Chapter 6: Resuscitation Adjuncts

 

Lesson Objectives

After completing this lesson, participants should be able to:

•   Identify situations in which suctioning may be used to resuscitate a patient.

•   Describe how to properly use a suctioning device.

•   Identify situations in which the health care provider would consider using an oral or nasal airway device.

•   Demonstrate how to use various ventilation devices to minimize the risk of contamination.

•   Describe how to use an automated external defibrillator (AED).

Approximate Time: 60 minutes

Skill Practice: Yes

DVD Covers Points in Lesson: Yes

PowerPoint™ Presentation Supports Points in Lesson: Yes

 

Teaching Points

•   When correctly used:

  Suction units help clear the airway.

  Airway devices help maintain a patent airway.

  Ventilation devices provide barriers against disease transmission.

  Defibrillators enhance survival for cardiac arrest patients.

•   You cannot maintain a patent airway or begin rescue breathing until the airway is clear.

•   Suction devices help prevent secretions from obstructing the airway or being aspirated.

•   There are two primary types of suction devices:

  Manual: do not require batteries or an electrical source; always ready to work; suction is applied by inserting the tip of the device into the patient’s mouth and squeezing.

  Mechanical: powered by rechargeable batteries, pressurized oxygen, or pneumatic devices; require familiarity with mechanisms for use and regular service checks; create a vacuum that draws obstructing materials from the patient’s airway.

•   Follow these steps when suctioning:

  Turn the patient’s head to the side. Roll the patient onto his or her neck side and keep the neck and body from twisting if you suspect spinal injury.

  Open the patient’s mouth and wipe away any debris with gloved fingers.

  Measure the suction catheter from the corner of the patient’s mouth to the earlobe to determine the proper depth to insert the end of the suction tip.

  Turn on the device, insert the suction tip, and suction slowly as you withdraw the catheter from the mouth.

•   When using suction devices, suction the adult for no longer than 15 seconds, the child for no longer than 10 seconds, and the infant for no longer than 5 seconds.

•   Artificial airways can be inserted to keep the tongue from blocking the airway.

•   Oral airways can only be used in unconscious patients without a gag reflex.

•   To insert an oral airway:

  Choose the correct size by measuring from the corner of the patient’s mouth to the earlobe or the corner of the mouth to the angle of the jaw.

  Open the patient’s airway using the head tilt-chin lift or jaw-thrust maneuver.

  Insert the oral airway along the roof of the mouth, with the curved tip toward the roof of the mouth. As the tip approaches the back of the throat, rotate the airway 180° so the tip points toward the chest.

  The flange should rest against the lips.

•   Nasal airways should be used on semiconscious or conscious patients with gag reflexes who do not have suspected fractures of the skull, nose, or midface.

•   To insert a nasal airway:

  Choose the right size. It must fit in the patient’s nostril. Measure from the tip of the nose to the earlobe or the tip of the nose to the angle of the jaw.

  Open the patient’s airway using the head tilt-chin lift or jaw-thrust maneuver.

  Lubricate the airway with a sterile, water-based lubricant or with sterile water or saline solution if lubricant is not available. If using the right nare, the bevel should face the septum. If using the left nare, insert the airway pointing upward.

  Insert the airway through the nostril following the nasal passage straight back, not upward. Do not force the airway if you meet resistance. Instead, try inserting it into the other nostril.

  Listen for airflow through the airway.

•   Mouth-to-mask ventilation can deliver an adequate volume of air if the health care provider ensures a tight mask seal on the face.

•   Ventilation masks, in general, offer some protection from disease transmission.

•   No matter the type you use, the mask must fit well, have a one-way valve, be made of transparent material, have an oxygen port, and be available in infant, child, and adult sizes.

•   Learn how to use all mask types correctly.

•   To perform mouth-to-mask rescue breathing:

  Position yourself at the patient’s head.

  Open the patient’s airway using the head tilt-chin lift or jaw-thrust maneuver.

  Place the mask over the patient’s mouth and nose.

  Using both hands, grasp the mask and the patient’s jaw. Press down on the mask with your thumbs as you lift up on the jaw with your fingers to create a good seal between the mask and the patient’s face.

  Place your mouth over the mouthpiece and perform rescue breathing.

•   The bag-mask device has three components (a self-inflating bag, valve, and mask) and can be used with an oral and/or a nasal airway. It delivers a higher concentration of oxygen than a ventilation mask alone.

