CCP Fall 2013 - Week 2
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. What would you like to do?
What critical blood gas results indicate acute respiratory distress?
- pH < 7.2
- PaCO2 > 55 mmHg
- PaO2 < 60 mm Hg
What are the recommended therapies for COPD - Asthma - Chronic Bronchitis?
- β2 selective sympathomimetics
- ketamine (Ketalar®)
- Steroids ** Late phase Rx/Hyper-Responsiveness prophylaxis
What are the risk factors for PE?
- Oral contraceptives
- Greenfield filter
What is the hallmark presentation for PE?
- Acute respiratory distress
- SPO2 that doesn't respond to high flow O2
Describe the physiology of pneumonia
Localized infection results in the accumulation of consolidated proteins in inflammatory factors
Under what principle does a Volume Targeted ventilator function?
Ventilator delivers a pre-set volume when triggered, regardless of airway pressures. AKA “volume limited”
Under what principle does a Pressure Targeted ventilator function?
Ventilator delivers gas when triggered until a preset pressure is reached. AKA “pressure limited"
What are the two ventilator targeting/limiting modes?
Pressure & Volume
How does Controlled Mandatory Ventilation work?
Ventilator delivers a preset Vt or PIP @ a preset rate. Pt cannot initiate breaths. May lead to pt apprehension & air hunger in awake pt.
How does Assist Control ventilation work?
- Ventilator delivers a preset Vt or PIP w/every breath. Pt is able to trigger breaths, but a backup rate is set in the event the patient breathes below the set rate.
- May be poorly tolerated in awake pts d/t the asynchrony of pt & machine cycle length
- May be associated w/respiratory alkalosis
- May worsen air trapping in COPD pts
How does Intermittent Mandatory Ventilation (IMV) work?
IMV Combines a preset # of breaths w/a preset Vt or PIP w/the capability of intermittent pt generated breaths.
How does Synchronized IMV work?
- Ventilator senses the start of a pt breath. The mandatory breath is delivered in synchrony w/the pt’s effort
- Allows for various modes of support from complete support to spontaneous breathing
- Risks: Hyperventilation, Respiratory alkalosis & air trapping COPD pts
Which ventilation mode is generally considered the safest?
Synchronized IMV (SIMV)
What is the formula for determining Minute Volume?
Minute Volume (Ve) = Vt x f
What is the normal range for Ve in an adult?
4 - 8 L/min
What is the normal tidal volume (Vt) for an adult?
6 - 10 mL/kg
What is the normal rate (f) for an adult?
8 - 20/min
What is the normal I:E ratio for an adult?
1:2 or 1:3
What is the normal FiO2 for an adult?
0.21 - 1.0
What is the normal PPLAT for an adult?
What is the mnemonic for troubleshooting High Pressure alarms?
- S – suction
- C – connections
- O – obstructions
- P – pneumothorax
- E – ETT dislodgement or displacement
How quickly will a tension develop in the vented patient who develops a pneumothorax with the vent in High Pressure Alarm?
1 to 2 ventilations
Once identified, what is the 1st maneuver to treat the vented pt that develops a pneumothorax?
D/C from vent
What do PIP & PPLAT alarms prompt you to investigate?
- PIP Alarms: Think Airway problem
- PPLAT Alarms: Think Lung problem
What do you ☑ when you have a ↓ Pressure Alarm?
- O2 delivery/supply system
- All connections to pt
- Leaks in vent circuit
- All settings
- Evaluate for ETT dislodgement/extubation
- ↓ ETCO2 or loss of waveform
- ↓ SPO2
- Hypovolemia (Δ space available for lung expansion: ↑ Space ⇝ ↑ Volume ⇝ ↓ Pressure in Container [Lungs]) [Requires significant ↓ in circulating volume]
What should you ☑ when you have a low sat alarm?
- Consider SaO2 vs. SpO2 issues (probe placement)
- Appropriate Vt set?
- Appropriate f (rate)?
- Appropriate inspiratory time?
- ETT placement
- Consider PEEP
What effect does Methemaglobinemia (MetHgb) have on SPO2 readings?
