Class 5 (Initial Assessment with Airway/Breathing/Chest Injury) Ch8 (Partial) , Ch4 (Partial) , Ch7 & Ch27 (Part

1. Class 5 (Initial Assessment with Airway/Breathing/Chest Injury)Ch8 (Partial), Ch4 (Partial), Ch7 & Ch27 (Partial)

2. Patient Assessment (Review) • Scene size-up • Initial assessment • Focused history and physical exam • Vital signs • History • Detailed physical exam • Ongoing assessment

3. Scene Size-up • Dispatch information • Inspection of scene • Scene hazards • Safety concerns • Mechanism of injury • Nature of illness/chief complaint • Number of patients • Additional resources needed • Consider Spinal Precaution

4. Initial Assessment • Develop a general impression. • Assess mental status. • Assess airway. • Assess the adequacy of breathing. • Assess circulation. • Identify patient priority.

5. Develop a General Impression • Occurs as you approach the scene and the patient • Assessment of the environment • Patient’s chief complaint • Presenting signs and symptoms of patient • Sick or Not-Sick • Awake or eyes closed

6. Assessing Mental Status • 2 Parts • Responsiveness • How the patient responds to external stimuli • Orientation • Mental status and thinking ability

7. Testing Responsiveness • AAlert • VResponsive to Verbal stimulus • PResponsive to Pain • UUnresponsive • If patient responds, what is the response

8. Testing Orientation • Person • Place • Time • Event

9. Obtaining Consent • If patient is awake • Introduce self. • Ask patient’s name. • Check orientation. • Obtain consent. • If unresponsive • Implied consent.

10. Chief Complaint • Most serious problem voiced by the patient • May not be the most significant problem present

11. Initial Assessment: A-B-C Triad C • Find & treat immediate threat to life • Lack of an airway • Ineffective breathing • Circulatory collapse • Bleeding • Shock • A B C all of equal importance • Starting with bleeding control (C) appropriate in an awake patient A B

12. Airway & Respiratory A&P

13. Infant and Child Anatomy • Structures less rigid • Airway smaller • Tongue proportionally larger • Dependent on diaphragm for breathing

14. Lung & Pleura A&P

15. Diaphragm • Has characteristics of both voluntary and involuntary muscles • Dome-shaped muscle • Divides thorax from abdomen • Contracts during inhalation • Relaxes during exhalation

16. A for Airway

17. Airway Assessment • Part of the A-B-C initial assessment triad • Usually start with airway • Care begins with ensuring airway is patent • Talking patient has an airway • Unresponsive patients must be supine to start the assessment process • Tongue most common obstruction • Have suction device ready

18. Skill Drill 7-1: Position Unconscious Pt 1 2 3 4

19. Assessing the Airway • If patient is talking, airway is open • If patient is unresponsive, airway is probably closed • Airway management process • Do I need to open the airway: Yes or No? • If yes, open via manual technique • Do I need to suction the airway: Yes or No? • If yes, suction the airway • Do I need to use an airway: Yes or No? • If yes, insert oral or nasal airway

20. Airway & Breathing Management • Airway • Head Tilt • Jaw Thrust • Look in airway and suction if needed • Look, listen & feel for breathing • Breathing adequate than O2 via nonrebreathing mask • Breathing inadequate than O2 via Bag Valve Mask

21. Signs of Airway Obstruction in the Unconscious Patient • Obvious trauma, blood, or other obstruction • Noisy breathing such as bubbling, gurgling, crowing, or other abnormal sounds • Patient is unresponsive • Extremely shallow or absent breathing • Patient is unable to speak

22. Head Tilt–Chin Lift • Kneel beside patient’s head. • Place one hand on forehead. • Apply backward pressure. • Place tips of finger under lower jaw. • Lift chin. Head tilt-chin lift

23. Jaw-Thrust Maneuver • Kneel above patient’s head. • Place fingers behind angle of jaw. • Use thumbs to keep mouth open.

24. Assessment of the Airway • Look. • Blood, vomit, teeth or fluid in airway • Equal chest rise and fall • Listen. • Noise from mouth or nose • Lung sounds

25. Suctioning Equipment (1 of 2)

26. Suction Equipment (2 of 2) French, or whistle-tip, catheter

27. Suctioning Technique (1 of 2) • Check the unit and turn it on. • Select and measure proper catheter to be used. • Open the patient’s mouth and insert tip. • Suction as you withdraw the catheter. • Time limit • Adult: 15 seconds • Children: 10 seconds • Infants: 5 seconds • 2 minutes ventilation-15 seconds suction. Repeat.

