all right airway h5 in the packet in the shot packet so when we look at airway we got to start with some basics here so remember normal respirations are 12 to 20 heart rate is 60 to 100 whole socks should be 96 to 100 and the end title should be 35-45 now if i give you a scenario and the person is breathing 24 times a minute heart rate's 112 pulse ox is 92 and m title is 50. that person is in respiratory distress respirations are up heart rate's up pulse ox is a little low they're what we call mild hypoxia mild hypoxia is 88 to 94 on a pulse ox moderate hypoxia is 84 to 88 and anything below 84 is severe hypoxia all right so this person's mild hypoxia if oxygen level goes down i switch from aerobic to anaerobic which makes acid level go up and when acid level goes up co2 level goes up that's why the co2 has gone up so this person is in respiratory distress it's mild though agree so let's say i put them on a cannula just for giggles let's say you put them on a nasal cannula say four liters per minute remember a nasal cannula is designed to be flown at two to six liters per minute put them on a candy left four how do i know they're getting better okay so what i should expect to see is i should expect respirations to move back towards 20 heart rates move down towards 100 pulse ox to move up towards 96 and entitle to move down towards 45. i want to go from the abnormal range and start moving back towards normal if my treatment's working does that make sense so let's say that it says you have a patient breathing 24 times a minute you put them on a nasty cannula and now they are breathing 28 times a minute heart rate's 120 post stocks 88 percent end title is 55 they're getting better or worse so if the candy lid didn't help them what's next to my toolbox so now i put them on an underrated if the non-rebreather is working their ventilation should go from 28 back towards 20. heart rate should go towards 100. full socks should come up end title should go down towards 35 to 45. that's how i know my treatment's working if i put them on a cannula they didn't get better i went to an under breather they didn't get better now i'm going to go to positive pressure ventilation so let's say they're at 32 140 80 and 70. non-breather they got worse so now i'm going to positive pressure ventilate two-person bbm one person bvm whatever okay cpap i'll get there in just a second positive pressure ventilation once i start bagging them i've missed my opportunity for cpap so somewhere between non-rebreather and positive pressure ventilation i have to consider cpap if i miss my opportunity for cpap and i start bagging them i'm probably not going to get to go backwards to cpac and there is not a specific number of when you should use cpap okay there's not and what i mean by that is i can't sit here and tell you any person breathing 30 times a minute automatically put them on cpac okay i can't say that if i go home and run today which i plan to i'm probably going to be breathing 40 times a minute by about a mile too i don't need cpap you see what i'm saying so we have to look at our patient the goal is before they become depressed and they start wanting to nod off and go to sleep because they're tired of breathing so hard the goal is before we get here to positive pressure somewhere between non to breather and positive pressure we get them on the cpap when our opportunity is and that's all going to depend on what the patient looks like in front of us and i'm not trying to fluff you all but basically you're going to only learn that with experience because there is no magic number i could say you have a 19 year old breathing 32 times a minute with asthma and shortness of breath but he's only been like that for five minutes he doesn't need cpap does he but if he's been like that for eight hours i probably need to get him on cpap sooner if i had a 70 year old breathing 32 times a minute after five minutes if they're in poor health already after five minutes i need to get cpap on them right now because they're gonna crash because they're already old and worn out so that's why there's not a set number of that you're gonna have to lose your patient my experience has been when you start seeing them kind of get that dazed look that's your opportunity right there and if you don't get on it you're going to miss it you know and i'm i hate to be like that well you know that you just you can't give it numbers because everybody is so different and that patient's going to look different the sooner you use cpap the better just remember pressure above 90 got to be breathing deep enough to break the 5 to 10 centimeters of water and they've got to be alert and able to tolerate it yes what did you mean by missed the opportunity for seats i've never really because if they become unresponsive or lethargic we can't put them on cpap if their heart rate gets too low we can't put them on cpap if the blood pressure gets too low and when we get when we start bagging them usually what will happen because they're you've got to think about it if i walked up to you right now and i said let me put this bbm on you and breathe for you you're going to what i know you're going to fight it so if they're letting you put that bb in on them and force air into them they have basically what quit trying and they have to be trying for cpap to work because they have to be able to still take that deep breath and break that five centimeters of water on my pressure setting and that's why i'm saying you'll miss it because if you if they're letting you bag them then they're not going to they're not going to have enough fight in them to breathe deep enough for the cpap and that's what i mean by missing that opportunity think about it like this if you put cpap on a dead person what's it going to do because they're not breathing you know it's kind of like your scba if you hold your breath your scba just sits there until you take a what right and so that's why once we start bagging we've missed our opportunity my experience has been when you start banging somebody they let you back them so they let you breathe for them and their fight goes away you know if you stop with me now it's kind of like you know who should we innovate people that let us if i tried to innovate anybody in this room you're going to put up a watch but if you have no fight to keep that laryngoscope blade from going in your mouth you probably need it does that make sense and that's what i'm saying we'll miss the opportunity yeah i had an old instructor and he always told me if they let you innovate them i'm like what he goes if they can lay there and take that laryngoscope blade and e.t tube in their mouth and not bite you they need it inundated if they lay there and let you bag them they need ventilation all right and you're right somewhere between going to an honor breather and bagging i need to get that cpap on before i miss the opportunity but it's not clear cut and dry okay if positive pressure ventilation doesn't work and they continue to get worse what do i need to do next okay maybe it depends depends on whether they're still struggling or not all right i would tell you right now the registry is not a fan of rsi and just real quick rsi there's nothing about it that's rapid it typically takes about seven to ten minutes to prepare all your equipment pull up all your drugs and get everything ready to rsi somebody it's not a rapid anything at it the rapid is as soon as you finally get everything on drug you should rapidly