Airway Management Case Study 1
- May 15, 2008
Airway Management Case Study 1
You respond to a patient with a chief complaint of difficulty breathing. He has a history of congestive heart failure. Upon your arrival, you find the patient, a 55-year-old man gasping for air and unable to speak. His respiratory rate is 36 and profoundly labored. He has cyanosis around his lips and has cool, clammy skin. There are no signs of trauma.
- How will you manage this patient initially?
- What additional management is needed for this patient, based upon your re-assessment findings?
- How do you determine which patients require assisted ventilation as opposed to supplemental oxygen?
- How should this patient be managed, should he begin to vomit?
After approximately 2 minutes of initial airway management, you re-assess the patient and find that he is now unconscious and apneic. You also note that he has widespread cyanosis to his entire facial and neck areas.
Case Study 1 Answers
Answer 1: This patient is clearly demonstrating signs of inadequate breathing (inability to speak, "gasping for air" and cyanosis) therefore; he needs immediate assisted ventilation with a bag-valve mask device and 100% oxygen. Due to the absence of trauma, the head-tilt, chin lift maneuver is the preferred technique of opening the airway.
Answer 2: Now that the patient is unconscious, an oropharyngeal airway must be placed to maintain patency of his airway. Additionally, you must monitor this patient for vomiting and be prepared to suction. The increasing cyanosis should prompt you to evaluate whether or not you are administering 100% oxygen to the patient. In doing this, you should ensure that a reservoir is attached to the BVM, that the BVM is attached to 100% oxygen, and that you are maintaining an adequate face-to-mask seal.
Answer 3: By fully assessing all parameters of a patient's respirations (rate, regularity, and quality), as well as level of consciousness, you will be able to determine the approach to airway management that will most effectively sustain the patient's life. Ask yourself: "Are the patient's respirations effective enough to maintain adequate oxygenation, ventilation, and overall perfusion?" Keep in mind that the most reliable indicator of a patient's overall perfusion status is level of consciousness. There are no "set in stone" standards that dictate which patients require assisted ventilation versus supplemental oxygen. The only exception to this rule is the apneic patient.
Answer 4: In the event that the patient vomits, he should immediately be placed on his side (laterally recumbent) and suctioned for no longer than 15 seconds. Suction is provided while removing the catheter. Be sure and remove the oral airway prior to suctioning.
Case Study 1 Synopsis
In this case study, you were managing a patient with inadequate breathing from the very beginning. In addition to not being able to speak because of such labored breathing, he was displaying the following signs of inadequate perfusion:
- Diaphoresis
- Diaphoresis (cool, clammy skin) is a sign that blood is being shunted from the periphery of the body (the skin) to more critical organs in the body such as the heart, lungs, kidneys, and brain. The sympathetic nervous system (fight or flight response) results in peripheral vasoconstriction that is responsible for this shunting of blood. Diaphoresis is an early indicator of inadequate perfusion, since the skin is one of the first organs from which blood is redistributed.
- Cyanosis
- Cyanosis is a bluish-gray color of the skin that indicates a lack of oxygen in the arterial blood. As a result of separation of hemoglobin and red blood cells (the components of the blood that carry oxygen), the arterial blood becomes deoxygenated. Recall that deoxygenated blood is darker red in color. Internally, deoxygenated blood is actually more blue than red. This explains the color of the patient's skin. It takes approximately 40-50% of hemoglobin-red blood cell separation before cyanosis manifests therefore; it is a late sign of inadequate perfusion.
Patients who are gasping for air and showing signs of inadequate perfusion should be managed with assisted ventilation immediately. The patient in this case study, due to congestive heart failure, had a back up of blood in the lungs. This directly inhibits the exchange of oxygen and carbon dioxide. Positive pressure ventilation will force excessive amounts of blood from the lungs, thereby improving oxygen-carbon dioxide exchange in the alveoli.
As with many patients in respiratory failure, this patient became unconscious and apneic, which further required you to insert an oropharyngeal airway and monitor for vomiting. In cases like this, immediate transport is critical to the patient's survival. Additionally, the EMT should consider requesting an ALS unit, as this patient will require more invasive airway support, such as endotracheal intubation.
Since the definition of shock (hypoperfusion) is inadequate tissue perfusion and this patient's problem is secondary to a respiratory problem, he is in respiratory shock.