28. Suctioning Technique (2 of 2) 2 1 3 4

29. Basic Airway Adjuncts (1 of 6) • Oropharyngeal airways • Keep the tongue from blocking the upper airway • Allow for easier suctioning of the airway • Used in conjunction with BVM device • Used on unconscious patients without a gag reflex

30. Basic Airway Adjuncts (2 of 6) Inserting an oropharyngeal airway 1. Select the proper size airway. 2. Open the patient’s mouth. 3. Hold the airway upside down and insert it in the patient’s mouth. 4. Rotate the airway 180° until the flange rests on the patient’s lips.

31. Basic Airway Adjuncts (3 of 6) 1 2 3

32. Basic Airway Adjuncts (4 of 6) • Nasopharyngeal airways • Semi-conscious patients who cannot maintain airway • Can be used with intact gag reflex • Should not be used with head injuries or nosebleeds

33. Basic Airway Adjuncts (5 of 6) Inserting a nasopharyngeal airway 1. Select and size the airway. 2. Lubricate the airway. 3. Gently push the nostril open. 4. With the bevel turned toward the septum, insert the airway.

34. Basic Airway Adjuncts (6 of 6) 1 2 3 4

35. Recognizing an Obstruction (1 of 2) • Obstruction may be partial or complete. • Is patient able to speak or cough? • If patient is unconscious, attempt to deliver artificial ventilation.

36. Causes of Foreign Body Obstruction • Relaxation of the tongue • Vomited stomach contents • Blood clots, bone fragments, damaged tissue • Swelling caused by allergic reactions • Foreign objects

37. Removing an Obstruction (2 of 2) • Perform Heimlich maneuver. • Use suction if needed. • If attempts to clear the airway are unsuccessful, transport rapidly.

38. Stomas and Tracheostomy Tubes • Ventilations are delivered through the stoma. • Attach BVM device to tube or use infant mask. • Stoma may need to be suctioned. • Seal nose and mouth

39. B for Breathing & Oxygen

40. Breathing Process: Inhalation • Active part of breathing • Diaphragm and intercostal muscles contract, allowing the lungs to expand. • Enlarging lungs causes a drop in air pressure • The decrease in pressure allows lungs to fill with air. • Air travels to the alveoli where exchange of gases occurs.

41. Breathing Process: Exhalation • Normal breathing does not require effort to exhale • Diaphragm and intercostal muscles relax. • As the muscles relax, all dimensions of the thorax decrease. • Pressure in the lungs increases. • Air flows out of the lungs.

42. Exchange of Oxygen andCarbon Dioxide • Oxygen-rich air is delivered to alveoli with inspiration. • Oxygen diffuses into the blood. • The body does not use all the inhaled oxygen.

43. Control of Breathing • Brain stem controls breathing. • Increases breathing rate if the carbon dioxide level in blood becomes too high • Hypoxic drive is a “backup system.” • Activates when oxygen levels fall to stimulate breathing

44. Assessing Breathing • B for breathing has 2 questions • Is breathing adequate? • Does patient need oxygen? • Pt not breathing always needs oxygen • Pt with adequate breathing may need oxygen • Breathing management process • Is patient breathing adequately: Yes or No? • If no, than ventilate patient with BVM & O2 • If yes, does patient need supplemental oxygen: Yes or No? • If yes, give oxygen via non-rebreathing mask

45. Inadequate breathing To fast To slow To shallow To deep Accessory muscle use Retractions Cyanosis Altered mental status Absent lung sounds Nasal flaring Speaking in 2-3 word sentences Adequate breathing 12-20 times minute Normal depth Quiet No effort Pink skin Talking full sentences Normal mental status Clear breath sounds Assessing Breathing

46. Assessing Breath Sounds

47. Normal Breathing Characteristics • Normal rate • Adequate depth • Regular rhythm • Good breath sounds in both lungs • Regular rise and fall movements in the chest • Easy, not labored

48. Normal Breathing Rates Adults 12 to 20 breaths/min Children 15 to 30 breaths/min Infants 25 to 50 breaths/min

49. Irregular rhythm Labored breathing Muscle retractions Agonal Accessory muscle use Abnormal lung sounds Cheyne-Stokes Pale or blue skin Cool, clammy skin Faster respiratory rate Seesaw respirations Nasal Flaring Reduced volume Central neurogenic hyperventilation Recognizing Inadequate Breathing

50. The Body’s Need for Oxygen