innovate but the prep that goes in on that especially in the metroplex you could probably be at the hospital in the amount of time it took you to pull up all the drugs not only that there's a lot of debate on whether paramedics should actually be allowed to innovate anymore or not and a lot of ems systems are no longer allowing their paramedics to innovate that's a whole nother topic uh king tubes will stay your eye jails but what they're finding is because of the frequency of innovations most of our paramedics are not proficient i i don't do a whole lot with the ems committee at the at our fire department last time i was on it was a few years ago we had 186 innovations in irving fire department out of 21 000 calls for the entire year we have 200 paramedics 90 of our innovations occurred south of 183 i personally had a good year i had six innovations that year so stop and think about that i have 186 innovations for an entire year and i have 200 paramedics but 90 of my innovations occurred south of 183 so are my guys proficient at innovate probably not and when you stop and look at the less frequency that innovations are occurring because we are going to see path we do have better preventative drugs we do have better medications on the ambulance than we had 25 years ago we don't innovate near as many people which means our skills what degrade so the next question comes all right so how do we get innovations the ors don't even hardly innovate anymore those of y'all that did or rotations a lot of times they use a what i do igl or lma so they don't even innovate a whole lot more not only that but if i have 200 paramedics in the city of irving how do i rotate them through an or rotation and what anesthesiologist is going to take that liability so then the next option is do i put an airway mannequin at every station and make the guys innovate three times when they first walk in the door probably should that also cost money so that's why there's a whole debate about innovation in ems right now and i'm not going to pick the side i see both sides of it so if we can't even agree whether we should still be innovating can we agree on rsi and i'm going to say that judging in here if we looked at people's rsi protocols everybody has different drugs and different set order that they give them in it's just the way it is a lot of medical directors rely on socks and but subsequently is a depolarizing agent causes fasciculations as we talked about yesterday and it's contraindicated in any type of spinal cord trauma are we most likely to rsi a car wreck with potential spinal cord trauma but when you ask him why do you give sucks and that the medical director goes well because in two minutes if they haven't got them tubed it wears off yeah but if they do get them tube they got to follow it up with a middle mid mid term or uh the mind's going blank not short acting but uh and it's not long acting like a medium lasting uh sedative atomic that something like that you've got to turn around and sedate them further and put them down more you know well if you miss it well if i paralyze them why can't i just put a king tube in or igel or element whatever backup airway device you carry and they just look at you like uh and it's a trust issue but i mean that that's it i mean it it's just so if the registry does ask you rsi questions okay here is when they want you to rsi somebody it is the very last thing to try because everything else is fail they were clenched i couldn't bag them i couldn't easily innovate them i couldn't get a king tube in i had no other way to put air into this patient than to go ahead and sedate them that was it all the other attempts had failed i couldn't bag them they were combative they were clenched i couldn't easily innovate i had no other option to put air into them rsi is a last ditch not a first rsi should only be done because this failed this failed cpap failed positive pressure failed innovation failed i have no other way to forcibly put air into this person other than to use rsi and too many paramedics use it as the first line and that's not the way it was ever intended and that's another reason why they're looking at pulling rsi from the national curriculum yes cry so the only time i should ever do a cry because surgical or needle is if i have a complete airway obstruction or i have an anatomy disfiguration like i can remember 16 year old for those of y'all that know me i always say lean forward pull the trigger don't flinch you'll it up too uh it's just it's my term of endearment so i ran a 16 year old little s10 pickup buy for less parking lot north side oklahoma city girlfriend breaks up with him he has his shotgun in the front seat flinches blows his bottom jaw off how are we going to innovate that guy you're not so we ended up having to cry kim those are the type you're going to cry cracked a guy at the k.a house uh there in norman on frat row swallowed a goldfish as part of rush week instead of going head first went telfet first fanned out squirted lidocaine in there couldn't get it dug out ended up having to crack it it's those things that we have to cry rsi is not going to help those people like that rsi and somebody with no jaw is not going to help you get an airway where rsi is going to help you is when you have that clinched head injury with irregular respirations in six breaths a minute and you cannot physically pry their jaw apart to get the larendoscope laid in there that's where rsi is going to help you or you have that combative chf or asthma patient that you've tried all the drugs and you can't get them to tolerate cpap and no other way to get air and butyrol in them now it's time to rsi it's a last-ditch effort not at first and too often paramedics treat it as oh well he's drawn combative let's rsi and we ain't gonna fight him oh well they're chf patient let's just go ahead and rsi well did you try nitro did you try cpap did you try morphine and lasik or did you go straight to rsi because you can't and our own people have made rsi by using it overzealously when it's not necessary are making it go away from the curriculum because of our own stupidity i would tell you right now between working in oklahoma city in the ghetto for almost seven years working some in norman in a college town with a hundred thousand people and only two ambulances busy busy busy and then working south irving for 17 years maybe 10 times total in my career in 27 years in my life man i wish i would have had an rsi because i had no other way to get airway the other however many thousands of runs i have found a way to treat that patient without rsi it's not a first ditch effort it's a last it should be because there's no other way to take care of the spaceship not because well i can could you have nasally innovative could you use cpap could you have done other things prior to having to rsi somebody and then even then the training and stuff that goes with it so registry's not big on it if they do want rsi it's last ditch and there's no other way to get air into that as far as the drugs for rsi go because there is no set rsi standard okay some places use sucks and vex some places use automate some places use raw i mean there's all kinds of different things out there so here's what the registry will do if they ask you about rsi drugs which of the following is a uh drug used in rsi for initial sedation versed atropine lidocaine or sucks versus sedation which one of these is a fast-acting depolarizing paralytic verse said