Initiation and Modification of Initiation and Modification of Therapeutic ProceduresTherapeutic Procedures

Initiate, Conduct, or Modify Respiratory Care Techniques in an Emergency Setting

BLS

Be able to properly administer BLS to adults and children.

NBRC CRT exam will not reflect recent AHA changes –

ABC of resuscitation rather than CAB

ACLS

Adult Resuscitation Protocols

Identify the 4 cardiac arrhythmias that cause most common adult cardiopulmonary emergencies.

Medications Common ACLS IV medications

Medications that can be instilled through ET tube

Monitoring and Assessment Periodic pulse / respiration checks

ECG

Pulse oximetry

End-tidal CO2

ABG

Pediatric and Neonatal Emergencies

Pediatric Resuscitation Most likely exam scenario is pulseless arrest Know pediatric doses for medications / defibrillation shock Most common medical emergency with pediatric patients is airway

obstruction

Neonatal Resuscitation Flaccid, cyanotic, or apneic infants require stimulation and

supplemental O2 Manual ventilation required if color, heart rate, breathing not

restored within 30 seconds Heart rates below 60 always require chest compressions in

neonates.

Treat a Tension Pneumothorax

You must be familiar with the common signs and symptoms, as well as emergency treatment, of tension pneumothorax (a potentially life-threatening disorder).

DiagnosisPredisposing factors:

High airway pressures with mechanical ventilation (> 40-45 cm H2O)

Chest trauma

Excessively high compliance i.e. advanced emphysema

Clinical Manifestations

Rapid decline in cardiopulmonary status (hypoxemia, hypotension)

Decreased or absent breath sounds on the affected side

Hyperresonance when percussing the affected side

Possible subcutaneous emphysema

Tracheal shift away from affected side

Rapid increase in ventilator pressures (if mechanical or manual ventilation in use)

Shock and/or PEA in severe, untreated cases.

Chest X-ray Confirmation

Initial TreatmentEmergency decompression of the chest (needle thoracostomy)

Patient Transport

NBRC expects you to be competent in transporting critically ill patients.

Ensure patient safety

Intra-hospital transport as well as land / air external transport

AARC guidelines for contraindications to transport are based on any of the following not being reasonably ensured during transport:

Provision of adequate oxygenation and ventilation Maintenance of acceptable hemodynamic performance Adequate monitoring of the patient’s cardiopulmonary status Maintenance of airway control

Patient TransportIntra-Hospital Patient Transport

Patient transport must address the following:

Communication Transport team must communicate with team at receiving location Before transport, receiving location confirms readiness to receive patient Members of health care team notified of timing of transport and needed equipment Documentation includes physician’s order, indications for transport, and patient status throughout.

Personnel At least two persons must accompany critically ill patients Usually a critical care nurse and respiratory therapist

Equipment BP monitor, pulse oximeter, cardiac monitor/defibrillator Airway management and secretion clearance, oxygen, BVM or ventilator Basic resuscitation drugs, sedation /narcotic analgesics IV fluids, medications, fully charged battery-operated infusion pump

Monitoring Duplicate as much as possible monitoring provided in originating unit

Continuous ECG monitoring Continuous pulse oximetry Periodic measurement of blood pressure, pulse rate, and respiratory rate Periodic assessment of breath sounds

Patient Transport

Air and Land Transport

Unique aspects

Choosing among ground and air transport modes

Managing increased patient movement and stimulation

Accommodating the need for special personnel and equipment

Addressing the effects of altitude on PaO2 and closed air spaces.

Team

Physician, respiratory therapist, nurse or paramedic

ACLS skills

Medical Emergency Teams

Rapid Response TeamsICU nurse, physician or physician assistant, respiratory therapistCriteria for activation for adults

Acute change in mental status or overall clinical appearance Heart rate < 40 or > 130, or respiratory rate < 8 or >

30/min Systolic blood pressure < 90 SpO2 < 90%, especially with supplemental O2 Acute change in urinary output to < 50 ml over 4 hours

Common interventions performed by RC Airway suctioning Adjusting FiO2 Providing noninvasive ventilation Administering bronchodilators Intubation

Disaster Management

NBRC expects you to be prepared for preparedness planning or implementation of triage and decontamination/isolation procedures.

