Transcript Physical Exam

Respiratory
Emergencies
Beyond the Objectives
1
Discussion Points:
 Respiratory Anatomy & Physiology
 Pathophysiology
 Assessment of the Respiratory
System
 Management of Respiratory
Disorders
 Specific Respiratory Diseases
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Anatomy & Physiology
Review
• Function
• Takes in oxygen
• Disposes of wastes
• Carbon dioxide
• Excess water
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Anatomy & Physiology
Review
a) Nose and mouth
b) Oropharynx
c) Nasopharynx
d) Pharynx
c) Epiglottis
d) Larynx
e) Cricoid cartilage
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Anatomy & Physiology
Review
Lower Airway
a) Trachea
b) Lungs
c) Bronchi
d) Bronchioles
e) Alveoli
f) Diaphragm
g) Intercostal Muscles
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Anatomy & Physiology
Review
• Bronchioles
• Smallest airways
• Walls consist entirely
of smooth muscle (no
cartilage present)
• Constriction increases
resistance to airflow
• Dilation reduces
resistance to airflow
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Anatomy & Physiology
Review
• Alveoli
• Air sacs
• Site of oxygen and
carbon dioxide
exchange with
blood
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Anatomy & Physiology
Review
Pleura
-Visceral
-Parietal
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Anatomy & Physiology
Review
• Inhalation
• Diaphragm and
intercostal muscles
contract, increasing
the size of the thoracic
cavity.
• Air flows into the
lungs.
- Active Process
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Anatomy & Physiology
Review
• Exhalation
-Diaphragm and intercostal
muscles relax decreasing
the size of the thoracic
cavity.
-Air flows out of the lungs.
-passive process
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Anatomy & Physiology
Review
• Alveolar/capillary exchange
• Oxygen-rich air enters the
alveoli during each
inspiration.
• Oxygen-poor blood in the
capillaries passes into the
alveoli.
• Oxygen enters the capillaries
as carbon dioxide enters the
alveoli.
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Anatomy & Physiology
Review
• Capillary/cellular
exchange
• Cells give up carbon
dioxide to
the capillaries.
• Capillaries give up
oxygen to the cells.
O2 + Glucose
The Cell
CO2 + H2O
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Adequate/Inadequate Breathing
Assess…..
Rate
Rhythm
Quality
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Adequate/Inadequate Breathing
• Rate
• Normal Rate
• Adult – 12-20/minute
• Child – 15-30/minute
• Infant – 25-50/minute
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Adequate/Inadequate
Breathing
• Rhythm
• Regular
• Irregular
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Adequate/Inadequate
Breathing
• Quality
• Breath Sounds
• Effort of Breathing
• Chest Expansion
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Adequate/Inadequate
Breathing
• Other indications that your patient is
breathing inadequately.
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Cyanosis
Cool Clammy Skin
Nasal Flaring
Agonal Respirations
Tripoding
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Anatomy & Physiology
Review
• Infant & Child Airway
Considerations
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Smaller airway passages
Large tongue
Softer pliable structures
Cricoid cartilage is narrowest point.
Heavily dependant on diaphragm
Larger head
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Discussion Point:
In our initial assessment, we find that our
lethargic 20y/o patient is breathing
36bpm with shallow respirations and
becoming increasingly cyanotic.
-What else would you like to know?
-What are our treatment options?
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When you determine that a patient’s breathing is
inadequate, provide artificial ventilation with
supplemental oxygen.
Means of providing Artificial Ventilation:
1- Pocket face mask with supplemental O2.
2- Two-rescuer BVM ventilation with supplemental O2.
3- Flow restricted oxygen-powered ventilation device.
(Not appropriate for infant and children.)
4- One-rescuer BVM ventilation with supplemental O2.
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Oxygen & Artificial Ventilation
in Children and Infants
• As a general rule in the prehospital setting, apply as much
oxygen as the patient will
tolerate.
