1	Chapter 13 Airway Management and Ventilation
2	Upper Airway Nasal cavity Oral cavity Pharynx
3	Pharynx Nasopharynx Oropharynx Laryngopharynx
4	Anatomy of the upper airway
5	Larynx Thyroid cartilage Cricoid cartilage Glottic opening Vocal cords Arytenoid cartilage Pyriform fossae Cricothyroid cartilage
6	Lower Airway Anatomy Trachea Bronchi Alveoli Lung parenchyma Pleura
7	Anatomy of the pediatric airway
8	Anatomy of the alveoli
9	Introduction Respiration is the exchange of gases between a living organism and its environment. Ventilation is the mechanical process that moves air into and out of the lungs.
10	Pulmonary circulation
11	Diffusion of gases across an alveolar membrane
12	Measuring Oxygen and Carbon Dioxide Levels Partial pressure is the pressure exerted by each component of a gas mixture. Partial pressure of a gas is its percentage of the mixture’s total pressure.
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14	Normal Arterial Partial Pressures Oxygen (PaO₂) = 100 torr (average = 80 – 100)
15	Factors Affecting Oxygen Concentration in the Blood Decreased hemoglobin concentration. Inadequate alveolar ventilation. Decreased diffusion across the pulmonary membrane when diffusion distance increases or the pulmonary membrane changes. Ventilation/perfusion mismatch occurs when a portion of the alveoli collapses.
16	Factors Affecting Carbon Dioxide Concentrations in the Blood (1 of 2) Hyperventilation lowers CO₂ levels due to increased respiratory rates or deeper respiration. Causes of increased CO₂ production include: Fever Muscle exertion Shivering Metabolic processes resulting in the formation of metabolic acids.
17	Factors Affecting Carbon Dioxide Concentrations in the Blood (2 of 2) Decreased CO₂ elimination results from decreased alveolar ventilation. Respiratory depression, airway obstruction, respiratory muscle impairment, obstructive diseases
18	Respiratory Rate Involuntary; however, can be voluntarily controlled. Chemical and physical mechanisms provide involuntary impulses to correct any breathing irregularities.
19	Chemoreceptors Located in carotid bodies, arch of the aorta, and medulla. Stimulated by decreased PaO₂, increased PaCO₂, and decreased pH. Cerebrospinal fluid (CSF) pH is primary control of respiratory center stimulation.
20	Nervous Impulses from the Respiratory Center Main respiratory center is the medulla. Neurons within medulla initiate impulses that produce respiration. Apneustic center assumes respiratory control if the medulla fails to initiate impulses. Pneumotaxic center controls respiration.
21	Hypoxic Drive Hypoxemia is a profound stimulus of respiration in a normal individual. Hypoxic drive increases respiratory stimulation in people with chronic respiratory disease.
22	Stretch Receptors The Hering-Breuer reflex prevents over-expansion of the lungs.
23	Normal Respiratory Rates
24	Respiratory Factors
25	Tidal Volume (V_T) Average volume of gas inhaled or exhaled in one respiratory cycle Average adult male:
26	Residual Volume (RV) The amount of air remaining in the lungs at the end of maximal expiration
27	Airway Obstruction The tongue is the most common cause of airway obstruction.
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29	Alveolar Minute Volume (V_A-min) Amount of gas that reaches the alveoli for gas exchange in one minute
30	Dead Space Volume (V_D) Amount of gases in tidal volume that remains in the airway. Approximately 150 mL in adult male.
31	Tidal Volume (V_T) Average volume of gas inhaled or exhaled in one respiratory cycle Average adult male:
32	Other Causes of Airway Obstruction Foreign bodies Trauma Laryngeal spasm and edema Aspiration
33	Initial Assessment Is the airway patent? Is breathing adequate? Look, listen, and feel. If patient is not breathing, open the airway and assist ventilations as necessary.
34	Focused History Onset Symptom development Associated symptoms Past medical history Recent history Does anything make symptoms better or worse?
35	Inspection Skin color Patient’s position Dyspnea Modified forms of respiration Rate Pattern Mentation
36	Auscultation Listen at the mouth and nose for adequate air movement. Listen with a stethoscope for normal or abnormal air movement.
