Airway Breathing

Circulation Management

3/28/17 1
 Airway-Assessment
Inspect the patient's airway while maintaining
cervical spine stabilization and/or
immobilization.
Partial or total airway obstruction may threaten
the potency of the upper airway.
Observe for the following:
Vocalization
Tongue obstructing airway in an unresponsive patient
Loose teeth or foreign objects
Bleeding
Vomitus or other secretions
Edema

3/28/17 2
 Airway-Intervention
Airway Patent

Maintain cervical spine stabilization and/or

immobilization
Any patient whose mechanism of injury,
symptoms, or physical findings suggests a
spinal injury should be stabilized or remain
immobilized.
If the patient is awake and breathing, he or
she may have assumed a position that
maximizes the ability to breathe.
Before proceeding with cervical spine
stabilization, be sure interventions do NOT
compromise the patient's breathing status.
3/28/17 3
 Airway Totally Obstructed or
Partially Obstructed - Position
Position the patient in a supine position. If
the patient is not already supine, logroll
the patient onto his or her back while
maintaining cervical spine stabilization.
Remove any head gear, if necessary, to
allow access to the airway and cervical
spine; removal of such gear should
be/done carefully and gently to prevent
any manipulation of the spine.

3/28/17 4
 Airway Totally Obstructed or Partially
Obstructed Cervical Spine Stabilization

If the patient has not been stabilized,

manually stabilize the head. Stabilization
includes holding the head in a neutral
position.
If the patient is already in a rigid cervical
collar and strapped to a backboard, do NOT
remove any devices. Check that the devices
are placed appropriately.
Complete spinal immobilization with a
backboard and straps should be done at the
completion of the secondary assessment,
depending on the degree of resuscitation 5
3/28/17
required and the availability of team
Airway Totally Obstructed or Partially
Obstructed Open and clear airway

Techniques to open or clear an obstructed

airway during the primary assessment include:
Jaw thrust
Chin lift
Removal of loose objects or foreign debris . .
Suctioning
Maintain the cervical spine in a neutral position.
Do not hyperextend. Flex. or rotate the neck
during these maneuvers.
Suctioning and other manipulation of the
oropharynx must be done gently to prevent
stimulation of the gag reflex and subsequent
vomiting and/or aspiration.
3/28/17 6
 Airway Totally Obstructed or Partially Obstructed -
Open and clear the airway

Insert an oropharyngeal or nasopharyngeal

airway
Consider endotracheal intubation (oral or
nasal route)
Ventilate the patient with a bag-valve-mask
device prior to endotracheal intubation.
Oral endotracheal intubation is done with
the patients cervical spine in a neutral
position and without any extension or
flexion of the cervical spine. This requires a
second person to hold the patient's head in
this position.
3/28/17 7
 Airway Totally Obstructed or Partially
Obstructed - Open and clear the airway

Blind nasotracheal intubation is NOT

indicated when the patient is apneic or
when there are signs of major mid-face
fractures (e.g., maxillary fractures. Basilar
skull fractures or fractures of the frontal
sinus or cribriform plate are considered
relative contraindications.
The use of neuromuscular blocking agents
alone or in combination with other drugs
administered before intubation is usually
dictated by institutional protocols.
3/28/17 8
 Airway Totally Obstructed or Partially
Obstructed - Open and clear the airway
In rare circumstances, the patient's
condition may restrict passage of an end
tracheal tube.
To establish an airway, a needle
cricothyroidotomy may be performed with
an over-the-needle catheter placed into
the trachea through the cricothyroid
membrane.
Another method is surgical
cricothyroidotomy in incision is made in
the cricothyroid membrane, and a tube
is placed into the tracheae
3/28/17 9
 Breathing-Assessment
Life-threatening compromises in
breathing may occur with a history
of any of the following:
Blunt or penetrating injuries of the
thorax
Patient striking the steering column
or wheel
Acceleration, deceleration, or a
combination of both types of forces
(e.g., motor vehicle crashes, falls.
3/28/17 10
 Breathing Assessment
Spontaneous breathing
Chest rise and fall (depth and symmetry)
Skin color
General respiratory rate Normal Slow Fast
Pattern of breathing Regular Irregular Cheyne
Stokes
Integrity of the soft tissue and bony structures of the
chest wall
Use of accessory and/or abdominal muscles
Bilateral breath sounds: Auscultate the lungs
bilaterally at the second intercostal space
midclavicular line and at the fifth intercostals space at
the anterior axillary line.
Jugular veins and position of trachea
3/28/17 11
 Breathing-Interventions
Breathing Present: Effective