sucks lidocaine or accommodate which of the following is an intermediate drug used in rsi atropine lidocaine verse set or accommodate if they ask you anything it's going to be that cut and dry and usually most students have zero to one rsi related drug questions on their tasks those of you y'all have taken before and usually it's a it's a sucks or a verse set every once in a while throw it's holiday but it's not like they're going to sit there and ask you about rock and deck and all the other stuff it's really what would you use for sedation they may say which of the following drugs is used to decrease icp in a head injury during rsi atropine lidocaine burst or uh sucks light cane light can't decreases icp because remember if i block that sodium channel it blocks the nerve impulse from contracting which means they're not going to go and clench when you hit the back of that gag and drive the icp up so that would be why it came out choice but zero to one rsi specific drugs there may be a couple of questions where i ask you when it's indicated all right yes so i've seen a practice question before it was like literally which had faster on set rock or back and i like to figure it out was digging through my drug sheets you're saying don't worry about stuff like that not that those of y'all that have taken the test recently y'all remember any rock bag i have a i see me accommodate the sucks diverse that uh and so the non-depolarizing means it doesn't affect the sodium potassium pump which is basically everything but sucks and then the only thing that's going to affect the sodium casting pump is the sucks in the lidocaine and you don't want the you wouldn't want the depolarizing correct paper yeah i don't want the sucks for potential spinal cord trauma because what happens if you have a spinal cord injury your muscles tense to help what protect that injury that's why we get swelling inflammation to hold it in place they do this and now they're fasciculating it can end up causing spinal damage and they can still seize despite being paralyzed a person can have a seizure darren sucks and that's not catching so that should take care of those three things right there that you saw in your test i'm trying to think anything else uh opposite what happens if my ventilations are a tartness 48 full stock 70 well here's the general rule of thumb gcs less than a ventilation is less than eight check for a guide and prepare to innovate okay once again no gag they let you put a tube in their mouth they need it so this person right here anybody less than a i'm going to ventilate restaurant race down heart rate's down this person when they can tell you they can't breathe is in distress this person is in respiratory what failure respiratory failure is just like decompensated shock yesterday in compensated shock everything was up decompensated shock everything was down so if respiratory rates down heart rate's down level of consciousness is down that is respiratory failure if you do not immediately ventilate respiratory failure they are going to go into respiratory rest and after four minutes of respiratory arrest depending on what their oxygen level was they are most likely going to end up in what cardiac arrest so anybody less than eight ventilate and prepare to innovate easy enough anybody less than eight ventilate and prepare to innovate how do i know what order innovation should occur your adult airway management check sheet your adult airway management check sheet said you should say bsi then we have to consider c-spine because that will dictate how we open the airway we open the airway we check for a gag if there is no gag we ventilate pre-oxygenate and prepare our equipment correct and then after we prepare our equipment then we innovate when you did skills check off if you would have walked in with a airway head on the table and the original blade and you walked straight up to the mannequin and you innovated would you have passed that skill station no so if you go straight to innovation on the registry you are not going to pass that question because you have to consider c-spine open the airway check for a gag ventilate pre-oxygenate then innovate so if i have a person at nick on the floor which of the following should you do first consider c-spine inubate king tube or ventilate consider c-spot because that's how i'm going to open the airway to ventilate them and then after i ventilate them then i can innovate her kingdom i have to go through that checklist okay i have to go through that checklist and this is respiratory failure which is decompensated i need to ventilate them if i start ventilating them and they stay the same or get worse then i would innovate if i'm ventilating this person and the respirations come up to 10 pulse ox comes up in the 90s in tidal co2 starts coming down towards 45 ventilations is what okay working give it a few more minutes and see if we get them awake enough that we don't have to do this so if my treatments work and stick with it now this also will pertain to bronchitis asthma copd and pneumonia for example let's say that i got a person and they're wheezing let's say that i get there they're breathing 24 times a minute wheezing heart rate's 118. pulse ox is 98 and in title is 60. based on those numbers what do i think is wrong that's causing this person to wings they're still getting air in but they're not getting the co2 out so i suspect it's what asthma what should i give this person first day i should give a butyrol by itself per textbook i do not start with the butter all in attribute i know it happens all the time in the field but for textbook and manufacture here's why the imputerol we give is 2.5 milligrams and three meals that is standard correct atrovent is .5 milligrams and three meals correct so if i mix these two together in one nebulizer that is six milliliters of food albuterol is the rescue side of the equation atrovent is preventative so if i have a person that's called 9-1-1 for wheezing my goal is to fix the emergency and then once i fix it prevent it from coming back if i was to mix the two in the beginning it's going to double the amount of time it takes for the rescue properties to kick in here's an illustration i have a wedge and i have a pry bar and i need to get this door open i can take the wedge and that wedge isn't going to do much for me is it the pry bar is going to do what though open the door so the pry bar is your butter all and it's designed to open the door the atroven is the wedge to prevent re-closure so what i need to do is i need to get that pry bar i need to get that door open and then i need to shove a wedge in it to prevent re-closure if i start with the wedge it does mean no good because the door's not left open and if i add the wedge in the very beginning it doubles the amount of time it takes for the initial onset of a butyrol to occur most of the time three millimeters of fluid will nebulize completely in six to ten minutes on average you have humidity and some other things to go into factor but if i add another three cc's to that now we're talking 12 to 20 minutes before they get the 2.5 milligrams of the butyrol which is the rescue side that's why the textbook says first treatment should be a butyrole only second and third we should add a butyrol plus atrovent a a now that's testing purposes okay if you run on somebody and they've already done a couple of home nebulizers they've already puffed their inhaler you can start with an a but for testing