• Utilize artificial/positive
pressure ventilation when the
patient is apneic, gasping, or
when there is persistent
cyanosis despite oxygen.
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Assess for Adequate Artificial
Ventilation
Observe for Chest Rise
Sufficient Rate
-12bpm for adults (1 breath every 5 sec.)
-20bpm for children and infants
(1 breath every 3 sec.)
Heart rate returns to normal
What are other signs of adequate
artificial ventilation?
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Inadequate Artificial
Ventilation
Chest does not rise and fall with artificial
ventilation.
Rate is too slow or too fast.
Heart rate does not return to normal.
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Breathing Difficulty
(Signs & Symptoms)
 Shortness of Breath
 Restlessness
 Increased Pulse Rate
 Increased Breathing Rate
 Skin Color Changes
• Cyanotic
• Pale
• Flushed
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Breathing Difficulty
(Signs & Symptoms)
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Noisy Breathing
Inability to Speak
Retractions
Shallow or Slow Breathing
Abdominal Breathing
Coughing
Irregular Breathing Rhythms
Patient Position
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Assessment of the Respiratory
Emergency
Scene Size-up
• Threats to Safety
• Identify rescue environments having decreased
oxygen levels.
• Gases and other chemical or biological agents.
• Clues to Patient Information
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Assessment of the Respiratory
Emergency
• Initial Assessment
• General Impression
• Position
• Color
• Ability to speak
• Respiratory effort
• LOC
• AVPU
• Chief Complaint/Apparent
Life Threats
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Assessment of the Respiratory
Emergency
Initial Assessment (cont):
 Airway
-Assure there is no obstruction
-Proper ventilation cannot take place without an adequate airway.
 Breathing
-Absent or abnormal breath sounds
-Speaking limited to 1–2 words
-Use of accessory muscles or presence of retractions
 Circulation
-Tachycardia
-Severe central cyanosis, pallor, or diaphoresis
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Focused History
& Physical Exam
History
SAMPLE History
OPQRST History
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Paroxysmal nocturnal dyspnea and orthopnea
Coughing and hemoptysis
Associated chest pain
Smoking history or exposure to secondary smoke
Similar Past Episodes
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Focused History
& Physical Exam
Physical Examination
Inspection
• Look for asymmetry, increased diameter, or
paradoxical motion.
Palpation
• Feel for subcutaneous emphysema or tracheal
deviation.
Percussion
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Focused History & Physical Exam
Physical Examination (cont.)
Auscultation
• Normal Breath Sounds
• Clear
• Equal
• Abnormal Breath Sounds
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Stridor
Wheezing
Rhonchi
Rales/crackles
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Focused History & Physical Exam
Physical Examination (cont.)
 Extremities
• Look for peripheral cyanosis.
• Look for swelling and redness, indicative of a venous clot.
• Look for finger clubbing, which indicates chronic hypoxia.
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Focused History & Physical
Exam
Vital Signs
Heart Rate
• Tachycardia.
Blood Pressure
• Pulsus paradoxus.
Respiratory Rate
• Observe for trends.
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Focused History
& Physical Exam
• Assume that an elevated respiratory rate
in a patient with dyspnea is caused by
hypoxia. A persistently slow rate
indicates impending respiratory arrest.
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Focused History & Physical Exam
• Diagnostic
Testing
• Pulse Oximetry
• Inaccurate
readings
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Focused History & Physical Exam
• Other Diagnostic
Testing
• Peak Flow
• Dextrose
Monitoring???
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Management of
Respiratory Emergencies
Basic Principles
• Maintain the airway.
• Protect the cervical spine if trauma is suspected.
• Patients breathing inadequately should be assisted
with artificial ventilation.
• Any patient with respiratory distress should receive
oxygen.
• Oxygen should never be withheld from a patient
suspected of suffering from hypoxia.
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Management of
Respiratory Emergencies
Basic Principles (cont.)
All patients in respiratory distress are a
priority transport.
They have the potential to decline very
rapidly.
