I



Detailed Lesson Plan

Chapter 10

Airway Management, Artificial Ventilation,

and Oxygenation

480–540 minutes

|Chapter 10 objectives can be found in an accompanying folder. |

|These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. |

|Minutes |Content Outline |Master Teaching Notes |

| |Introduction |Case Study Discussion |

|5 |During this lesson, students will learn special considerations of assessment and management of the airway and |Are there any obvious reasons to suspect problems with the |

| |breathing status and techniques of oxygen administration. |patient’s airway, breathing, and circulation? |

| |Case Study |What actions will you take to determine any problems with the |

| |Present The Dispatch and Upon Arrival information from the chapter. |patient’s airway, breathing, and circulation? |

| |Discuss with students how they would proceed. | |

| |Respiration | |

|10 |Respiration refers to the gas exchange process that occurs between the alveoli or cells and the capillaries, or to | |

| |the utilization of glucose and oxygen during normal metabolism in cells. | |

| |Respiration has four distinct components. |Teaching Tip |

| |Pulmonary ventilation—The mechanical process of moving air in and out of the lungs |Ask students to explain back to you the four components of |

| |External respiration—The gas exchange process that occurs between the alveoli and the surrounding pulmonary |respiration to ensure their understanding before moving to the|

| |capillaries |next section. |

| |Internal respiration—The gas exchange process that occurs between the cells and the systemic capillaries | |

| |Cellular respiration and metabolism—The process through which glucose is broken down in the presence of oxygen to | |

| |produce ATP, carbon dioxide, and water |Critical Thinking Discussion |

| | |Without glucose circulating in the blood, what component or |

| | |components of respiration will be affected? Why? |

| | | |

| |Respiratory System Review—Anatomy of the Respiratory System | |

|20 |The upper airway—Extends from the nose and mouth to the cricoid cartilage | |

| |Nose and mouth | |

| |Pharynx | |

| |Epiglottis | |

| |Larynx | |

| |The lower airway—Extends from the cricoid cartilage to the alveoli of the lungs | |

| |Trachea | |

| |Bronchi and bronchioles | |

| |Lungs | |

| |Diaphragm | |

| |Respiratory System Review—Mechanics of Ventilation (Pulmonary Ventilation) Review |Teaching Tip |

|35 |Ventilation is the passage of air into and out of the lungs. |Allow students to demonstrate and increase learning by asking |

| |Inhalation, or inspiration, is the process of breathing air in. |them to explain concepts first, and then fill in gaps and |

| |Exhalation, or expiration, is the process of breathing air out. |correct inaccuracies. |

| |Inhalation | |

| |The diaphragm and the intercostals muscles contract. | |

| |The diaphragm moves slightly downward. | |

| |The size of the chest cavity increases. | |

| |Negative pressure is created inside the chest cavity. | |

| |Air is drawn in by way of the nose, mouth, trachea, and bronchi into the lungs. | |

| |Exhalation | |

| |The diaphragm and the intercostals muscles relax. | |

| |The diaphragm moves slightly upward to its resting position. | |

| |The size of the chest cavity is reduced. | |

| |The pressure in the chest cavity becomes positive. | |

| |Air is forced out of the lungs. | |

| |Control of respiration | |

| |Respirations are controlled by the nervous system. | |

| |The respiratory centers that control impulses sent to respiratory muscles include the dorsal respiratory group | |

| |(DRG), ventral respiratory group (VRG), apneustic center, and pneumotaxic center in the brain stem. | |

| |Chemoreceptors monitor levels of oxygen, carbon dioxide, and pH in arterial blood. | |

| |Patients with chronic obstructive pulmonary disease (COPD) have chronically elevated carbon dioxide levels in | |

| |arterial blood. | |

| |Chemoreceptors in COPD patients become insensitive to changes in carbon dioxide and instead rely on oxygen levels | |

| |to regulate breathing. | |

| |Respiratory System Review—Respiratory Physiology Review | |

|30 |Oxygenation is the process by which the blood and the cells become saturated with oxygen. |Discussion Questions |

| |Hypoxia is an inadequate amount of oxygen being delivered to the cells. |What is the process by which body cells receive oxygen? |

| |Causes |What are signs of early hypoxia and late hypoxia? |

| |Occluded airway | |

| |Inadequate breathing | |

| |Inadequate delivery of oxygen to cells by the blood |Critical Thinking Discussion |

| |Inhalation of toxic gases |A trauma patient has an injury to the lung that has allowed |

| |Lung and airway diseases |air to separate the pleural layers (pneumothorax). How will |

| |Drug overdose that suppresses respiratory center |this affect ventilation? |

| |Stroke | |

| |Injury to the chest or respiratory structures | |

| |Head injury | |

| |Signs | |

| |Tachypnea | |

| |Dyspnea | |

| |Pale, cool, clammy skin | |

| |Tachycardia | |

| |Elevation in blood pressure | |

| |Restlessness and agitation | |

| |Disorientation and confusion | |

| |Headache | |

| |Cyanosis | |

| |Loss of coordination | |

| |Sleepy appearance | |

| |Head bobbing | |

| |Slow reaction time | |

| |Altered mental status | |

| |Bradycardia | |

| |Response to signs of hypoxia | |

| |If airway is open and breathing is adequate, apply a nonrebreather mask and administer high-flow, | |

| |high-concentration oxygen. | |

| |If breathing status is inadequate, begin positive pressure ventilation. | |

| |Alveolar/capillary exchange (external respiration) | |

| |Deoxygenated blood moves into the capillaries surrounding the alveoli. | |

| |Oxygen-rich air moves into the alveoli. | |

| |Oxygen diffuses into the capillaries and carbon dioxide diffuses into the alveoli. | |

| |Hemoglobin in the blood picks up most of the oxygen. | |

| |The blood carries oxygen through the arterial system to the capillaries of the body. | |

| |Carbon dioxide is exhaled from the alveoli and out of the lungs. | |

| |Despite adequate oxygenation, cellular hypoxia may still result from any disturbance in the delivery or the | |

| |off-loading of the oxygen. | |

| |Capillary/cellular exchange (internal respiration) | |

| |Oxygenated blood moves into the capillaries surrounding the body cells. | |

| |Cells have high levels of carbon dioxide and low levels of oxygen. | |

| |Oxygen diffuses into the cells and carbon dioxide diffuses into the blood. | |

| |Deoxygenated blood moves into the venous system, where it is transported back to the lungs for has exchange. | |