purposes they want the ibuterol by itself for the first treatment and that's why all right that is why now a butyral bronchodilates atrovent does not bronchodilate atrovent prevents bronchoconstriction and the other thing that atrovent does because it blocks the parasympathetic nervous system a lot of times it helps with the secretions the parasympathetic nervous system to dump and dilate is the sludge side of our body the salivation lacquer nation urination defecation gastric evacuation that's what the parasympathetic does so in asthma when they get a allergen whether it's mold pet dander smog whatever a lot of times something triggers that asthma so they have their reaction to it in their lungs the lungs constrict to not let any more of that bad air in and then they secrete fluid to try and flush that allergen out of there the problem with that fluid is it becomes thick and they have a hard time moving out of the bronchials so what atrovent does is it helps with the fluid secretion and it prevents bronchoconstriction whereas the butyrol bronchodilates but it doesn't do anything about the fluid nor does it prevent it from coming back if you think about all the tv commercials now what do they say when you see singulair advair combivents all of those commercials they say not to be used as a rescue inhaler use twice daily what that means is the person wakes up in the morning they puff their attribute before their lungs are constricted because if they're not constricted i'm going to block them from constricted if they're already constricted it's not going to do me any good which is why the rescue inhaler is the ibuterol so the goal is they wake up in the morning they puff their attribute before they're constricted they go through the day 12 hours later they puff their attribute again before they become constricted and they don't need a rescue in hay if they called us they need the rescuing heaven does that kind of make sense now what happens if we give them a ton of a butyrole and never add out your debt we used to do this all the time in the field when we look let's say that this is normal aveoli and bronchioles it becomes constricted and extremely narrow and as a result of that we have that high-pitched whistling so i give them a whole bunch of butyrol and i end up being given so much of buterol that now they bronchodilated and the bronchioles are twice the size as normal for everything that goes up it must come so when the sympathetic becomes over stimulated what's the parasympathetic want to do match it so the whole time the sympathetic is making them dilate because it's my emergency fight or flight the parasympathetic is behind the scenes going i can't wait for you to wear off because i'm going to slam them shut because we're not supposed to be open that far so as soon as the imbuteral would wear off they would slam back shut and that's where we got the status asthmaticus because we didn't have the preventative atrovent and stuff we carry now so we would give this person 5 10 12 15 milligrams of butyral and then as soon as that last treatment wore off they would shut down tighter than when we got there we couldn't figure out why so that's why we started to do a nebs and mixing the butyrol and atrovent because we want to open them up but we want to prevent reclosure in the parasympathetic from kicking in so the first treatment of uteral only the second and third treatment we have the atrodex if my treatments are working in this particular case respiratory rate and heart rate should actually go down a butyrole will make your heart rate go down if you needed it that's the key now i know the side effect of a butyrol according to textbook is tachycardia and i agree if you're sitting here your heart rate 60 and i give you a butyrole treatment it is going to make you tachycardic because of the beta 1 side effects of it however if your heart rate's 140 and you can't breathe when i make you breathe better what's going to happen to your heart rate it's going to go down so you need to understand that when they talk about side effects and drugs it's talking about if a person doesn't need the drug what's going to happen when we give it to them yeah if you don't need a butter oil and your heart rate 60 it's going to make you go to 100 something but if you're at 140 and need it as you start to feel better and your anxiety goes away your heart rate's going to come down so if my treatments are working just like what we had earlier these numbers should move back towards normal and this carbon dioxide level should start to move back towards normal the carbon dioxide in bronchospasms on the capnography is going to start doing that and a sharp fin instead of a nice square even exhalation plateau that sharp thin is that bronchospasm or bronchoconstriction because remember in asthma they can suck air in because that is active exhalation is passive it's relaxation they can't force the air out it's kind of like breathing through a straw i can suck air in and use the accessory muscles but when i try to blow out it's constricted and i can't exhale forcefully because my diaphragm is designed to relax and go back into place so as a result of that they can suck air in which means they can get oxygen in but they can't get the co2 out which is why wheezing occurs initially on exhalation which is why in the beginning stages of asthma your pulse ox should be normal too much co2 good or bad so what would you expect the color and temperature of an asthma attack to be red and flushed warm because the co2 is causing vasodilation so i would expect my asthma attack to have a normal pulse ox high co2 and be red in appearance and i would expect wheezing only on exhalation because they can suck air in using accessory muscles this patient right here a buterol is probably going to work as well as after that if for some reason it doesn't work heart rate goes up respiratory rate goes up pulse ox goes down in tidal continues to go up what do i try after three treatments of a butyrol two of them without your back subcuffy subqeppy or tubulin because what we need to think about if three treatments have failed we're about 20 minutes into this call now we need to emergency rescue them that's where sub qfe comes in so three treatments have failed no improvement sub qp if i'm staying here i probably don't need to move to the epi but if i'm getting worse i need to move to the epi solumna draw solumedraw is not an emergency drug and what i mean by that is it's not going to work in 30 seconds after i get it matter of fact it's probably going to take 15 to 30 minutes before the effects of the sodium metal ever kick in so in an emergency situation it does mean no good right now however the sooner i give medrow on this run the sooner it's going to kick in and help them long term and maybe prevent them having to be innovated at the hospital does that make sense there is no hard fast rule on when you should give sodomedral i would say that if you're going to give solumedral first of all are we taking the patient to the hospital second of all how many treatments are we going to have to give them and those should be your guiding factors whether we use solution or not so for example let's say that i walk in 20 year old asthma patient he or she says hey i ran out of my butter all this morning i just need a quick treatment and then i'm going to run up to walmart and get it refilled i got a good pulse ox cap nose a little high a little bit of sharp pen they're moving good air