Airway/
Ventilation
&
Shock
Jami Windhorn, RN BSN CPN
TNCC ENPC
Objectives
• Identify Airway and Ventilation
Issues in Trauma Patient
• Describe Nursing Assessment and
Intervention of the Trauma Patient
• Identify Types of Shock
• Describe Signs and Symptoms of
Shock
• Discuss Nursing Assessment and
Interventions for Shock
Upper
Airway Anatomy
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Mouth
Nose
Pharynx
Oropharynx
Nasopharynx
Epiglottis
Trachea
Lower Respiratory Anatomy
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Cricoid Cartilage
Larynx
Bronchi
Lungs
Pleura/Pleural
Space
• Diaphragm
Ventilation
• Inhalation
* Diaphragm moves down, ribs move
up and out, air flows in
• Exhalation
* Diaphragm moves up, ribs move
down and in, air flows out
• Gas exchange occurs to oxygenate
the body
Airway Assessment
• Obstruction
* Tongue
* Loose Teeth
* Blood/Vomit
* Foreign Body
* Edema
Patient History
• Type of Trauma?
• Burn?
• Pre-Existing Respiratory Disease?
• Drugs? Smoking?
• Loss of Consciousness?
Nursing Assessment:
Airway
• Open airway – Head Tilt Chin Lift
• Maintain C-Spine
• Suction any blood, vomit or objects
from airway
• Can the patient talk?
• Trauma to airway?
Opening the Airway
Airway Management
• Oral Airway
• Nasopharyngeal
Airway
Laryngeal Mask Airway
Combitube
King Airway
Intubation
• If unable to maintain an open airway
and patient is requiring Bag/Mask
Ventilation, endotracheal intubation
may be necessary
RSI:
Rapid Sequence Intubation
• The process of quickly inducing
anesthesia (Sedation and Paralytics)
in a patient in order to intubate
• Sedation is used to reduce anxiety
• Paralytics are used in a patient who
is awake, has a gag reflex and is
agitated or combative
RSI Steps
• Preparation: Gather all supplies
• Preoxygenation
• Pretreatment: Atropine or Fluid Bolus
• Paralysis
• Protect and Position: Cricoid Pressure
• Proof of Placement
• Post-Intubation Management
Tube Placement
Confirmation
• Auscultate breath
sounds
• Equal chest rise
and fall
• Exhaled Carbon
Dioxide detector
“Gold is Good”
• Chest X-Ray
Contraindications
to RSI
• Hypotension
• Total upper airway obstruction
• Total loss of oropharyngeal
landmarks
• Paralytic can mask seizure activity
Inadequate Ventilation
• Due to:
* Pain
* Loss of Consciousness
* Spinal Cord Injury
* Trauma to Chest causing flail
chest, broken ribs, pneumothorax
• All trauma patients
should have on
100% Oxygen via
a Non-Rebreather
mask to allow for
adequate
oxygenation
Nursing Assessment:
Ventilation
• Trauma to the chest
• Dyspnea
• Level of Consciousness
• Symmetrical chest rise and fall
• Listen for Breath sounds
• Tracheal Deviation?
