# Confusing airway question..



## Jay506 (Jun 16, 2011)

*9. What would be the correct sequence of treatment for a 76 year old female with a pulse of 142. The patient is also cyanotic around the lips and nail beds?

Your Answer: Ventilate her with a BVM and transport

Incorrect

Correct Answer is: Continue assessing en route to the hospital and apply high flow O2

Other answers:

Continue assessment to determine cause and call ALS

Perform a rapid trauma assessment and transport rapidly

Rationale: Getting the patient some oxygen is priority number one under these circumstances. Doing so on the way to the hospital without delay would be necessary.
*

Hello all, was looking for some words of wisdom for the above question, answer and rationale.  If a person is showing signs of inadequate ventilation(cyanotic)...wouldn't you want to ventilate for them(BVM) as opposed to simply applying high flow o2?  Or are they one in the same?  I thought simply applying high flow o2 would be via NRB mask.  

I imagine this is one of those questions where there are more than one correct answer and we should pick the "best", so does anyone know why this would be considered the "best" answer?

Thanks for any info.


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## MassEMT-B (Jun 16, 2011)

They are showing signs of inadequate perfusion, it doesn't mention rate or chest rise and fall/tidal volume to say if they are breathing adequately or not. Perfusion is the actual o2 entering the cells and taking the co2 and other bi products away. The fact they are cyanotic just means not enough o2 is getting the cells. For your class you are suppose to use the BVM based on their breaths per a min and their chest rise and fall. A patient becoming cyanotic would be an indication of o2. If I am confusing at all, ill try and explain it better. I have a tendency to confuse that crap out of other people while it all makes sense to me haha.


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## Akulahawk (Jun 16, 2011)

Jay506 said:


> *9. What would be the correct sequence of treatment for a 76 year old female with a pulse of 142. The patient is also cyanotic around the lips and nail beds?
> 
> Your Answer: Ventilate her with a BVM and transport
> 
> ...


Two things jump out at me. One is that NOTHING is said about the patient's respiratory drive. This patient may be ventilating fine... but needs more oxygen. Start with that. Two, you want to be able to continue doing assessments during transport to determine the need for additional therapy. You _might_ eventually have to use the BVM, but at this point, nothing is pointing to needing to...


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## MrBrown (Jun 16, 2011)

Bag mask is only for somebody who has an inadequate tidal or minute volume.

This lady could have adequate ventilation but inadequate oxygenation, remember the two are very different, separate processes.


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## Jay506 (Jun 16, 2011)

MassEMT-B said:


> They are showing signs of inadequate perfusion, it doesn't mention rate or chest rise and fall/tidal volume to say if they are breathing adequately or not. Perfusion is the actual o2 entering the cells and taking the co2 and other bi products away. The fact they are cyanotic just means not enough o2 is getting the cells. For your class you are suppose to use the BVM based on their breaths per a min and their chest rise and fall. A patient becoming cyanotic would be an indication of o2. If I am confusing at all, ill try and explain it better. I have a tendency to confuse that crap out of other people while it all makes sense to me haha.



No, not confusing at all, very helpful actually.  I guess I got confused and thought being cyanotic is a direct sign of inadequate breathing when in reality it's inadequate perfusion?  So only artificial ventilation when there's signs of poor ventilation such as chest rise, tidal volume?  If it seems like there breathing(ventilating) fine a NRB will do, but if not only then use BVM?


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## Jay506 (Jun 16, 2011)

Thanks for help everyone


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## MassEMT-B (Jun 16, 2011)

Jay506 said:


> No, not confusing at all, very helpful actually.  I guess I got confused and thought being cyanotic is a direct sign of inadequate breathing when in reality it's inadequate perfusion?  So only artificial ventilation when there's signs of poor ventilation such as chest rise, tidal volume?  If it seems like there breathing(ventilating) fine a NRB will do, but if not only then use BVM?



Its like how all squares are rectangles but not all rectangles are squares. If someone is breathing inadequately eventually they will become cyanotic, but they can become cyanotic while breathing adequately. If they are breathing fine then yea a NRB will do fine. If they are not breathing adequately you will most likely use a BVM with high flow o2. That is it from me, just a basic. I am sure a higher level provider will be around to fill in the gaps or what I missed or go into more in-depth than I can.


