Don't walk in front of me,

I may not follow.

Don't walk behind me,

I may not lead.

Just walk beside me,

And be my friend.

It has come to my attention that there are specific aspects of life that no person can function without. It is not a specific item, but rather certain people. As I reached for my phone at 2:24 am this morning, I was reminded that I have the greatest friends ever. Seriously, who really wants a phone call at 2:24 am that goes something like this: "I can't sleep. I'm really wide awake. I had bad nightmeres... Are you busy?" I have two friends that, instead of dreading that call, look forward to it because they know I called them and not someone else. And yet, there is the person, that I bring the same issues up again and again. She doesn't get annoyed, but looks to see what changed between in the time it was ok. And after that, she let's me talk it out again. That's when I realize, it isn't so different now then it was before!

What sparked this realization of something that has been going on for a long time? I had a long weekend. And during that weekend. I spent alot of time with a few people... and I realized just what they put up with. And their unconditional friendship.

Capnography

1.      Oxygenation and Ventilation

a.       What is the difference?

b.      Oxygenation—read through oximetry

                                                  i.      Non-invasive measurement

                                                ii.      Percentage of oxygen in red blood cells

                                              iii.      Changes in ventilation take minutes to be detected.

                                              iv.      Affected by motion artifact, poor perfusion and some dysrhythmias

c.       Ventilation—read through capnography (smoke graph)

                                                  i.      Partial pressure (mmHg) or volume (% volume) of co2 in the airway at the end of exhalation

                                                ii.      Breath-to-breath

d.      Oxygenation

                                                  i.      Oxygen for metabolism

e.       Ventilation

                                                  i.      Carbon dioxide for metabolism

f.       Capnography gives immediate information on breathing

Hypoxia not only stops the motor, it wrecks the engine.”

1.      The most important steps in patient care are obtaining and maintaining a patent airway.

a.       Oxygenation of the body’s tissues occurs through the processes of breathing and circulation

b.      The primary objective of emergency care is to ensure optimal ventilation.

c.       Airway maneuvers are often neglected skills.

d.      Airway failure is death within 6-10 minutes

2.      major preventable causes

a.       failure to assess

b.      failure to detect

c.       failure to intervene/correct

3.      neglected skills

a.       poor skills

b.      BVM

c.       Head positioning

d.      Failure to asses/reassess

4.      10 commandments of airway management

a.       Remain calm

b.      Is it open? Will it stay that way?

c.       Do you have to suck anything out of it?

d.      Do you have to stick anything into it?

e.       First priority is ventilation (BVM)

f.       If you need help, get it early

g.      Have a game plan and a back up

h.      If you can’t ventilate, intubate

i.        If you can’t intubate: ventilate

j.        If you can’t intubate and can’t ventilate: you must CUT!

k.      Keep track of Time

l.        If your first attempt doesn’t succeed, figure out WHY, then do it differently the second time

m.    Practice, Practice, Practice—these are perishable skills.

5.      Know the following:

a.       Sinuses

                                                  i.      Frontal

                                                ii.      Sphenoid

                                              iii.      Maxillary

b.      Airway anatomy

                                                  i.      Frontal sinus

                                                ii.      Turbinates-warms and humidifies air by spinning it- filters

                                              iii.      Nasal cavity

                                              iv.      Soft palate

                                                v.      Uvula

                                              vi.      Tounge

                                            vii.      Vallecula

                                          viii.      Epiglottis

                                              ix.      Hyoid bone

                                                x.      Vocal chords— create the glottic opening.

                                              xi.      Glottic opening— the air space between the vocal cords

                                            xii.      Thyroid cartilage

                                          xiii.      Cricoid cartilage

                                          xiv.      Trachea

                                            xv.      Esophagus

                                          xvi.      C1

                                        xvii.      C2

                                      xviii.      C3

                                          xix.      Ethmoid sinus

1.      Nasopharynx—facial bones, divided by the septum, lined with mucus membrane/cilia, turbinates, sinuses

2.      Oropharynx- teeth, tongue, palate, adenoids, epiglottis, vallecula

3.      Hypopharynx--

4.      Larygopharynx

                                            xx.      Larynx

1.      attached the hyoid bone

2.      thyroid cartilage

3.      glottic opening

4.      arytenoids cartilage

5.      pyriform cartilage

6.      cricoid ring

7.      cridothyroid membrane

c.       nerves of the neck

                                                  i.      facial

                                                ii.      vagus

                                              iii.      accessory

                                              iv.      hypoglossal

                                                v.      phrenic nerve—controls the diaphragm

d.      **if someone has eye flutter, they have a gag reflex

6.      surfactant—lubricates and allows for the exchange of gas

7.      Atelectasis—sticky airways

8.      Surfactant—a chemical substance coating the pulmonary alveoli walls, that reduces surface tension thus preventing collapse of the alveoli after expiration.

