Monthly Archives: May 2016

Adult Basic Life Support and Resuscitation

by ,

h16The likely-hood of being involved in any medical emergency is often slim at best, many individuals will go about their lives never having dealt with any type of medical event. Although this may be a rare occurrence, by having first aid knowledge and skill you are greatly increasing your chances of successfully aiding an individual if they suddenly become unwell, or suffer a cardiac arrest. What is a cardiac arrest? This is when the heart stops beating for whatever reason, and it’s a condition which often leads to the death of the individual. The cardiac arrest scenario is one which you’ll typically see on medical drama programs where they are doing cardio-pulmonary resuscitation (CPR) and shocking them with a defibrillator. These dramatised resuscitation attempts are often littered with inaccuracies and mistakes, however you get the idea of what a cardiac arrest is.

So what do you do if an individual were to collapse in front of you suffering from a cardiac arrest, first it’s important not to panic. By panicking you are losing control of what to do and this will not provide any help for the individual. Make sure you are in a safe environment. Do not approach your patient if they are in a dangerous predicament, for example, they’ve collapsed in the middle of a busy road. Ensure that the environment and settings allow for a safe approach so that you don’t become a casualty yourself. If it is impossible to approach the patient, the call 999. If it is safe to approach, try to make contact with the individual. Once contact has been made but they are unresponsive, check to see if they are breathing or have a pulse. You can do this by leaning over their mouths and listening for breath, and by feeling for a pulse by the wrist. If you haven’t done so already, you need to call 999 and ask for an ambulance.

You will need to begin chest compression’s, the location for this is at the centre of the chest. Ensure that the patient is on their back and on a hard surface, place a flat palm atop the centre of the chest and interlock your other hand on top of it. The centre of the chest is where the sternum is located, or often anatomically land-marked in-between the nipples. You will need to begin chest compression’s, do this by pushing down into the chest at a depth of 5-6 cm’s. After pushing down allow the chest to recoil fully, then push down again. Continue this cycle at a rate of 100-120 compression’s per minute, so around 2 every second. Depending where you are, there may be an automated external defibrillator (AED) nearby. These are often located in shopping centres and town halls, there are often many public initiatives raising money to fund AED placements in public places. Ask passers by if they are able to run and find an AED. If you are able to find one, open the pack and there will be clear instructions on how to use it. If possible try to keep someone doing CPR on the chest at all times, any time off the chest will allow for irreversible damage to be at it’s maximum to the body. The same goes for when you start to feel tired, ineffective CPR will also hinder the resuscitation attempt. If passers by are willing, try to alternate CPR every 2 minutes. Give them clear instruction on how to do CPR.

In the AED there will b two pads with a picture of where to place them, one goes on the upper right chest, the other on the far left side of chest. By turning the AED on, it will talk you through the use of the device. It may ask you to stop CPR so that it can analyse the rhythm, once it’s analysed it will advise to shock or continue CPR. If you are shocking, ensure nobody is touching the patient and that it is safe to do so. Continue doing CPR and following the advice of the AED until help arrives. By doing CPR and using an AED if available you are greatly increasing the chance of success for the patient.

Respiratory Anatomy and Physiology

by ,

h15The respiratory system is in place to extract Oxygen (O2) from the atmosphere and get rid of Carbon Dioxide (CO2). O2 is used in chemical reactions by the cells to create energy for use in their metabolic activities, CO2 is usually a waste product created from these reactions.

The respiratory system can often be segmented into the ‘upper respiratory tract’ and the ‘lower respiratory tract’. Upper consists of the nose, the pharynx, and the larynx.

The nose and nasal cavity are used as a main source of air entry and are lined with columnar cells (ciliated columnar epithelium) which contain mucus secreting goblet cells. At the anterior of the nose there are also nasal hairs. Within the nasal cavity, conchae exist to increase surface area and cause a turbulence effect for air passing through. The respiratory function of the nose is to warm the air (which is done by the increased vascularity of the nose which explains the potential large blood loss during epistaxis), and to clean and humidify it (which is done through mucus coated nasal hairs trapping dirt and moist mucosa humidifying the air).