37	Abnormal Respiratory Patterns (1 of 3) Kussmaul’s respirations Deep, slow or rapid, gasping; common in diabetic ketoacidosis. Cheyne-Stokes respirations Progressively deeper, faster breathing alternating gradually with shallow, slower breathing, indicating brain stem injury.
38	Abnormal Respiratory Patterns (2 of 3) Biot’s respirations Irregular pattern of rate and depth with sudden, periodic episodes of apnea, indicating increased intracranial pressure. Central neurogenic hyperventilation Deep, rapid respirations, indicating increased intracranial pressure.
39	Abnormal Respiratory Patterns (3 of 3) Agonal respirations Shallow, slow, or infrequent breathing, indicating brain anoxia.
40	Positions for auscultating breath sounds
41	Palpation Palpate chest wall for tenderness, symmetry, abnormal motion, crepitus, and subcutaneous emphysema. Assess compliance of lungs.
42	Manual Airway Maneuvers What Are They?
43	Airway before applying Sellick’s
44	Sellick’s maneuver (cricoid pressure)
45	Airway with Sellick’s applied (note compression on the esophagus)
46	Basic Mechanical Airways What Are They? When are the used?
47	Endotracheal intubation is clearly the preferred method of advanced airway management in prehospital emergency care.
48	Hyperventilate patient. NOT!!! Preoxygenate. YES!!!!
49	Laryngoscope blades
50	ETT, stylet, and syringe, assembled for intubation
51	Endotracheal Intubation Indicators Respiratory or cardiac arrest Unconsciousness Risk of aspiration Obstruction due to foreign bodies, trauma, burns, or anaphylaxis Respiratory extremis due to disease Pneumothorax, hemothorax, hemopneumothorax with respiratory difficulty
52	Advantages of Endotracheal Intubation Isolates trachea and permits complete control of airway Impedes gastric distention Eliminates need to maintain a mask seal Offers direct route for suctioning Permits administration of some medications
53	Disadvantages of Endotracheal Intubation Requires considerable training and experience Requires specialized equipment Requires direct visualization of vocal cords Bypasses upper airway’s functions of warming, filtering, and humidifying the inhaled air
54	Complications of Endotracheal Intubation Equipment malfunction Teeth breakage and soft tissue lacerations Hypoxia Esophageal intubation Endobronchial intubation Tension pneumothorax
55	Placement of Macintosh blade into vallecula
56	Confirm placement with an ETCO₂ detector.
57	Esophageal detector device
58	If the bulb does not refill, the tube is improperly placed.
59	Secure tube.
60	Glottis visualized through laryngoscopy
61	Endotracheal Intubation with In-line Stabilization
62	Hyperventilate patient and apply c-spine stabilization.
63	Apply Sellick’s maneuver and intubate.
64	Ventilate patient and confirm placement.
65	Secure ETT and apply a cervical collar.
66	Reconfirm placement.
67	Endotracheal Intubation in a Child
68	The Pediatric Airway Smaller and more flexible than an adult. Tongue proportionately larger. Epiglottis floppy and round. Glottic opening higher and more anterior. Vocal cords slant upward, and are closer to the base of the tongue. Narrowest part is the cricoid cartilage.
69	"ETT size (mm" ETT size (mm) =
70	Hyperventilate the child.
71	Prepare the equipment.
72	Insert the laryngoscope.
73	Insert ETT and ventilate the child.
74	Confirm placement and secure ETT.
75	Reconfirm ETT placement.
76	Ventilation of Pediatric Patients Mask seal can be more difficult. Bag size depends on age of child. Ventilate according to current standards. Obtain chest rise and fall with each breath. Assess adequacy of ventilations by observing chest rise, listening to lung sounds, and assessing clinical improvement.
77	Continuously recheck and reconfirm the placement of the endotracheal tube.
78	The only indication for a surgical airway is the inability to establish an airway by any other method.
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80	Anatomical landmarks for cricothyrotomy
81	Open Cricothyrotomy
82	Oxygen Delivery Devices
83	Ventilation Methods Mouth-to-mouth Mouth-to-nose Bag-valve device Demand valve device Automatic transport ventilator
84	Suctioning Techniques Wear protective eyewear, gloves, and face mask. Preoxygenate the patient. Determine depth of catheter insertion. With suction off, insert catheter. Turn on suction and suction while removing catheter (no more than 10 seconds). Hyperventilate the patient.
