CPR LECTURE SERIES-130911 THIS LECTURE SLIDES CONTAIN COPYRIGHT MATERIAL

INTERNATIONAL NURSING WEBINAR: BTCLS & HDM (8 – 9 APRIL 2023) :

PERSATUAN PERAWAT NASIONAL INDONESIA

BTCLS: AIRWAY & BREATHING

MANAGEMENT
ASSOC PROF DR. HJ. ABDUL ALI BIN RAJA MOHAMED, ASA, PSK, PPL
◼ASSOC PROF IN EMERGENCY MEDICINE, HEAD OF EMERGENCY MEDICINE,
◼DIRECTOR, MAHSA CENTRE FOR CLINICAL SKILLS EDUCATION AND TRAINING,
◼HEAD, SCHOOL OF EMERGENCY MEDICAL SERVICES & SCIENCES.
◼FACULTY OF MEDICINE, MAHSA UNIVERSITY.
◼ MEMBER NATIONAL EXECUTIVE BOARD,VICE-CHAIRMAN,MRCS. & DEPUTY CHAIRMAN MRCS SELANGOR
◼ (1989-2008 : HEAD OF TRAUMA & EMERGENCY CENTRE, UMMC, UNIVERSITY MALAYA)
◼ (DIRECTOR, ACADEMY OF PARAMEDICAL SCIENCES, CUCMS:2008-2011)
◼ (PRINCIPAL/CEO, CYBER PUTRA COLLEGE, CYBERJAYA:2011-2016)
◼ INTL. MEMBER-AMERICAN COLLEGE OF EMERGENCY PHYSICIANS (ACEP)
◼ INTL. MEMBER- NATIONAL ASSOCIATION OF EMS PHYSICIANS (NAEMSP)
◼ PREMIUM PROF. MEMBER, COUNCIL ON CARDIOPULMONARY & CRITICAL CARE, AMERICAN HEART ASSOCIATION
◼ ADVISOR, MALAYSIAN ASSOCIATION OF PREHOSPITAL PARAMEDIC PRACTITIONERS
◼ AHA ECC BLS/ACLS INSTRUCTOR
◼ PRESIDENT, MEDICALERT FOUNDATION MALAYSIA.
C-aarm
Abu Huraira reported: The Messenger of Allah, peace and blessings be upon him, said,
“Whoever travels a path in search on knowledge, Allah will make easy for him a path to Paradise.”
Source: Ṣaḥīḥ Muslim 2699

KUALA LUMPUR

C-aarm
Leaders in
Nursing, Paramedical,
MBBS, Dental DDS
 UNIVERSITY MALAYA MEDICAL CENTRE (UMMC), UNIVERSITY MALAYA, KL

#59 in QS Global World Rankings 2022

UMMC EMERGENCY CENTRE
 Learning Outcomes:

◼ Causes of Airway and Breathing problems

◼ A & B Protocols in Medical Cases
◼ A & B Protocols in Trauma Cases
◼ Various Techniques of Managing A & B
◼ Monitoring of A & B
Causes Airway and Breathing Problems in
Unconscious Pt:
⚫ A- Alcohol, Acidosis
⚫ E- Endocrine, Electrolyte, Encephalopathy, Environmental
⚫ I- Infection, Intoxication
⚫ O- Oxygen, Opiates, Overdose
⚫ U- Uremia
⚫ T- Tumor, Trauma, Thermal, Toxin
⚫ I- Insulin
⚫ P- Poisonings, Psychosis, Porphyria,
⚫ S- Stroke, SAH, Seizures, Syncope-(post- icteric), Shock
 RESPIRATORY DISTRESS
• Tachycardia
• Increased respiratory effort
• Inadequate respiratory effort
• Abnormal airway sounds
• Tachycardia
• Pale, cool skin (warm, red, diaphoretic)
• Agitation/Changes in level of consciousness
• Use of Abdominal muscles to assist in breathing
 RESPIRATORY FAILURE
• Marked tachypnoea
• Bradypnoea, Apnoea
• Increased/Decreased/
• No respiratory effort
• Poor distal lung air movement
• Tachycardia (early)
• Bradycardia (late)
• Cyanosis
• Stupor/Coma (late)
 RESPIRATORY ARREST
• Absence of breathing
• Gasping <6/min, No chest movement
 WHY TEAM APPROACH?
VERTICAL APPROACH - SINGLE APPROACH HORIZONTAL APPROACH - TEAM APPROACH

