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Now, we’re going to take a look at the respiratory arrest case, and you are the ACLS team leader, and you’ve come across a 25-year-old male patient that appears to be unresponsive. A witness states that the person was wheezing and having a very difficult time breathing before they collapsed. The scene is safe and all of your personal protective equipment is in place. Now, your first step is to make sure you’re practicing basic life support before we get into advanced life support. The first step is to verify if the patient is unresponsive. So you direct a team member to tap and shout. The patient does not respond, so you call the code team. Next, you direct a team member to check for a pulse and for breathing. The patient is not breathing but does have a pulse. The team member at the airway should place a basic airway adjunct and start rescue breathing with a bag valve mask at 15 liters per minute with oxygen. The leader will direct the airway person to give 1 breath every 6 seconds. Now it’s important to look for good chest rise and fall to make sure that the breaths are indeed effective. Next, the leader directs the defib monitor team member to get a set of vitals and attach the ECG monitor. The vitals are blood pressure 100 over 70. Pulse is 94 and weak. O2 sat is around 94%. The ECG shows normal sinus rhythm. And since the ECG is normal, oxygenation is good, and the BP is stable, we’ll need to continue giving breaths and consider what caused the respiratory arrest. In preparation for further treatment, an advanced airway should be placed and an IV should be established.
In this lesson, we're going to take a look at a respiratory case that you could be confronted with at some point in your career. And at the end of the lesson, we'll take a brief look at alternative airway devices.
For the purpose of this lesson, we're making you the team leader throughout this entire scenario, a move that will be repeated throughout this section of your ProACLS course. Here's what you know about the scene and situation:
Let's also assume that the scene is safe and all personal protective equipment is available or in use.
Pro Tip #1: While we've probably pointed this out before, it's important to remember that before engaging in any advanced life support actions, you must first practice basic life support (BLS) baselines effectively.
1. The first thing you need to do is verify that the patient is indeed unresponsive. To this end, you (the team leader) direct a team member to use the tap and shout sequence to determine responsiveness. You find the patient to be unresponsive and call in a code team.
2. You direct a team member to check the patient for a pulse and signs of normal breathing. Your team finds that the male patient has a pulse but is not breathing normally.
3. You then direct the team member in charge of airway management to place a basic airway adjunct and begin rescue breathing with a bag valve mask at 15 liters per minute with oxygen.
4. You direct the airway management team member to give 1 breath every 6 seconds.
Pro Tip #2: Make sure to look for visible signs of good chest rise and fall to ensure the rescue breaths are effective.
5. You then direct the team member in charge of the defibrillator and monitor to get a set of vitals and attach the ECG monitor to the patient. The vitals the team member gives you are as follows:
a. Blood pressure: 100/70b. Pulse rate: 94 and weakc. O2 saturation: 94 percentd. ECG: normal sinus rhythm
Since the ECG is showing a normal sinus rhythm, oxygenation is stable, and the patient's blood pressure is normal, you continue providing rescue breathing and consider possible underlying causes for the patient's respiratory arrest. In preparation for further treatment, you also decide to plan for an advanced airway and establish IV access.
If you find yourself in a clinical situation where endotracheal intubation is unsuccessful, and basic airway management techniques do not provide adequate ventilation, alternative airway devices that allow you to secure a patent airway should be considered immediately:
Proper verification of placement is accomplished by ventilating into the tube that produces clear and equal breath sounds and no epigastric sounds. This must also be objectively confirmed using waveform capnography.