- “SPO2 reads low when it’s high & high when it’s low”
- With MetHgb > 40% will direct the SPO2 to 85%
The acutely deteriorating respiratory pt will commonly exhibit:
PaCO2 > 55 mmHg
Normal minute volume should be
What does a PaCO2 of > 55 mmHg indicate?
Ventilatory failure w/retention of CO2
What 3 criteria should we use to guide our decision to intubate?
- Current Airway Patency
- Oxygenation or ventilation failure
- Expected clinical outcome
What mnemonic is used to identify a Difficult Airway & what does it stand for?
- L – Look
- E – Evaluate 3-3-2-1
- M – Mallampatti
- O – Obstructions
- N – Neck mobility
Describe the Mallampati Classification Scores
- Class I: Full visibility of the Pharyngeal arches, Tonsillar pillars, Soft palate & Uvula
- Class II: Visibility of the Soft palate & Part of the pendent uvula
- Class III: Visibility of the Soft palate & only the base of the uvula
- Class IV: Visibility of only the hard palate
Describe the 3-3-2-1 airway evaluation
- 3 fingers upright into pts mouth
- 3 fingers fit below chin btn mandible and laryngeal cartilage
- 2 fingers btn larynx & hyoid bone
- 1 finger btn upper & lower jaws after displacing mandible forward
Describe the Difficult Airway Algorithm
What is the ideal agent for awake technique?
- ~ 96% of pts retain their respiratory drive when properly dosed
- Short acting
- Risks: Myoclonus – Usually self relieving
What makes an RSI candidate?
- Requires sedation
- Expect to be able to intubate
- Expect to be able to ventilate
What is the purpose of RSI?
To prevent aspiration
What are the 7 P's of the RSI process?
- Preparation - Lemon Soda
- Pre-oxygenation - 5 min vs accelerated, BVM vs mask
- Premedication - Load & wait 3 min
- Paralysis w/Induction - Induction followed immediately by NMBA
- Protection & positioning - Sellick’s & proper alignment
- Placement & proofing of ETT - Tube sizes, 1°
- & 2° verification
- Post-intubation management - Tube restraints, Sedation &/or paralysis
Sum up the Airway Algorithms in 2 questions
- 1: Is the pt unconscious/unresponsive/near death?
- 2: Is this a Difficult Airway
What is the dose & the indications for use of Lidocaine in airway procedures?
- 1-1½ mg/kg
- Tight heads & Tight lungs
What is the dose & indication for use of Fentanyl in airway procedures?
- 1-3 υ/kg
- Attenuation of stress/autonomic response to noxious stimuli
What is the dose & indications for the use of Atropine in airway procedures?
- 0.5-1.0 mg
- Dry up saliva caused by Ketamine
- Treat bradycardia caused by SUX - esp Peds
What is the induction dose for etomidate?
What are the non-barbituate induction agents?
What is the induction dose for ketamine?
What is the induction dose for midazolam and what is the primary risk with it's use?
- 0.05-0.15 mg/kg
- Profound hypotension
What is the induction dose for Fentanyl?
What is the paralytic dose for succinylcholine?
- Adult: 0.5-1.5 mg/kg
- Child: 2 mg/kg
- Infant: 3 mg/kg
What is the onset & duration of action for succinylcholine when used as a paralytic?
- Onset: 30-60 sec
- DOA: 3-4 min (80%), 9-13 min (95%)
What are the side effects of succinylcholine when used as a paralytic?
- CV: Bradyarrhythmias, VF/VT (problematic w/2nd bolus & K+ disorders)
- K+ shifts (0.5 mEq/L w/typical ETT dosing), much higher in Ach disorders
- NEURO: ↑ ICP, ↑ IOP & ↑ IGP (Attenuate well w/defasciculating premed)
What is the Dose for vecuronium [VEC] (Norcuron)?
What is the Onset for vecuronium [VEC] (Norcuron)?
What is the Duration Of Action for vecuronium [VEC] (Norcuron)?
What is the Dose for rocuronium [ROC] (Zemuron)?