they're talking in sentences i may go ahead and give them a butyrole then maybe another one with the atrovent to give them time to get to the pharmacy i'm not probably not taking that person in the hospital i don't need to be giving them sodium versus i walk in and i see this in asthma let's say i got 128 88 and 70. what does that 88 tell me they're not getting oxygen they're not inhaling now so not only do they have expiratory wheezing they also have inspiratory and eventually when they get inspiratory weason those bronchials are soaked shut they can't get air in and out this tells me that they've already burned through their four to six minutes of stored oxygen and now their pulse ox is starting to fall is my butyrol going to be as effective in this patient because they can't suck enough air in which is why they're becoming hypoxis so i know this person probably needs to go to the hospital and i know i'm going to end up with multiple treatments so let's get the salumetrol on board quicker because then it's going to work soon and that's just kind of the general rule there's not like you know respirations are x you have to give solid material just understand that it's going to take a while to work so if i'm going to be transported and given multiple treatments the sooner we give sodium draw the better off the discrimination would you start with you on that fish on this one no no not necessarily because of all the tachycardic side effects i got with the athey but now if we if we made it in the low 80s and they've already tried multiple treatments i'd be starting them on cpap right away because then if they're still breathing a little bit you may be able to force air in with that cpap and force the immuta all in it but once again to uc baff they have to be able to suck hard enough to break that five to ten centimeters of water because you cannot be lighter right yes you can yeah that's correct so for so for like a registry scenario well they give you you might have to run through your your drugs so here here's what they would say 26 year old male status asthmaticus multiple nebulizers have failed what's your next option three treatments it's refractory yeah i'm looking at subcuta they may use turbulene or breathing every once in a while that is basically a sub-q injection like epi specifically designed for bronchodilation it can also be used to stop pre-term labor or they give you fb attribute layer it'll be one yeah it'll be one of the other um what about mad so here's where we get to mag okay mag is last ditch because of the heart side effects so imagine i have this asthma person i have done a butyrole attribute they were getting worse i gave them solumedrol i put them on cpap they're getting worse i give them suck qep and they are locked down what has happened is if you remember back to yesterday all contractions in the body occur from sodium moving into the cell and potassium moving out what has happened in status asthmaticus if i can't relieve it with the butyrol atroven and sub qep sodium has gotten stuck in the cell and potassium's gotten out so it's got stuck in this bronchoconstriction state yesterday how do we make the sodium potassium reset calcium made it start what reset it back so mag is a last-ditch effort the other problem we have with mag is mag takes 10 to 20 minutes to infuse 1 gram is 10 minutes 2 grams is 20 minutes so why do we give it that slow even in asthma what's the biggest side effects of mad bradycardia and hypotension so on this person that's having status asthmaticus and everything is failed eventually they're going to start bradying down so i can't go slam and mag in them to reverse the asthma because they're starting to move towards respiratory failure so that's why it's a last-ditch effort but i don't want to slam it it's given over the 10 to 20 minutes so if i said you have status asthmaticus all treatments have failed which of the following would you consider valium versed ativan or mac mad and that's how that maybe works all right uh the higher the pulse ox the more likely a buterol is to work on your asthma patients uh be aware that we have some old school medics out there that think pole socks is end-all be-all and they're like look you're fine your pool socks is 100 there's nothing wrong with you in your life yeah but they're breathing 42 times a minute and wheezing and there's at no 70. yes they can currently get oxygen but they can't get that acid and co2 out and remember acid has to be eliminated every exhalation oxygen i got four to six minutes for stuff to go wrong before i run out of oxygen so that co2 is just as important if not more important than oxygen in this patient so my asthma is three treatments no relief epi solumendral and cpap anywhere in the middle of that equation all right uh so we good on asthma shark thin bronchospasms look at chronic bronchitis blue bloaters three months out of the year for two consecutive years they're overweight they're always sick they always have bronchitis that's a chronic bronchitis look at your treatment though treatment for chronic bronchitis is the exact same of what we just talked about for asthma correct first treatment of uterus second and third is butyrole and atrovet no relief consider subcutane use caution if the person has cardiac issues because the tachycardia effects of epi one thing i would add to give to your chronic bronchitis as well as your asthma patients give them a fluid bolus why would i recommend giving fluid bolus to asthma and bronchitis patients yeah and what happens if i give you a whole bunch of fluid it helps thin the secretions and the thinner the secretions the easier it is to get out of your nose so think of it like this you've got rock hard crusted boogers in your nose you can't blow it the only thing you can do is try to go up there and pull them out either by picking your nose tweezers whatever all right you gotta suction that stuff out what happens though if i give you a whole bunch of fluid and we change it into a liquid snot that you can blow and help clear out and that's what given fluids to my asthma patients my bronchitis patient bronchitis patients and pneumonia patients does is it helps thin those secretions to where the atrogen is more effective and they can move those secretions out of the bronchials if you innovate an asthma patient i'm trying to remember if they're still putting this on there or not if you innovate an asthma patient and they are extremely difficult to back and the breast sounds are really diminished give them a fluid bolus and consider squirting 10 to 20 cc's of saline down the e.t tube because what has happened is they have a giant mucus plug on the alveoli and by squirting uh saline down the tube it helps moisten that plug and hopefully break it loose to where the air can force it out of the way and that's why they start becoming hard to bag because of how tight they are from the mucus and the plug that's built up inside those bronchials and the alveoli so once again wood can help us in those patients one thing to help you determine on the chronic bronchitis we said three months out of the year for two consecutive years or more they chronically have bronchitis uh also there's what's called the 40 rule the 40 rule he has packs a day of cigarettes times years so if they only smack a smoke one pack a day it would take approximately 40 years for them to develop copd if they smoke two packs a day it would take them 20 years so that's why when you take a patient to the