Week 11

Week 11
Reflection:
Using the Gibb's Reflective Model, i will be reflecting on the practical session we had on the 11th of April, 2016.
Description: This week we practiced for our OSCE that was coming up. I did two scenarios. The first was a moderate asthma attack. I have the patient high flow oxygen, 5mg of salbutamol and 500mcg of ipratropium bromide. The second scenario was a FBAO that lead to cardiac arrest. I asked for assistance from an EMT, which started compressions. I took over the ventilation and inserted an LMA, delivering 1 breath every 5-6 seconds. We did ten cycles and I provided 2 shocks since the rhythm was VF. After 10 cycles, I was able to observe the foreign body in the airway. I asked the EMT to stop compressions and removed the obstruction using Magill’s forceps. The patient continued being apneic, so I continued providing ventilations at a rate of 1 breath every 5-6 seconds. The patient then regained his consciousness and breathing. He still had some difficulty breathing, and he had history of asthma and did not take his Salbutamol inhaler dose that day. For these reasons I provided the patient with 5mg of Salbutamol and rapidly transported him to hospital. I passed both scenarios.
Feelings: I was confident in the first scenario, since I have practiced similar scenarios previously. However, in the second scenario I was a little nervous and did not feel fully sure of what I had to do. I followed what I know and when I knew I passed it felt really good. I felt proud of myself.
Evaluation: I passed both OSCEs so I believe I did a good job in both scenarios. Nonetheless, I felt nervous in the second one because I never practiced a similar scenario previously. Therefore, passing it made me feel really good because it was my first time and I passed it!
Analysis: It’s a little stressful but fun to be thrown in a scenario I never practiced before. This is the nature of paramedic work, you never know what case you might get. Therefore, I really enjoyed doing the second scenario, and passing was the cherry on top. I passed the first scenario because I followed the guidelines for moderate asthma in the JRCALC (2013). I passed the second one because I followed the AHA guidelines for a choking patient and cardiac and respiratory arrest. Those are the guidelines required from me and I executed them well. This allowed me to pass.
Conclusion: In conclusion, having a surprise scenario that I’ve never done before is really good for me as a future paramedic. This reminds me of the nature of my future job and helps test my skills to act in any situation/ scenario. I really enjoyed this lab session and am really happy that I passed both scenarios.

Action Plan: I plan to continue practicing until I am perfect in my approach and treatment. I would like to work hard to do really well and not just pass. Also, I want to ask my teacher to give me more surprise scenarios so I can continue developing and testing my skills on the spot, as it would be in real life.

Learned Concepts:
This week we did the tutorial case study for week 11. The following are my notes:

Image 1: My notes for Part A of the tutorial.

Image 2: My noted for Part B of the tutorial.

Biggest Impression

This semester and in this course, the thing that made the biggest impression on me as a paramedic is all the drugs and managements i learned this semester. Through the practical sessions and scenarios i was able to apply what i learned from the lectures. This helped me advance greatly in my clinical approach and critical thinking. Therefore, the biggest impression would be my overall advancement in my ability to manage a various range of respiratory conditions. Moreover, through this course i learned a very wide range of advanced skills such as IV cannulation, IMI, SC injection, and intubation. As a paramedic, this course has had a huge impact on my growth and progression to becoming skilled and efficient.

Strengths and Limitations
I believe my strengths include managing asthmatic and COPD patients. Also, i feel i am strong in remembering medications, their indications, and doses. However, i feel i am a little weak in remembering the contraindications for the drugs, which is really bad. To improve on that i will try to allocate some time everyday to learn the contraindications of the drugs i learned till now. Moreover, i feel strong in the advanced skills like IV, IM, and SC injections since i practiced these skills multiple times. Also, i believe i became stronger in my intubation skills. However, i think my knowledge about pediatrics and their management is still not where i want it to be. This is a limitation i need to work on by reading more about pediatrics and giving more time to this topic to fully understand the complications pediatrics face, that are unique to them. 

Week 10

Week 10
Reflection:

Using the Gibb's Reflective Model, i will be reflecting on the practical session we had on the 4th of April, 2016.