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## medichopeful (Jun 16, 2011)

MassEMT-B said:


> Its like how all squares are rectangles but not all rectangles are squares. If someone is breathing inadequately eventually they will become cyanotic, but they can become cyanotic while breathing adequately. If they are breathing fine then yea a NRB will do fine. If they are not breathing adequately you will most likely use a BVM with high flow o2. That is it from me, just a basic. I am sure a higher level provider will be around to fill in the gaps or what I missed or go into more in-depth than I can.



I'll jump in here really quick and just delve into this a bit more.

First, think of the oxygen cascade, the path of oxygen into the body, and the physiology/pathphysiology of breathing.

When you breath, air is drawn in by a lowering of the diaphragm, which increases the volume of the lungs.  This increase in volume leads to a decrease in the pressure in the lungs, which causes air to rush in.  Once this air comes in from the atmosphere, it travels through the naso/oropharynx, down the trachea, through the bronchioles, and into the lungs.  Once in the lungs, the oxygen is "handed over" to the hemoglobin (and the bloodstream in general, not all oxygen is carried in Hb), where is is then distributed to the cells, where it leaves the hemoglobin and helps with cellular respiration.

This is a pretty basic rundown, but it should give us a good starting point.  We're dealing with the different causes of cyanosis, and we'll focus on two causes: lack of air intake, and lack of oxygen exchange.

The purpose of a BVM is to force air into the lungs to make sure that the patient is getting enough oxygen to survive and support cellular respiration.  If the problem is that the patient is not drawing in enough air (for example, from diaphragm malfunction, obstruction, tachypnea, dyspnea, etc.), simply putting them on a NRB or NC isn't going to do much good.  Sure it will give them oxygen, but how much of that is being put to good use?  Not necessarily much if they're not drawing in enough of it to make a difference!  So you're going to have to assist them in taking in air.  for example, if they have a diaphragm injury and it's not doing its job, you'll have to replace the diaphragm with a BVM.  Make sense?

Now let's take a look at the other case, where they're drawing in enough air but there's a problem internally.  For example, let's say some of the alveoli aren't functioning correctly, and thus not the correct amount of oxygen is making it's way into the bloodstream.  This may not be a case of not taking in enough air, but rather not exchanging enough oxygen at the cellular or alveolar level.  So what would be a good way to deal with this?  If they're taking in enough air, why force more in with a BVM?  What they need is a higher concentration of air, which will (hopefully) increase their SpO2.

Does this make sense or help you out?  I hope it does! lol

Eric


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## jwk (Jun 16, 2011)

Jay506 said:


> No, not confusing at all, very helpful actually.  I guess I got confused and thought being cyanotic is a direct sign of inadequate breathing when in reality it's inadequate perfusion?  So only artificial ventilation when there's signs of poor ventilation such as chest rise, tidal volume?  If it seems like there breathing(ventilating) fine a NRB will do, but if not only then use BVM?



Just a couple things...

Cyanosis is a sign of inadequate oxygenation, which may come from any number of different causes.  

Breathing(ventilating) are not the same thing.  Someone who is breathing may not be ventilating well (hypoventilation).

The two processes we're concerned with are oxygenation (getting oxygen into the lungs and blood and out into the tissues) and ventilation (getting CO2 out of the bloodstream and exhaled out of the lungs.  Some patients have problems with one or the other - and some have problems with both.


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## njemtbvol (Jun 16, 2011)

idk about you guys, but pulse of 142 and cyanotic, I'm CYA and calling medics..


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## MassEMT-B (Jun 16, 2011)

njemtbvol said:


> idk about you guys, but pulse of 142 and cyanotic, I'm CYA and calling medics..



In real life, yes (well not at my service, all trucks are ALS but I digress) but, these are questions I am guessing for a class. EMT class is for you to learn what to do, not just call ALS and do no real interventions but perform an assessment. But to know how to deal with situations to the best of your ability for when maybe there isn't an ALS intercept available or whatever the case maybe.


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## usalsfyre (Jun 16, 2011)

njemtbvol said:


> idk about you guys, but pulse of 142 and cyanotic, I'm CYA and calling medics..



Even if your closer to the ED than to a paramedic unit?


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## Akulahawk (Jun 16, 2011)

njemtbvol said:


> idk about you guys, but pulse of 142 and cyanotic, I'm CYA and calling medics..