What is the Onset for rocuronium [ROC] (Zemuron)?
What is the Duration of Action for rocuronium [ROC] (Zemuron)?
Describe the concept of a "Sterile Cockpit"
No conversations take place on the flight deck that are not related to the safe operation of the aircraft.
When should "Sterile Cockpit" guidelines be observed?
Per FAA during any "Critical Phase of Flight"
Describe "Critical Phase of Flight"
All flight phases except straight, level, cruise flight
When should a Post Accident Incident Policy be implemented?
A POST ACCIDENT INCIDENT POLICY (PAIP) should be implemented 15 minutes after an aircraft fails to give a position report or is overdue to arrive.
What is the minimum staffing requirements for accreditation at the ALS level:
- 2 personnel attending to the pt
- at least 1 is EMT-P
What is the minimum staffing requirements for accreditation at the Critical Care Level level:
- 2 personnel attending to the pt
- Dual medic vs Medic/RN
What is the minimum staffing requirements for accreditation at the Specialty Transport level:
- 2 personnel attending to the pt
- Specialty Care personnel must be accompanied by at least 1 regularly scheduled Air Medical personnel
- & all personnel must have basic safety orientation
What is the Minimum Crew training requirement?
- Didactic & clinical portions specific & appropriate for the mission statement & scope of care of the medical transport service
- Includes Stress Recognition & Managment
How many hours and what type should pilots have?
2000 hrs rotorcraft hrs w/1000 hrs as PIC & 100 hrs as PIC @ night
Pilot initial training should include
- Terrain & Weather
- Orientation to Hospital
- Infection Control
- Pt loading & unloading
- Medical systems on aircraft
- CRM: Crew Resource Management
- EMS/Public Service Agencies
- Instrument Meteorologic Conditions (IMC) Recovery procedures by reference to instruments or IFR currency
- 5 hrs area orientation w/2 hrs @ night as PIC prior to EMS missions
Discuss Uniforms & Protective Equipment recommendations
- Protective clothing & dress codes pertinent to mission profile
- Boots or sturdy footwear
- Reflective material at night
- Flame retardant clothing
- How does your flight suit fit?
- ¼” between your flight suit & you
- All cotton natural fibers beneath flight suit
- Nomex is not required, retardant quality is
- Environment appropriate
- Hearing protection
What safety issues does CAMTS address in their recommendations?
- Refueling Policies
- Oxygen Delivery
- Latex Allergies
- Weather minimums
- Cellular phones
- Night Vision Goggles
- Safety committee
- Minimum medical equipment
What are the CAMTS recommended VFR weather minimums?
- Day 500' Ceiling x 1 mile visibility
- Night: 800' Ceiling x 2 miles visibility
- Cross Country
- Day 1000' Ceiling x 1 mile visibility
- Night 1000' Ceiling x 3 miles visibility
What is the # 1 cause of aeromedical crashes?
Pushing weather (esp @ night)
What does VMC stand for?
Visual Meteorological Conditions: You can visually identify where the sky and the ground meet
What does IMC stand for?
Instrument Meteorological Conditions: You cannot visually identify where the sky and the ground meet
What does VFR stand for?
Visual Flight Rules: Rules for flight during VMC
What does IFR stand for?
Instrument Flight Rules: Rules for flight during IMC
What are the in-flight emergency procedures?
- Lay Patient Flat
- Assure Patient Straps Secure
- Turn Off O2
- Secure Equipment
- Confirm your belts are secure
- Helmet visor down
- Assume crash positions
What are the Crash/Post Crash Procedures?
- Emergency Transmit Freq 121.5
- ELT activation occurs around 4 g
- If the pilot is incapacitated on termination of movement:
- Disengage the throttle
- Disengage the fuel
- Disengage the battery
- Don’t exit the aircraft until movement stops
- Exit and meet crew members @ 12o’clock
- Secure shelter, fire, then water & finally food
What is required for safe night scene landings?
Communications w/Ground personnel
What are recommended LZ sizes?
- Day: 75' x 75'
- Night: 100' x 100'
What would you like to do?
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