Transcript
I'll be taking a look a little bit deeper dive in the next phase of this process of patient assessment.
And it would be taking a look specifically at the airwave breathing challenges in sports injury.
So just a little bit of disclosure.
I am a co owner of Action Medical Consultants, no endorsement, brand of equipment display.
Objectives.
We're gonna look at the accurate assessment of airway and breathing, identify some some key factors, and then take a look at some interventions then we'll have some application here at the end.
So we go back to this slide, and and and if you haven't sort of put this together, Ray was really focused on number 2.
And that is the c size up and the really, really bad things that could take place and what we need to be prepared for.
And so I'm going to dive into number 3 here, and just a bigger reference as a series of webinars that we're going to have every month is we're gonna constantly be building on top of this So this is just the beginning of a large curriculum that will stack up, and we will get into a lot more of the secondary assessment in vitals and and some of the more application, but we're doing a thirty thousand foot view on these core of front components.
So as we dive into this, this is reflective of of number 1.
Are you prepared?
Do you have a scope of practice that aligns with your equipment?
Do you have medical direction over this?
Do you know how to use it?
Have you checked it?
All of the preparation that goes into an emergency action plan can't overstate the preparedness of having the right equipment at the right time.
There's nothing more frustrating.
Than being in an emergency situation and reaching to grab something and it's not there or it doesn't work.
So always making sure that we are prepared before we go into a scene.
So in this, we're gonna take a look at airway of breathing of unstable patients and just sort of talk about some of the overarching themes that are around us, these ABCs really raise focused a lot more on the c element of this, and we're gonna dive into the a and b element.
So when we take a look at, like, what what do we do when it comes to the airway?
Well, first, we have to make sure the airway is open.
And so when an unconscious patient, Our practical skills that we apply is either a gel thrust or a or a head tilt chin lift.
And so that's how we establish or evaluate, and we will listen and feel.
That's an unconscious space.
And what about a conscious space?
And when we're trying to see what are the what are the blockages that could possibly be taking place?
And so if you listen to these long I'm saying and I and I hopefully, you can hear it.
Alright.
I'm going to assume you heard that.
So if you could yeah.
Let me know when it comes to Ray, Could you hear that?
No.
I was not able to hear it, but you may want to you know, if we need to, you know Yeah.
I don't want to access activity.
Yeah.
That's fine.
We're we're gonna keep moving on.
But if you can Google long sounds on the Internet pretty easy.
But the point is that if you hear a strata versus a crackling versus a wheezing, having a fundamental knowledge of the respiratory system is critical for you to be able to understand what you're up against.
So if you're here wheezing, you're typically going to have a constriction of the bronchial tube as well as a mucous secretion and a swelling.
If you hear straddlers, you're going to hear a typically an upper airway constriction.
Where the pipe is getting smaller.
And if you hear crackly, you wanna typically hear a fluid accumulation somewhere now realized saks all the way up through.
So just understanding that it doesn't have to be a complete blocked airway.
Airways can be block in a multitude of factors, some that are significant, some that are minor, but just a just a indication that block airway or airway blockages can come in a wide variety of forms and the ability to have an intervention for that on the most aggressive side will be the suctioning aspect that would be needed In most cases, medication is going to address most of these, but you can have a variety of block elements here.
Okay.
2nd big one here is the tongue occlusion.
And so when we think about the tongue, it's mostly in the It's mostly in the unconscious person, but I'm going to play this and just as a reminder of how important this tongue is in in the blockage.
So you can see right here where their tongue is sitting back in the back of the airway.
Of course, we know this is quite often as sleep apnea where the tongue rocks back and begins to block in course You don't have to be able to have this, but but we call this snorkeling.
Snorkeling is a hot pitched sound or a strider sound.
But just the role of the tongue that plays in this blockage is very important to respect that.
And so we have an indication of an unconscious person.
And as I said, well, we need to do the job for us.
They're a head to toe channel lift, but probably the number one thing in teaching this to students, as I've told it for many, many years, is they will get so excited about look, listen, and feel that they forget to do the head to your chin lift on the jaw for us, which is that's the whole idea behind it is you have to get that tongue off the back of the throat in order to get a good evaluation of the airway and the breathing process.
