This is the lecture I gave to the paramedics during a course

1. Life Threatening Conditions
K.S. CHEW (MD, MMED)
Emergency Medicine Department
School of Medical Sciences
UniversitiSains Malaysia

2. Life Threatening Conditions are conditions
that compromise the
AIRWAY
BREATHING
CIRCULATION

3. Overview
• Examples of conditions threatening to the:
• Airway
– Trauma: Facial trauma, facial burns
– Non-trauma: anaphylaxis, asthma, foreign bodies
airway obstruction
• Breathing
• Circulation

4. Overview
• Examples of conditions threatening to the:
• Airway
• Breathing
– Trauma: Chest trauma – tension pneumothorax,
open pneumothorax, flail chest
– Non-trauma: asthma, pulmonary embolism
• Circulation

5. Overview
• Examples of conditions threatening to the:
• Circulation
– Trauma: Cardiac tamponande
– Non-trauma: acute myocardial infarction, acute
thoracic dissection

6. AIRWAY

7. Why Airway Management?
• Maintain a patent airway
• Facilitate mechanical ventilation in respiratory
failure
• Optimize pulmonary gas exchange; thus prevent
hypoxic damage to the brain and other vital
organs
• Reduce risk of aspiration
• Reduce risk of nosocomial pneumonia and assist
in removal of bronchial secretions

8. Effects of Hypoxia
0 – 2 min Cardiac Irritability
0 – 4 min Brain damage not likely
4 - 6 min - brain damage possible
6 - 10 min - brain damage very likely
More than 10 min - irreversible brain damage

9. Effects of Head-
Tilt Chin-Lift
Alignment of oral axis,
pharyngeal axis and
tracheal axis

10. Importance of Opening the Airway
The most common cause of ventilation difficulty during
resuscitation is an improperly opened airway
(AHA Guidelines 2005)

11. Opening the Airway
• Lay Rescuer – open the airway using head-tilt
chin lift maneuver for non-trauma victims and
gentle chin lift for trauma. Jaw thrust no
longer recommended because it is difficult to
learn and perform, often not effective.
• Health Care Provider – Head tilt-chin lift if not
trauma. If trauma, apply manual in-line
stabilization and jaw thrust.

12. Opening the Airway
• If airway obstruction persists despite jaw
thrust, attempt head tilt-chin lift even in
trauma
• This is because maintaining a patent airway
and providing adequate ventilation is a
priority in CPR (AHA Guidelines 2005)
• Furthermore, this complication of damaging
the cervical cord has not be documented and
the relative risk is unknown (ERC Guidelines 2005)

13. Effects of Head-
Tilt Chin-Lift
Alignment of oral axis,
pharyngeal axis and
tracheal axis

18. Remember to protect
the cervical spine in
cases of trauma

19. Use bags or pillows,
etc, to immobilize the
cervical spine

20. OROPHARYNGEAL AIRWAYS

21. Oropharyngeal Airways
• OPAs are sized by length in centimeters, and
are available in sizes for all ages.
• A typical adult female will take an 8-cm OPA,
and an adult male, 9 or 10 cm.

22. How To Perform?
• In adults – insert ‘upside down’ until tip touch
hard palate and then rotate 180° before
inserting further
• Can also insert directly (non-inverted way)
with use of tongue depressor
• This is preferred in children because of risk of
trauma to delicate soft tissue

23. Size of OPA can be
estimated from the
edge of ear lobe
(angle of mandible)
to the corner of
mouth (incisor teeth)

24. Emergency Care When The
Victim is Choking

26. Universal Sign of Choking

27. Performing Heimlich
Maneuver (abdominal thrust)
only if the upper airway
obstruction is complete or
near total complete
Observe is victim is whether
cyanosed, or if his voice
becomes muffled or his cough
becomes ineffective

28. Position to place your fist
between the xiphoid
process and the umbilicus

29. Use one hand as the fist.
The other hand to grasp
the fist and BE
PURPOSEFUL and
DELIBERATE. Thrust
upwards and inwards.

30. If, at any time, the victim
collapses, lie him flat and
proceed as you would in
BLS sequence.

31. Open the airway to see if
foreign body is present; if
no, attempt rescue breaths
(five attempts for two
effective breaths) and start
chest compression if pulse
not present or no signs of
life.