Administer oxygen via a

nonrebreather mask at a flow
rate sufficient to keep the
reservoir bag inflated: during
inspiration, usually requires a
flow rate of at least 12
liters/minute and may require 15
liters/minute
3/28/17 12
 Breathing-Interventions
Breathing Present: Ineffective
When spontaneous breathing is present
but ineffective, the following may
indicate a life-threatening condition
related to breathing:
Altered mental status (i.e. restless, agitated)
Cyanosis, especially around the mouth
Asymmetrical expansion of the chest wall
Use of accessory and/or abdominal muscles
Sucking chest wounds
Paradoxical movement of chest wall during
inspiration and expiration
Tracheal shift from the midline position.

3/28/17 13
 Breathing-Interventions
Breathing Absent
Ventilate the. Patient via a bag-valve-
mask device with an attached
oxygen reservoir system 100%
Assist with endotracheal intubation:
ventilate with oxygen via a bag-valve
device attached to an oxygen
reservoir system

3/28/17 14
 Circulation - Assessment
Palpate a central pulse (e.g., femoral or carotid)
initially to ensure adequate circulation.
Palpate the pulse for quality (i.e., normal, weak, or
strong); and rate (i.e., normal, slow, or fast).
Inspect and palpate the skin for color, temperature,
and degree of diaphoresis
Inspect for any obvious signs of external bleeding
If there are other members of the trauma team
available, auscultate the blood pressure. If not.
proceed with the primary assessment and auscultate
the blood pressure at the beginning of the secondary
assessment.
3/28/17 15
 Circulation-Interventions
Circulation: Effective
If the circulation is effective, proceed
with assessment and intervene
according to interventions for
ineffective circulation, as indicated.

3/28/17 16
 Circulation-Interventions
Circulation Present: Ineffective
Although the pulse is present, other signs
may indicate inadequacy of the circulation
such as:
Tachycardia
Altered level of consciousness or mental status
(e.g., agitated, confused)
Uncontrolled external bleeding
Distended or abnormally flattened external
jugular veins
Pale, cool, diaphoretic skin
Distant heart sounds

3/28/17 17
 Hemorrhage Control
Capillary bleeding
Venous bleeding
Arterial bleeding

3/28/17 18
 Circulation-Interventions
Circulation: Effective or Ineffective
Control any uncontrolled external bleeding
by:
Applying direct pressure over the bleeding site
Elevating the bleeding extremity
Applying pressure over arterial pressure points
The use of a tourniquet is rarely indicated:
however, if the above interventions do not
control the bleeding and operative bleeding
control is not readily available, a tourniquet may
be the last resort.

3/28/17 19
Cont. Circulation-Interventions
Circulation: Effective or Ineffective
Cannulate two veins with large-bore 14- or 16-
gauge catheters, and initiate infusions of lactated
Ringer's solution or N/S
Use warmed solutions
Use plastic bags to facilitate pressurized infusion
Use "V" tubing for possible administration of
blood
Use rapid infusion device, as indicated
Use normal saline (0.9%) in intravenous tubing
through which blood is administered
Venous cannulation may require a surgical
cutdown and/or central vein puncture
Obtain a blood sample to determine the ABO and
3/28/17 20
 Circulation-Interventions
Circulation: Absent
If a patient does not have a pulse, CPR
is indicated.
However, it is possible to have
Electrocardiographic activity even
when the pulse and blood pressure
cannot be auscultated:
Initiate cardiopulmonary resuscitation
(CPR)
Initiate advanced life support measures
Administer blood, as prescribed
3/28/17 21