Description: We practiced for the preparation and insertion of advanced airways. At first, using a laryngoscope, I tried to locate the vocal cords on the mannequin. I then tried inserting an endotracheal tube (ETT). The first couple of times I failed, and it ended up in the esophagus but I kept trying until I was successful. I practiced doing this, as well as inflating the ETT cuff and checking that the tube was positioned correctly in the trachea by looking for symmetrical chest rise. I practiced this multiple times until I was able to accomplish intubation and checking for correct positioning within 26 seconds. Following this I learned and practiced locating the cricothyroid membrane on my colleague Asma and the mannequin. The first few times I found it hard to locate the membrane, but after a few attempts I was able to pinpoint it. We also practiced using a combitube and King LT.

Feelings: I was very thrilled to be learning new and advanced skills this lab session. I got a little frustrated when I was not able to insert the ETT correctly after multiple attempts. However, when I was able to perform this skill, I was very excited and happy. It felt really good when I was able to continuously do it right and within 26 seconds! It was interesting learning to locate the cricothyroid membrane. I was confused at first as to how to locate it but after attempting multiple times, I was successful. This was satisfying. It was very interesting to learn and perform insertion of combitube and King LT.

Evaluation: At first, I did not do very well at inserting the ETT, but as I practiced more I improved. In the end, I did a very good job and performed intubation in less time than is expected, which was great. When trying to locate the cricothyroid membrane I did not do a very good job at first. Nonetheless, in the end, I was successful at palpating the membrane and recognizing it, which was good. I also did a good job at inserting the combitube and King LT, since i got sufficient chest rise in both from the first trial.

Analysis: Learning to intubate is crucial for me to learn as a future paramedic, since this will be a skill expected from me. Also, this skill can be lifesaving in situations such as respiratory arrest. I must keep practicing this skill to perfect it to avoid complications that could result if this skill is not performed properly. It is very important that intubation be performed in as little time as possible, ideally in a maximum of 30 seconds. This is because the patient will not be receiving any oxygen during intubation, and ventilations should be interrupted for no more than 30 seconds. It is vital to know how to locate the cricothyroid membrane in order to perform cricothyrotomy.To be fair, combitube and King LT are blindly inserted, making them very easy. This allowed me to correctly insert both of these tubes from the first time.

Conclusion: In the end, learning how to insert advanced airways and cricothyrotomy comes with great responsibility. Intubation must be perfected and done in less than 30 seconds. I was able to do it in less time and that is a very good start. Although at first I found difficulty in both skills, constant practice helped me improve almost immediately.

Action Plan: I plan to practice using a laryngoscope correctly and intubate as much as I possibly can before the semester ends. Also, I plan to time myself while I do this advanced skill to keep up my record, and maybe even reduce the time to accomplish intubation. I also want to try locating the cricothyroid membrane on different people in my life, so that I am able to perfect localizing it. I also want to continue practicing inserting combitubes and King LT tubes, just to familiarize myself with them more and be able to perfect using these two tubes.

Video 1: Me performing intubation using a laryngoscope and ETT.

Image 1: After my insertion of the combitube.

Video 2: Me inserting the King LT into the patient's airway and checking for correct placement. 

Learned Concepts

This week we learned about the pediatric airway and how it is different to the adult airway. We also learned some pediatric respiratory emergencies.

In pediatrics, the head is large compared to the adult, their arms and legs are shorted, and the midpoint in their length is at the umbilicus.

Pediatrics have a large head, small mandible, small neck, a large and posteriorly placed tongue, high glottic opening, and small airways. The smallest part of a paeds airway is at the cricoid cartilage. In adults its the glottis opening. Also, the epiglottis in pediatrics is larger than that in adults. Pediatrics also have poor accessory muscle development, less rigid thoracic cage, horizontal ribs, are diaphragm breathers, and have an increased metabolic rate and oxygen consumption.

The main differences between adult and pediatric airways is the pediatrics' have a more rostral larynx, large tongue, angled vocal cords, differently shaped epiglottis, and a funneled shaped larynx.

Effects of these differences:

1. Large tongue:

• Obstructs airway
• Obligates nasal breathing
• Difficult to visualize larynx

2. Angled vocal cords:

• Difficulty in nasal intubation

3. Differently shaped epiglottis:

• More difficult to lift an infant's epiglottis with laryngoscope blade (usually use straight Miller's blade).