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What Kind of Respiratory
Emergencies
Might I Encounter???
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Upper-Airway Obstruction
• Common Causes
• Tongue, Foreign Matter, Trauma, Burns
• Allergic Reaction, Infection
• Assessment
• Differentiate cause.
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Upper-Airway Obstruction
Management
• Conscious Patient
• If the patient is able to speak, encourage
coughing.
• If the patient is unable to speak, perform
abdominal thrusts.
• Determine if there is a complete obstruction or
poor air exchange.
• If either one is present, provide up to five
abdominal thrusts in rapid succession.
• If they fail, repeat until obstruction is relieved or
patient becomes unconscious.
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Upper-Airway Obstruction
Management (cont.)
• Unconscious Patient
• Open the airway.
• Attempt to give two ventilations.
• If they fail, reposition the head and reattempt.
• Administer abdominal thrusts.
• Attempt finger sweeps if foreign body is visualized.
• If foreign body is removed, resume ventilation.
• If unsuccessful, continue abdominal thrusts and sweeps.
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Adult Respiratory Distress
Syndrome
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Sepsis
Aspiration
Pneumonia
Pulmonary Injury
Burns/Inhalation Injury
Oxygen Toxicity
Drugs
High Altitude
Hypothermia
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Near-Drowning Syndrome
Head Injury
Pulmonary Emboli
Tumor Destruction
Pancreatitis
Invasive Procedures
• Bypass, hemodialysis
• Hypoxia, Hypotension, or
Cardiac Arrest
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Adult Respiratory
Distress Syndrome
Pathophysiology
• High Mortality
• Multiple Organ Failure
• Affects Interstitial Fluid
• Causes increase in fluid in the interstitial space
• Disrupts diffusion and perfusion
Assessment
• Symptoms Related to Underlying Cause
• Abnormal Breath Sounds
• Crackles and rales
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Adult Respiratory
Distress Syndrome
Management
• Manage the underlying condition.
• Provide supplemental oxygen.
• Support respiratory effort.
• Provide positive pressure ventilation if respiratory
failure is imminent.
• Monitor vital signs.
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Obstructive Lung Disease
Types
• Emphysema
• Chronic Bronchitis
• Asthma
Causes
• Genetic Disposition
• Smoking and Other Risk Factors
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Emphysema
• Pathophysiology
• Exposure to Noxious Substances
• Exposure results in the destruction of the walls of
the alveoli.
• Weakens the walls of the small bronchioles and
results in increased residual volume.
• Cor Pulmonale – hypertrophy of the right
ventricle
• Polycythemia – an excess of red blood cells
• Increased Risk of Infection
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Emphysema
Assessment
• History
• Recent weight loss, dyspnea with exertion
• Cigarette and tobacco usage
• Lack of Cough
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Emphysema
Assessment
• Physical Exam
 Barrel chest
 Prolonged
expiration and
rapid rest phase
 Thin
 Pink skin due to
extra red cell
production
 “Pink puffer”
 Hypertrophy of
accessory
muscles
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Chronic Bronchitis
Pathophysiology
• Results from an increase in mucussecreting cells in the respiratory tree.
• Alveoli relatively unaffected.
• Decreased alveolar ventilation.
Assessment
• History
• Frequent respiratory infections.
• Productive cough.
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Chronic Bronchitis
Assessment (cont.)
• Physical Exam
• Often overweight
• Rhonchi present on
auscultation
• Jugular vein
distention
• Ankle edema
• Hepatic congestion
• “Blue bloater”
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Bronchitis and Emphysema
Management
• Establish and maintain airway.
• Support breathing.
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Find position of comfort.
Provide O2
Monitor oxygen saturation.
Be prepared to ventilate.
• Establish IV access.
• Administer medications.
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Asthma
Pathophysiology
• Chronic Inflammatory Disorder
• Results in widespread but variable air flow
obstruction.
• The airway becomes hyperresponsive.
