Normal RateAdult: 12 to 20/minute 張

靜初Child: 15 to 30/minute Infant: 25 to 50/minute

Regular Rhythm Adequate Quality

Movement of air at mouth, noseChest expansion adequate, symmetrical (equal)Breath sounds present, equalMinimum effort of breathingAdequate tidal volume (depth)

Skin changesPale, cool, clammy: Early signCyanosis: Late, unreliable sign

Retractions of soft tissues above clavicles, between ribs, below rib cage

Flaring of nostrils “Seesaw” breathing in infants

Decreased level of consciousness GCS <9 Cerebral injury Surgery Medical problems

Tongue Dentures Food stuffs Vomit Blood Secretions

Suction Postural airway manoeuvres Basic life support chocking protocol

Up to 5 back slapsUp to 5 abdominal thrustsOnly if unconscious up to 5 chest thrustsIf unsuccessful to clear airway then

Basic Life Support

壓額抬下巴 Remove any visible obstruction from

the victims mouth, including dislodged dentures. Leave well fitting dentures in place

Techniques Insert catheter into oral cavity without

suction Insert only to base of tongue or end of

tracheostomy tubeApply suction, move catheter from side to

sideSuction no longer than 15 seconds in adults,

10 seconds in children, 5 seconds in infantsRinse catheter with saline or water to

prevent obstructionInstalled suction unit provides a vacuum of >300mmHg.

Never suction further than you can see.

Always suction on the way out. Never suction for longer than 15

seconds. Always oxygenate the patient before

and after suctioning.

1. Mouth-to-mask with supplemental oxygen

2. Two-person bag-valve mask with oxygen reservoir and supplemental oxygen

3. Flow restricted, oxygen-powered ventilation device (manually-triggered ventilator)

4. One-person bag-valve mask with oxygen reservoir and supplemental oxygen

Mouth-to-MouthOpen airwayPinch nose closed or seal nose with

cheekTake deep breathSeal lips around patient’s mouth to create airtight sealBlow into patient’s mouth rapidly for 1-2 seconds until patient’s chest rises

Mouth-to-MaskConnect mask to oxygen at 15 liters per

minuteKneel directly above patient’s headApply mask to patient’s facePlace thumbs along sides of mask, index

fingers of both hands under patient’s mandible

Blow into one-way valve for 2 seconds until patient’s chest rises

Bag-valve maskSelf-inflating bagOne-way valveFace maskOxygen reservoir

Must be connected to oxygen to perform most effectively

BVM IssuesProvides less volume than mouth-to-

maskSingle rescuer may have difficulty

maintaining air-tight sealTwo rescuers using device are more

effectiveOral or nasal airway should be inserted

BVM Technique (Two Rescuer)Have assistant squeeze bag with two

hands until chest risesVentilate every 5 seconds for adults,

every 3 seconds for infants and children

BVM Technique (One Rescuer)› Form a “C” around ventilation port with

thumb, index finger› Use middle, ring, little fingers under jaw

to maintain chin lift, complete seal› Squeeze bag with other hand until chest rises› Ventilate every 5 seconds for adults, every 3 seconds for infants and children

1.NPA useful in trismus, biting, clenched jaws or maxillofacial injuries.

2.Used with caution in suspected fracture of skull base. 3.NPA is better tolerated than OPA in not deeply

unconscious patients. 4.Insertion damages nasal mucosa, resulting in bleeding.5.It is too long to stimulate laryngeal or glossopharyngeal reflexes, laryngospasm, retching, or vomiting.

Used on responsive patients who need help keeping tongue out of airway

Insertion is uncomfortable for responsive patients

Unresponsive patients who are snoring Unresponsive patients with gag reflex

TechniqueMeasure from tip of nose to earlobeEnsure airway will fit through nostrilLubricate with water-soluble lubricantInsert with bevel toward base of nostril

or septumIf resistance is met, try other nostrilDo not use in patients with mid-face

trauma or possible basilar skull fractures

Measure from corner of mouth to earlobe or angle of jaw

Used on unresponsive, apneic patients without gag reflex

Helps hold tongue away from back of throat

Any patient in deep coma who cannot protect his airway.(Gag reflex absent.).

Any patient in imminent danger of upper airway obstruction (e.g. Burns of the upper airways).

Any patient with decreased L.O.C, GCS <= 8.

Severe head and facial injuries with compromised airway.

Any patient in respiratory arrest Respiratory failure 1. Hypoventilation/Hypercarbia - Paco2

> 55mmhg 2. Arterial hypoxemia refractory to O2 -

Paco2 < 70 on 100% O2

Pre-intubation1. Preoxygenation; Achieved by providing 3

minutes of high-flow oxygen till SaO2 >95% 2. If spontaneous ventilation is insufficient,

assist ventilation with a bag-mask device.