1 PRIMARY SURVEY 0
PRIMARY SURVEY: AcBCDE 2 SECONDARY SURVEY
0
AcB 3 RESUSCITATION & DEF Mx
C D&E
SECONDARY SURVEY: SAMPLE,
HEAD-TOE EXAM & Mx ? SAMPLE
? 10
HEAD- TOE MIN

RESUSCITATION & MX
DEFINITIVE Mx

?
60 MIN ?
TIME
BLS & ACLS method

C
A

D
ATLS method

13
OXYGEN

5H
&
5T
BLS & ACLS

AIRWAY & AIRWAY &

BREATHING BREATHING
MANAGEMENT MANAGEMENT

15
MEDICAL MANAGEMENT: BLS & ACLS TRAUMA MANAGEMENT: ATLS

◼ Preparation
– Team Assembly
– Equipment Check
◼ Triage
– Sort patients by level of acuity
◼ Primary Survey
– Designed to identify injuries that are
immediately life threatening and to treat them
as they are identified
◼ Resuscitation
– Rapid procedures and treatment to treat injuries
found in primary survey before completing the
secondary survey
◼ Secondary Survey
– SAMPLE/Full History and Physical Exam to
evaluate for other traumatic injuries
◼ Monitoring and Evaluation, Secondary adjuncts
◼ Transfer to Definitive Care
– ICU, Ward, Operating Theatre, Another facility

16
 Primary Assessment:
THE PRIMARY ASSESSMENT: AIRWAY
Is the Airway patent?
Is an advanced Airway indicated?
Is proper placement of Airway
Device confirmed?
Is tube secured and placement
reconfirmed frequently?
ACTION
Maintain Airway patency
Use Advanced Airway Management if
needed 9LMA, ETT,
Confirm placement of AD:
Physical examination
Quantitative waveform capnography
Secure and Check frequently
Quantitative waveform capnography
Monitor the Airway
17
 Primary Assessment
BREATHING
Are ventilation and oxygenation
adequate?
Are quantitative wave form
capnography and oxygen saturation
monitored?
ACTION
Give supplementary oxygen when
indicated
• Cardiac arrest give 100% oxygen by
appropriate device
• SpO2 > 94%
Monitor the adequacy of ventilation
• Clinical criteria – chest rise &
cyanosis
• Quantitative wave form
capnography
• Oxygen Saturation?
18
“Early assessment and management of patients with multiple injuries is carried our using the ATLS
protocol. The role of the trauma team is to apply the principles of Advanced Trauma Life Support (ATLS) to
rapidly identify and treat life-threatening injuries during the primary survey”.
Bailey & Love: Short Practice of Surgery

◼ Preparation
– Team Assembly
– Equipment Check
◼ Triage
– Sort patients by level of acuity
◼ Primary Survey
– Designed to identify injuries that are
immediately life threatening and to treat them
as they are identified
◼ Resuscitation
– Rapid procedures and treatment to treat injuries
found in primary survey before completing the

ATLS® secondary survey

Advanced Trauma Life Support
◼ Secondary Survey
– SAMPLE/Full History and Physical Exam to
evaluate for other traumatic injuries
◼ Monitoring and Evaluation, Secondary adjuncts
◼ Transfer to Definitive Care
– ICU, Ward, Operating Theatre, Another facility
◼Golden Hour and ATLS Trauma Care
◼Mechanism of Injury
◼Basics of Trauma Management
– Triage

–Primary Survey – Life-Threats

– Secondary Survey – SAMPLE History & Head-to-Toe Exam
– Life-saving Procedures and Techniques
– Resuscitation
– Documentation
– Definitive Management

ATLS MANUAL 2020

 Primary Survey

◼ Exsanguinating external haemorrhage Control

◼Airway Control & Cervical Spine Control
◼Breathing & Ventilation Control
◼Circulation & Hemorrhage Control
◼Disability & need for CT Scan
◼Exposure & Control of the Environment