er they say how long you been smoking and how much do you smoke and if the person has a ratio of half a day and years above 40 then there are high risk for copd and copd could be pulmonary emphysema or chronic bronchitis chronic bronchitis is blue bloaters pulmonary emphysema is pink puffers pulmonary emphysema is the only patients that actually breathe based on o2 everybody in this room breathes based on co2 here's why if i hold your breath if i tell you to hold your breath and not exhale your oxygen level's fine for a few minutes but what are you stacking up in your body now co2 and so when you stack up co2 that's bad you're going to vasodilate guess what your r rate's going to do it's going to go up it will go up to compensate so the reason why our body breathes off co2 is because it tells us did i have oxygen did i have a heart to pump it did i have blood to transport it did i have pressure to force it into the capillaries and if the capillaries have sugar to convert it to atp and if so is my gas at 35 to 45 where it's supposed to be that's the only way for the body to tell homeostasis if that number changes the body's gonna instantly react versus oxygen i can have all the oxygen in the world but if the heart's not moving it it doesn't do me any good i could have all the oxygen in the world but if i'm losing blood it's not going to do me any good i could have all the oxygen in the world but if there's no pressure to force it through the pre-capillary sphincter into the into the capillaries it does me no good that's why we measure carbon dioxide because it's the end result of all body systems working appropriately and if that number changes it stimulates the brain to recognize holy crap my end title is 60. something's gone wrong increased heart rate increased respirations oh my goodness panic let's see if we can figure out why and it happens every three to five seconds every time we have cell that's why our chemoreceptors are set on c on co2 the problem with the emphysema patient is instead of having an alveoli that looks like a balloon sac their avioli has actually collapsed and deflated itself because it's lost its elastasine properties so if i handed you a deflated balloon would you inhale or exhale to blow it up exhale so what they do is they partially exhale to reinflate this balloon to create surface area in order to exchange oxygen and carbon dioxide so what do they re-inflating that balloon with carbon dioxide so as a result of that they are going to track carbon dioxide in their alveoli if they were to fully exhale what would happen to their carbon dioxide level and what would happen to their alveolar sac it would collapse so as a result of that they never fully exhale they they puff to prevent complete elimination of co2 well because they're trapping all this co2 to keep the ravioli open their co2 level will start to crop climb if you and i co2 level gets above 45 that's going to trigger our respirations and heart rate to go up well their co2 is slowly going to start to climb in the beginning their body is going to try to compensate for this increased carbon dioxide so every time i raise my hand i want you to take a breath all right breathe just normal breathe breathe breathe breathe breathe breathe breathe breathe breathe how you feel not too good little lightheaded now imagine having to breathe that fast you only did that for 15 seconds imagine you have to breathe that fast every minute every hour every day for the rest of your life to try and keep your co2 level normal oh by the way you can't fully exhale because in your lungs will class how tired would you be how many calories would you burn how developed would your accessory muscles become you'd be ripped that's why they become thin and barrel chested because they're trying to eliminate that co2 but they never can so as a result of that their chemoreceptors go screw that i cannot get my number down anymore so the chemoreceptors as a backup measure oxygen if the oxygen is a hundred percent does the brain recognize the problem no so what happens is their chemoreceptors adjust to where when they recognize hypoxia it drives them to breathe this is what hypoxic drive is so if i have jace up here his brain sits there and he goes hey man you're 90 take a breath hey you're 90 take a breath hey you're 90 take a breath oh you're a hunter you don't need to breathe anymore i just knocked out his what because he no longer recognizes he's hypoxic so the brain has to no longer re remind him to breathe that's what hypoxic drive is because of the high levels of co2 too much co2 is bad bad things cause my vessels to vasodilate all that red-borne blood goes beneath the skin makes them red in appearance pink puffers purslets pulmonary emzema the reason why they breathe through purse lips we're all going to look dumb together open your mouth stick out your tongue take a deep breath now do it through purse lips which one created pressure first lips so they are essentially seeping themselves through pursed lips to force air through their constricted alveoli and then they puff because if they fully exhale it would deflate their alveoli because they've lost their elastos properties this is what true hypoxic drive is pink puffer's first lip pulmonary emphysema now how do i know if this is normal for them or not well we put our vital signs back up here 60 to 100 heart rate 12 to 20 respirations but instead of having a pulse ox of 96 to 100 percent they need to be mildly hypoxic 88 to 94 and then we expect their end tidal co2 to be greater than 50. now they may or may not need oxygen to keep them in that 88 percent a lot of times they do need supplemental oxygen it'll be on a couple liters by cannula so let's say that i run 64 year old female history of cp copd she steps off the curve and breaks her ankles all right and they give you this for vital signs 98 18 92 54. that's her vital signs do we need to adjust her cannula from two liters no no no plus why are we there she broke her ankle and this is normal for a copd patient what if i told you you have a 63 year old female complaining of trouble breathing 112 24 92 percent and 60. she's on 2 liters by canula is that normal for her or not let me ask you this if it was normal she wouldn't be compensating she wouldn't be too kidney so even though this 92 percent is in the normal pulse ox range for a copd hypoxic drive this tells me that that's a little low for her so i need to go ahead and give her what i need to go from two liters on a candy let it maybe six i wouldn't want to go straight to another breather because if i get her to a hundred percent here's what's going to happen it takes approximately 10 minutes to resupply all of our red blood cells with oxygen it takes another 10 minutes before the chemoreceptors quit activating based on oxygen needs so on average it takes approximately 20 minutes to knock out somebody's hypoxic drive the average transport time according to the rest registry parameters is 15 minutes so on my average call if i put them on an honor breather i'm probably not going to knock out their hypoxic drive however if i work in a rural area the roads are snowing i see the ambulance breaks down catches fire on the side of the road which is actually a test question where the bridge is out what does that do to your 20 minutes or the 15 minute transport time makes it longer which puts the patient more at risk for knocking out their what epoxy drives so if i got this person and let's say they're on two