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 • • • • • • • Mouth Nose Pharynx Oropharynx Nasopharynx Epiglottis Trachea Lower Respiratory Anatomy • • • • • 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???