So that is a very important out that you have to always remember is in respect how much the tongue can include the airway when you're trying to do an evaluation.
And so we go into the evaluation of somebody that is breathing too slow.
So when we say radiate typically, we're looking at breaths of less than 8 breaths per minute, also classified as agonist respirations, and they are they are a clear indication that it is inadequate, and you will have to do some form of positive pressure ventilation.
Now you see on our screen, A bag valve mask is probably the most common technique where you're going to have to force air into those lungs.
A pocket mask is also appropriate.
And mouth to mouth is another technique, typically not as a healthcare professional, but the whole idea is that we're going to respent those loans and with the hopes that it will restart itself But in most cases, we're just ensuring that adequate oxygen is getting too long to intrapenia so that we get the respiration that is needed in order to deliver oxygen and to and to remove carbon dioxide.
So it is an important element that we evaluate less than 8 breaths per minute and are just in general inadequate breathing or when we teach CPR, we call that signs of circulation.
Which kind of bundles a lot of of those elements, meaning pale cool clammy skin in conjunction with inadequate breathing, but bradypeanium.
So then we move to now breathing too fast.
And if we know anything about the physiology of the respiratory system, and we know anything about what we call dead space.
Dead space is basically the the air that never gets to the idealized sack.
So take a deep breath right now.
Right?
How many milliliters did you breathe in?
On average adult, take a deep breath back.
You breathe in about 500 milliliters.
Well, only 2 thirds of that actually got to that Veloc sec.
Well, what happened to the other third?
That's what we call dead space.
It never made it to there.
It's called tidal volume.
So start reading real fast right now.
Read real fast.
Like your tachympedia right above 30, 1 every second.
1 every 1 every second would put you about 60.
Right?
You can do this at 30.
And so we had a lot of that air that you were breathing real fast in dead space.
Which means it never got the Velox act.
So even though you were breathing really fast, very little actually got to the Velox sex.
So it's as if you were not breathing at all.
And so the body is trying to fight to recover that and the challenge into the Lima is the idea that you're blowing off too much c 02, which is really is really the driving factor of the whole reading process.
So what do we do?
Like like like understanding, like, when you're reading too fast that it is not getting to the respiratory till they got VLS sack for respiration.
You're going you you man, you're throwing your whole breathing process off of whack.
So what do you do?
Well, first of all, as as we're not here to dive too deep into interventions at at this point, but you're gonna try to coach them down and try to reestablish your norm or try to capture some more CO to.
But if they go unconscious, then you definitely have all indications to begin positive pressure ventilation with a doctor, it looks like they're breathing.
They're breathing really fast.
But, again, it's dead space.
It's not getting to that mailbox.
So you have to begin to supplement that with positive pressure ventilation and supplement it with CO2.
Alright.
So Another element that we have to consider is tidal volume, and that includes just like we said, shallow breathing now.
A lot of things can calls this, it can be more than just hyperventilation syndrome, drug overdose, the psychological effects, real fractures, pain sedation, a lot of reasons.
And so this is just a graph to reemphasize that we're not getting enough tidal volume.
We have a lot of air just going to the dead space.
It doesn't make it to that Villasack, and we need to perform interventions.
So this can be a very critical state at first the body's compensating and it doesn't look as bad, but a person will not last very long when they have an inadequate tidal volume.
One of the last elements here is just the overall compliance of this wonderful thing called the respiratory system, which is just more than just two lungs and an airway that that comes out to two holes, right, the nose and amount.
This this lungs is quite a fascinating physiological element with the pleural space and the pleural space having negative pressure in it.
It's like a suction cup that splits the lungs, and then you have the the elasticity of the lungs, and then you have this thing called the heart between the lungs.
So there's not a lot of space in it to play with, but that space is all under pressure.
It's all under a cavity, and it works beautifully by the big thing called a diaphragm pushing and pulling.
And so you have this wonderful sort of the last stability that is taking place that allows you to breathe.
And sometimes those elements of pressure within the pleural space, within the cardio thoracic space, they get out of balance, and that begins to throw this whole thing into a spiral.
So the compliance element I that again was a thirty thousand foot view of all the major things that could go wrong when it comes to you evaluating airway and reading under the primary assessment.