| |Respiratory System Review—Pathophysiology of Pulmonary Ventilation and External and Internal Respiration | |

|25 |A disturbance in pulmonary ventilation, oxygenation, external respiration, internal respiration, or circulation can|Discussion Question |

| |lead to cellular hypoxia and anaerobic metabolism. |What are some illnesses and injuries that can impair |

| |Anaerobic metabolism is associated with insufficient energy production and the buildup of lactic acid. |oxygenation? |

| |A severe alteration in perfusion can decrease glucose delivery to cells. | |

| |Without fuel, cells will eventually die. | |

| |Causes for disruption in the mechanical process of pulmonary ventilation |Knowledge Application |

| |Interruption of nervous system’s control |Describe patient situations with various cardiac, |

| |Structural damage to the thorax |cardiovascular, respiratory, or nervous system problems. Have |

| |Increased airway resistance |students explain how each problem can lead to hypoxia and |

| |Disruption of airway patency |anaerobic metabolism. |

| |The exchange of gas can be disrupted. | |

| |Pneumonia, pulmonary edema, and drowning cause fluid to hinder the movement of oxygen from the alveoli to the | |

| |capillaries. | |

| |Diseases such as emphysema distort the alveoli and change the surface for effective gas exchange. | |

| |Inhaled toxic gases interfere with oxygen use by the cell. | |

| |Poor perfusion or a decreased ability to carry blood can lead to cellular hypoxia. | |

| |Pulmonary embolism | |

| |Tension pneumonthorax | |

| |Heart failure | |

| |Cardiac tamponade | |

| |Anemia | |

| |Hypovoemia | |

| |Respiratory System Review—Airway Anatomy in Infants and Children | |

|10 |Mouth and nose | |

| |Mouths and noses are smaller and more easily obstructed. | |

| |Infants are obligate nose breathers. |Discussion Question |

| |Pharynx |What are differences in pediatric respiratory systems as |

| |Children are more prone to posterior displacement of tongue at level of pharynx. |compared to adults’? |

| |Epiglottis can protrude into the pharynx, causing obstruction. | |

| |Trachea and lower airway | |

| |Passages are narrow, softer, and more flexible than those of adults. |. |

| |Obstructions are more likely with flexion or extension. | |

| |Padding under the shoulders is necessary to keep trachea open. | |

| |Cricoid cartilage | |

| |Cartilage is less developed and less rigid. | |

| |Under ten years of age, cricoid is narrowest portion of upper airway. | |

| |Chest wall and diaphragm | |

| |Chest wall is softer and more pliable, leading to greater compliance. | |

| |Infants and children rely more on diaphragm than intercostals muscles. | |

| |If chest does not rise easily during artificial ventilation, assume an airway is not open, the airway is occluded | |

| |by an obstruction, or the ventilation volume is inadequate. | |

| |Oxygen reserves | |

| |Less oxygen is available during periods of inadequate breathing or apnea. | |

| |Twice the metabolic rate of adults | |

| |Become hypoxic more rapidly than adult patients | |

| | Airway Assessment—Airway Functions and Considerations |Discussion Questions |

|10 |A patent airway is an open airway. |What are indications that a patient has a patent airway? |

| |Airway functions and considerations |Why is opening the airway the first step in the primary |

| |Airway and respiratory tract is the conduit that allows air to move from the atmosphere into the alveoli. |survey? |

| |The airway must remain patent. | |

| |Any obstruction of the airway will lead to poor gas exchange and potential hypoxia. | |

| |The degree of obstruction will directly affect the amount of air available for gas exchange. | |

| |Mental status of a patient typically correlates with the status of the airway. | |

| |An alert, responsive patient has an open airway. | |

| |A patient with an altered mental status or who is unresponsive has the potential for airway occlusion. | |

| |IX. Airway Assessment—Abnormal Upper Airway Sounds |Discussion Question |

|10 |When assessing the airway of a patient with a severely altered mental status |What are indications that a patient’s airway is not patent? |

| |Open the mouth manually. | |

| |Perform a manual airway maneuver. | |

| |Inspect the inside of the mouth. | |

| |Listen for any abnormal sounds. | |

| |Sounds that indicate airway obstruction | |

| |Snoring—Upper airway is partially obstructed by the tongue or relaxed tissues in the pharynx. | |

| |Crowning—Muscles around the larynx spasm and narrow the opening into the trachea. | |

| |Gurgling—Blood, vomitus, secretions, or other liquids are present in the airway. | |

| |Stridor—Swelling in the larynx causes significant upper airway obstruction. | |

| | Airway Assessment—Opening the Mouth |Teaching Tip |

|10 |Crossed-finger technique |Ensure all equipment necessary to demonstrate each skill is |

| |Kneel above and behind the patient. |readily available. |

| |Cross the thumb and forefinger of one hand. | |

| |Place the thumb on the patient’s lower incisors and forefinger on the upper incisors. | |

| |Use a scissors motion to open the mouth. | |

| |Inspect the airway | |

| |Suction any foreign substances. | |

| |If suction equipment is not available and no spine injuries are suspected, turn the patient on his side and wipe | |

| |the fluids or sweep the mouth to remove them. | |

|10 |Airway Assessment—Opening the Airway | |

| |Open and maintain a patent airway. |Discussion Question |

| |Manual airway maneuvers |Explain the steps used in opening and maintaining a patient’s |

| |Head-tilt, chin-lift |airway. |

| |Jaw-thrust | |

| |Suction | |

| |Mechanical airways | |

| |Oropharyngeal airway |Teaching Tip |

| |Jaw-nasopharyngeal airway |Demonstrate each skill first in “real-time,” then step-by-step|

| |Head-tilt, chin-lift maneuver |with explanations, and then in “real time” again. |

| |Usage | |

| |Should be used when opening the airway in a patient who has no suspected spine injury | |

| |Must be supplemented with a mechanical airway device if the airway cannot be adequately maintained | |

| |Procedure | |

| |Apply pressure with one hand backward on patient’s forehead. | |

| |Place tips of fingers of the other hand underneath the bony part of the lower jaw. | |

| |Lift the jaw upward. | |

| |Continue pressing on the forehead to keep the head tilted backward. | |

| |Lift the chin and jaw so the teeth are brought nearly together. | |

| |Head-tilt, chin-lift maneuver in infants and children |Class Activity |

| |Same as for adults except for a variation in head positioning |Give students the opportunity for guided practice of airway |