85	Bag-valve mask with built-in colorimetric ETCO₂ detector
86	Demand valve and mask
87	Chapter 1 The History
88	Components of a Patient History Establishing rapport Chief complaint History of the present illness Past medical history Current health status Family history Psychosocial history Review of systems
89	Patient Rapport
90	Patient Rapport – Setting the Stage If a patient’s chart is available, review it before interviewing the patient. Use this information to gain clues about the patient.
91	Patient Rapport – The First Impression Present yourself as a caring, competent, and confident health care professional.
92	Patient Rapport – Building Trust When you introduce yourself to the patient, shaking hands or offering a comforting touch will help build trust.
93	Patient Rapport – Asking Questions Use a combination of open-ended and closed-ended questions.
94	Patient Rapport – Language and Communication Use appropriate language. Use an appropriate level of questioning, but do not appear condescending. When encountering communication barriers, try to enlist someone to help. Actively listen.
95	Patient Rapport – Active Listening Facilitation Reflection Clarification Empathy Confrontation Interpretation Asking about feelings
96	Patient Rapport – Sensitive Topics A paramedic must learn to become comfortable dealing with sensitive topics. It is important to earn a patient’s trust.
97	The Present Illness OPQRST-ASPN Onset of the problem Provocative/ Palliative factors Quality Region/Radiation Severity Time Associated Symptoms Pertinent Negatives
98	You should take your patient’s medications with you to the hospital, when practical.
99	Special Challenges (1 of 2) Silence Overly talkative patients Multiple symptoms Anxiety Depression Sexually attractive or seductive patients Confusing behaviors or symptoms
100	Special Challenges (2 of 2) Patients needing reassurance Anger and hostility Intoxication Crying Limited intelligence Language barriers Hearing problems Blindness Talking with families or friends
101	If the patient cannot provide useful information, gather it from family or bystanders.
102	Chapter 2, Part 1 Physical Exam Techniques
103	Topics Techniques of Inspection, Palpation, Auscultation, and Percussion Evaluation of Mental Status Examination of the Body Regions Special Considerations
104	Introduction Although patient assessment formally starts with the history, the physical examination actually begins when you first set eyes on your patient. The purpose of the physical exam is to investigate areas that you suspect are involved in your patient’s primary problem.
105	Examination Techniques Inspection Palpation Auscultation Percussion
106	Measurement of Vital Signs Pulse Respiration Blood pressure Body temperature Pulse oximetry
107	"Measure vital signs early" Measure vital signs early in the physical examination and, in the emergency situation, repeat them often and look for trends.
108	General Survey Appearance Vital signs Additional assessments Pulse oximetry Cardiac monitoring Blood glucose determination End tidal CO₂
109	Appearance (1 of 2) Level of consciousness Signs of distress Apparent state of health Vital statistics Sexual development
110	Appearance (2 of 2) Skin color and obvious lesions Posture, gait, and motor activity Dress, grooming, and personal hygiene Odors of breath or body Facial expression
111	Thermometers Electronic Obtains temperature reading in 15–30 seconds Different colored probes for oral and rectal use Tympanic Obtains temperature reading in less than 5 seconds Measures the temperature of blood flowing near the TM Not accurate in infants and small children; must penetrate the ear canal Disposable strips Obtains temperature reading in about 1 minute Not very accurate—affected by environment
112	Pulse Oximeter Noninvasive device that measures the saturation of hemoglobin in the capillary blood
113	Capnography Capnometry: The measurement and display of carbon dioxide (CO₂) on a digital or analog monitor. Maximum inspiratory and expiratory CO₂ concentrations during a respiratory cycle are displayed. Capnography: A graphic display of instantaneous CO₂ concentration (FCO₂) versus time or expired volume during a respiratory cycle (CO₂ waveform or capnogram). Capnograms: CO₂ waveforms which can be of two types: FCO₂ can be plotted against expired volume or against time during a respiratory cycle.