Now I wanna spend a little bit of time.
I need your input your feedback.
And so let's let's we've got about 4 things here, and we got got some time to take a look at this.
What is your impression of this girl when it comes time for?
Let me open up my chat here, make sure I can see your responses.
So let's take a look here.
Known a road trip, and this girl says, I've gotta throw up.
And her, you know, that potential airway blockage can potentially happen.
Let me see in your chat.
Like like, what's your priority clear airway versus seeing safety?
This individual had that dilemma that we throw up in the middle of Buzzwell was not prepared to capture this.
And so these look like significant chunks.
And if we mishandle this airway, we can bad things can happen with the epiglottis.
So in the chat, will you do clear airway versus scene safety?
Which one would you consider to be the most important?
Clear airway or scene safety.
Put it in a chat.
Let's see.
Russell says clear in the airway.
Clear the airway, Danielle.
Yeah.
Go ahead.
Yeah.
Doctor Harp, I guess one question would be, is is the bus moving, or is it still?
Great question.
See, that that I don't give you a video.
If I had a video and you say Don't talk to give me a lot more information, I can make a better decision.
Sometimes you do have a lot of information.
Sometimes you have limited information.
I'm going to say that the air that the bus is moving.
They did not stop for her.
So I'm gonna I'm gonna throw in the bus is moving down the road.
And this girl's throwing up, she sticks her head out the window, you're trying to support her hand.
She stuck her head out the window, throwing up, which and the bus is moving.
Yeah.
So the point here is that sometimes you're thrown between a rock and a hard place.
The rock and hard place here is that you have to clear the airway.
That is like paramount for this girl to continue.
To get air while you're trying to manage the scene and sometimes they merge at the worst time ever, but you have to gauge which one gathers the most critical attention that you need.
Now at some point in time, as your manager's airway, you deem that that scene is becoming unsafe then you would have to pull her head back in.
We'll have to vomit and clear her airway.
You do not like this, but you would have to do that inside of the bus.
And then all of a sudden seeing safety takes care amount.
If you were coming up on a roadside, are you about to enter into something that could hurt that girl?
Sometimes you got a teeter totter between seeing size up and an airway in a scene like this.
Okay.
Next question here.
What's missing in this to anybody?
Everybody figure out what's missing.
What is the provider not doing or have not done yet.
Anybody?
What are they missing?
What are they what are they not done it yet that they need to do.
That's part of scene size up.
But he caught it yet?
Oh, excellent.
Daniel, gloves.
She had a she she has a protector herself.
Now that's easier said and done on how it means carrying gloves in their pocket.
Riding down a road on a bus trip with an athlete.
But but yeah.
Absolutely.
Once again, rocking hard place.
See safety versus BSI.
And so you're trying to support her head.
So if she doesn't banging around, you're trying to keep it outside the bus, while you keep the same safe, and you're trying to eliminate your exposure.
And then eventually, you will try to get protect your gloves as quick as you can.
You know, we make these checklists look so easy and clear like BSI C safety MOI number of patients do you need any more help than than your CABs.
Right?
Check, check, check, check, check, but in real time, you have to quite often manage all of those at the spur of the moment and and apply those principles.
So Good.
Let's take a look at another one.
Let's do athlete in a dorm.
Call you down.
Work in a camp in this summer.
And say you need to kept you need to come and check on Bob here.
Bob Bob is laying there.
Unconscious, you walk in.
So as far as airway goes and you have to evaluate, and can is he breathing or not?
How can you tell?
Can you tell without rolling him over?
Say yes or no.
Can you tell him can you tell if he's breathing without rolling him over?
Do you wanna roll him over before you start evaluating his breathing?
Do you wanna roll him over before you start evaluating his briefly?
So That's that's, again, it's like, I would really like to see and evaluate him before I move him because I got more questions to ask, like, did he hit his head?
Right?
Is it seem safe?
Do I have my gloves on?
Like like, I'm I'm processing things and I really don't wanna move anybody just yet, but I'm on a very short leash Yeah.
Yes.
You could feel for breathing or use glasses that could be fogged up.
Yeah.
Absolutely.
I'm on a very short time frame to make this determination because we know the brain can only last without oxygen.