| |With an infant, head should be tilted back into a neutral position. |management skills. |

| |Place a pad behind the shoulders to keep the airway open. | |

| |Only the index finger of one hand lifts the chin and jaw. | |

| |Take care not to press on soft tissue beneath the chin. | |

| |Jaw-thrust maneuver | |

| |Usage | |

| |Patient’s head and neck must be brought into a neutral, in-line position if a spine injury is suspected. | |

| |This maneuver is used to open the airway without tilting back the head and neck. | |

| |The jaw is displaced by the EMT’s fingers. | |

| |Must be supplemented with a mechanical airway device if the airway cannot be adequately maintained | |

| |Procedure | |

| |Kneel at the top of the patient’s head. | |

| |Place your elbows on the surface upon which the patient is lying. | |

| |Put your hands at the side of the patient’s head. | |

| |Grasp the angles of the patient’s lower jaw on both sides. | |

| |Use the thumb to retract the lower lip if the lips close. | |

| |Jaw-thrust maneuver in infants and children | |

| |Follow the same procedure as for adults. | |

| |Insert an airway adjunct if the jaw thrust does not open the airway. | |

| |Positioning the patient for airway control | |

| |Modified lateral position is used if patient has altered mental status and may be at risk for aspirating blood, | |

| |secretions, or vomitus. | |

| |Place patient’s arm flat on the ground at a right angle to the body. | |

| |Log roll the patient onto his side. | |

| |Place the hand of the opposite arm under his lateral face and cheek. | |

| |Bend the leg at the hip and knee to stabilize. | |

| |If a spine injury is suspected, the patient must remain supine. | |

|10 |Airway Assessment—Suctioning | |

| |Standard Precautions during suctioning | |

| |Protective eyewear, mask, and gloves should be worn. |Discussion Question |

| |An N-95 or high-efficiency particular air (HEPA) respirator should be worn if a patient is known to have |What precautions should be taken when suctioning? |

| |tuberculosis. | |

| |Suction equipment | |

| |Mounted suction devices | |

| |Portable suction devices | |

| |Suction catheters | |

| |Hard or rigid catheter—A Yankauer catheter, commonly known as a tonsil tip or tonsil sucker, is used to suction the| |

| |mouth and oropharynx of an unresponsive patient. | |

| |Soft catheter—Known as a French catheter, it is used in suctioning the nose and nasopharynx and in other situations| |

| |where the rigid catheter cannot be used. |Critical Thinking Discussion |

| |Technique of suctioning |What will happen if you ventilate a patient who has blood or |

| |Position yourself at the patient’s head. |vomit in the airway? |

| |Turn on the suction unit. | |

| |Select the appropriate catheter. | |

| |Measure the catheter and insert it into the oral cavity without suction. | |

| |Apply suction only on the way out of the airway. | |

| |If necessary, rinse the catheter with water to prevent obstruction of the tubing. |Teaching Tip |

| |Special considerations when suctioning |Cover all steps and criteria on the skill check-sheets used |

| |Log roll the patient on his side and clear the oropharynx with a finger if secretions or vomitus cannot be removed |for later student testing. It is more difficult to change |

| |quickly by suctioning. |behaviors, once learned, than to teach them initially. |

| |If both suctioning and artificial ventilation are needed, apply suction for 15 seconds followed by positive | |

| |pressure ventilation with supplemental oxygen for two minutes, and then repeat. | |

| |Monitor the patient’s pulse, heart rate, and pulse oximeter reading while suctioning to identify any decrease in | |

| |blood oxygen levels due to the removal of the residual volume of air. | |

| |Before suctioning a patient who is being artificially ventilated, ventilate at a rate of 12 ventilations per minute| |

| |for five minutes, then suction and resume ventilation. | |

| |Airway Assessment— Airway Adjuncts | |

|10 |Oropharyngeal (oral) airway | |

| |Consists of a semicircular device of hard plastic or rubber that holds the tongue away from the back of the airway.| |

| |Patient must be completely unresponsive and have no gag or cough reflex. |Discussion Question |

| |If the patient gags at any time during insertion, the device must be removed. |What are advantages and disadvantages of oral and nasal |

| |Size and method must be appropriate for the patient |airways? |

| |If the device is too long, it can push the epiglottis over the opening of the larynx. | |

| |If the device is inserted improperly, it may push the tongue back into the airway. | |

| |Procedure |Video Clip |

| |Select the proper size airway. |Go to |

| |Open the patient’s mouth using the crossed-finger technique. |and click on the mykit link for Prehospital Emergency Care, |

| |Gently rotate the airway 180 degrees when it comes in contact with the soft palate at the back of the roof of the |9th edition to access a video clip describing OPA insertion. |

| |mouth. | |

| |Alternate method involves the use of a tongue depressor (blade). | |

| |Nasophayngeal (nasal) airway | |

| |Consists of a curved hollow tube of soft plastic or rubber with a flange or flare at the top end and a bevel at the| |

| |distal end. | |

| |Use of this device is indicated for patients in whom the oral airway cannot be inserted. |Animation |

| |It can be used on a patient who is not fully responsive and needs assistance in maintaining an open airway. |Go to |

| |Avoid using in patients with a suspected fracture to the base of the skull or severe facial trauma. |and click on the mykit link for Prehospital Emergency Care, |

| |Procedure |9th edition to access an animation reviewing OPA, NPA, and |

| |Measure the airway. |suction techniques. |

| |Lubricate the outside of the airway well. | |

| |Insert the device in the larger or more open nostril, with the bevel facing the septum or floor of the nostril. | |

| |Check that air is flowing through the airway. | |

| | | |

| | | |

| | |Knowledge Application |

| | |After students have practiced rote skills, put the skills in |

| | |context by providing lab scenarios that call for |

| | |decision-making. |

| |Assessment of Breathing—Relationship of Tidal Volume and Respiratory Rate in Assessment of Breathing | |

|45 |Minute volume |Teaching Tip |

| |Minute volume typically correlates to how adequately a patient is breathing. |Draw a simple sketch of the respiratory system on the white |

| |A decrease in either tidal volume or respiratory rate may lead to a severe decrease in minute volume. |board and shade in the dead space to illustrate the concept. |

| |The EMT must know both respiratory rate and tidal volume before making any decision about the adequacy of | |

| |breathing. |Critical Thinking Discussion |

| |Alveolar ventilation |What are some things that would cause changes in tidal volume |

