Brett

A patient was bitten by fire ants and is unconscious. He has severe edema to the face and neck and generalized urticaria. Breath sounds are difficult to hear, and loud inspiratory stridor is noted. Which of the following interventions has the highest priority? A. Endotracheal intubation B. Administration of epinephrine C. Administration of diphenhydramine D. Immediate transport

A. Endotracheal intubation The patient's upper airway is rapidly swelling as evidenced by the markedly diminished breath sounds and loud inspiratory stridor. If the patient is not promptly intubated before the airway completely closes, you will have to perform a cricothyrotomy or the patient will die. After the airway is secured and the patient is being adequately oxygenated and ventilated, you should administer epinephrine, followed by diphendydramine (Benadryl). Transport the patient as soon as possible.

Which of the following is the MOST appropriate and effective method of oxygenating a semiconscious patient with slow, shallow breathing? A. Nasal cannula at 1 to 6 L/min B. Nonrebreathing mask at 15 L/min C. Bag-mask device and high-flow oxygen D. Oxygen-powered transport ventilator

C. Bag-mask device and high-flow oxygen Patients with slow, shallow (reduced tidal volume) breathing are not taking in sufficient amounts of air to maintain adequate minute volume and require some form of positive-pressure ventilation. This is especially true for patients who are semiconscious or unconscious. Assist the patient's ventilations with a bag-mask device attached to high-flow oxygen. Neither the nasal cannula nor the nonrebreathing mask will improve the patient's tidal volume, and would therefore be of little benefit to the patient with inadequate ventilation. Transport ventilators are used for unresponsive apneic patients, generally after they have been intubated.

A 30-year-old man overdosed on a large quantity of codeine and has respirations of 6 breaths/min with reduced tidal volume. Which of the following conditions will he develop initially? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis As respirations decrease in rate and depth (tidal volume), carbon dioxide is retained by the body. This leads to an initial state of respiratory acidosis. If left untreated, metabolic acidosis will result as the cells of the body begin producing lactic and pyruvic acid secondary to anaerobic metabolism. Remember that the treatment for acidosis, regardless of the underlying cause, is adequate ventilation.

A 50-year-old man with a self-inflicted gunshot wound to the face is apneic. He has multiple fractures of the mandible, massive soft tissue damage, and severe oropharyngeal bleeding. Which of the following methods of airway control will be MOST effective for this patient? A. Orotracheal intubation B. Nasotracheal intubation C. Surgical cricothyrotomy D. Oral airway and bag-mask ventilation

C. Surgical cricothyrotomy Managing the airway of a patient with massive maxillofacial trauma can present a challenge to even the most experienced paramedic. In this case, orotracheal intubation would be extremely difficult because of the blood in the patient's mouth and his mandibular fractures (orotracheal intubation relies on a stable mandible). Nasotracheal intubation is contraindicated because the patient is apneic. Bag-mask ventilations will likely be ineffective because maintaining a mask seal will be extremely difficult. Furthermore, bag-mask ventilation in a patient with active oropharyngeal bleeding will force blood into the lungs, causing the patient to aspirate. Although considered as a last resort, this patient is a candidate for a surgical (open) cricothyrotomy.

An elderly man is unresponsive and apneic. What should you do? A. Perform immediate intubation. B. Provide two rescue breaths. C. Assess his cardiac rhythm. D. Assess for a carotid pulse.

D. Assess for a carotid pulse. After determining that an adult patient is unresponsive and apneic, you should assess for a carotid pulse for at least 5 seconds but no more than 10 seconds. If a pulse is present, provide rescue breathing (10 to 12 breaths/min in the adult). If a pulse is absent, begin CPR (starting with chest compressions), then open the airway and give two rescue breaths. Continue CPR and assess his cardiac rhythm as soon as possible. If you are able to effectively ventilate the patient with an oral airway and bag-mask device, intubation should not be a high priority. Furthermore, you should not attempt intubation until the patient has received at least 2 to 3 minutes of preoxygenation. Rare is the need to immediately intubate anyone.