Extra uterine life is not possible until 24-25 weeks of gestation. This is because pulmonary surfactant is produced by Type II pneumocytes at 24 weeks of gestation. There is sufficient pulmonary surfactant present after 35 weeks of gestation.
Premature infants are prone to RDS due to insufficient surfactant. Dexamethasone can be given to mature lungs quickly and accelerate fetal surfactant production.
Oxygen consumption in infants is twice that in adults.
In pediatrics the minute alveolar ventilation is more dependent on increased RR than on tidal volume. Greater oxygen consumption= increased RR.
Ratio of alveolar minute ventilation to FRC is doubled under circumstances of hypoxia. However, the infant's FRC is diminished and desaturation can occur rapidly!
Signs of respiratory distress in pediatrics:

1. Tripod  position
2. Nasal flaring
3. Retractions

 In such cases must supply high flow oxygen via NRB and find out cause of respiratory distress.
In airway edema, if the radius of the airway is halved, resistance increases by 16 times!!!
8 signs to look for in RSA:

1. Cyanosis
2. Tachypnea
3. Wheezing
4. Tracheal shift
5. Tachycardia(may be bradycardia in neonate)
6. Head bobbing, stridor, prolonged expiration
7. Abdominal breathing
8. Grunting (CPAP)

Signs of impending respiratory failure include:

• Increase work of breathing
• Tachypnea/ tachycardia
• Nasal flaring
• Drooling
• Grunting
• Wheezing
• Stridor
• Head bobbing
• Use of accessory muscles
• Cyanosis
• Irregular breathing/ apnea
• Altered LOC
• Inability to lie down
• Diaphoresis

When evaluating the airway must examine: Facial expression, nasal flaring, drooling, color of mucus membranes, RR, voice change, mouth opening, size of mouth, mallampati, loose/missing teeth, size and configuration of palate, size and configuration of mandible, location of larynx, stridor, baseline O2 saturation, and body habitus.
Goals of airway management is to protect the airway adequately ventilate, and adequately oxygenate. Positioning is KEY!
We learned how to properly place a BVM on an infant's face and how to obtain a proper seal. Also, we learned how to insert an OPA,NPA, and how to position the child in the sniffing position, by placing a towel under the child's shoulders.
Miller blade is preferred for infants and young children since it facilitates the lifting of the epiglottis. Macintosh blades are usually used on older children and adults. Blade size depends on body mass of pt.
LMA is useful in  difficult airway situations, such as a conduit of drug administration. Disadvantages of LMA include laryngospasm and aspiration. There are 7 sizes of LMAs and size depends on patient's weight.
Respiratory assessment includes assessing the patient's position, general appearance, speech, breath sounds, and RR.
RR in: Newborn: 40-60breaths/min; Infant: 20-50 breaths/min; Small child: 20-35 breaths/min; Large child: 15-25 breaths/min.
Signs of hypoxia in infants: Pallor, bradycardia, hypotension, apnea, lethargy.
Signs of hypoxia in children: Restlessness, cyanosis, tachycardia (bradycardia late sign), tachypnea.
Signs of CO2 retention: Sweating, tachycardia, bounding pulse, pupillary dilatation, hypertension, cardiovascular and CNS depression.
We also discussed asthma and revised what occurs in asthma: Bronchospasm, mucosal swelling and mucosal plugging. We also revised how to manage asthmatic patients. The algorithm stays the same as in adults, however, medication doses differ in pediatrics. For children above 6 years, the dose of Salbutamol remains 5mg, however, for children less than 6 years old the dose is 2.5 mg.
Ventilation rates are as follows:
Infant: 15-20 breaths/min
Small child: 10-15 breaths/min
Large child: 8-12 breaths/ min
Acute epiglottitis is rapidly developing inflammation of epiglottis and adjacent tissues, due to bacterial infection. This can cause life-threatening airway obstruction. Caused by: Hib, Streptococcus pyogenes, Streptococcus pneumoniae, Staphylococcus aureus.
Peaks at 3-6 years of age and can be seen in older children and some adults.
S&S:

• Distress
• Sitting leaning forward
• Dysphagia
• Drooling
• Septic
• Anxious
• Sudden onset and rapid progression
• No cough
• Expiratory snore

To examine patients with epiglottitis simply depress tongue. Will visualize enlarged, cherry red epiglottis. However, this examination can lead to complete airway obstruction, therefore, must be avoided.
Acute epiglottitis has:

• Inflammed cherry red epiglottis
• Thickened aryepiglottic folds
• Oedematous arytenoid cartilages