21
AIRWAY CONTROL

22
 THREATENED AIRWAY
1. TONGUE- Tone
• HEAD INJURY
• ALCOHOL INTOXICATION
• DRUG INTOXICATION
• HYPOXIA & HYPOGLYCEMIA
1. BLOOD & SECRETIONS
2. VOMITUS
3. LOCAL INJURY
4. FOOD & FOREIGN BODY
5. DENTURES
6. OEDEMA –I,I,T
7. BURNS
8. HAEMATOMA
9. TUMOUR
 Airway and Protection of Spinal Cord
◼Why first in the algorithm?
– Loss of airway can result in death in < 3 minutes
– Prolonged hypoxia = Inadequate perfusion, End-organ damage
◼Airway Assessment
– Speech - Full Sentence >>>>> O2
– Airway Obstruction? = Hoarseness, Stridor, Crowing
Gurgling, Snoring
Vital Signs = RR,
Sat % O2
– Mental Status = Agitation, Somnolent,
– Unconscious = Tongue fallback?
– Ventilation Status = Accessory muscle use, Retractions,
Respiratory distress
25
•OXYGEN

26
OXYGEN

5H
&
5T
NON-REBREATHING FACE MASK

90 to 95% with Oxygen flow rate

at over 12 litres per minute with
Inflated reservoir bag
 Airway and Protection of Spinal Cord
◼Why first in the algorithm?
– Loss of airway can result in death in < 3 minutes
– Prolonged hypoxia = Inadequate perfusion, End-organ damage
◼Airway Assessment
– Speech
– Not Clear? Airway Obstruction? = Hoarseness, Stridor, Crowing
Gurgling, Snoring
Vital Signs = RR,
Sat % O2
– Mental Status = Agitation, Somnolent,
– Unconscious = Tongue fallback?
– Ventilation Status = Accessory muscle use, Retractions,
Respiratory distress
29
Airway Interventions
◼ Maintenance of Airway Patency
– Suction of Secretions
– Jaw thrust
– Oropharyngeal Airway
– Nasopharyngeal Airway
– Definitive Airway
◼ Airway Support
– Oxygen
– NRFM (95%) Ignis, Wikimedia Commons
– Bag Valve Mask
– Definitive Airway
◼ Definitive Airway
- LMA
Endotracheal Intubation (100%)
◼ In-line cervical stabilization
Surgical Crichothyroidotomy
U.S. Navy photo by Photographer's
Mate 2nd Class Timothy Smith,
Wikimedia Commons 30
31
 GUEDEL

BERMAN

OROPHARYNGEAL AIRWAY &

NASO-PHARYNGEAL AIRWAY

32
 MUST HAVE THE
WHOLE SET

CORRECT OROPHARYNGEAL
AIRWAY PLACEMENT
NEED TO SIZE THE OPA
TO PT’s AIRWAY:
INCISOR TEETH TO
ANGLE OF MANDIBLE

OPA MUST COMFORTABLY

LIFT THE TONGUE
CORRECT NASOPHARYNGEAL
AIRWAY PLACEMENT

TIP OF NOSE TO
THE EAR LOBE

NPA MUST COMFORTABLY

LIFT THE TONGUE
 PROVIDING BASIC BASIC AIRWAY SKILLS USED TO VENTILATE A PATIENT
VENTILATION:
B Head Tilt – Chin Lift (Medical cases)
C Jaw – Thrust without head extension (Poly Trauma cases)
Mouth to Mouth ventilation
Mouth to Nose ventilation
Mouth to Barrier Device ventilation
Bag-Valve-Mask Ventilation

TOUNGE OBSTRUCTION
 Indications:
No Breathing
BVM VENTILATION: RR: <8/min
1-PERSON CE-TECHNIQUE Elective Ventilation-Preoxygenation
2-PERSON CE-TECHNIQUE

36
LMA-LARYNGEAL MASK AIRWAY

37
38
ENDO-TRACHEAL INTUBATION

39
SURGICAL AIRWAY- CRICOTHYROIDOTOMY

40
NEJM 2022
CERVICAL SPINE CONTROL
Those patients that meet the criteria or have an indication
• acute altered level of consciousness, < GCS 14
• midline neck or back tenderness,
• focal neurologic symptoms,
• deformity of the spine,
• distracting injuries
• Intoxication

