Check for decrease level of consciousness (?) Check for debris/foreign material Observe for snoring and/or wheezing Observe for stridor (75%) Observe for coughing Observe for the universal sign Observe for facial trauma especially to the jaw Observe for neck trauma and swelling Observe for allergic reaction Headtilt-Chinliftmaneuver Jaw-Thrust maneuver Airway insertion Oropharyngeal Nasopharyngeal The above are all independent nursing actions Endotracheal Tube (ETT) Intubation Tracheostomy (Surgical) Crico-thyrodotomy (Surgical) The above are interdependent nursing actions. The nurse does not perform the procedure but makes preparations for and assist the physician. They are also called definitive airway management Observe for the presence/absence of spontaneous breathing Look; listen; and feel Observe rate- 12-20 Observe depth- rise and fall movement at the epigastrium (corresponds to contraction and relaxation of the diaphragm Observe rhythm- regular pattern of inspiration and expiration Observe effort- effortless with no use of accessory muscles Observe for nasal flaring- sign of severe respiratory distress Observe for symmetry- equal rise and fall of chest (each hemi-thorax should rise and fall equally) Observe for defects to the chest wall- puncture wounds; fractures, bruising etc Observe for flailing chest wall- indicates chest wall instability due to multiple rib fractures Observe for paradoxical breathing- chest wall falls when the person breathes in and rises when the person breathes out. Heavy abdominal breathing might be present Observe for cyanosis and decreased SPO2 readings Rescue breaths: Mouth to mouth Mouth to mask Bag-valve mask Administer oxygen Elevate head of bed Teach and encourage deep breathing Stabilizechest wall Chest tube insertion (Tube Thoracostomy ETT and mechanical ventilation Pain management Assess level of consciousness Observe for uncontrolled external hemorrhage Assess pulse Rate- 60-100 Volume- feeble, bounding, normal Rhythm- regular Assess blood pressure Observe for cyanosis: Peripheral Central Observe skin color and temperature Observe neck veins Hemostasis of any external bleeding Administer IV fluids Administer prescribed medications Trendelenburg position Assess level of consciousness: Alert Voice (responds to) Pain (responds to Unresponsive Observe flexion and extension Assess speech Coherence Comprehension Observe pupils Size- in adults varies from 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark Reactivity to light + reactive - non-reactive +/- sluggish Assess ICP: 1/3 of pulse pressure ETT: If clinical evidence of raised intracranial pressure or ICP > 20mmHg Medication: Phenytoin load 15mg/kg over 1 hour if structural abnormality on CT or if history of fitting Mannitol osmotherapy can be considered (0.25g/kg – 1g/kg) as an alternative to hypertonic saline Prepare for surgery