So what about his tongue?
Is his tongue an issue in this thing?
Is it is it a potential blockage.
He would need to be on his back for it to really, but at the same time, It could be.
Could there be other things blocking his airway?
Yes.
But we would roll him over after we determine whether or not he's breathing adequately.
Because if we can determine out why he's laying down, I'm okay with leaving him there for a short period of time until we can gather more information.
So just rolling somebody.
I hate that one.
I see people do that.
Just, hey.
You okay.
We roll him over.
No.
Let's do an evaluation of his airway before we roll him over.
Alright.
Very good.
The cease my precautions are needed.
How do you open his airway?
Well, that's gonna be as we know a job for us once we get him over, and we have any indication that it was a a potential blocked airway, then we're going to lift that tongue off the back of that throat once we get him over.
Alright.
Got 2 more to go.
Got about 8 minutes here.
So what would be your impression that we achieved the plan?
I know this is cartoonish, looks like AI generated, but but it really does a good do a good job of us looking at the patient doing an assessment, but I'm just curious.
I know what I said, but before I announce what I've think my general impression about her airway and what I'm expecting her lung sounds to be before I even evaluate them.
What do you think?
Her long sounds are going to sound like even before you get a stethoscope out or you start to get closer and listen.
Yeah.
Russell says straddlers.
I'll pit sound.
K.
You bet I'll.
Yeah.
Danielle says she's thinking she's thinking asthmatic out.
Anybody else?
Kind of blocked airway would this type of athlete have Chad said shortness of breath?
Yeah.
I would assume that if she's breathing more than 30 times per minute, it's dead space.
No matter what the blockage is, oxygen is not getting to the Avila sac.
So she's breathing above 30, and I can evaluate that within a second.
When I look at her breathing, I didn't even introduce myself, and I can tell whether or not she is getting adequate respiration, so definitely shortness.
If I had to guess between crackling, asthma, And Strider Strider will be a hot pit sound where the pipes are are shrinking.
I would my first guess would be asthmatic.
So as I would approach this, is she's breathing more than 30 within what causes asthma.
And we're not gonna go deep into that, but the mechanism is that the bronchospasms mix in with some mucous secretion is causing this wheezing sound.
But it's a yes.
Right?
It's your impression.
It's your evaluation.
It's your interpretation, and it's all happening incredibly fast.
Alright.
Let's take a look at this one.
General impression on chief complaint, athlete's gravity's chest, you have some information, limited information as to what's going on.
What would you say?
Chest pain, are breathing difficulties in your gut feeling as you walk up to this athlete.
Which one would you which one would you anticipate to be.
You know?
And he also says chest pain.
Now with that chest pain difficulty breathing.
See, you're good.
You're good.
And y'all get this just like we do.
And this is just a quick review at how we take for granted our experiences in common sense as to doing an assessment before we even introduce our sales get permission like we're already well down the pathway.
However, However, we can't rule out breathing difficulties, but we do.
It starts to lean us into chest pain versus breathing difficulties.
But they can also be related because 1, because you understand the anatomy of the pleural space and the thoracic cavity, and that that pleural space and that diaphragm can be manipulated with.
And, yes, you can have chest pain that then leans you into breathing difficulties in the whole theme becomes derailed very quickly.
Okay?
My last question before I turn it over for Q And A and Take your shoulder pads off or leave them alone.
What do you think?
That's always my dilemma.
This dude is hurting.
This dude is you you were trying to take a pair of shoulder pads like that off these days?
Now it is not an easy task to get those suckers all without a pair of scissors.
And then you know the cost and who's gonna fuss at you.
You know?
Russell, Ben says not yet.
Leave him alone.
Have you all you all you all realize all I already do is to get those things off.
And if you have somebody under stress and you try to take them off, gosh.
That's even more stressful and at at least would take me a minute and a minute and a half to try to get those off not cutting them off.
And, yeah, I'm with you.
I would start with leaving them alone.
Even though they're stupid tight across their chest, We would know we'd have to get under there and there we go.
Yeah.
We would have to start loosen them up, like, undo the straps, undo the strings, give the same room to breathe.
Like, let's take a look at the assessment.
You need to touch.