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1. Provide ventilation2. Keep airway patent3. Permits suction of airway secretions

4. Ensures delivery of a high concentration of O2

5. Provides a route for administration drugs (NAVEL)

6. Facilitates delivery of a selected tidal volume7. Protects airway from aspiration

Trauma of the teeth, cords, arytenoid cartilages, larynx and related structures.

Ventilation withheld for unacceptably long period

Delayed or withheld chest compressions Esophageal or bronchial intubation Failure to secure the tube Failure to recognize misplacement of

the tube

Hypertension and tachycardia can occur from the intense stimulation of intubation

Transient cardiac arrhythmias related to vagal stimulation or sympathetic nerve traffic may occur

1.Inexperienced providers use airway devices for which they are adequately trained.

2.Tracheal intubation require either frequent experience or frequent retraining.

1. Cricoid pressure: protect regurgitation and ensure placement in tracheal orifice.

2. Pressure with thumb and index fingers.

3. Avoid overzealous pressure to occlude airway and impair tracheal intubation.

4. Maintain cricoid pressure until cuff tube is inflated.

5. The BURP (Backward, Upward, Rightward Pressure) technique.

1. Assist with tracheal tube insertion by providing stiffness to tube and by allowing direction of tube to be controlled better during manipulation.

2. Stylet not extend beyond the distal end of tube.

1. Difficulties in intubation occur because inability to bring vocal cords into view through the laryngoscope.

2. Visualization is by flexing neck and extending head at atlanto-occipital joint ("sniffing position").

3. Once vocal cords are seen, tube is placed and cuff is just beyond the cords.

4. Tube lying at a depth marked 19-23 cm at front teeth.5. Cuff inflated with just enough air to occlude airway

(usually 10 mL) 25-35cmH2O6. An adequate seal confirmed by listening at larynx. Air

is added to cuff just until audible air leak around tube disappears.

D-displacement O-obstruction P-pneumothorax E- equipment

1.Confirm placement by auscultating at epigastrium, midaxillary and anterior chest line on the right and left sides of the chest.

2.Secondary confirm placement with ET CO2 or esophageal detector (Class IIa).

3.Clinical signs of proper tube placement (such as condensation in the tube, auscultateion at lungs and abdomen, and chest rise) are not always reliable indicators.

1. It depends on ability to aspirate air from lower airways through a tube in cartilage-supported rigid trachea.

2. Air is not aspirated because esophagus collapses when aspiration is attempted.

3. Misleading results in obesity, pregnancy or status asthmaticus or copious tracheal secretions.

Presence of exhaled CO2 indicates proper tracheal tube placement.

A lack of CO2 on detector means that the tube is in the esophagus.

Always have a suction unit available. An intubation attempt should never

exceed 30 seconds. Oxygenate the patient pre and post

intubation with a bag-valve-mask.(100% O2).

Have sedative medication available if needed. (e.g. Midazolam 15mg/3ml)

Always recheck tube placement manually guided by oxygen saturation readings.(Spo2).

輕微呼吸症狀的病人 (SaO2 95-100%)最高提供氧氣濃度到 44%流速每調高 1L/min, 病患吸入 O2 分壓可增加

4%. 氣流量不超過 5L/min

AMI – 4L/min COPD – 2L/min 張口呼吸將氣流經口不而不 經鼻子

用在 SaO2 90-95% 提供氧氣濃度 35-60% 流速是 6-10L/min 氣流量不超過 6L/min

不建議流速 < 6L/min CO2 retension

昏迷

用於需提供高濃度氧氣的狀況 (CO intoxication or low SaO2)氣流為單向 , 最高提供氧氣濃度到 95-100%流速 6L/min 氧氣濃度到 60%每分鐘增加 1L 的流速 濃度增加 10%流速 10-15L/min 氧氣濃度 95-

100%

提供固定氧氣濃度COPD 給予太高氧氣濃度 降低呼吸趨動

力 流速 4-8L/min 氧氣濃度到 24-

40%流速 10-12L/min 氧氣濃度 40-

50%

Latex-free, silicone rubber tube connected to an elliptical mask with an inflatable outer rim

Re-useable up to 40 times (Autoclave)

Open the mouth and press the tip of the cuff upward against the palate and flatten the cuff against it

Use index finger to guide LMA, pressing backwards along the palate towards ears until resistance is felt

The tip now rests in the hypopharynx

Use other hand to press down on LMA tube while removing index finger

Inflate with 2-4 ml air to seal (60 cm H20 maximum)

Don’t hold the tube while inflating the balloon, it moves outward a little as it seats properly

April 2004 Richard Lake 52

Can you save a life if you have to?