9.      Total lung volume2

a.       Adult male—6 Liters

10.  FIO

a.       % of oxygen in inspired air

11.  Dalton’s Low of partial Pressures

a.       All gas pressures added together equal 100%

12.  brain

a.       pons—primary respiratory center

b.      Medulla—coordinates breathing, heart rate, swallowing, coughing, vomiting, blood vessel, diameter

c.       Hyperventilation causes excessive loss of CO@ which results in cerebral vascular constriction, decreased cerebral perfusion.

d.      Carbonic drive—receptors in the brain stem measuring carbon dioxide

e.       Hypoxic drive—“back up” receptors in brainstem, aorta, and carotid arteries.

13.  pediatric notes

a.       smaller mouth and nose

b.      tongue

14.  Indications of intubation

a.       When you can’t ventilate an unresponsive patient with conventional methods

b.      When patients cannot protect their airway (coma, respiratory and cardiac arrest)

c.       When prolonged artificial ventilation is needed

d.      In patients experiencing or likely to experience upper airway compromise.

e.       In unresponsive patients who lack a gag reflex

f.       When there is decreased tidal volume due to slow respirations

g.      When there is airway obstruction due to foreign bodies, trauma, or anaphylaxis

1.      General principles of Pathophysiology

a.       Topics

                                                  i.      Describe the distribution of water in the body

                                                ii.      Discuss common physiologic electrolytes

                                              iii.      Review mechanisms of transport

1.      Osmosis, diffusion, ect.

                                              iv.      Discuss hemostasis & blood types

b.      Distribution of water

                                                  i.      Total body weight/ total body water

                                                ii.      Intercellular—ICF (45% / 7%)

                                              iii.      Extracellular –ECF (15% / 25%)

1.      Intravascular (4.5% / 7.5%)

2.      Interstitial (10.5 %/ 17.5%)

c.       Fluid distribution

                                                  i.      Intracellular (75%)

                                                ii.      Interstitial (17.5%)

                                              iii.      Intravascular (7.5%)

2.      Edema

a.       Fluid accumulation in the interstitial compartment

                                                  i.      Causes

1.      lymphatic ‘leakage’

2.      Excessive hydrostatic pressure—excessive water pressure

3.      Inadequate osmotic pressure

4.      Ascities—full body edema

3.      Fluid out put in:

a.       Feces—5%

b.      Skin—25%

c.       Lungs (respiration)—11%

d.      Urine— 59%

4.      Osmosis versus diffusion

a.       Osmosis is the net movement of water from an area of low solute concentration to an area of higher solute concentration across a semi permeable membrane

b.      Diffusion of water is the movement of solutes from an area of high solute concentration to an area of lower solute concentration.

c.       Osmosis is the diffusion of water

5.      Tonicity

a.       Isotonic solutions

                                                  i.      Same solute concentration as blood

                                                ii.      If injected into a vein: no net movement of fluid

1.      ex. 0.9% sodium chloride solution—normal saline

b.      Hypertonic

                                                  i.      Higher solute concentration then blood

1.      If injected into a vein—fluid moves out of the veins.

c.       Hypotonic

                                                  i.      The solute outside the cell is lower then the inside

                                                ii.      Water moves from low solute to high solute

                                              iii.      The cell swells and eventually bursts!

d.      Infusion

                                                  i.      Infusion of isotonic solution into veins—no fluid movement

                                                ii.      Infusions of hypertonic solution into veins – fluid movement into veins

                                              iii.      Infusion of hypotonic solution into veins – fluid movement out of veins

6.      Ion Distribution

a.       Cations- positively charged ions

b.      Anions- negatively charged ions

7.      Role of electrolytes

a.       Nervous system

                                                  i.      Propagation of action potential

b.      Cardiovascular system

                                                  i.      Cardiac conduction and contraction

8.      Composition of blood

a.       8% of total body weight is blood

                                                  i.      Plasma 55%

1.      water 90%

2.      solutes 10%

b.      formed elements: 45%

                                                  i.      platelets

                                                ii.      erythrocytes

9.      Hematrocrit

a.       % of RBC in blood

                                                  i.      Normal:

1.      37%-47% (female)

2.      40%-54% (male)

10.  Blood components

a.       Plasma: liquid portion of blood

b.      Contains proteins:

                                                  i.      Albumin(60%): contribute to osmotic pressure

                                                ii.      Globulin (36%): lipid transport and antibodies

                                              iii.      Fibrinogen(4%): blood clotting

c.       Formed Elements

                                                  i.      Erythrocytes

1.      ‘biconcave’ disc

2.      7-8 mcm diameter

3.      Packed with hemoglobin

4.      4.6 -6 million RBC/MM^3 (males)

5.      Anucleate

6.      120 day life span

7.      2 million replaced per second!

                                                ii.      Leukocytes

1.      most work done in tissues

2.      Infection control

                                              iii.      Thrombocytes

1.      platelets

2.      cell fragments

3.      form platelet plugs

                                              iv.      Hemostasis

1.      the process of topping bleeding

2.      three methods

a.       vascular constriction

b.      platelet plug formation

c.       coagulation—the formation of blood clots

                                                v.      Fibrinolysis—breaking down clots

1.      plasminogen

2.      tissue plasminogen activator

3.      Plasmin

11.  Bottom line of Acid-Base

a.       Regulation of (H+)

                                                  i.      Normally about 1/3.5 million that of [Na+]

                                                ii.      0.00004 mEq/L (4 x 10-8 Eq/L)

b.      Dependent upon

                                                  i.      Kidneys

                                                ii.      Chemical buffers

c.       Precise regulation necessary for peak enzyme activity

d.      Normal PH is between 7.35 and 7.45

12.  Acid Base

a.       Acids release H+

b.      Bases absorb H+

c.       PH is a log of H+

                                                  i.      As H+ increases the ph decreases

                                                ii.      As H+ decreases the Ph increases

13.  Buffers

a.       Weak acid and conjugate bas pair

b.      Buffers resist pH changes

14.  Ph scale

a.       0—hydrochloric Acid

b.      1—Gastric Acid

c.       2—Lemon Juice

d.      3—Vinegar, Beer

e.       4—Tomatoes

f.       5—Black coffee

g.      6—Urine

h.      7—Blood

i.        8—Sea water

j.        9—baking soda

k.      10—Great salt lake

l.        11—Ammonia

m.    12—Bicarbonate

n.      13—Oven Cleaner

o.      14—NaOH

15.  Acid bas compensation

a.       Buffer system

b.      Respiratory system

                                                  i.      Co2 = hydrogen

1.      as respiration increases, co2 decreases, hydrogen decreases

2.      As respiration decreases, co2 increases, hydrogen increases

c.       Renal system

16.  Disorders

a.       Respiratory Acidosis—

                                                  i.      Patient is breathing too slowly.

1.      seen in a patient who is on heroine

b.      Respiratory Alkalosis

                                                  i.      Patient is breathing to fast

c.       Metabolic Acidosis

                                                  i.      Producing to much H+

d.      Metabolic Alkalosis

17.  Normal values

a.       pH: 7.35-7.45

b.      PCO2: 35-45

18.  Abnormal values

a.       Respiratory acidosis

                                                  i.      Decreases PH

                                                ii.      Increases Co2

b.      Respiratory alkalosis

                                                  i.      Increase pH

                                                ii.      Decreases PCO2

c.       Metabolic Acidosis

                                                  i.      Low pH

                                                ii.      PCO2 high

d.      Metabolic Alkalosis

                                                  i.      Increase Ph

                                                ii.      Normal (increase if compensation)

e.       The higher hydrogen goes, the lower the pH goes

f.       Acidosis is low Ph numbers

g.      Alkalosis is high Ph numbers

h.      Co2 is not directly related to metabolic acidosis or alkalosis. It is related to respiratory acidosis and alkalosis.

i.        Respiratory opposes; metabolic agrees

The heart relies almost exclusively on electrolytes.  