| |Alveolar ventilation is the amount of air breathed in that reaches the alveoli. |and respiratory rate? |

| |Decreases in tidal volume can reduce the amount of air reaching the alveoli. | |

| |A high respiratory rate can lead to a decrease in alveolar ventilation. |Discussion Question |

| | |Why does tidal volume decrease at abnormally high respiratory |

| | |rates? |

| | | |

| | |Knowledge Application |

| | |Give several pairs of respiratory rate and tidal volume values|

| | |and have students calculate the minute volume to illustrate |

| | |the effects of changes in the values. |

| | |Give several tidal volumes and respiratory rates and have |

| | |students calculate alveolar ventilation. |

| |Assessing For Adequate Breathing—Adequate Breathing | |

|30 |Rate, rhythm, quality, and depth of respirations should be assessed. |Teaching Tip |

| |Look |Explain to students that they will more readily recognize what|

| |Inspect the chest. |is abnormal if they take every opportunity to observe what is |

| |Observe the patient’s general appearance. |normal, in terms of respiration. |

| |Decide if the breathing pattern is regular or irregular. | |

| |Look at the nostrils to see if they are open wide during inhalation. | |

| |Listen | |

| |Assess the patient’s speech. | |

| |If the patient is unresponsive, listen for air escaping from the nose and mouth. | |

| |If an adequate volume of air is not heard being exhaled, the tidal volume should be considered inadequate, and the | |

| |patient must be ventilated. |Class Activity |

| |Feel |Provide pairs of students with stethoscopes and have them |

| |Feel the volume of air escaping from the patient’s nose and mouth during exhalation. |practice listening for one full inspiration and expiration for|

| |If you do not feel an adequate volume of air, the tidal volume should be considered inadequate, and the patient |the presence of breath sounds. |

| |must be ventilated. | |

| |Auscultate | |

| |Place stethoscope at the second intercostals space at the midclavicular line. | |

| |Listen to one full inhalation and exhalation. | |

| |Determine if breath sounds are present and equal bilaterally. | |

| |Adequate breathing characteristics | |

| |Rate—Respiratory rate within appropriate range of respirations depending on age | |

| |Rhythm—Pattern is regular. | |

| |Quality—Breath sounds are equal and bilateral. | |

| |Depth—Chest rises fully with each inhalation. | |

| |Respiratory distress occurs when a patient is working harder to breathe and needs supplemental oxygen. | |

| |Assessing For Adequate Breathing—Inadequate Breathing |Discussion Questions |

|30 |Inadequate breathing leads to inadequate oxygen exchange and inadequate delivery of oxygen to cells. |What are signs of inadequate breathing? |

| |Inadequate breathing leads to inadequate elimination of carbon dioxide. |What are causes of inadequate breathing and respiratory |

| |Inadequate breathing leads to inadequate cellular hypoxia. |arrest? |

| |Categories | |

| |Respiratory failure—Respiratory rate and/or tidal volume is insufficient. |Critical Thinking Discussion |

| |Respiratory arrest—Patient completely stops breathing. |In what circumstances could a patient with a normal |

| |Stroke |respiratory rate and tidal volume be hypoxic? |

| |Myocardial infarction | |

| |Drug overdoes | |

| |Toxic inhalation | |

| |Electrocution and lightning strike | |

| |Suffocation | |

| |Traumatic injuries to the head, spine, chest, or abdomen | |

| |Airway obstruction by a foreign body | |

| |Agonal respirations are gasping-type breaths. | |

| |Ineffective respirations | |

| |Require positive pressure ventilation | |

| |Often associated with cardiac arrest |Discussion Question |

| |Signs of inadequate breathing |What are agonal respirations? |

| |Rate—Respiratory rate is either too fast or too slow. | |

| |Tachypnea is excessively rapid breathing rate. | |

| |Bradypnea is an abnormally slow breathing rate. |Knowledge Application |

| |Rhythm—Pattern is irregular. |Describe several patient presentations and have students |

| |Quality—Breath sounds are decreased or absent. |determine if breathing is adequate or inadequate. |

| |Depth—Chest wall movement is minimal and does not rise adequately during inhalation. | |

| |Making the Decision to Ventilate or Not |Knowledge Application |

|15 |Deciding whether to ventilate or to use oxygen alone can mean the difference in whether a patient survives. |Describe several patient presentations and have students |

| |If either the respiratory rate or the tidal volume is inadequate, the patient needs to be ventilated. |determine if breathing is adequate or inadequate. |

| |Techniques of Artificial Ventilation—Differences between Normal Spontaneous Ventilation and Positive Pressure | |

|10 |Ventilation | |

| |Positive pressure ventilation (PPV) is a technique in which air is being forced into the patient’s lungs. | |

| |Physiological differences in patient receiving PPV | |

| |Air movement | |

| |Airway wall pressure | |

| |Esophageal opening pressure | |

| |Cardiac output | |

| |Techniques of Artificial Ventilation—Basic Considerations | |

|10 |Methods of artificial ventilation | |

| |Mouth to mask | |

| |Bag-valve mask (BVM) operated by two people |Video Clip |

| |Flow-restricted, oxygen-powered ventilation device |Go to |

| |Bag-valve mask (BVM) operated by one person |and click on the mykit link for Prehospital Emergency Care, |

| |Considerations |9th edition to access a video clip reviewing the components of|

| |Maintain a good mask seal. |two-person BVM. |

| |Deliver adequate volume of air to sufficiently inflate the lungs. | |

| |Allow for simultaneous oxygen delivery. | |

| |Standard Precautions | |

| |Risks of coming in contact with secretions, blood, or vomitus are relatively high. | |

| |Use gloves and eyewear. | |

| |Use a face mask if necessary. |Weblink |

| |Use a HEPA or N-95 respirator if tuberculosis is suspected. |Go to |

| |Adequate ventilation |and click on the mykit link for Prehospital Emergency Care, |

| |Ventilation must not be interrupted for greater than 30 seconds. |9th edition to access a web resource on effective BVM |

| |Indications of adequate ventilation |ventilations. |

| |Rate of ventilation is sufficient. | |

| |Tidal volume is consistent and sufficient to cause the chest to rise during each ventilation. | |

| |Patient’s heart rate returns to normal. | |

| |Color improves. | |

| |Indications of inadequate ventilation | |

| |Ventilation rate is too fast or too slow. | |

| |Chest does not rise and fall. |Discussion Question |

| |Heart rate does not return to normal. |What are signs of inadequate ventilation? |