While that is probably a VERY good idea in real life... testing doesn't assume real life. In any event, aside from calling the medics, how would you treat the cyanotic adult patient who has a pulse rate of 142? Do nothing until the medics arrive? Remember,  you may be in a place where BLS transports nearly EVERYTHING and ALS may or may NOT be readily available.


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## njemtbvol (Jun 16, 2011)

Akulahawk said:


> While that is probably a VERY good idea in real life... testing doesn't assume real life. In any event, aside from calling the medics, how would you treat the cyanotic adult patient who has a pulse rate of 142? Do nothing until the medics arrive? Remember,  you may be in a place where BLS transports nearly EVERYTHING and ALS may or may NOT be readily available.



In real life I'm putting her on O2, doing assessments, taking a history (in testing don't forget last oral, (( funny story about that, on the day of my pratical when I went through sample, my instructor told me that if he ever heard that I asked that on anything other than a diabetic he's revoking my EMT license)) and seeing if medics are more than about 10 mins away, if so i'm transporting with hopes of a rendezvous


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## usalsfyre (Jun 16, 2011)

njemtbvol said:


> (( funny story about that, on the day of my pratical when I went through sample, my instructor told me that if he ever heard that I asked that on anything other than a diabetic he's revoking my EMT license))


Your instructor's not looking at the big picture. This can be a VERY important thing to know come airway management time.


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## njemtbvol (Jun 16, 2011)

true true, he was an old schooler..O2 on everyone and smith if he coudn't understand/spell your last name.
not saying he was right, just that it was a funny story


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## usalsfyre (Jun 16, 2011)

njemtbvol said:


> true true, he was an old schooler..O2 on everyone and smith if he coudn't understand/spell your last name.
> not saying he was right, just that it was a funny story


Just making sure you didn't subscribe to the same theory. I probably want to know if my respiratory failure patient washed down two helpings of clam chowder with a 40oz bottle of Old English 30 minutes ago lol.


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## medichopeful (Jun 16, 2011)

Ignore.


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## njemtbvol (Jun 16, 2011)

usalsfyre said:


> a 40oz bottle of Old English 30 minutes ago lol.



If you can't tell if your patient had one of these by the way their breath smells..lol
But I do get what your saying, tho I only ask when I think it's relevant. if my pt. just broke her arm, she could have eaten a 8 course meal laced with acid and it won't make a difference..well on my report sheet for the CC anyway


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## Jay506 (Jun 17, 2011)

jwk said:


> Just a couple things...
> 
> Cyanosis is a sign of inadequate oxygenation, which may come from any number of different causes.
> 
> ...



You're right, sorry I meant breathing(respirations), I knew that much haha, but I definitely understand what the problem is now.  Very helpful


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## colorado207 (Jun 17, 2011)

Jay506 said:


> *9. What would be the correct sequence of treatment for a 76 year old female with a pulse of 142. The patient is also cyanotic around the lips and nail beds?
> 
> Your Answer: Ventilate her with a BVM and transport
> 
> ...


*

I had almost the exact same question.. plus tripod-ing. I thought BVM too. my instructor reminded me that some COPD Pts are constantly cyanotic! (which I have actually seen!) I guess It's more about tidal volume and RR. (But damn! that pulse rate is pretty high!)*


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## colorado207 (Jun 17, 2011)

usalsfyre said:


> Your instructor's not looking at the big picture. This can be a VERY important thing to know come airway management time.



I was under the impression that last oral intake was really important for the OR... :unsure: !


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## usalsfyre (Jun 17, 2011)

colorado207 said:


> I was under the impression that last oral intake was really important for the OR... :unsure: !



Maybe...but unless the patient becomes somehow unconscious anesthesia is gonna ask again anyway.


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## jwk (Jun 17, 2011)

usalsfyre said:


> Maybe...but unless the patient becomes somehow unconscious anesthesia is gonna ask again anyway.



I'll ask, and assume the patient has a full stomach regardless of what they tell me.  However, if they tell me they had two Big Macs on the way to the ER (happens all the time) I'll believe them.


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## usalsfyre (Jun 17, 2011)

jwk said:


> I'll ask, and assume the patient has a full stomach regardless of what they tell me.  However, if they tell me they had two Big Macs on the way to the ER (happens all the time) I'll believe them.



Certainly the best way of operating.