42
 C-spine Immobilization
◼Return head to neutral position
◼Maintain in-line stabilization
◼Correct size collar application
◼Blocks/tape
◼Sandbags

Paladinsf
(flickr)
James Heilman, MD, Wikimedia
43
Commons
BREATHING /
VENTILATION
CONTROL
44
 Primary Assessment
BREATHING
Are ventilation and oxygenation
adequate?
Are quantitative wave form
capnography and oxygen saturation
monitored?
ACTION
Give supplementary oxygen when
indicated
• Cardiac arrest give 100% oxygen by
appropriate device
• SpO2 > 94%
Monitor the adequacy of ventilation
• Clinical criteria – chest rise &
cyanosis
• Quantitative wave form
capnography
• Oxygen Saturation?
45
46
 ATLS: LIFE-THREATENING CONDITIONS IN THE CHEST:
BREATHING & VENTILATION:

• 1- Open Pneumothorax
• 2- Tension Pneumothorax
• 3- Massive Haemothorax
• 4- Flail Chest
• 5- Cardiac Tamponade
FIX IT
47
SPONTANEOUS / TRAUMATIC PNEUMOTHORAX
• REDUSED A/E
• HYPER RESONANT PERCUSSION
&
OPEN PNEUMOTHORAX
• OPEN SUCKING CHEST WOUND
• REDUSED A/E
• HYPER RESONANT PERCUSSION

3-SIDED OCCLUSIVE SEAL

CHEST TUBE THORACOTOMY
WITH UNDERWATER SEAL

48
 OPEN PNEUMOTHORAX-
3-SIDED OCCLOSIVE DRESSING

49
TENSION PNEUMOTHORAX
• REDUCED A/E
• RESONANT PERCUSSION
• TRACHEAL SHIFT

• NEEDLE THORACOSTOMY
• CHEST TUBE THORACOTOMY
• WITH UNDER WATER SEAL

50
Breathing- Life threatening conditions in Chest

◼Needle Thoracostomy
– Midclavicular line
– 14 gauge angiocath
– Over the 2nd rib or
– Safe Triangle
– Rush of air is heard

51
MASSIVE HAEMOTHORAX
• >30% BLOOD LOSS = SHOCK
• REDUSED A/E
• DULL PERCUSSION

• TWO 14G IV ACCESS WITH TRANSFUSION

• CHEST TUBE THORACOTOMY
• WITH UNDER WATER SEAL

52
FLAIL CHEST
• PARODOXICAL BREATHING
• PERSISTANT HYPOXIA
• RESPIRATORY DISTRESS

• TREAT HYPOXIA
• SPLINTING WITH STRAP BANDAGE
• INTUBATION WITH PARALYSIS
• WITH PROPHYLACTIC CHEST TUBE
• WITH UNDERWATER SEAL
• WIRING & PLATING 53
CARDIAC TAMPONADE
BECK’S TRIAD:
• ENGORGED NECK VEINS
• MUFFLED HEART SOUNDS
• REDUSED BP

• ULTRA-SOUND CONFIRMATION >>>>>

54
 CONDITION DIAGNOSTIC FEATURES EMERGENCY TREATMENT
1 OPEN PNEUMOTHORAX Open sucking wound 3-Sided Occlusive Dressing
Auscultation- Reduced air entry Chest tube with UWS

Percussion- Hyper-Resonant
2 TENSION PNEUMOTHORAX Tracheal Shift Needle Thoracostomy
Auscultation- Reduced air entry Chest tube with UWS

Percussion- Hyper-Resonant
3 MASSIVE HAEMOTHORAX S/S of Hemorrhagic Shock 14 G I/V Access + IV Fluid/Blood
Auscultation- Reduced air entry Chest tube with UWS