| |Color does not improve. | |

| |Cricoid pressure | |

| |Also known as Sellick maneuver | |

| |Can be used to reduce complications associated with positive pressure ventilation | |

| |Used only in unresponsive patients | |

| |Requires an EMT to apply pressure to the cricoid cartilage | |

| |Techniques of Artificial Ventilation—Mouth-to-Mouth Ventilation |Critical Thinking Discussion |

|10 |Mouth-to-mouth and mouth-to-nose technique |Demonstrate both adequate and inadequate ventilations and have|

| |The EMT forms a seal with his mouth around the patient’s mouth or nose. |students critique your technique. |

| |The nose is pinched during mouth-to-mouth ventilation and the mouth is closed during mouth-to-nose ventilation. | |

| |The EMT uses his exhaled air to ventilate. | |

| |Limitations | |

| |Inability to deliver high concentrations of oxygen | |

| |Risk posed to EMT by contact with patient’s body fluids | |

| |Techniques of Artificial Ventilation—Mouth-to-Mask and Bag-Valve Ventilation: General Considerations |Discussion Question |

|10 |Ventilation volumes and duration of ventilation |What are the advantages and disadvantages of mouth-to-mask |

| |Adjust the rate of ventilation based on whether the patient has a pulse. |ventilation? |

| |If the patient has a pulse, the tidal volume should be enough to make the chest rise during each ventilation. | |

| |If the patient does not have a pulse, the ventilation rates are reduced and are performed in conjunction with chest| |

| |compressions. | |

| |Gastric inflation | |

| |Decreasing the ventilation volume is aimed at reducing the incidence of gastric distension and potential | |

| |regurgitation. | |

| |A smaller tidal volume reduces airway pressure and avoids causing the lower sphincter in the esophagus to open. | |

| |Higher tidal volumes can force the esophageal sphincter to open, causing gastric inflation. | |

| |An air-filled stomach can cause contents to enter the esophagus, leading to regurgitation and aspiration. | |

| |Aspiration of gastric contents may interfere with gas exchange and cause pneumonia. | |

| |Inflated stomach places pressure on the diaphragm, which can lead to ineffective ventilation. | |

| |Techniques of Artificial Ventilation—Mouth-to-Mask Ventilation | |

|10 |A plastic pocket mask is used to form a seal around the patient’s nose and mouth. | |

| |The EMT blows into the mask to deliver ventilation. | |

| |Advantages | |

| |One EMT can achieve a better mask seal. | |

| |Direct contact is eliminated. | |

| |Exposure to patient’s exhaled air is prevented. | |

| |Adequate tidal volumes can be achieved. | |

| |Supplemental oxygen can be administered. | |

| |Disadvantages | |

| |Some EMTs perceive the mask as posing a greater risk of infection. | |

| |The EMT may fatigue after a period of time. | |

| |The highest possible concentration of oxygen cannot be delivered. | |

| |Mask requirements | |

| |Transparent material | |

| |Tight fit | |

| |Oxygen inlet | |

| |Variety of sizes | |

| |One-way valve at the ventilation port | |

| |Mouth-to-mask technique—No suspected spine Injury | |

| |Connect one-way valve to ventilation port and tubing to an oxygen supply. | |

| |Use cephalic technique or lateral technique. | |

| |Place the mask on the patient’s face so that a tight seal is achieved. | |

| |Blow into the ventilation port of the mask. | |

| |Mouth-to-mask technique—Suspected spine injury | |

| |Connect one-way valve to ventilation port and tubing to an oxygen supply. | |

| |Position yourself at the top of the patient or at the side. | |

| |Place the mask on the patient’s face so that a tight seal is achieved. | |

| |Deliver ventilation. | |

| |Ineffective ventilation | |

| |Reposition the head and neck. | |

| |Change from a head-tilt, chin-lift to a jaw-thrust maneuver or vice versa. | |

| |Readjust the face mask. | |

| |Administer a greater tidal volume. | |

| |Insert an oropharyngeal or nasopharyngeal airway. | |

| |Techniques of Artificial Ventilation—Bag-Valve-Mask Ventilation |Discussion Question |

|10 |A bag-valve-mask (BVM) device is a manual resuscitator used to provide positive pressure ventilation. |How does the bag-valve-mask technique compare to use of |

| |Choose the appropriate size for the patient. |manually triggered devices? |

| |Use only enough volume to cause the chest to rise. | |

| |Combine with an oxygen source to deliver close to 100 percent oxygen. | |

| |Advantages | |

| |Convenient for the EMT | |

| |Ability to deliver enriched oxygen mixtures | |

| |Disadvantages | |

| |May not consistently generate the tidal volumes possible with mouth-to-mask ventilation | |

| |Requires two EMTs for best results | |

| |May fatigue the operator | |

| |Bag-valve-mask technique—No Suspected Spine Injury | |

| |Two-person BVM technique | |

| |One-person BVM technique | |

| |Ineffective ventilation | |

| |Check the position of the head and chin. | |

| |Check the mask seal. | |

| |Assess for an obstruction. | |

| |Check the bag-valve-mask system. | |

| |Use an alternative method of positive pressure ventilation if the chest still does not rise and fall. | |

| |Insert an oropharyngeal or nasopharyngeal airway if you need to maintain an open airway. | |

| |Check if the abdomen rises with each ventilation or appears to be distended | |

| |The head-tilt, chin-lift maneuver is not performed properly. | |

| |The patient is being ventilated too rapidly or with too great a tidal volume. | |

| |Bag-valve-mask technique—Patient with suspected spinal injury | |

| |Establish and maintain in-line spinal stabilization as a priority. | |

| |Maneuvers must be performed with care to avoid movement of the head or spine. | |

| |Ideally, the technique is best performed by three EMTS. | |

| |If only two EMTs are at the scene, it may be necessary for one to hold the in-line stabilization with his thighs | |

| |and knees. |Discussion Question |

| |Apply cricoid pressure if possible. |What modifications in technique are needed when ventilating a |

| | |patient with suspected spine injury? |

| |Techniques of Artificial Ventilation—Flow-Restricted, Oxygen-Powered Ventilation Device (FROPVD) |Knowledge Application |

|10 |Flow-restricted, oxygen-powered ventilation device (FROPVD) is a method of positive pressure ventilation that will |Provide several patient scenarios and ask students to select |

| |deliver 100 percent oxygen to the patient. |the preferred way of ventilating the patient and have them |