liters let's bump them up to four liters if 4 liters is working heart rate should what respiratory rate should pulse ox may or may not change capital may change a little bit but this tells me they're compensating or not does that make sense so if heart rate and respiratory rates normal and pulse ox between 88 and 94 and they didn't call you for shortness of breath probably don't need to adjust it if they call you for shortness of breath and heart rate and respiratory rate is compensating probably need to adjust their cannula now we can put a patient on an honor breather so let's say that i have this right here let's say that i run on copd patient respiratory distress they've been taking a butyrole and i get there and they're this 134 28 80 and 90 on the cabinet believe it or not your cat note can go much higher than your screen shows if they're on two or four liters of canva is that working no no so i put them on non-rebreather if the non-rebreather's working the heart rate should come back to normal respiration should come back to normal pulse ox should come up towards 88 to 94 and the end title should start to come back down towards 50 correct so let's say 12 minutes go by and i'm now here 116 100 and 40. you better take them off that can't off that not a route because you're starting to relax them so much that if i continue down this path i'm going to knock out their what i possibly drive and what happens when you knock out their toxic drive is they quit breathing on their own and it takes several weeks to months to get them weaned off the ventilator before they'll breathe again on their own because they have to go from 100 where they're going i don't even got to breathe i just lay here to fighting for every breath and learning how to live in a hypoxic state again that's why we don't want to knock out their hypothesis drop so you can use a knot or breather on an emphasis patient the key is when they're at 80 put them on an honor breather when they start getting in the upper 80s to low 90s take the non-rebreather off put them back on a cannula and see how they tolerate it they were at 80 percent i put them on an honor breather i got them to 94. let's take it off and put them back on the cannula i put them at four liters and they maintain 94 and their heart rate's less than 100 cool let's stick with it if they fall back down in the 80s put them back on the non-rebreather we're just using that long enough to get out of the danger zone and then turning around and pulling it back off and going back to the canyon if you may if you make them lethargic you're going to have to ventilate them and then you're going to have to innovate and then they're going to have to end up at a skilled nursing facility on a vent for months to be weaned off and they're going to have to slowly get that pulse ox back down to where they live in mild hypoxia of 88 to 94 percent now because of the excessive carbon dioxide they are going to produce more red blood cells this is called polycythemia the hemoglobin on red blood cells not only carries oxygen but it also carries co2 that's why it's called carboxy hemoglobin what do they have too much of that needs transported what do they have too little of so they end up producing more red blood cells called polycythemia which makes them even redder in appearance they also end up vasodilated as a result of that the back pressure in their chest from always being basically inflated with trapped carbon dioxide puts pressure on the right atrium and right ventricle and makes it pump harder to overcome that chest pressure as a result of that that sa node has a hard time firing which is why a lot of times that sa node will go into what rhythm afib that's how your copd patients end up in a fit so your copd patients are at risk of afib and the afib increases the risk of what from yesterday ischemic stroke o'clock so that's how they start that cascading effect plus they smoked and did all the years of nicotine and nicotine increases the risk of clots as well so now they've doubled their stroke risk we're good on asthma pneumonia classic pneumonia is what they're going to ask about you on the test more than likely classic pneumonia occurs in young healthy people that are able to get up and move around so if i get pneumonia and i'm able to move around and walk that pneumonia is probably going to be in only what one low so i have a greener yellow productive cough with a fever and one lobe will be congested with bronchi that's classic pneumonia classic pneumonia i give them food to help thin the booger snot and flim along and then i give them the butyrol to open it up and then definitively they need antibiotics to take care of the infection the manufacturer says it is not a good idea to give attribute to pneumonia patients because if you dry that secretion up and you make it rock hard it creates a mucus plug and they can't get that booger snot and flim out it's the same reason why lasix is contraindicated in pneumonia patients because it drives that crust out and it creates a rock heart film and now they can't move air in and out of their lungs if you give lasix to pneumonia patient you increase your chances of mortality by about 40 percent now it's easy in a young person because they got a fever they got one side congested they got a yellow or green productive cough give him some fluid give him some of buterol take him to the hospital real world where do we see our pneumonia patients at nursing homes and because their bed can find can't get up and move around they're laying flat and bad that booger snot and flam ends up in both lows so now i walk in out here and you're going okay is that booger snot flim or is that rel's and chf most ers will not administer lasiks now without a portable chest that's right because they have to make sure they're not accidentally giving lasiks to pneumonia patients so how can i tell in the field with the nursing owned patient that has a history of chf the chf and constantly having food in their lungs becomes stagnant and bacteria grows and develops bilateral pneumonia so how do i tell the difference is it bilateral pneumonia or is this chf exasperation without a chest x-ray in the nursing home if it's new onset pneumonia they should have a fever so if the skin is pink warm and dry the infection will also cause vasodilation and drop their blood pressure a little bit versus yesterday in chf they were cool pale clammy and hypertensive because of the epi release and angiotensin release so if i walk in and i have crappy breast sounds and i have lower than normal blood pressure a 70 year old does not typically have a blood pressure 102 they're probably getting into 140 to 160 range so i walk in and i got a 70 year old pink warm dry skin fever lower than normal blood pressure fluids in a meteorol i walk in i got a 70 year old and they got crappy breast sounds cool pale clammy tachycardia high blood pressure maybe nitro opposite treatments form skin temp will help you tell the difference between chf and pneumonia all right classic pneumonia what's going to be on the test one lobe yellow or green productive cough aspiration in pneumonia occurs after they get a foreign substance in their lungs and their immune system triggers to go fight the infection somebody aspirates on beer they aspirate on food after choking and near drowning they'll develop pneumonia all right and that will be bilateral foreign body aspiration moving over to the top of the next page top page six foreign body