• Palpate chest for deformities
Nursing Assessment
Continued
• Use of accessory muscles
• Agonal respirations
• Tachypnea
• Bradypnea
• Irregular breathing patterns
Tension
Pneumothorax
• Symptoms:
* Deviated Trachea
* Absent breath sounds on one side
* Restlessness
* Cyanosis
• Prepare for Needle Thoracentesis and
chest tube insertion
Ongoing Assessment
• Work of Breathing
• Pain
• Level of Consciousness
• Breath Sounds
• ABGs
• Chest X-Rays
• Respiratory Rate
• Effectiveness of Interventions
SHOCK
Types of
Shock
• Cardiogenic
• Hypovolemic
• Distributive
• Obstructive
• Shock is a medical condition arising
from poor tissue perfusion that is
insufficient to meet the oxygen and
nutrient demands of the body
causing metabolic activities to slow
or stop
Cardiogenic Shock
• Cardiac tissue is damaged and
unable to supple sufficient blood flow
• Common Causes:
* Acute MI
* Dilated Cardiomyopathies
* Blunt Cardiac Trauma
* Arrhythmias
Cardiogenic Shock
Symptoms
• Hypotension
• Cool, clammy skin
• Distended jugular veins
• Tachyarrhythmias
• Fatigue
Cardiogenic Shock
Treatments
• Oxygen
• Cardiac Meds – Dopamine,
Epinephrine, Norepinephrine
Hypovolemic Shock
• Condition caused by inadequate
blood volume which does not allow
the heart to pump enough blood to
the body
• Most common form of shock
Hypovolemic Shock
Symptoms
• Anxiety
• Hypotension
• Rapid, thready pulse
• Hypothermia
• Thirst and Dry mouth
• Cool, mottled skin
Hypovolemic Shock
Treatments
• Control the bleeding
• Fluid boluses
• Blood Transfusions
• Oxygen
Distributive Shock
• Maldistribution of blood volume and
flow results from loss of vasomotor
tone causing peripheral vasodilation
• Three types:
* Septic Shock
* Neurogenic Shock
* Anaphylactic Shock
Septic Shock
• Overwhelming Infection
• Seen in patients with Disseminated
Intravascular Coagulation (DIC) and
Multiple Organ Dysfunction
Syndrome (MODS)
Septic Shock Symptoms
and Treatments
• Symptoms:
* Fever
* Vasodilation
• Treatments:
* Fluid boluses
* Oxygen
* Antibiotics
Neurogenic Shock
• Caused by a Spinal Cord Injury or
any Injury to the central nervous
system
Neurogenic Shock
Symptoms & Treatments
• Symptoms:
* Hypotension
* Warm, dry skin
Treatments:
* Fluid Boluses
* Vasopressors – Norepinephrine
* Atropine
Anaphylactic Shock
• Severe whole body allergic reaction
• Insect bites/stings, horse serum,
food allergies and drug allergies
Anaphylactic Shock
Symptoms & Treatments
• Symptoms:
* Respiratory Distress
* Unconsciousness
* Hives
* Angioedema
Treatments:
* Remove the antigen
* Epinephrine
* IV Fluids
Pathophysiology of Shock
• 3 stages:
1. Compensated:
Compensatory mechanisms are
initiated to maintain normal tissue
perfusion and organ functions
Pathophysiology of Shock
2. Progressive:
Compensation begins to fail
leading to tissue damage
3. Irreversible:
Untreated shock leads to loss of
perfusion to the whole body –
Vasomotor, cardiac and hepatic
failure
Lungs
• Permeability increases
• High oxygen
consumption
• Respiratory acidosis
• Lactate levels increase
• Lungs become stiff
• Tachypnea
Kidneys
• Vasoconstriction causes acute renal
failure
• Proximal tubules and
ascending Loop
of Henle are
damaged
Heart
• Subendocardial
hemorrhages are
common
• Myocardial cells
are clumped
• Damage resembles
shock or drowning
injuries
• Peripheral
Vasoconstriction
Brain
• Altered mental
status
• Infarcts
• Laminar necrosis
GI Tract
• Infarction of GI Epithelium
• Fluid Imbalances
• Acidosis
• GI tract may appear
bloody and swollen
Liver
• Liver
necrosis/ischemia
• Elevated Bilirubin
• Pancreas may also
have ischemic
injury
• Glycogen broken
down into glucose
Nursing Assessment
• Obvious signs of bleeding
• Quality of Respirations
• Level of consciousness
• Auscultate heart, breath and bowel
sounds
• Skin color and temperature
• Pain
Nursing Care
• Administer oxygen, fluids and pain
medicine
• Blood Transfusion
• Control external bleeding
• Gastric tube? Foley?
• Watch for development of
coagulopathies
• Collaboration of the team
Questions???