respiratory distress and respiratory failure Do-not-intubate status Neuromuscular respiratory failure Decompensated obstructive sleep apnea Cystic fibrosis Acute respiratory distress syndrome

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84 Contraindications Cardiac instability Shock and need for pressor support Ventricular dysrhythmias Complicated acute myocardial infarction GI bleeding - Intractable emesis and/or uncontrollable bleeding Inability to protect airway Impaired cough or swallowing Poor clearance of secretions Depressed sensorium and lethargy Status epilepticus Potential for upper airway obstruction Extensive head and neck tumors Any other tumor with extrinsic airway compression Angioedema or anaphylaxis causing airway compromise

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86 BiPAP

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88 Masks

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93 Nasal

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102 WTF?!?!

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