aspiration is a distraction for her or actually it's a uh basically a post-choking all right if somebody has partial airway obstruction we can assist them with the heimlich or back blows if they have a complete airway obstruction and become unconscious we start chest compressions after 30 compressions if we're by ourself we look in see if we can see the object and pull it out all right that's basically that's your aha expect four to eight choking bls aed cpr type questions you're gonna see a couple of them on there all right it's just what you're going to say they're going to ask you complete airway obstruction and choking immediately start compressions partial airway obstruction ask them if they're choking and then do abdominal thrust or heimlich maneuver if they become unconscious dark chest compressions uh what happens in 4-body aspiration is they cleared the object but it scratched their throat so now they have localized swelling and inflammation in the oral pharynx so that person needs humidified what oxygen how do you make humidified oxygen put three cc's of saline in the nebulizer and run it in you can run it through a mass whatever that helps uh give the immune humidified oxygen if i have a complete airway obstruction so let's say that you had a person choking you try to do the heimlich they become unresponsive you start chest compressions you open the airway and you see a piece of steak in there and you cannot get that steak out what should you try before going to a surgical or needle crop yeah i tried forceps and i can't get it out and i can't get air in huh yeah main stimulus shove it on into the right main step if i at least get it out of the trachea and push it all into the right main stem i've never done it but that's what the textbook says that at least opens up the left side for ventilation all right so go ahead and push it on through because something is better than nothing all right so that's a foreign body aspiration uh why talking about right lean stem real quick when we talked about right main stem here's what we're looking at besides breast sounds which would be if i have a right main stem because the right main stems at roughly 30 to 40 degrees versus the left main stem about 60 degrees that tube can make that corner very easy so besides having clear breath sounds on the right and absent on the left how do i know if i have a right mainstream innovation okay maybe one size to the chest rising and falling what else what if i told you this 25 year old female innovated with the 7.0 etp you notice that she has 24 centimeters at the t what is the most likely cause right main stem now how do i know the depth it should be at 15. it is e t tube size times three that would give you the approximate centimeters at the t so 8.0 should be 24. now if it is more than one or two centimeters off i've probably gone too deep and got in the right mainstem if i said 25 year old female 7.0 and she is 16 centimeters at the teeth it's probably in the way esophagus if it's this shallow it's probably an esophagus if it's really deep it's probably the right mainstay all right they won a 7.0 for females 8.0 for males if a person is obese we increase by what initially half so if i said a obese 25 year old female i would want that et2 to be what size seven and a half so then it'll be seven and a half times three which would be what 22.5 you gotta calculate so you add a half and then double it no you add a half so you would go from seven to seven and a half and then you would multiply seven point five times three to get your depth and a v small would be approximately eight and a half all right or for quick references you could pick something roughly the size of their index finger because that's the glottic opening that we're going through right hyperventilation we covered respiratory failure is decompensated shock which basically means everything is gone what down so if i'm telling you i can't breathe and i'm tachycardic i'm in respiratory what distress i'm compensated if i become altered bradycardic respirations are going down i am in respiratory and i immediately ventilate respiratory failure to prevent respiratory arrests peritonsillar abscess is a distractor for epiglottitis if i said fever sore throat drooling lean and poured in a three-year-old it's probably epiglottitis if i said fever sore throat drooling foul-smelling breath and a 28-year-old it's a pair peritoneur abscess they have an abscess pocket on the back of their throat on their tonsils makes it hard to swallow because of the infection their breath will stink all we can do for them is general supportive care they have to go in they'll incise it drain it and they will end up a lot of times giving them iv antibiotics depending on the severity of that peritons their abscess it's just a distraction for epileptics a couple other things on airway and we'll take a quick break besides the et2 formula know the difference between a wisconsin and a miller blade or is there they're the same the wisconsin and miller blade are the straight leg the macintosh is the curved know which one directly lifts the epiglottis versus which one indirectly lifts the other box miller in wisconsin it's a straight it goes to the epiglottis the mac is curved it goes in the vallecula and indirectly lifts the epiglobus uh also no the stylet should never go past what murphy's eye what is murphy's eye on the et tube it's a side on it to where if the end of the e.t tube is obstructed you can still get air out the side reason why we don't want the skylight to go past that because he can poke through murphy's eye just like he can the end of the et tube and puncture through the back of the wall of the esophagus which will now let stomach contents into the lungs uh how many ccs of air should be in the pilot balloon of the et2 uh they may ask you about a king tube which is roughly 60 to 80 cc's depending on the type you're using those of you all that have taken it uh every once a while they'll also ask you the percentage of a cannula which is 24 to 44 percent niner breathers are dependent on what textbook you read 90 to 100 at 12 to 15 liters per minute and once while they'll ask that i got that in the end of the package one more time 24 to 44 percent is nasal cannula and the other one non rebreather is 90 to 100 depending on what textbook you read most commonly on the registry they'll use 95 to 100 because that catches every textbook that's out there some textbooks say 85 some say 90 some say 95. so what was that oxygen what percent so cannula will give you 24 to 44 oxygen uh what specific device would you be used for copd patients to where you can dial the exact concentration of oxygen in somebody that's breathing a venturi mask a venturi mask what it is is it has color-coded either connections or it has a dilaflow on it and you can adjust that to specific oxygen so you say you wanted to keep that copd patient because you're going to be with them for three hours on a long distance transfer you can specifically adjust that to a specific percentage to help keep them in that 88 to 94 percent range plus it doesn't drop their nose like you can with us all right any questions over the airway anything else you guys have seen all right uh let's take 10 minutes i want to try and get through medical and that will pretty much finish out this packet to where after launch we just have obpd and ox all right yes would you say don't let the styling go into the murky side yeah don't let it go past murphy's eyes