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You may not be ready for airway emergencies
ED nurses play critical role in identification
If you noticed increased lethargy and confusion in your patient, would you suspect an airway problem?
"These are two very basic signs of hypoxia," says Tia Valentine, RN, CEN, clinical nurse educator for the ED at University of California -- San Diego Medical Center. "The ED nursing role is very important when it comes to identification, prevention, and caring for airway emergencies."
Valentine gives the following suggestions:
Use end tidal carbon dioxide monitoring.
ED nurses are using this monitoring more frequently for early recognition of airway emergencies, reports Valentine. "We can trend the numbers and, frequently, show well in advance if someone is going to have issues," she says. "It helps with the carbon dioxide-retaining patient, as well as the overdose patient."
Valentine says that end tidal monitoring "is really coming to the forefront with early recognition of airway issues. And, since it can be done via endotracheal tube, bag valve mask or nasal cannula, there is no real reason not to use the therapy."
Familiarize yourself with equipment.
"Within the ED, we have some very sophisticated equipment that allows us to aggressively resuscitate patients," says Valentine. "We even have a jet-vent readily available should the need arise."
A glidescope is used to visualize the glottis and posterior airway during intubation, and an advanced airway bag contains the cricothyroidotomy and tracheotomy airway devices. (See related stories on what equipment to check before every shift and what to bring when transporting a patient, p. 113.)
Perform routine mock codes.
ED nurses practice insertion of nasal trumpets, oral suctioning, and removal of foreign bodies from the oral and nasal cavities. "We also practice appropriate bag-valve-mask breathing, ensuring a rate of no more than six to 10 breaths/minute," says Valentine.
Valentine reports that her ED has performed studies that showed that during resuscitation, "less is more." "By placing the focus on having a solid seal around the mouth from the mask and using modest inhalation rates instead of rapid breaths, our outcomes are improved," she says.
Don't assume that an elderly person's confusion is related to dementia or Alzheimer's.
This assumption is a dangerous practice, as the patient's confusion actually might be due to hypoxia, warns Valentine. "And, as an elderly person is frequently difficult to wean from the ventilator compared to a younger person, basic comprehension of subtle signs of hypoxia are important," she adds.
Equipment glitches can be dangerous
Always check airway equipment at the beginning of every shift, warns Ann Heywood, RN, BSN, CEN, SANE, trauma nurse coordinator for the Emergency Care Center at Champlain Valley Physicians Hospital Medical Center in Plattsburgh, NY.
"Ensure that you have a functioning bag valve mask and suction ready for use in your rooms," says Heywood. "You don't want to put yourself or the patient in the position that when your patient is boarded and collared and starts to vomit, you have no suction."
Check the suction set up to ensure its patency before the time of need occurs. Turn it on and verify there is suction at the end of the tubing, says Heywood. "The time to assemble a bag valve mask is not when identifying the patient needs assistance," she says. "These should assembled ready for use in every room. Oral airways should be readily available on the headwalls, as well."
Have a bag valve mask available as back-up
If the bag valve mask is tossed aside when the patient is intubated, retrieve it and bring it with the patient wherever they are going, advises Ann Heywood, RN, BSN, CEN, SANE, trauma nurse coordinator for the Emergency Care Center at Champlain Valley Physicians Hospital Medical Center in Plattsburgh, NY.
If the patient is accidentally extubated on the elevator, in transport to CT, or the intensive care unit (ICU), you will need that mask to ventilate with the bag valve until the patient can be successfully intubated again, she explains.
"A transport bag is ideal to use for transfers to CT or ICU for the intubated patient," says Heywood. "The bag can include extra masks, oral airways, and emergency drugs."