Page 152 - JSOM Fall 2020

AIRWAY-SPECIFIC PFC NURSING GUIDELINES/ a massive resuscitation, or replacement fluids. Consider
ASSESSMENT/TASKS ultrasound evaluation if available.
• Oral suction (or in-line/tube suctioning, if placed) as in-
dicated during routine patient assessments Naso-/Orogastric Tube (NGT/OGT) and Abdominal Care
• Nose and mouth moistened every 4 hours (as applicable)
• Lip Balm applied every 1 hour • Consider placing an NG/OG tube for prolonged care of
• Teeth brushed every 12 hours—Prevents pneumonia intubated/cricothyrotomy patient or those with an SGA
and other infections. in place (if a compatible port is available on the SGA).
• Auscultate lungs every 1 hour. If available, get a second • Abdominal palpation AND auscultation every 2 hours.
medic to double check and verify if sounds are ques- • Nutrition ONLY under telemedicine guidance (optional
tionable or cannot otherwise auscultate. Extra diligence and not indicated in first 72 hours).
should be given to check for diminished breath sounds
for suspected pneumothorax, as well as for pulmonary *Loos PE, Glassman E, Doerr D, et al. Documentation in
edema, especially if giving aggressive fluids in the case of prolonged field care. J Spec Oper Med. 2018;18(1):126–132.

APPENDIX C: BAG-VALVE-MASK TECHNIQUE

Proper technique is essential to perform successful bag-valve- careful observation and delivery of an assisted synchronous
mask (BVM) airway management. Patients should be in the breath should be a priority.
supine position, neck in a neutral position and the occiput
slightly elevated (on a folded blanket, sheet, small pillow, etc.) Some additional considerations are below:
to achieve a “sniffing position,” with the opening of the ears
at the same level as the sternal notch. Masks should be of the 1. If unable to perform adequate single hand C & E clamp,
proper size and should be fitted to the face to obtain a seal. use two-handed technique with a second person to bag.
This is best achieved by first placing the tapered portion of the 2. Do not press mask down onto face when performing
opening of the C & E clamp; visualize you are lifting face into mask.
3. Be aware fingertips on “E-clamp” should be positioned on
the bones of the mandible and not on soft tissue, which
mask over the bridge of the nose, then covering the patient’s
mouth. If using the one-person method, the non-dominant had could possibly occlude the airway.
should use the “C & E” method with the thumb and index 4. Use “BOOTS” to predict difficult face-mask seals: Bearded,
finger forming a C to cover the mask, and the middle, ring Obese, Old, Toothless, Snoring. In addition, maxillofacial
and small fingers forming an E on the bone of the mandible trauma and edema from burns may prevent effective venti-
effectively lifting the jaw into the mask (rather than pressing lation by BVM.
the mask onto the face). 5. NPA should be used to assist with face mask ventila-
tions (unless obvious contraindications such as mid-face
trauma). OPA are also effective in obtunded patients or
The other hand should gently squeeze the bag delivering
a breath at a rate of one squeeze every 5–6 seconds. There those who have received chemical sedation or neuromuscu-
should not be a leak around the mask, and you should be able lar blockade.
to observe the rise and fall of the patient’s chest. An ETCO 6. For bearded patients, lubrication of mask may assist seal.
2
monitor may be placed in-line with the bag and mask. PEEP Tegaderm occlusive dressings over beard may also help if
should be used with the BVM and initially set to 5mmHg. available. (If Tegaderm is used in sedated patient, consider
Every attempt should be made to maintain a seal to ensure pulling off before medication wears off, to lessen pain.)
continued PEEP. If the patient is breathing spontaneously, 7. Consider mask straps to make face-mask seal more “hands
free,” especially if a non-medic is assisting you with BVM.

150 | JSOM Volume 20, Edition 3 / Fall 2020