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## AMF (Jun 17, 2011)

The highest flow of O2 is via BVM, you know


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## njemtbvol (Jun 17, 2011)

AMF said:


> The highest flow of O2 is via BVM, you know



true, but somehow granny isn't going to like it when you're forcefully squeezing air down her throat when she's got adequate tidal volume..


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## jwk (Jun 17, 2011)

AMF said:


> The highest flow of O2 is via BVM, you know



Or do you mean highest FiO2?


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## DesertMedic66 (Jun 17, 2011)

colorado207 said:


> I was under the impression that last oral intake was really important for the OR... :unsure: !



Be very careful saying "oral intake". You might get more info then you want. :huh: It's happened soo many times to us we just say ate and had to drink.


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## colorado207 (Jun 18, 2011)

haha what!? 
:huh:


I can already tell, I'm going to get addicted to this forum.


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## Jay (Jul 12, 2011)

Colorado... "Last oral intake" is from your SAMPLE questions, it is the "L" and is basically the last time the patient had something to eat or drink, I usually ask "What time did you last have something to eat or drink?", if it sounds like a "meal" then I add "Any snacks? Any alcoholic beverages? Soda? Water? or anything else?", interesting thing is I never got asked once by the patient or their family why I am asking the way that I do. Even with the other questions you should probe enough to get a solid understanding for your report, e.g. "Have you taken any medications either Rx or OTC? Herbs? Drugs...etc." for meds and even with allergies, "are you allergic to any medications? foods? pollen, grass? or anything else?"... You will learn that probing can mean answers, for example what if they are allergic to shellfish and ate it 20 minutes ago but probing unveiled the answers that you were looking for.

Now onto the meat and potatoes of this post... If the Pt is in tachycardia, the odds of them being hypoxic are more than just fair because the heart will not have adequate time to pump and refill causing a decrease in effective circulation and thus hypoxia. It is true that ALS can administer drugs such as lidocaine or amiodarone or cardiocert but if the patient can tolerate the ride to the ER and you can advise the ER of the pending arrival and if it is within protocol than transport! I definitely could not condone bagging because first of all we don't know the Resps/Min. Secondly the hypoxia is caused by the cardiac condition which could be a million different things so a NRB would be the way to go. If you could check the SpO2 before the NRB is applied and afterwards I would be fairly certain that you would see the SpO2 is 94 or below and may rise steadily on high flow O2. It shouldn't drop. Also, is the patient conscious? Would they even tolerate the bagging? Always play it safe and try to think the questions through to uncover the best answer.


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## colorado207 (Jul 13, 2011)

Jay said:


> Colorado... "Last oral intake" is from your SAMPLE questions, it is the "L" and is basically the last time the patient had something to eat or drink, I usually ask "What time did you last have something to eat or drink?", if it sounds like a "meal" then I add "Any snacks? Any alcoholic beverages? Soda? Water? or anything else?", interesting thing is I never got asked once by the patient or their family why I am asking the way that I do.



Oh yep I know that. But there's a debate over how often the question is needed and/or useful. Other than diabetic and food allergy emergencies, the only reason I could assume that it would be a question often asked (especially in trauma Hx), is for anesthesiologist in the OR (should surgery become necessary.) Or perhaps knowing how much or how likely that person is to vomit.
Do you really always get so in depth with your LOI line of questioning? Or are you referring to cases where you suspect that you really need to know more about LOI from some other indicator?


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## hippocratical (Jul 17, 2011)

Jay said:


> "Last oral intake" is from your SAMPLE questions, it is the "L" and is basically the last time the patient had something to eat or drink...



I gotta ask on this one, because it's been bugging me -> Ages ago I did a Wilderness FA course where they advised that "L" should be "Last ins and outs"... So anything eaten/drunk + defecation + (here's a good one) Menstruation.

Got a female Pt? Has abdominal pain and spotting? Allegedly not pregnant? 
Q: "When was your last period?" 
A: "oh yeah, it's been about 4 months but that cant be it..."

Anyone else advise "L" being this?


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## colorado207 (Jul 17, 2011)

hippocratical said:


> I gotta ask on this one, because it's been bugging me -> Ages ago I did a Wilderness FA course where they advised that "L" should be "Last ins and outs"... So anything eaten/drunk + defecation + (here's a good one) Menstruation.
> 
> Got a female Pt? Has abdominal pain and spotting? Allegedly not pregnant?
> Q: "When was your last period?"
> ...




ooohhh cool.  yeah that is waaayyy better than simply last oral intake. (Maybe they just didn;t want a bunch of basics running around asking insignificant MOI trauma patients when was the last time they had a BM.^_^
hehe.) But yeah that is a way better use for the 'L'. Thanks!