| |Advantages |defend their selection. |

| |Delivers 100 percent oxygen | |

| |Can be used by one EMT | |

| |Disadvantages | |

| |Can be used on adults only | |

| |Not carried on all EEMS units | |

| |EMT is unable to feel the compliance of air. | |

| |Gastric distention often occurs with this device. | |

| |Improper use can rupture a patient’s lungs. | |

| |FROPVD | |

| |Check the unit for proper functioning. | |

| |Check the oxygen source for adequate supply. | |

| |Open the airway. | |

| |Insert an oropharyngeal or nasopharyngeal airway. | |

| |Apply the adult mask. | |

| |Connect the flow-restricted, oxygen-powered ventilation device to the mask. | |

| |Activate the valve, and deactivate as soon as the chest begins to rise. | |

| |Monitor for adequate rise and fall of the chest. | |

| |FROPVD problems | |

| |Reevaluate the position of the head and chin. | |

| |Check the mask seal. | |

| |Check for foreign body obstruction of the airway. | |

| |Techniques of Artificial Ventilation—Automatic Transport Ventilator (ATV) | |

|10 |The automatic transport ventilator (ATV) is a device use for positive pressure ventilation. |Teaching Tip |

| |Provide and maintain a constant rate and tidal volume. |Emphasize the importance of learning and performing skills |

| |Maintain adequate oxygenation of arterial blood. |correctly and with great care to avoid complications. |

| |Most use oxygen as their power source, delivering 100 percent oxygen. | |

| |Can deliver oxygen at lower inspiratory flow rates for longer inspiratory times | |

| |Less likelihood of gastric distention | |

| |Most use oxygen as their power source, delivering 100 percent oxygen. | |

| |Advantages | |

| |EMT is free to use both hands to hold the mask and maintain the airway. | |

| |Device can be set to specific values. | |

| |Alarms indicate low pressure or disconnection. | |

| |EMT can apply cricoids pressure. | |

| |Disadvantages | |

| |The device cannot be used once the oxygen supply is depleted. | |

| |Some ATVs cannot be used in children less than five years of age. | |

| |It is not possible to feel an increase in airway resistance or decrease in the compliance of the lungs. | |

| |ATV recommended features | |

| |Time- or volume-cycled | |

| |Lightweight 15/22 connector | |

| |Rugged design | |

| |Default peak inspiratory pressure limit of 60 cm H2O that is adjustable | |

| |Audible alarms | |

| |Ability to deliver 50-100 percent oxygen | |

| |Inspiratory time of one second | |

| |An adjustable inspiratory flow of 30 lpm for adults and 15 lpm for children | |

| |Rate of ten breaths per minute for adults and 20 breaths per minute for children | |

| |ATV techniques | |

| |Check that ATV is properly functioning. | |

| |Attach the ATV to a mask. | |

| |Seal the mask on the face. | |

| |Select tidal volume and rate. | |

| |Turn on the unit. | |

| |Observe the chest for rise and fall, and adjust if needed. | |

| |Monitor continuously. | |

| |Techniques of Artificial Ventilation—Ventilation of the Patient Who Is Breathing Spontaneously | |

|10 |Assess the patient and recognize the need for ventilation. | |

| |Signs of inadequate breathing | |

| |Altered mental status | |

| |Inadequate respiratory rate | |

| |Poor chest rise and fall | |

| |Fatigue from increased work of breathing | |

| |Problems that may be encountered | |

| |Combativeness in the hypoxic patient who does not cooperate | |

| |Inadequate mask seal | |

| |Overventilation leading to lung injury | |

| |Risk of regurgitation and aspiration | |

| |Explain the procedure to the patient | |

| |Breathing patients who would need ventilation | |

| |Patient with reduced minute volume (hypoventilation) | |

| |Patient with adequate respiratory rate but inadequate tidal volume (hypopnea) | |

| |Patient with adequate tidal volume but a slow respiratory rate (bradypnea) | |

| |Patient with a fast respiratory rate (tachypnea) that leads to hypopnea. | |

| |Techniques of Artificial Ventilation—Continuous Positive Airway Pressure (CPAP) | |

|10 |Continuous positive airway pressure (CPAP) is a form of noninvasive positive pressure ventilation. | |

| |Used in awake and spontaneously breathing patients |Discussion Question |

| |Delivered via a tightly fitted mask |What are advantages and disadvantages of CPAP? |

| |Generates a continuous flow of air under positive pressure. | |

| |Delivery of air is intended to inflate collapsed alveoli, improve oxygenation, and reduce patient’s work of | |

| |breathing. | |

| |The continuous pressure created by CPAP prevents fluid leakage into the alveoli and forces fluid that has leaked | |

| |out of the alveoli. | |

| |Indications for CPAP | |

| |Patient criteria | |

| |Awake and alert | |

| |Able to maintain airway | |

| |Able to breathe on his own | |

| |Indications for patient in severe respiratory distress | |

| |Congestive heart failure | |

| |Pulmonary edema | |

| |Chronic obstructive pulmonary disease (COPD) | |

| |asthma | |

| |Contraindications for CPAP | |

| |Apnea | |

| |Inability to understand or obey commands | |

| |Inability to maintain his own airway | |

| |Unresponsiveness | |

| |Responsiveness only to verbal or painful stimuli | |

| |Cardiac arrest | |

| |Need for frequent suctioning | |

| |Relative contraindications | |

| |Pulmonary trauma | |

| |Increased intracranial pressure | |

| |Abdominal distention with a risk of vomiting | |

| |Hypotension | |

| |Administering CPAP | |

| |Inform the patient about the CPAP device. | |

| |Coach patients to decrease their anxiety. | |

| |Work quickly yet slowly enough to allow the patient to become comfortable. | |

| |BiPAP | |

| |Bilevel positive airway pressure | |

| |Similar to CPAP but allows for different airway pressures | |

| |Use in prehospital care is not recommended | |

| |Techniques of Artificial Ventilation—Hazards of Overventilation |Discussion Question |

|10 |Overventilation can lead to serious complications. |What are signs of overventilation? |

| |Cardiac arrest patients | |

| |Can lead to a decrease in cardiac output, blood pressure, and perfusion | |

| |May not allow for the development of negative pressure between compressions | |

| |May lead to decrease in the perfusion of both the coronary vessels in the heart and cerebral vessels in the brain | |