•   With a reservoir and oxygen source attached, bag-mask devices deliver 90% to 100% oxygen. Without supplemental oxygen and a reservoir, the bag-mask is still more effective than mouth-to-mouth or mouth-to-mask breathing.

•   Use of the bag-mask device must be practiced regularly. Results are best when two providers use the device.

•  One provider maintains an open airway and mask-to-face seal; the second provider squeezes the bag.

•   Bag compressions and rescue breathing should be smooth, not forceful.

•   Oxygen-powered ventilators are similar to bag-mask devices, but you press a trigger to force air into the patient’s lungs instead of squeezing a bag. They are attached to an oxygen cylinder.

•   Oxygen-powered ventilators deliver high oxygen concentration (as much as a bag-mask device), protect from disease, and are easy to use. However, they require oxygen to operate and should not be used in infants, children, or patients with a chest injury.

•   Rescue airway devices are inserted without direct visualization of the vocal cords. They can maintain a patent airway and allow for adequate ventilation.

  Advantages: ease of placement; no mask seal needed; relative protection against aspiration.

  Disadvantages: ineffectiveness if the cuff malfunctions; requires proper assessment of lung sounds; cannot be used on all patients; devices that enter the esophagus are contraindicated in patients with esophageal diseases or corrosive substance ingestion; the King LT and LMA come in various sizes.

  Esophageal Tracheal Combitube (ETC)

              Multilumen airway (double-lumen tube and two balloon cuffs).

    Will allow ventilation if inserted into the esophagus (primary tube; blue [#1] lumen) or the trachea (secondary tube; clear [#2] lumen).

    Usually enters the esophagus, but if it enters the trachea, it acts as an endotracheal (ET) tube.

    Clear cuff at the lower end of the tube seals off the esophagus or trachea when inflated following tube insertion.

    Flesh-colored cuff in the middle seals off the oropharynx.

    When syringes are attached to the pilot balloons, they inflate the two cuffs.

  The King LT

              Single-lumen airway.

              Blindly inserted into the esophagus.

    Curved tube with ventilation ports between two inflatable cuffs.

    Both cuffs are inflated simultaneously with a syringe attached to a single valve.

    Distal cuff seals the esophagus; proximal cuff seals the oropharynx

    Openings between the cuffs provide ventilation when placement is confirmed

  Laryngeal mask airway (LMA)

    Supraglottic device that features a single-lumen with a mask-like cuff that protects the airway.

    When placed correctly, blocks off larynx and allows air to enter the trachea only.

    Inserted in mouth and slid down the back of the throat until resistance is met.

•   Endotracheal intubation (or use of any advanced airway device) should not interrupt chest compressions; the health care provider who inserts the ET tube should be skilled in advanced airway management.

•   Once an advanced airway device is in place during cardiac arrest, you should deliver continuous chest compressions (at least 100 per minute) and ventilations (8 to 10 breaths per minute).

•   Do not attempt to synchronize compressions and ventilations. Do not pause chest compressions to deliver a ventilation.

•   After an advanced airway device is inserted, visualize chest rise, verify bilateral lung sounds, confirm the absence of sounds over the epigastrium, and perform quantitative waveform capnography continuously throughout the resuscitation attempt, particularly when moving or transferring the patient.

•   Quantitative waveform capnography is the recommended method of confirming initial advanced airway placement and monitoring ongoing advanced airway placement. Capnography measures end-tidal CO2 and provides real-time objective data via LED reading and a visible waveform on the cardiac monitor/defibrillator.

•   Circulatory Assist Devices

  Impedance threshold device (ITD): enhances the changes in intrathoracic pressure during chest compressions to increase blood flow to the heart and blood pressure, improve circulation to the brain, and increase the chance of survival after cardiac arrest. Note: if return of spontaneous circulation (ROSC) occurs, the ITD must be removed from the advanced airway device.

  Mechanical CPR device: in theory, provides superior vital organ blood flow and increased blood pressure compared to standard CPR; beneficial when personnel are limited; can prevent provider fatigue; includes a circumferential vest and inspiratory impedance valve. There is currently no evidence that automatic mechanical compression devices have shown improvement in survival compared to standard CPR.

•   Ventricular fibrillation (V-Fib) is the most common initial rhythm seen in sudden cardiac arrest (SCA).

•   The most important factor for surviving SCA is early defibrillation. Defibrillation is a process whereby a direct electrical current (DC) is passed through the heart, momentarily stopping all electrical activity to try to restart the heart with a normal rhythm.