For managing this patient make sure not to examine throat and not distress the child. Transport this patient rapidly to the hospital.
To treat a child with acute epiglottitis must provide hydration, humidification, oxygen, mechnical ventilation in acute stridor and can administer 100mg of hydrocortisone.
Bacterial LTB is caused by Staphylococcus aureus. Causes sloughing of respiratory epithelium. S&S: Hoarseness, stridor, dry cough, high grade fever, child supine but restless.
Laryngo-tracheo-bronchitis i.e. Croup is the commonest infective cause of stridor in children. Mean age for presentation is 18 months. This disease is a viral infection. Presents as gradual onset, hoarseness, dry cough (barking cough), low grade fever, child prefers to lie down but restless, dysphagia and drooling absent, and stridor.
On assessing this child, the child must be placed in a position of comfort on the child's parent's lap. Children often adapt the tripod position on their own. At all times, must approach the child in a calm manner. Any intervention that is likely to upset the child must be avoided. Distressing the child can precipitate an acute deterioration and complete airway obstruction.
To treat this patient can give oral Dexamethasone, IV Hydrocortisone, Racemic Adrenaline nebulization, humidification and mucolytic drugs.  All patients with stridor must be transferred to hospital!!! Intubation/tracheostomy for acute stridor.
Bronchiolitis is an acute inflammatory disease of the lower respiratory tract, resulting in obstruction of the small airways. Characterized by rapid respiration, chest retractions, and wheezing.
S&S:

• Mainly occurs in winter
• Age group usually 2-6 months
• Unwell for 1-2 days
• Hx of runny nose
• Gradual onset of irritating cough
• Increased distress with wheezy breathing
• Respirations are shallow 
• RR of 70-90
• Nasal flaring
• Wheezing, prolonged expiration
• Low grade fever
• Cyanosis, exhaustion, and hypoxia
• Respiratory failure may occur
• Dehydration

Management of bronchiolitis: Minimal handling, careful observation and monitoring, provide oxygen, Salbutamol may be beneficial, artificial ventilation if respiratory failure occurs, and transport.
Bronchitis: Inflammation of the bronchi characterized by hypertrophy and hyperplasia of seromucus glands and goblet cells lining the bronchial airways. Symptoms include productive cough with greenish-yellow sputum.
Upper Airway obstruction in croup must just maintain basic care and transport. In epiglottitis must NOT inspect airway, maintain basic care and transport.

Additional Readings
From the additional readings i found some interesting information. In one of the articles it discussed how to distinguish between epiglottitis and croup.
The typical presentation of epiglottitis is acute occurrence of high fever, severe sore throat, drooling and difficulty in swallowing. Also, patients with epiglottits tend to sit up and lean forward to enhance airflow. The most common DD for acute epiglottitis is croup and FBAO. Epiglottitis can be differentiated from croup from the S&S. For croup, the S&S are more prevalent in the wintertime. Croup has a gradual onset, low-grade fever, barking cough, absence of drooling and dysphagia (Abdallah, 2012).

Image 2: Algorithm for asthma management in children. Adopted from (JRCALC, 2013).

The Modified Taussig croup scale was mentioned in the lecture but not explained. I further searched and found it in the JRCALC(2013).

Image 3: Modified Taussig croup score for assessing croup. Adopted from (JRCALC, 2013).

The Ipratropium bromide dosage was not mentioned in the lecture so i found it in the JRCALC(2013).

Image 4: Dosage according to age of Ipratropium Bromide. Adopted from (JRCALC, 2013).

References

Abdallah, C. (2012). Acute epiglottitis: Trends, diagnosis and management. Saudi Journal of Anaesthesia, 6(3), 279-281. doi: 10.4103/1658-354X.101222

Join Royal Colleges Ambulance Liaison Committee. (2013). UK ambulance services: Clinical practice guidelines 2013(4^th edition). Bridgwater: Class Professional Publishing.

Stand Out Moment

 

Initially i did not really understand the difference between croup and epiglottitis. After reading the article by Abdallah (2012), now i understand the difference. In this article it was very clearly described and highlighted the differences between these two diseases. 

Biggest Impression
All the managements i learned this week have made an impression on me as a paramedic. Most importantly, learning how to intubate and insert supraglottic airways made a very big impression on me. They are key skills needed to manage unconscious patients' airways and, therefore, learning these skills is very important to me as a paramedic.