The pharynx follows in the next step of the upper respiratory tract. The pharynx begins at the end of the nasal cavity (nasopharynx), extends past the back of the mouth and tongue (oropharynx), and finishes at the larynx and oesophagus (laryngopharynx). The walls of the pharynx contain mucous membrane lining, submucosa, and smooth muscle. The respiratory functions for the pharynx include passage of air, warming and humidifying of air (done through the vascularity of the walls and moist mucosa), protection from pathogens (bacteria etc. through the placement of the tonsils and lymphatic tissue), and assistance in speech (through acting as a resonating chamber for sound).

The last of the upper respiratory tract ends with the larynx (voice box). The larynx is mainly made up from cartilage, dividing into 4 main structures: the thyroid cartilage, the cricoid cartilage, the arytenoid cartilage, and the epiglottis. The thyroid, cricoid and arytenoid are made up from hyaline cartilage, and the epiglottis is made up from elastic fibrocartilage. In-between the arytenoid cartilage are the vocal cords and entrance to the trachea. The respiratory functions of the larynx are to protect the lower respiratory tract (through the epiglottis blocking the passage of food into the trachea whilst eating and swallowing), to humidify and warm the air (through the moist mucosa and vascularity of the walls), and to produce speech and sound (through the use of the vocal cords).

The lower respiratory tract consists of the trachea, the lungs, the bronchi and bronchioles, the respiratory bronchioles and alveoli.

The trachea begins the lower respiratory tract anatomy, consisting of 16 to 20 incomplete ‘C’ shaped hyaline cartilage rings atop of each other. There are three layers of tissue which enclose the trachea and cartilaginous rings; the outer consists of fibrous and elastic tissue which enclose the cartilage. The middle consists of the cartilage and smooth muscle that wraps around the trachea. The inner layer is lined with columnar cells (epithelium) which contain mucus secreting goblet cells. The respiratory functions of the trachea are to warm and humidify air, to expel mucus with unwanted particles and dust (through cilia on the inner lining cells wafting mucus upwards towards the larynx where it can be either swallowed or coughed up), to provide a cough reflex (nerve endings in the larynx, trachea, and bronchi stimulate a cough reflex when irritated), and provide support and patency to the airway (through the C-shaped cartilage providing support to keep the airway open but also allow flexibility for movement and swallowing food).

The lungs are the organs which contain the further lower respiratory tract, and assist in the inspiration and expiration of air. The left lung consists of a superior and inferior lobe, the right consists of a superior, middle, and inferior lobe. The pulmonary artery, veins, and left and right bronchus enter the lungs through the hilum. Surrounding the lungs are the pleura and pleural cavity; visceral pleura coats the outside of the lungs, parietal pleura coats the inside of the chest wall and thoracic surface of the diaphragm, and the pleural cavity is the space between which contains no air, only a thin film of serous fluid. With the pleura in place the surfaces can glide over each other easily and can only be pulled apart with great difficulty. With the expansion of the chest wall and diaphragm during inspiration, atmospheric pressure within the lungs drop and air floods in to stabilize the level to normal. On relaxation of the chest the pressure increases and air is forced out.

The bronchi stem from the trachea acting as openings for air into the lungs. The left bronchus is about 5cm long and narrow, whereas the right is 2.5cm long and wider. The bronchi (more cartilaginous in structure) further expand and branch off into bronchioles (which are less cartilaginous and more smooth muscle and epithelial). The bronchioles further lead on to the end of the lower respiratory tract where the gaseous exchange can take place. Further down the bronchioles, ciliated epithelium are replaced with non-ciliated epithelium and mucus secreting goblet cells disappear. The respiratory functions of the bronchioles are to regulate the control of air entry (through contraction or relaxation of smooth muscle in the walls), and provide warming and humidifying to the air.

The bronchioles divide further into smaller respiratory bronchioles and end with the alveoli. These are thin membrane pockets (or sacks) which are surrounded by capillaries and supported by elastic fibres. Gaseous exchange happens between the membrane wall of the alveoli and capillary, which are fused firmly together and known as the respiratory membrane. Septal cells lying between the squamous cells of the alveoli secrete surfactant which prevents the alveoli from drying out. There are about 150 million alveoli in the adult lung which provide gaseous exchange. The respiratory functions of the alveoli are to provide the centre of gaseous exchange between O2 and CO2.