114	Capnography Real-time measurement of exhaled carbon dioxide concentrations An indirect monitor for the differential diagnosis of hypoxia Obtained by end-tidal carbon dioxide (ETCO₂) detector Colormetric pH paper changes colors once CO₂ hits the paper Electronic Monitors
115	Capnography – Pitfalls May provide a false positive Antacid use Carbonated beverages Continues to drop CO₂ levels in cardiac arrest
116	Skin Characteristics to Assess Color Moisture Temperature Texture Mobility and turgor Lesions
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118	Palpate the posterior chest for tactile fremitus (voice transmission). Asymmetrical voice transmission points to disease on one side. Recite “1, 2, 3” or “99.”
119	Tactile Fremitus (Voice Transmission) Increased: Pneumonia or any disease that causes compression or consolidation of lung tissue Decreased: Emphysema, effusions, pulmonary edema, bronchial obstruction, or any form of lung or pleural disease
120	Adventitious Breath Sounds Crackles—light crackling, popping, nonmusical sounds heard usually during inspiration Wheezes—continuous, high-pitched musical sounds similar to a whistle Rhonchi—continuous sounds with a lower pitch and a snoring quality
121	Sites for Cardiac Auscultation Location: Right upper sternal border Left upper sternal border Left lower sternal border Apex
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124	Abdominal Trouble Indicators Cullen’s sign—discoloration around the umbilicus suggestive of intra-abdominal hemorrhage Grey-Turner’s sign—discoloration over the flanks suggesting intra-abdominal bleeding Ascites—swelling in the flanks and abdomen Borborygmi—loud, prolonged, gurgling bowel sounds
125	Examination of the Abdomen (1 of 3) Inspection Contour Pulsations/masses Bulging flanks Inspect skin Inspect umbilicus
126	Examination of the Abdomen (3 of 3) Palpation Palpate lightly then deeply in all four quadrants. Differentiate between voluntary and involuntary guarding. If a mass is detected note its location, size, shape, consistency, tenderness, pulsation, and mobility. Assess peritoneal irritation and rebound tenderness.
127	Examination of the Musculoskeletal System Pain Swelling Deformity Symmetry Tissue changes Compare strength Range of motion Crepitus
128	Interaction of Bone, Muscle, and Tendon
129	Chapter 3 Patient Assessment in the Field
130	Topics Scene Size-up The Initial Assessment The Focused History and Physical Exam The Detailed Physical Exam The Ongoing Assessment
131	"Patient assessment means conducting a..." Patient assessment means conducting a problem-oriented evaluation of your patient and establishing priorities of care based on existing and potential threats to human life.
132	Components of Patient Assessment Initial assessment Focused history and physical exam Ongoing assessment Detailed physical exam
133	Scene Size-up Body substance isolation Scene Assessment Scene safety Location of all patients Mechanism of injury Nature of the illness
134	Scene Assessment Routes of extrication for crew and patient Number of patients Need for additional resources Extrication equipment Additional transport units Additional manpower Use of all of your senses.
135	"The initial assessment is designed..." The initial assessment is designed to identify and immediately correct life-threatening patient conditions of the Airway, Breathing, and Circulation (ABCs).
136	Initial Assessment Steps Form a general impression. Stabilize the cervical spine. Assess the baseline mental status. Assess the airway. Assess breathing. Assess circulation. Determine priority.
137	Priority Determination Once the initial assessment is completed, determine the patient’s priority.
138	Top Priority Patients Poor general impression Unresponsive Conscious but cannot follow commands Difficulty breathing Hypoperfusion Complicated childbirth Chest pain and BP below 100 systolic Uncontrolled bleeding Severe pain Multiple injuries
139	The Focused History and Physical Exam
140	Types of Patients Trauma patient with significant mechanism of injury Trauma patient with isolated injury Responsive medical patient Unresponsive medical patient
141	Rapid Trauma Assessment
142	DCAP-BTLS Deformity Contusion Abrasion Penetration Burns Tenderness Lacerations Swelling
143	The Isolated-Injury Trauma Patient No significant mechanism of injury Shows no signs of systemic involvement Does not require an extensive history Does not require a comprehensive physical exam
144	"The history takes precedence over..." The history takes precedence over the physical exam in the medical patient.
145	The History of the Present Illness (OPQRST-ASPN) Onset Provocation or Palliation Quality Region/Radiation Severity Time Associated Symptoms Pertinent Negatives
146	"The physical exam of the..." The physical exam of the medical patient is aimed at identifying medical complications rather than signs of injury.