| |Spontaneously breathing patient | |

| |Large amounts of air may become trapped in the alveoli. | |

| |Pressure in the chest will remain higher than it should. | |

| |May cause capillaries in the lungs to become compressed and obstruct blood flow | |

| |Would reduce the negative pressure in the chest | |

| |May reduce cardiac output, blood pressure, and perfusion of essential organs | |

| |Special Considerations of Airway Management and Ventilation—A Patient with a Stoma or Tracheostomy Tube | |

|10 |A stoma is a surgical opening in the front of the neck. | |

| |Tracheostomy | |

| |Stoma may result from a tracheostomy, in which a cut was made in the trachea | |

| |A tracheostomy tube is often inserted into the stoma to hold it open. | |

| |Laryngectomy |Discussion Questions |

| |Stoma may result from a laryngectomy, in which all or part of the larynx has been removed. |What are reasons a patient may have a stoma? |

| |Total laryngectomy—No longer any connection of the trachea to the mouth and nose |What is the difference between a partial and a total |

| |Partial laryngectomy—Some of the tracheal connection to the mouth and nose remains |laryngectomy? |

| |Bag-valve-mask-to-tracheostomy-tube ventilation | |

| |Device is designed so it can connect to the tracheostomy tube. | |

| |It may be necessary to seal the patient’s mouth and nose. | |

| |You may need to use a soft suction catheter first. | |

| |You may need to seal the tube and ventilate through the mouth and nose. | |

| |Bag-valve-mask-to-stoma ventilation | |

| |Remove all coverings from the stoma. | |

| |Clear the stoma of foreign matter. | |

| |Keep the patient’s head straight. | |

| |Fit a mask over the stoma and hold the mask seal in place. |Teaching Tip |

| |Squeeze the bag delivering ventilation and watch for adequate chest rise and fall. |Show students examples of tracheostomy tubes and demonstrate |

| |Seal the nose and mouth if needed. |how the standard adapter for the bag-valve-mask fits the tube.|

| |Mouth-to-stoma ventilation | |

| |This method is not recommended because of exposure to respiratory secretions and droplets. | |

| |Follow the same procedure for adult ventilation with a bag-valve mask, but form the mask seal over the stoma | |

| |instead of the mouth. | |

| |If there is no other option, use a barrier device over the stoma. | |

| |Special Considerations of Airway Management and Ventilation—Infants and Children |Knowledge Application |

|5 |Establishing an airway |Ask students to instruct you in providing airway management |

| |Place the infant’s head in a neutral position without hyperextension. |and ventilation on a pediatric airway mannequin. |

| |Place the child’s head in a neutral position and then only slightly extended. | |

| |Providing positive pressure ventilation | |

| |Avoid excessive ventilation volume and pressures. | |

| |Gastric distension can impede lung inflation, cause vomiting or rupturing. | |

| |Choosing a bag-valve-mask device | |

| |Use a device with a minimum volume of 450-500 mL without a pop-off valve. | |

| |Disable a pop-off valve if it is present. | |

| |Maintaining a patent airway | |

| |Insert an orophrayngeal or nasopharyngeal airway if the airway cannot be maintained. | |

| |Insert an airway if prolonged ventilation is necessary. | |

| |Special Considerations of Airway Management and Ventilation—Patients with Facial Injuries | |

|5 |Blunt injury can cause swelling that may occlude the airway. |Discussion Question |

| |An airway adjunct may be necessary. |What are the challenges of airway management in patients with |

| |Avoid the use of a nasopharyngeal airway with mid-face trauma. |facial trauma? |

| |Positive pressure ventilation may be needed to force ventilation past the swollen airway. | |

| |Bleeding into the pharynx may cause problems with airway management. | |

| |Special Considerations of Airway Management and Ventilation—Foreign Body airway Obstruction | |

|5 |Follow the procedure for foreign body airway obstruction to establish an airway in patients with known upper airway| |

| |foreign body obstruction. | |

| |Check for foreign body obstruction in unresponsive patients for whom attempts at ventilation have been | |

| |unsuccessful. | |

| |Responsive, choking patients | |

| |Instruct patient to cough. | |

| |Do not perform abdominal thrusts. | |

| |Place patient on high-concentration oxygen/ | |

| |Manage the patient as complete foreign body obstruction if breathing becomes weak and ineffective. | |

| |Signs of severe partial airway obstruction | |

| |Cough that becomes silent | |

| |Stridor heard on inhalation | |

| |Increase in labored breathing | |

| |Special Considerations of Airway Management and Ventilation—Dental Appliances | |

|5 |Dentures | |

| |If secure, leave in place. | |

| |If loose, remove them. | |

| |Reassess mouth frequently | |

| |Oxygen Therapy—Oxygen Cylinders | |

|6 |Cylinders are given letter designations according to their size. | |

| |Duration of flow | |

| |The amount of oxygen in a tank can be determined from the gauge and the psi of pressure remaining. | |

| |Use a simple formula to determine the oxygen duration of a tank. | |

| |The flow rate is directly related to how fast oxygen is depleted from the tank. | |

|6 |Oxygen Therapy—Safety Precautions |Discussion Question |

| |Keep combustible materials away from the cylinder. |What precautions must be taken when handling and administering|

| |Never smoke in any area where oxygen cylinders are in use or on standby. |oxygen? |

| |Store the cylinders below 125° F. | |

| |Never use without a properly fitting regulator valve. | |

| |Keep valves closed when cylinder is not in use. | |

| |Keep cylinders secured. | |

| |Never place any part of your body over the cylinder valve. | |

| |Oxygen Therapy—Pressure Regulators | |

|6 |A regulator reduces the high pressure in the cylinder to a safe range. |Teaching Tip |

| |A regulator is attached by a yoke. |Show students examples of various oxygen delivery devices, |

| |The yoke prevents a regulator from being attached to other types of gas. |cylinders, and regulators to familiarize them with the |

| |Types of regulators |equipment. |

| |High-pressure regulator | |

| |Can provide 50 psi to power a flow-restricted, oxygen-powered ventilation device | |

| |Has only one gauge and a threaded outlet | |

| |No mechanism for controlling and adjusting the flow rate | |

| |Therapy regulator | |

| |It can administer oxygen from 0.5 lpm to 25 lpm. | |

| |It typically has two gauges, one indicating pressure and the other indicating measured flow of oxygen. | |

| |The pressure decreases with the volume. | |

| |The pressure is directly affected by ambient temperature. | |

| |Oxygen Therapy—Oxygen Humidifiers |Teaching Tip |

|6 |Oxygen humidifiers add moisture to oxygen that exits the tank. |Show and explain each of the devices as you talk about them. |