Percussion- Hyper- Dull

4 FLAIL CHEST Paradoxical Breathing Oxygen & Anesthetist Referral
Severe Hypoxia Prophylactic Chest tube with UWS

Subcutaneous Emphysema & Others

5 CARDIAC TAMPONADE Engorged neck veins Ultra-Sound guided
Reduced Blood Pressure Pericardiocentesis & Open Repair

Muffled Heart sounds

55
SURFACE MARKING OF THE SAFE TRIANGLE

NEEDLE THORACOSTOMY

SAFE TRIANGLE

• CHEST TUBE THORACOTOMY

• WITH UNDER WATER SEAL

56
SURFACE MARKING OF THE SAFE TRIANGLE

NEEDLE THORACOSTOMY

SAFE TRIANGLE

• CHEST TUBE THORACOTOMY

• WITH UNDER WATER SEAL

57
58
 Classic Radiographic Findings
◼Diaphragmatic rupture w/ spleen herniation

Author unknown,
http://commons.wikimedia.org/wiki/File:Diaphragmatic_rupture_spleen_herniation.jpg 59
 Classic Radiographic Findings
◼Widened Mediastinum – Aortic Injury

Author unknown,
www.trauma.org/index.php/main/image/45/print
60
ACUTE HAEMORRHAGE: EXTERNAL: Trauma
P/R Bleed
P/V Bleed
Haematemesis
70 Kg Haemoptysis
INTERNAL: CHEST
ABDOMEN
PELVIS
THIGH

5L SIGNS ??? &

SYMPTOMS ???
IVV
 CLASSIFICATION OF HAEMORRHAGIC SHOCK
NO SIGNS CLASS I CLASS II CLASS III CLASS VI
Blood Loss:
Percentage < 15% 15 – 30% 30-40 % ➢ 40%
Volume < 750 ml 750 – 1500 ml 1500-2000 ml ➢ 2000 ml

1 Pulse Rate 100 bpm 100-120 bpm > 120 bpm ➢ 120 bpm
➢ thready
2 Capillary Refill Normal Slow Slow Undetectable

3 Respiratory Rate Normal Normal > 20 /min > 20 /min

4 Urinary Flow Rate ml/h > 35 20-35 10-20 0-10

5 Extremities Normal Pale, Cool Pale, Cold Pale, Cold, Clammy

6 Blood Pressure:
Systolic Unchanged Normal Reduced Very Low
Diastole Unchanged Raised Reduced Unrecordable

7 Complexion Normal Pale Pale Ashen

8 Mental Status Alert Anxious Confused, Drowsy, Stupor,

Restless Aggressive Unconscious
 TYPE CAUSE PATHO SYMPTOMS SIGNS VITAL SIGNS
PHYSIOLOGY PR RR SKIN SPO2 GCS BP
1 HYPOVOLUMIC LOSS OF BLOOD, FLUIDS REDUCED VOLUME, GIDDINESS, PALLOR COOL,
VENOUS RETURN, LETHARGY, SWEATING, COLD,
CARDIAC OUTPUT, ANXIOUS, ANXIOUS CHILL,
REDUCED BP AMS, RESTLESS CLAMMY,
LOC MOTTLED
2 CARDIOGENIC MI, ARRHYTHMIAS PUMP FAILURE, CARDIAC CHEST ANXIOUS, COOL,
CARDIOMYOPATHY, VALVE FAILURE, PAIN, DIZZINESS,, LETHARGY COLD,
VALVE FAILURE, DECREASED CARDIAC NAUSEA, DIAPHORESIS CHILL,
TAMPONADE, DRUGS, C. OUTPUT VOMITING, CLAMMY,
TRAUMA PALPITATIONS, MOTTLED