147	Assessing the Unresponsive Medical Patient Initial assessment Rapid medical assessment Brief history
148	Detailed Physical Exam
149	Ongoing Assessment (2 of 2) Mental status Airway patency Breathing rate and quality Pulse rate and quality Skin condition Transport priorities Vital signs Focused assessment Effects of interventions Management plans
150	Chapter 4 Clinical Decision Making
151	"Making critical decisions" Making critical decisions requires critical judgment— the use of knowledge and experience to diagnose patients and plan their treatment.
152	Critical Decision Making The ability to anticipate The ability to prioritize The ability to problem-solve Relies heavily on knowledge base An ability to learn from past mistakes
153	A Paramedic …must gather, evaluate, and synthesize a lot of information in very little time. …can then develop a field diagnosis—a prehospital evaluation of the patient’s condition and its causes.
154	Acuity The severity or acuteness of your patient’s condition.
155	Classes of Acuity Those with obvious life-threats Those with potential life-threats Those with non-life-threatening presentations
156	Protocol A standard that includes general and specific principles for managing certain patient conditions
157	Standing Orders Treatments you can perform before contacting the medical direction physician for permission
158	Algorithm Schematic flow chart that outlines appropriate care for specific signs and symptoms
159	Paramedic’s Critical Thinking Skills (1 of 2) Knowing anatomy, physiology, and pathophysiology Focusing on large amounts of data Organizing information Identifying and dealing with medical ambiguity
160	Paramedic’s Critical Thinking Skills (2 of 2) Differentiating between relevant and irrelevant data Analyzing and comparing similar situations Explaining decisions and constructing logical arguments
161	"Be like the duck" Be like the duck— cool and calm on the water’s surface, while paddling feverishly underneath!
162	Putting It All Together The Six Rs Read the scene. Read the patient. React. Re-evaluate. Revise the management plan. Review your performance.
163	Chapter 5 Communications
164	Basic Communication Model Sender has an idea, or message. Sender encodes message. Sender sends message. Receiver receives message. Receiver decodes message. Receiver gives feedback to sender.
165	The EMS Response (1 of 2) Detection and citizen access Call-taking and emergency response Pre-arrival instructions Call coordination and incident recording
166	The EMS Response (2 of 2) Discussion with medical direction physician Transfer communications Back in service, ready for next call
167	Elements of Medical Patient Report Paramedic identification Patient identification Subjective data Objective data Plan
168	Elements of Trauma Patient Report Paramedic identification Patient identification Mechanism of injury Injuries Plan
169	Written Record of Incident May be the only source of information for persons subsequently interested in the event Record of the incident from beginning to end Provides a source of identifying pertinent reportable clinical data from each patient reaction
170	Uses for PCRs Medical Administrative Research Legal
171	Oral Statements Whenever possible, quote the patient—or other source of information—directly.
172	Elements of Good Documentation Accuracy Legibility Timeliness Unaltered Professionalism Completeness
173	The Proper Way to Correct a Prehospital Care Report
174	Two Narrative Formats CHART Chief complaint History Assessment Rx (treatment) Transport SOAP Subjective Objective Assessment Plan
175	Documentation Revisions When: as soon as the need for revision is identified. Date and time of revision must be documented. Who: always made by the original author of the document being revised. How: written on a separate, supplemental report form.
176	Chapter 7 Assessment-Based Management
177	Avoid tunnel vision while working toward a field diagnosis.
178	Factors Affecting Assessment and Decision Making Personal attitudes Uncooperative patients Patient compliance Distracting injuries Environmental and personal considerations
179	"Treat every patient in the..." Treat every patient in the manner in which you want your loved ones treated, and you will never go wrong.
180	When multiple responders are on scene, everyone should have a designated task.
181	Roles of the Team Leader Obtain history Perform physical exam Present patient Handle documentation Act as EMS commander
182	Roles of Patient Care Provider Provide scene cover Gather scene information Talk to relatives/bystanders Obtain vital signs Perform interventions Act as triage group leader
183	General Approach to the Patient Scene size-up Initial assessment Resuscitative approach Contemplative approach Immediate evacuation Focused history and physical exam Ongoing assessment and detailed physical exam
184	Identify Life-Threatening Problems At all stages of the assessment, you must actively and continuously look for and manage life-threatening problems.
185	Presenting the Patient Establish trust and credibility. Develop effective presentation skills.