•   The earlier defibrillation is performed, the greater a patient’s chance for survival. Each minute that V-Fib persists, the patient’s chance of survival decreases by approximately 7% to 10%. After 8 to 10 minutes of cardiac arrest, heart damage is often so extensive the patient cannot survive.

•   The principals are the same for all automated external defibrillators (AEDs), but displays, controls, and options may vary.

•   Although not all cardiac arrest patients will need defibrillation, most adults who experience SCA will be in V-Fib.

•   The Heart’s Electrical Conduction System

  Sinoatrial node (SA node): heart’s pacemaker; approximately every second, emits an electrical impulse that travels to the atria, causing it to contract.

  Atrioventricular node (AV node): receives signals from SA node.

  When electrical impulses reach the Purkinje fibers in the ventricles, their muscular walls contract; this forces blood to surge from the heart through the rest of the body, resulting in a pulse.

•   V-Fib occurs when irregular impulses originate from multiple sites in the ventricles. The heart reacts erratically, resulting in the fibrillation of the ventricles. Fibrillation does not produce blood flow from the heart.

•   Ventricular tachycardia (V-Tach): abnormal electrical rhythm; heart beats at a rate of 150 to 200 beats per minute; contractions become ineffective and the heart cannot pump enough blood.

•   An AED may only be used on a patient who is in cardiac arrest (ie, unresponsive, not breathing, and pulseless).

•   Follow these steps when using an AED:

  After confirming that the patient is in cardiac arrest, begin CPR with chest compressions and apply the AED as soon as it is available.

  Once the AED is available, turn the equipment on.

  Expose the patient’s chest and ensure that the skin is clean and dry. Apply the AED pads to the victim’s bare chest and the cable to the AED. Do not interrupt CPR to apply the pads.

  Stop CPR, ensure that no one is touching the patient, and “analyze” the heart rhythm.

  If defibrillation is recommended, continue CPR while the AED charges.

  When the AED is charged, stop CPR, ensure that no one is touching the patient, and press the button marked “shock.”

  After defibrillation, immediately resume CPR starting with chest compressions.

  Perform CPR for 2 minutes (five cycles), then reanalyze the rhythm.

  Repeat the analysis, shock, and CPR steps until ALS personnel arrive or the patient starts to move.

•   The AED will give an error warning if the cables or pads are not secure. AEDs cannot be used in moving vehicles.

•   Resume CPR, starting with chest compressions, and prepare the patient for transport or transfer if the AED states “no shock advised.” Patients in cardiac arrest who do not respond to defibrillation or receive the “no shock advised” message need ALS measures.

•   AED Precautions

  Do not use alcohol to wipe the patient’s chest.

  Do not apply the pads directly over medication patches. Remove patches and wipe away residue before applying the pads.

  Place the pads at least 1” away from implantable pacemakers or automated implantable cardioverter/defibrillators.

  Do not attach the pads to any patient unless he or she is unresponsive, not breathing, and pulseless.

  Do not defibrillate a patient who is lying on a surface likely to conduct electricity.

  Do not shock or analyze the rhythm until everyone is clear of the patient.

•   AEDs can safely be used in patients under 8 years of age using pediatric-sized pads and a dose-attenuating system. However, if these are unavailable, use adult AED pads.

•   The AED should be applied after the first five cycles of CPR have been completed unless an otherwise healthy infant or child suddenly collapses. After the first five cycles, the AED should be used in the same manner as with an adult.

•   If the child is between 1 month and 1 year of age (an infant), a manual defibrillator is preferred to an AED. This is an ALS skill, so request ALS support immediately. If ALS personnel with a manual defibrillator are not available, use pediatric pads with a dose attenuator. If neither is available, use adult AED pads.

•   AED Maintenance

  Inspect your AED regularly as part of preventative maintenance.

  Check daily to ensure that all supplies are on hand, the unit is operational, the batteries are charged, and there is no damage to the unit.

  When the AED is turned on, it will perform a series of self-diagnostic tests.

  Check expiration dates on pads and batteries.

  Keep proper documentation on these inspections.

•   When using an AED, follow your local protocols and observe safety precautions.

 

Application

•   Participants should describe the proper technique for suctioning a patient using a manual or mechanical suctioning device.

•   Participants should describe how to properly insert an oral and nasal airway.

•   Participants should properly ventilate a manikin using various ventilation devices.

•   Participants should demonstrate the operation of an AED.

•   Participants should complete the “Check Your Knowledge” questions at the end of Chapter 6 in the textbook.

 

 

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