• Induced by a trigger, which can vary by
individual.
• Trigger causes release of histamine, causing
bronchoconstriction and bronchial edema.
• 6–8 hours later, immune system cells invade
the bronchial mucosa and cause additional
edema.
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Asthma
Assessment
• Identify immediate threats.
• Obtain history.
• SAMPLE & OPQRST history
• History of asthma-related hospitalization?
• History of respiratory failure/ventilator use?
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Asthma
Assessment (cont.)
• Physical Exam
• Presenting signs may include dyspnea, wheezing,
cough.
• Wheezing is not present in all asthmatics.
• Speech may be limited to 1–2 consecutive words.
• Look for hyperinflation of the chest and
accessory muscle use.
• Carefully auscultate breath sounds.
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Asthma
Management
• Treatment goals:
• Correct hypoxia.
• Reverse bronchospasm.
• Reduce inflammation.
• Maintain the airway.
• Support breathing.
• High-flow oxygen or assisted ventilations as
indicated.
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Asthma
Management (cont.)
– Establish IV access.
• Administer medications.
Status Asthmaticus
• A severe, prolonged attack that cannot be
broken by bronchodilators.
• Greatly diminished breath sounds.
• Recognize imminent respiratory arrest.
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Upper Respiratory
Infection (URI)
Upper Respiratory Infections
• Frequent patient complaint.
• Common pediatric complaint.
• Rarely life threatening.
Pathophysiology
• Frequently caused by viral and bacterial infections.
• Affect multiple parts of the upper airway.
• Typically resolve after several days of symptoms.
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Upper Respiratory
Infection (URI)
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Upper Respiratory
Infection (URI)
• Assessment
• Look for underlying illness.
• Evaluate pediatrics for epiglottitis.
• Management
• Maintain the airway.
• Support breathing.
• Treat signs and symptoms.
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Pneumonia
Infection of the Lungs
• Immune-Suppressed Patients
Pathophysiology
• Bacterial & Viral Infections
• Hospital-acquired vs. community-acquired.
• Infection can spread throughout lungs.
• Alveoli may collapse, resulting in a ventilation
disorder.
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Pneumonia
Assessment
• Focused History & Physical Exam
• SAMPLE & OPQRST:
• Recent fever, chills, weakness, and malaise
• Deep, productive cough with associated pleuritic
pain
• Tachypnea and tachycardia may be present.
• Breath sounds:
• Presence of rales/crackles in affected lung segments
• Decreased air movement in the affected lung
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Pneumonia
Management
• Maintain the airway.
• Support breathing.
• High-flow oxygen or assisted ventilation as
indicated.
• Monitor vital signs.
• Establish IV access.
• Avoid fluid overload.
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Lung Cancer
General Pathophysiology
• Majority are caused by carcinogens secondary to cigarette
smoking or occupational exposure.
• May start elsewhere and spread to lungs.
• High mortality.
Assessment
• Focused History & Physical Exam
• SAMPLE & OPQRST history
• Cancer-related treatments and hospitalizations.
• Physical exam
• Evaluate for severe respiratory distress.
Management
• Follow general principles.
• Administer oxygen, support ventilation.
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Toxic Inhalation
Pathophysiology
• Includes inhalation of heated air, chemical
irritants, and steam.
• Airway obstruction due to edema and
laryngospasm due to thermal and chemical
burns.
Assessment
• Focused History & Physical Exam
• SAMPLE & OPQRST history
• Determine nature of substance.
• Length of exposure and loss of consciousness.
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Toxic Inhalation
Management
• Ensure scene safety.
• Enter a scene only if properly trained and
equipped.
• Remove the patient from the toxic
environment.
• Maintain the airway.
• Early, aggressive management may be
indicated.
• Support breathing & provide O2.
• Establish IV access.
• Transport promptly.
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Carbon Monoxide Inhalation
Carbon Monoxide
• Odorless, Colorless Gas
• Results from the incomplete combustion of
carbon-containing compounds.