| |It consists of a container filled with sterile water. |Pass equipment (as appropriate) around the classroom for |

| |Oxygen leaving the regulator is forced through the water. |students to touch and examine. |

| |Generally required only if oxygen is delivered over a long period of time. | |

| |Humidified oxygen is recommended in asthma patients. | |

| |Oxygen Therapy—Indications for Oxygen Use |Discussion Question |

|6 |Recognized indications |What are the indications for oxygen administration? |

| |Cardiac or respiratory arrest | |

| |Positive pressure ventilation | |

| |Signs of hypoxia | |

| |SpO2 reading less than 95% | |

| |Medical conditions | |

| |Altered mental status | |

| |Unresponsive | |

| |Injuries to any body cavity pr central nervous component | |

| |Multiple fractures and multiple soft tissue injuries | |

| |Severe bleeding | |

| |Hypoperfusion | |

| |Exposure to toxins | |

| |Carefully asses the patient to determine the breathing status before deciding the method by which to supply oxygen.| |

| |Determine if the respiratory rate is adequate and if the tidal volume is adequate in order to apply oxygen by mask | |

| |or cannula. | |

| |If either the respiratory rate or the tidal volume is inadequate, begin positive pressure ventilation with oxygen | |

| |connected and flowing to the ventilation device. | |

| |Oxygen Therapy—Hazards of Oxygen Administration |Critical Thinking Discussion |

|6 |Hazards |What are some situations in which you should be cautious in |

| |Oxygen toxicity |administering oxygen to patients? |

| |Damage to the retina in premature newborns | |

| |Respiratory depression or respiratory arrest in patients with COPD | |

| |Never withhold oxygen from a COPD patient who is displaying any signs of hypoxia or who is suffering from | |

| |respiratory failure or arrest. | |

| |Oxygen Therapy—Oxygen Administration Procedures |Teaching Tip |

|6 |Explain to the patient why oxygen is needed, how it will be administered, and how the oxygen delivery device will |If supply levels allow, give students the experience of having|

| |fit. |an oxygen mask on the face (with oxygen flowing) to increase |

| |Procedure |empathy for patients. |

| |Check the cylinder to be sure it contains oxygen. | |

| |Remove the protective seal on the tank valve. | |

| |Open and then shut the valve to remove debris. | |

| |Place the yoke over the valve and align the pins. | |

| |Tighten the T-screw on the regulator. | |

| |Open the main cylinder valve about one-half turn to charge the regulator. | |

| |Attach the oxygen mask or nasal cannula tubing to the nipple of the regulator. | |

| |Open the flowmeter control. | |

| |Apply the oxygen mask or nasal cannula to the patient. | |

| |Oxygen Therapy—Terminating Oxygen Therapy | |

|6 |Remove the mask or cannula. | |

| |Turn off the oxygen regulator flowmeter control. | |

| |Turn off the cylinder valve. | |

| |Open the regulator valve. | |

| |Turn the regulator flowmeter control off. | |

| |Oxygen Therapy—Transferring the Oxygen Source: Portable to On-Board |Class Activity |

|6 |Switching over from a portable oxygen tank |Provide students with the opportunity for guided practice of |

| |Do not disconnect the oxygen tubing while the mask is on the patient. |the skills presented in this section. |

| |Remove the mask from the patient before attempting to switch over. | |

| |Reapply the mask once the oxygen has been reconnected and is flowing. | |

| |Oxygen tubing can become caught on equipment and stop the flow of oxygen, causing the patient to become hypoxic. | |

| |Oxygen Therapy—Oxygen Delivery Equipment | |

|6 |Nonrebreather mask |Knowledge Application |

| |It has an oxygen reservoir bag attached to the mask with a one-way valve that prevents the patient’s exhaled air |Describe a variety of patient conditions and ask students what|

| |from mixing with the oxygen in the reservoir. |type of oxygen delivery device would best suit the patient’s |

| |The flow from the oxygen cylinder should be set at a rate that prevents the reservoir bag from collapsing during |needs. |

| |inhalation. | |

| |You may need to coach the patient to breathe at a normal rate and depth. | |

| |Nasal cannula | |

| |It provides a very limited oxygen concentration. |Class Activity |

| |Delivered oxygen concentration ranges from 24 to 44 percent. |Supply groups of students with a selection of oxygen delivery |

| |Indicated for a patient who is not able to tolerate a nonrebreather mask. |devices so that they can practice applying the devices on each|

| |Consists of two soft nasal prongs connected by a thin tubing to the main oxygen source. |other under your supervision. |

| |Other oxygen delivery devices | |

| |Simple face mask |Video Clips |

| |Partial rebreather mask |Go to |

| |Venturi mask |and click on the mykit link for Prehospital Emergency Care, |

| |Tracheostomy mask |9th edition to access video clips on different types of oxygen|

| | |delivery devices and pulse oximetry. |

| |XI. Follow-Up |Case Study Follow-Up Discussion |

|10 |Answer student questions. |Why was the patient’s mouth suctioned before manual airway |

| |Case Study Follow-Up |maneuvers were used? |

| |Review the case study from the beginning of the chapter. |If the patient’s gag reflex was intact, what other techniques |

| |Remind students of some of the answers that were given to the discussion questions. |could be used to keep the airway patent? |

| |Ask students if they would respond the same way after discussing the chapter material. Follow up with questions to | |

| |determine why students would or would not change their answers. |Class Activity |

| |Follow-Up Assignments |Alternatively, assign each question to a group of students and|

| |Review Chapter 10 Summary. |give them several minutes to generate answers to present to |

| |Complete Chapter 10 In Review questions. |the rest of the class for discussion. |

| |Complete Chapter 10 Critical Thinking. | |

| |Assessments |Teaching Tips |

| |Handouts |Answers to In Review and Critical Thinking questions are in |

| |Chapter 10 quiz |the appendix to the Instructor’s Wraparound Edition. Advise |

| | |students to review the questions again as they study the |

| | |chapter. |

| | |The Instructor’s Resource Package contains handouts that |

| | |assess student learning and reinforce important information in|

| | |each chapter. This can be found under mykit at |

| | |. |

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MASTER TEACHING NOTES

• Case Study Discussion

• Teaching Tips

• Discussion Questions

• Class Activities

• Media Links

• Knowledge Application

• Critical Thinking Discussion

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