Department preparedness plan should consider Patient needs

Estimate numbers of patients who may require Ventilatory support Medical gas therapy (O2 or air) Suction

Personnel Number of staff required to meet patient needs Staff emergency call-back procedure Enlist non-respiratory personnel to perform manual ventilation

Equipment Maintain inventory of available ventilators Maintain adequate number of disposable BVMs to meet needs Determine backup equipment to meet needs Plan to acquire additional backup equipment Plan to transfer patients if backup equipment unavailable. Plan in place for failure of gas supply systmes

Estimate quantity of backup required for each gas Estimate ancillary equipment needs (regulators, portable suction, etc.) Deployment plan for distribution/maintaining backup gas sources

Common Errors to Avoid on the Common Errors to Avoid on the ExamExam

Never use an AED on an infant (< 1 year old)

Avoid compressions in excess of ½ to 1 inches during infant CPR to help prevent injury to the patient

Don’t treat the monitor!! If the monitor shows asystole but the patient appears awake, alert, and in no apparent distress, don’t begin CPR.

Never treat a pneumothorax with a needle decompression or a chest tube until the diagnosis has been confirmed by chest x-ray.

Never forget a manual resuscitator bag and a mask when you are transporting intubated and ventilated patients so you will be able to ventilate them if they become inadvertently extubated.

More Common Errors to Avoid on the More Common Errors to Avoid on the ExamExam

Never use an adult or pediatric manual resuscitator bag/mask to ventilate a neonate. Use the appropriate age-specific equipment.

Don’t forget that during air transport, it is often appropriate to increase the FiO2 in order to maintain adequate oxygenation, and it may also be necessary to temporarily adjust tidal volume and artificial airway cuff pressure to ensure the safety of mechanically ventilated patients.

Never wait for a physician to arrive to begin assessing a patient as part of a medical emergency team.

During management of respiratory epidemics, avoid droplet-producing procedures (e.g., nebulizers, chest physiotherapy on patients with suspected infections).

Exam Sure Bets Exam Sure Bets Always remember the ABCDs (Airway, Breathing,

Circulation, Defibrillation) of CPR

Always look, listen, and feel before starting CPR; the patient may be simply sleeping.

Always give compressions at a depth of 1 1/2 to 2 inches for an adult patient

If the chest doesn’t rise with the first breath in CPR, don’t panic – always reposition the head first and try another breath.

Always have an appropriate-sized BVM when transporting a critically ill patient.

More Exam Sure Bets More Exam Sure Bets Always suspect a tension pneumothorax when a

patient is rapidly deteriorating in the presence of any of the following: a unilateral decrease in breath sounds and chest expansion, hyerresonance when percussing the affected side, shifting of the trachea away from affected side, and subcutaneous emphysema.

When assisting a physician with a needle thoracostomy for the emergency treatment of a tension pneumothorax, always recommend that the needle be placed over the second rib in the midclavicular line.

More Exam Sure Bets More Exam Sure Bets

Always apply chest compressions to a neonate whose heart rate is less than 60.

When assisting in the transport of a critically ill patient, always ensure that you have an adequate oxygen supply and delivery device, as well as an array of age-appropriate respiratory equipment, including a manual resuscitator bag, transport ventilator/circuits, and intubation equipment.

Always practice droplet precautions, in addition to standard precautions, when examining a patient with symptoms of a respiratory infection.

Reference:Reference:

Certified Respiratory Therapist Exam Review Guide, Craig Scanlon, Albert Heuer, and Louis SinopoliJones and Bartlett Publishers