We need to feel and we need to begin to do.
But this could turn into hyperventilation really quick within Leases blowing off too much CO2.
Which then could potentially lead to some mucus accretion, and then we would have indications that our interventions are not working and we would then need to take them off and take more aggressive action.
So as we wrap this up, Again, it's a thirty thousand foot view.
Airway comes in the form of blockages.
It comes in the form of rates.
We have to do in a assessment.
We have to figure out very quickly how much trouble we're in, what quick interventions we can begin to start thinking about, and that leads us into sort of the review of our, you know, of where we're at in this evaluation process.
Right?
Any follow-up questions on that?
Yeah.
I think let's see if I I'm showing up here.
Hang on one second.
Let me do Sorry.
Doing a gallery thing.
So don't see if you have any questions, definitely throw them in the in the chat if you would or if you'd like to just raise your hand.
We can we will get you to turn the audio video on.
I guess when we have a minute or 2, waiting for questions.
So a couple of things kind of, I guess, if you were to look at.
One is chest compliance.
And those are 2 things that really kinda, you know, that.
And then another I'm not gonna hit a lot on is because there's a whole another conversation that you're looking at by entitled CO2 as that measurement side as well, but, boom, just compliance.
If you would talk a little bit about the difference we may have a coach who's not or just a just a bystander who's not exercising, who is not physically fit, doesn't have that in odor could you kinda talk briefly about the differences you may they may encounter versus an athlete who has a who would have a Holly viable chest wall or movable chest wall and what that difference may look like just from a how it affects the vital signs and things like that briefly.
Watch.
We me and Ray worked at Marathon on Saturday, and I've been working a lot of these racing events, and I'll spend about 5 hours at the finish line, 5 hours watching 4 thousand people run a marathon or half marathon, take their bodies to the max.
And when they came across the finish line, right, those first, third that finished, they were freaking machines.
They were by the time they got out of the tunnel, they they were already recovering because their elasticity, their compliance in their chest wall had been in well trained.
The last half to third of the people who cross it finish line, their compliance and their chest wall was not as developed and not as trained, and they were quite older.
And so those were the ones that did not respond very quickly and often needed assistance.
So it was pretty cool just physiologically to watch and think about or how the respiratory system can be taken to its max.
Yep.
And then watch individual bodies all respond differently to taking it to the max.
Now it wasn't an injury or illness But at the same time, it was outside of its normal capacity.
So in essence, it was an injury illness to run a half marathon or marathon.
And watch your body try to fight back and rebalance itself.
Yeah.
That's the one thing you see, you know, if you've like, those older if you see an older patient or someone who not can be younger who has a highly restrictive chest chest wall.
It could be from a disease, you know, a long term disease process.
They're just not they're for that for what that situation brings or not having that movement or could be, like, you showed that last image with the football player having the injury they're not able to move the chest wall.
It's a it's a they they're that chest wall compliance is is being restricted due to pain.
So our physical trauma, etcetera.
So not having that movement, it affects you hit on earlier hits title bot, and it impacts the levels the oxygenation perfusion levels, ventilation rates, the whole shoot max.
So then they start going into that that hyperventilation mode lap the which gets into another topic in well, my thought, we we're running out of time, but definitely one that we would want we're gonna talk on sooner or later, get someone to do this is on just the entitled c 02 and what that measure we didn't even hit into that today.
You didn't not even touch on that today.
That's a whole another topic in itself from a diagnostic criteria that really is, you know, an EMS uses a lot but we don't see the light.
The cost will probably probably come from a cost restriction, but it is something if you can just kind of eluded that for 30 seconds, and we'll wrap things up.
All that is in the measurement of how much c 02 you're blowing off, and it's used through a tool called capnography.
And so it's a critical measurement that is indicative of what ventilation rate that you should hit.
So whenever 5 is typically an adult, but you can be even more prescriptive.
It could be 1 every 4, 1 every 6.
All that does is just tells you the rate that you need to rebalance.
The breeding rate per person.
So it's just a prescriptive way to identify your ventilation rate
6 Crucial Breath Checks: Navigating Airway and Breathing Challenges in Sports Injuries
General Course Information
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Presentation (Video)
Updated Jan 22, 2024
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