• Often builds up to dangerous levels in confined
spaces such as mines, autos, and poorly
ventilated homes.
• Hazardous to Rescuers
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Carbon Monoxide Inhalation
Pathophysiology
• Binds to Hemoglobin
• Prevents oxygen from binding and creates
hypoxia at the cellular level.
Assessment
• Focused History & Physical Exam
• SAMPLE & OPQRST history
• Determine source and length of exposure.
• Presence of headache, confusion, agitation, lack of
coordination, loss of consciousness, and seizures.
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Carbon Monoxide Inhalation
Management
• Ensure scene safety.
• Enter a scene only if properly trained and equipped.
• Remove the patient from the toxic environment.
• Maintain the airway.
• Support breathing.
• High-flow oxygen or assisted ventilations as indicated.
• Establish IV access.
• Transport promptly.
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Pulmonary Embolism
Pathophysiology
• Obstruction of a Pulmonary Artery
• Emboli may be of air, thrombus, fat, or amniotic
fluid.
• Foreign bodies may also cause an embolus.
• Risk Factors
• Recent surgery, long-bone fractures, pregnancy.
• Pregnant or postpartum.
• Oral contraceptive use, tobacco use.
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Pulmonary Embolism
Assessment
• Focused History & Physical Exam
• SAMPLE & OPQRST history
• Presence of risk factors
• Sudden onset of severe dyspnea and pain
• Cough, often blood-tinged
• Physical exam
• Signs of heart failure, including JVD and
hypotension
• Warm, swollen extremities
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Pulmonary Embolism
Management
• Maintain the airway.
• Support breathing.
• High-flow oxygen or assist ventilations as
indicated.
• Establish IV access.
• Monitor vital signs closely.
• Transport to appropriate facility.
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Spontaneous Pneumothorax
• Pathophysiology
• Pneumothorax
• Occurs in the absence of blunt or penetrating trauma.
• Risk Factors
• Assessment
• Focused History
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SAMPLE & OPQRST history
Presence of risk factors
Rapid onset of symptoms
Sharp, pleuritic chest or shoulder pain
Often precipitated by coughing or lifting
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Spontaneous Pneumothorax
Assessment (cont.)
• Physical Exam:
• Decreased or absent breath sounds on affected side
• Tachypnea, diaphoresis, and pallor
Management
• Maintain the airway.
• Support breathing.
• Monitor for tension pneumothorax.
• JVD and tracheal deviation away from the affected side.
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Hyperventilation Syndrome
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Hyperventilation
Syndrome
Assessment
• Focused History & Physical Exam
• SAMPLE & OPQRST history
• Fatigue, nervousness, dizziness, dyspnea, chest pain
• Numbness and tingling in hands, mouth, and feet
• Presence of tachypnea and tachycardia
• Spasms of the fingers and feet
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Hyperventilation
Syndrome
Management
• Maintain the airway.
• Support breathing.
• Provide high-flow oxygen or assist ventilations
as indicated.
• Do NOT allow the patient to rebreathe exhaled
air.
• Reassure the patient.
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Croup
Pathophysiology
• Infection of the larynx
causing an upper airway
obstruction.
Assessment
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Children < 3 years of age.
Low grade fever
Slow onset
Barky cough
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Croup
• Management
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Calm Patient
Oxygen
Cool Air
Prepare for assist
ventilations
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Epiglottitis
Pathophysiology
• Infection and enflamation of
the epiglottis causing an
upper airway obstruction.
Assessment
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Children > 3 years of age.
High grade fever
Rapid onset
Drooling
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Epiglottitis
• Management
• Calm Patient
• Oxygen
• Encourage sitting
position
• Prepare for assist
ventilations
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Prescribed Inhalers
 Generic Names:
-albuterol
-isoetharine
-metaproteranol
 Trade Names:
-Proventil
-Ventolin
-Bronkosol
-Alupent
-Metaprel
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QUESTIONS
?
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