Assisting Intubation

by ,

h14This is a short article looking at assisting with intubation. Ensure you have a good knowledge of what all devices are called so to avoid confusion if the anaesthetist or paramedic asks for a certain device. Lay out all devices required in a sterile environment so they are ready at hand when needed. Ensure you have a range of sizes for the different tools available, e.g. size 7, 8, 9 ET tubes, size 3, 4 laryngoscope blade. Place the items to the side of the operator if you are required to do chest compressions, or be at hand ready to pass over items when required. Ensure there is a Bougie or Introducer at hand in case of a difficult intubation. If these items are used be prepared to assist in feeding the ET over them so that they can be placed in the airway.

Consider whether the patient will be a difficult intubation, do they have excessive features like a large tongue or neck. Is there evidence of airway obstruction where suction or forceps may be required to remove the debris. If there is no obstruction and the health care professional is finding it difficult to intubate, consider assisting in positioning of the
Airway bag

patient and conducting airway/intubation manoeuvres (if you are not actively conducting CPR).

Consider whether there is an object such as a pillow in the vicinity where you could place it under the patients’ neck to provide some better sight alignment of the airway (ensure the patient has no c-spine compromise before doing this). If able to do so, consider a jaw thrust manoeuvre or lifting of the chin to aid in opening up the airway and providing better sight. Consider the BURP (Backwards Upwards Right Pressure) manoeuvre, place some fingers on the trachea and apply some pressure in the ‘BURP’ order. The health care professional may direct you where to apply further pressure with what they can visualise.

You can use the Sellick manoeuvre where there is risk of the patient vomiting whilst being intubated. Locate the cricoid cartilage and apply pressure towards the oesophagus. The idea is to collapse the oesophagus so no vomit can pass through the passageway. Use judgement when applying pressure and be cautious if querying a c-spine injury.

Once the intubation process is complete have a 20ml syringe filled with air ready for the health care professional to inflate the cuff. You may need to assist in holding the stethoscope head when auscultating the patient for tube placement confirmation. Once the tube is confirmed and tied in place, attach a catheter mount and CO2 device. Confirm the presence of CO2 and begin ventilating the patient. If in a cardiac arrest scenario, you can now provide continuous ventilations. Move any of the unused equipment a safe distance away where it doesn’t get in your way but is close enough to grab again if needed.

How to Deal With a Choking Adult

by ,

h13Although choking isn’t a common phenomenon, it is an emergency situation where some simple first aid techniques could make all of the difference and save that person’s life. Choking is a time critical event, and by acting quick you can make all of the difference, if an individual cannot remove the foreign object occluding their airway, then suffocation and cardiac arrest will soon ensue.

What is the first thing when you realise that someone is choking, don’t panic. Keep calm and you will be best able to assist them. If you are not sure is someone is choking, simply ask them and they will give you an appropriate response. When you’ve established that the individual is choking, call 999 and ask for an ambulance, this means specialist help will be on its way. Try and encourage the patient to cough, coughing is the least invasive of the foreign away occlusion removal techniques. Individuals are sometimes able to dislodge the foreign body by coughing it out, but after a few attempts, or if they are completely ineffective/cannot cough, you will need to move onto the next technique.

Encourage the patient to lean forward, you now will need to give 5 back blows in the centre of the back, between the shoulder blades. Use a flat palm and put some force into the blow. With the patient leaning forward and the 5 back blows this can often cause enough force to dislodge the object. If these fail then you must move to abdominal thrusts. Stand behind the patient and interlock your arms at the top of their abdomen, just under where the diaphragm is. With sharp thrusts inwards and upwards 5 times, this can often cause enough pressure to shift the occlusion.

If neither of these techniques work then begin to alternate the two in a cycle, 5 back blows, 5 abdominal thrusts, 5 back blows, 5 abdominal thrusts… Continue this cycle until the object is removed or the ambulance arrives to take over care. If the patient becomes unconscious from choking and ends on the floor, start doing chest compression’s/cardiopulmonary resuscitation (CPR). The action of CPR can often allow for the object to be dislodged. Unless you can clearly see the object and easily grasp it, never place your hands in the persons’ mouth. By doing so you may be pushing the object further into their trachea, or you may cause them to be sick and that will further occlude the airway.