32. BREATHING

33. Examples of Life Threatening
Trauma Conditions to the
Breathing

34. Initial Assessment/Management in
TRAUMA
• Primary Survey
• Identifies most life-threatening injuries
• Resuscitation
• Airway control
• Ensure oxygenation / ventilation
• Needle / tube thoracostomy

35. Life Threatening Conditions In
Trauma
Primary Survey
• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Flail chest
• Massive hemothorax
• Cardiac tamponade

36. Tension Pneumothorax
Tension Pneumothorax: Etiology
• Parenchymal and/or chest-wall
injuries
• Air enters pleural space with no exit
• Positive pressure ventilation
– Collapse of affected lung
– Venous return
– Ventilation of opposite lung

37. Tension Pneumothorax
Tension Pneumothorax: Signs / Symptoms
• Respiratory distress
• Distended neck veins
• Unilateral in breath sounds
• Hyperresonance
• Cyanosis, late

38. Tension Pneumothorax
Tension Pneumothorax
• Immediate
decompression
• Clinical diagnosis, not
by x-ray

39. Asthmatic Attack

40. Asthmatic Attack
• Asthma sufferers have very sensitive airways,
and when they are exposed to certain triggers,
their airways narrow making it difficult for
them to breathe.
• An asthma attack can take anything from a
few minutes to a few days to develop

41. Signs and Symptoms
• pale, cool, clammy skin
• coughing, especially at night
• shortness of breath – using all the chest and
diaphragm muscles to breathe
• ‘sucking in’ of the throat and rib muscles
• Severe chest tightness
• wheezing – a high pitched raspy sound

42. Signs and Symptoms
• cyanosis around the lips (bluish colour)
• anxiety and distress
• exhaustion
• rapid, weak pulse
• little or no improvement after using reliever
medication (e.g. Bricanyl or Ventolin)
• severe asthma attack: collapse – leading to
eventual respiratory arrest

43. First Responder Care
With spacer
• shake inhaler and insert mouthpiece into
spacer
• place spacer mouthpiece in casualty’s mouth
and give 4 separate puffs of a blue/grey
reliever puffer

44. First Responder Care
Contd…
• give 1 puff at a time
• ask the casualty to breathe in and out
normally 4 times after each puff
• wait 4 minutes. If there is little or no
improvement, repeat the above sequence

45. First Responder Care
Without spacer
• shake inhaler
• place mouthpiece in casualty’s mouth.
• Give 1 puff as the person inhales slowly and
steadily

46. First Responder Care
contd…
• Ask the casualty to hold that breath for 4
seconds, then take 4 normal breaths
• Repeat until up to 4 puffs have been given
• Wait 4 minutes. If there is little or no
improvement, repeat the above sequence

47. CIRCULATION

48. Heart Attack

49. The Heart
• The normal human heart is a strong, muscular
pump a little larger than a fist.
• Each day an average heart “beats” (expands
and contracts) 100,000 times and pumps
about 2,000 gallons of blood.
• In a 70-year lifetime, an average human heart
beats more than 2.5 billion times.

50. In Myocardial Infarction,
time lost is myocardium
lost!!

51. Pre-hospital Care of MI Hospital fibrinolysis:
Door-to-Needle
within 30 min.
Not PCI
capable
EMS on-scene Inter-
Onset of 9-1-1
Hospital
• Encourage 12-lead ECGs.
symptoms of EMS
Transfer
• Consider prehospital fibrinolytic if
STEMI Dispatch
capable and EMS-to-needle within PCI
30 min.
capable
GOALS
5 8
EMS Transport
min. min.
Patient EMS Prehospital fibrinolysis EMS transport
EMS-to-needle EMS-to-balloon within 90 min.
within 30 min. Patient self-transport
Hospital door-to-balloon
Dispatch
within 90 min.
1 min.
Golden Hour = first 60 min. Total ischemic time: within 120 min.

52. Typical Chest Pain

54. Hollywood Heart Attack

55. Remember
With heart attack, every minute counts. If
the warning signs are present, do not waste
vital moments wondering whether it is a
heart attack or not. Take immediate action!

56. First Responder Care to Patient
with MI
• Recognize and Call (MOST IMPORTANT!)
• Rest the casualty in a position of comfort,
usually sitting
• Assist the casualty to take their medication
(nitroglycerine tablets)

57. First Responder Care to Patient
with MI
• If conscious, give casualty 1/2 an aspirin tablet
and have them chew it slowly, unless it is
known that the person has been advised not
to take aspirin
• Reassurance
• Stay with the casualty and observe him

68. Pads Position

69. Posterior Position

70. Defibrillation Cardioversion
Synchronised on the R
Not synchronised
wave
For
For cardiac arrest periarresttachyarrhythmias
(unstable)
Higher energy joules Lower energy joules
No escalating energy for Escalate for next shock
next shock (100 - 200 - 300 - 360J)