1.      IV therapy

a.       Definitions

                                                  i.      IV / Venipuncture

                                                ii.      Peripheral  / central

                                              iii.      Intraosseous Access

                                              iv.      Fluid Resuscitation

                                                v.      Medication access

                                              vi.      Crystalloids

                                            vii.      Colliods

                                          viii.      Isotonic

                                              ix.      Drip Rates

                                                x.      KVO / TKO

b.      Indication for venipuncture

                                                  i.      Volume

1.      dehydration

a.       water

b.      electrolytes

2.      Blood loss

a.       Colloids

b.      Crystalloids

                                                ii.      Venous access to circulation

1.      blood collection

a.       labs

b.      field chemistry

2.      Medication Administration

c.       Fluid resuscitation

                                                  i.      Dehydration and volume loss

1.      replace lost fluid or blood

2.      often requires 2-3 times the amount lost (2:1 rule)

                                                ii.      Shock management

1.      controversial

2.      Definitive therapy = surgery and blood replacement

3.      EMS-> judicious replacement

4.      Improve end organ perfusion (BP at 90-100 mm Hg)

d.      Equipment

                                                  i.      Normal saline

                                                ii.      Lactated Ringers

                                              iii.      5% dextrose in water (D5W)

                                              iv.      Other (D5 and ½ NS)

e.       Supplies

                                                  i.      IV catheters

1.      over the needle

2.      Thru the needle catheter

3.      Hollow Needle/ Butterfly needles

4.      Intraosseous needle

                                                ii.      Infusions sets

                                              iii.      Alcohol and Betadine

                                              iv.      Restricting Band

                                                v.      Tegaderm / venigard

                                              vi.      Tape

                                            vii.      Armboard (optional)

                                          viii.      Labels

                                              ix.      Saline lock

f.       Crystalloid fluids

                                                  i.      Volume replacements and increasing cardiac output and blood pressure

                                                ii.      Isotonic

                                              iii.      No proteins

                                              iv.      Moves into tissue over short time

g.      Colloid fluids

                                                  i.      Large proteins

                                                ii.      Remain in vascular space

                                              iii.      Blood replacement products

                                              iv.      Plasma substitutes

1.      dextran

2.      hetastarch

h.      choosing fluids and catheters

                                                  i.      catheters

1.      over the needle preferred (IO in peds) (18 & 20)

2.      Size depends on patients needs and vein size

3.      Large gauge and short length for volume replacement

                                                ii.      Vein selection

1.      for most patients, choose most distal

2.      Hand, forearm, antecubital space and external jugular

3.      Normal Anatomy provides clues to locations

4.      avoid injury, fistula, mastectomy side,

i.        Theory of fluid flow

                                                  i.      Flow= diameter ^4 / length

1.      larger catheters = higher flow

2.      Short catheter = somewhat high flow

                                                ii.      Other factors affecting flow

1.      tubing length

2.      size of vein

3.      temperature and viscosity of fluid

4.      warm fluids flow better then cold

j.        Tips on increasing flow

                                                  i.      Use a large vein

1.      large AC preferred for cardiac arrest, trauma, adenosine and D50 administration

                                                ii.      use short large bore catheter

k.      puncture tips

                                                  i.      talk to your patient

                                                ii.      flush air from tubing

                                              iii.      start distal, work medial

                                              iv.      Stabilize the extremity and skin

2.      Intraosseous (IO) Infusion and Vascular Access

a.       Common IV sites for Pediatric patients

                                                  i.      Peripheral extremities (hand, wrist, dorsal foot, antecubital)

                                                ii.      Peripheral other (external jugular, scalp, intraosseuos)

                                              iii.      Neonate (umbilical vein)

b.      Any drug or fluid that can be given IV may be given by the IO route

c.       Little interference during resuscitation

d.      Indications

                                                  i.      Required drug or fluid resuscitation due to an immediate life-threat

                                                ii.      At least 2 unsuccessful peripheral IV attempts

e.       Contraindications

                                                  i.      Placement in or distal to a fractured bone/pelvis

                                                ii.      Placement at a burn site

                                              iii.      Placement in a leg with a missed IO attempt

                                              iv.      Increased difficulty in patient older then 6 years.

f.       Placement location

                                                  i.      Anteromedial surface of the tibia

                                                ii.      Approximately 1-3 fingers (1-3cm) below the tibial tuberosity

                                              iii.      Generally safe location with large marrow cavity

                                              iv.      Avoid closer location to the knee due to growth plate

g.      Complications

                                                  i.      Sepsis

                                                ii.      Hematoma

                                              iii.      Cellulites

                                              iv.      Thrombosis

                                                v.      Phlebitis

                                              vi.      Catheter fragment embolism

                                            vii.      Infiltration

                                          viii.      Air embolism