3 ANAPHYLACTIC DRUGS IgE >> INFLAM. MEDIATORS ITCHINESS, RASH, WHEEZING,

BITES BRONCHOSPASM SWELLING FACE, URTICARIA, HIVES, EARLY
N/ N/
STINGS VASODILATION & EXUDATE CANNOT WARM,
POOLING OF BLOOD BREATH,SOB
REDUCED VENOUS RETURN WHEEZING, LATE COOL
REDUCED BP HOARSNESS OF
VOICE, GIDDINESS,
4 SEPTIC Gm Negative: DYSREGULATED HOST RESP HISTORY & INFECT qSOFA – >2pts EARLY
E Coli, Proteus Klebsiella, ORGAN DYSF >MOF FEVER >38C BP <100 w WARM,
Pseudomonas VASODILATION, CONFUSION VASOPRESSORS
Gm Positive: CAPILLARY LEAKAGE, DIFF BREATH LACTATE>2mmolL
S aureus, Fungi POOLING OF BLOOD, FATIGUE,MALAISE RR > 22 LATE COOL
Elderly, DM, REDUCED VENOUS RETURN NAUSEA & VOMIT AMS
Immunosuppression REDUCED BP REDUCED URINE (Anxious, flushed
Invasive Procedures REDUCED URINE OUTPUT Restless>GCS)
5 NEUROGENIC CERVICAL INJURY, SPINAL CORD INJURY, TRAUMA, PARALYSIS, EARLY
SPINAL DRUGS SYMPATHETIC DAMAGE, UNABLE TO MOVE, PARAESTHESIA,W
N WARM,
N N
REDUCED TONE NUMBNESS & ARM PINK
VASODILATION TINGLING, PRIAPISM,
POOLING OF BLOOD, NECK PAIN, INCONTINENCERE LATE COOL
REDUCED VENOUS RETURN UNABLE TO DUCED TONE
COPYRIGHT- Dr AAli REDUCED CARDIAC OUTPUT BREATH,
 Disability-Status
◼ Glasgow Coma Scale
– Eye
◼
◼
Spontaneously opens
To verbal command
4
3 GCS ≤ 8
◼ To pain 2
◼ No response 1 Intubate
– Best Motor Response
◼ Obeys verbal commands 6
◼ Localizes to pain 5
◼ Withdraws from pain 4
◼ Flexion to pain (Decorticate Posturing) 3
◼ Extension to pain (Decerebrate Posturing) 2
◼ No response 1
– Verbal Response
◼ Oriented/Conversant 5
◼ Disoriented/Confused 4
◼ Inappropriate words 3
◼ Incomprehensible words 2
◼ No response 1

64
 Increased ICP > Respiratory Patterns
• As ICP continues to rise, abnormal respiratory
patterns may develop
– Respiratory abnormalities associated with increased
ICP and significant brainstem injury include
• Hypoventilation
• Cheyne-Stokes breathing (which may accompany
decorticate posturing)
• Central neurogenic hyperventilation (which may
accompany decerebrate posturing)
• Ataxic breathing

Copyright © 2013 by Jones & Bartlett Learning, LLC, 65

an Ascend Learning Company
8) How does this DEVICE work?
 Oxygenated haemoglobin absorbs more infrared light and
allows more red light to pass through.
Deoxygenated haemoglobin absorbs more red light and allows
more infrared light to pass through

SPECTROPHOTOMETRY

Beer’s law: the intensity of transmitted light Lambert’s law: the intensity of transmitted light
decreases exponentially as the concentration of the decreases exponentially as the distance travelled
substance increases. August Beer, German Physicist through the substance increases. Johann Lambert,
(1825-1863) German Physicist (1728-1777)
 97%
95%

90% HYPOXIA

HYPOXIMEA

69
National Early Warning Score (NEWS) 2 | RCP
London

https://www.rcplondon.ac.uk/projects/outputs/natio
nal-early-warning-score-news-2
Dec 19, 2017 - NEWS2 is the latest version of the
National Early Warning Score (NEWS), first
produced in 2012 and updated in December 2017
SUMMARY:
Primary Assessment:
THE PRIMARY ASSESSMENT: AIRWAY
Is the Airway patent?
Is an advanced Airway indicated?
Is proper placement of Airway
Device confirmed?
Is tube secured and placement
reconfirmed frequently?
ACTION
Maintain Airway patency
Use Advanced Airway Management if
needed 9LMA, ETT,
Confirm placement of AD:
Physical examination
Quantitative waveform capnography
Secure and Check frequently
Quantitative waveform capnography
Monitor the Airway
72
 Primary Assessment
BREATHING
Are ventilation and oxygenation
adequate?
Are quantitative wave form
capnography and oxygen saturation
monitored?
ACTION
Give supplementary oxygen when
indicated
• Cardiac arrest give 100% oxygen by
appropriate device
• SpO2 > 94%
Monitor the adequacy of ventilation
• Clinical criteria – chest rise &
cyanosis
• Quantitative wave form
capnography
• Oxygen Saturation?
73
KERJA RESUSITASI A & B
MESTI ADA PEMIMPIN
 THE NOBLE QURA’AN -
BENEFIT Surah 41-Fussilat, Ayat-46
TO
OWNSELF
 THANK YOU
FOR HAVING THE PASSION
TO ‘SAVING LIVES’