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## MrBrown (Jul 17, 2011)

The idea behind the L was last oral intake and was supposed to be of importance for the Anaesthetist.

Now, do any of Brown's friends who are Senior Registrars or Consultants in anaesthesia actually care? No.


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## Akulahawk (Jul 18, 2011)

MrBrown said:


> The idea behind the L was last oral intake and was supposed to be of importance for the Anaesthetist.
> 
> Now, do any of Brown's friends who are Senior Registrars or Consultants in anaesthesia actually care? No.


They'll just assume that the patient just ate a huge meal and chased it with lots o'fluid and take the appropriate precautions to prevent aspiration during induction to anesthesia. Thus... they don't actually care much.

If that patient has been NPO for the past 12-24 hours... all the nicer for the anesthetist.


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## Handsome Robb (Jul 18, 2011)

Jay said:


> It is true that ALS can administer drugs such as lidocaine or amiodarone or cardiocert but if the patient can tolerate the ride to the ER and you can advise the ER of the pending arrival and if it is within protocol than transport!.



Sinus tachycardia with no ectopy and no severe hypertension isn't going to get any drugs or cardioversion.


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## Akulahawk (Jul 18, 2011)

NVRob said:


> Sinus tachycardia with no ectopy and no severe hypertension isn't going to get any drugs or cardioversion.


I pretty much second this. Sinus Tach w/o ectopy and the patient appears to be compensating/tolerating this well... I'm just going to sit back, relax and give the patient a nice quiet ride. As soon as the patient needs tx... I'll give it. otherwise...


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## Jay (Jul 18, 2011)

colorado207 said:


> Oh yep I know that. But there's a debate over  how often the question is needed and/or useful. Other than diabetic and  food allergy emergencies, the only reason I could assume that it would  be a question often asked (especially in trauma Hx), is for  anesthesiologist in the OR (should surgery become necessary.) Or perhaps  knowing how much or how likely that person is to vomit.
> Do you really always get so in depth with your LOI line of questioning?  Or are you referring to cases where you suspect that you really need to  know more about LOI from some other indicator?



You should question *everyone* in depth but take control of the Q&A so that their answers don't take all day. Regardless of the call, the rule of thumb for medical calls is: _*The more information, the better*_. You should get into the habit of formulating the way that you do your SAMPLE in the field so that you can rapid-fire and quickly gain vital information. Your SAMPLE for the EMT exam is another subject altogether. Trauma should be a faster evolution however information gathering is vital, this can be done en route with the stable patient. Just remember that symptoms can present differently and knowing how to ascertain the information can save your patients life.

How much field experience do you have? Just curious. Remember that everyone will develop a style based off of their individual field experience.

Now on that note, let's delve into Meds, if you ask if they have taken "Any medications including OTC's and herbs whether theirs or anyone else's or if they tad taken any illegal drugs or ETOH", this can rule out anaphylaxis in certain cases, it can be a precursor to find out if there are any contraindications such as sexual enhancement drugs and nitro, perhaps they got it from a friend... You may uncover a TCA OD or some other OD... etc. (which you normally have about one hour before they go down hill) All in all this type of questioning takes me 5 or 10 seconds to ask and about the same to get a good answer in most cases. You'd be surprised on what you will uncover. The most important precedent is to build a repertoire with your patient so that they know that your not an LEO and that their answers wont "get them in trouble".



hippocratical said:


> I gotta ask on this one, because it's been bugging me -> Ages ago I did a Wilderness FA course where they advised that "L" should be "Last ins and outs"... So anything eaten/drunk + defecation + (here's a good one) Menstruation.
> 
> Got a female Pt? Has abdominal pain and spotting? Allegedly not pregnant?
> Q: "When was your last period?"
> ...



Interesting. In Pennsylvania we are only required to inquire as to their last meal, beverages, etc. But I try to probe to see if there is any vomiting (or nausea for that matter) and every girl should be asked to see if pregnancy is an option if they are in the age ranging from puberty to menopause or anything in between. As far as menstruation, I know that we are professionals and we can pretty much ask anything as long as we present the question professionally but this one is new to me.


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