Transcript Chapter 11 - tmrservices.org

11: Respiratory Emergencies
Albuterol – Proventil, Ventolin
Actions: Drug is considered a b-2 agent relaxes smooth
muscle tissue in the lungs / b-1 speed up cardiac muscle
Indications: Acute bronchospasm in Chronic Obstructive
Pulmonary Disease (COPD) and acute asthma patients
Contraindications: Excessive tachycardia, cardiac
dysrhythmia, preexisiting hypertension
Side Effects: Tachycardia, hypertension, dysrhythmia,
anxiety, palpitations, N/V, dilated pupils
Dosage: (Adult) Metered Dose Inhaler – preset amount /
2.5mg with 3-5 ml saline via nebulizer
Special Considerations: Monitor vital signs and cardiac
monitor closely. Ensure the patient’s tidal volume is great
enough that he can entrain the medication deep into the
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pulmonary tree
Oxygen
Actions: Used for cellular metabolism/release of
energy
Indications: Respiratory distress, hypoxia, trauma
patients
Contraindications: Evidence of hypoxic drive –
possible ignition source or fire
Side Effects: None
Dosage: (Adult) Inhalation as a gas / Nasal
Cannula – 1-6 LPM; Simple mask – 8-10 LPM;
NRM – 10-15 LPM; BVM – 15 LPM
Special Considerations: Caution when used in
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proximity of a possible ignition source or fire
Epinephrine – Adrenaline Chloride
Actions: Cardiac stimulation, bronchodilation, and vascular bed
constriction – does not cross the blood-brain barrier or the
placental barrier
Indications: Frontline agent for arrest rhythms, Management of
bronchoconstriction in asthma and correction of the pulmonary
and vascular disturbances seen in anaphylactic shock
Contraindications: Should be avoided in those patient’s with
preexisting hypertension or tachycardia, acute coronary
syndrome, ischemic chest pain, narrow-angle glaucoma, and
advancing age.
Side Effects: Tachycardia, hypertension, cardiac dysrhythmias,
tissue necrosis with infiltration
Dosage: (Adult) Anaphylaxis – Autoinjector or 0.1-0.5mg SQ/IM
Special Considerations: Protect from light, monitor patient’s vital
signs and cardiac rhythm.
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1. Avoids contamination of equipment or replaces contaminated
equipment prior to use.
2. Confirms order (medication, dosage and route)
3. Informs patient of order for medication and inquires about allergies
4. Selects correct medication from drug box as requested by Examiner
5. Verbalizes check of medication for contamination and expiration date
6. Selects appropriate site and identifies it by pointing to (touching) the
site on self
7. Verbalizes recheck of the medication label
8. Prepares the injection site
9. Verbalizes recheck of the medication label
10. Removes safety cap from the injector
11. Performs steps 1-10 prior to step 12 and performs at least one (1)
recheck of the medication label
12. Places the tip of auto-injector against the injection site and pushes the
injector firmly against the injection site
13. Holds auto-injector against the site for 10 seconds
14. Removes auto-injector and applies pressure
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15. Disposes of contaminated equipment
1. Discuss and turn-in Patient Assessment Interview synopsis
– 3-5 sentances giving your plan and schedule for
conducting your interview
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Cognitive Objectives
(1 of 3)
4-2.1 List the structure and functions of the respiratory
system.
4-2.2 State the signs and symptoms of a patient with
difficulty breathing.
4-2.3 Describe the emergency medical care of the
patient with breathing difficulty.
4-2.4 Recognize the need for medical direction to assist
in the emergency medical care of the patient with
breathing difficulty.
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Cognitive Objectives (2 of 3)
4-2.5 Describe the care of a patient with breathing
distress.
4-2.6 Establish the relationship between airway
management and breathing difficulty.
4-2.7 List signs of adequate air exchange.
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Cognitive Objectives
(3 of 3)
4-2.8 State the generic name, forms, dose,
administration, actions, indications, and
contraindications for the prescribed inhaler.
4-2.9 Distinguish between the emergency medical care
of the infant, child, and adult patient with breathing
difficulty.
4-2.10 Differentiate between upper airway obstruction
and lower airway disease in the infant and child
patient.
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Affective Objectives
4-2.11 Defend EMT-B treatment regimens for various
respiratory emergencies.
4-2.12 Explain the rationale for administering an
inhaler.
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Psychomotor Objectives
4-2.13 Demonstrate the emergency medical care for
breathing difficulty.
4-2.14 Perform the steps in facilitating the use of an
inhaler.
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Respiratory System
12
Anatomy
and Function
of the Lung
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Characteristics of Adequate Breathing
• Normal rate and depth
• Regular breathing pattern
• Good breath sounds on both
sides of the chest
• Equal rise and fall of chest
• Pink, warm, dry skin
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Characteristics of Inadequate Breathing
• Pulmonary vessels become
obstructed.
• Alveoli are damaged.
• Air passages are obstructed.
• Blood flow to the lungs is
obstructed.
• Pleural space is filled.
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Signs of Inadequate Breathing
• Slower than 12
breaths/min or
faster than 20
breaths/min
• Unequal chest
expansion
• Decreased breath
sounds
• Muscle retractions
• Pale or cyanotic
skin
• Cool, damp
(clammy) skin
• Shallow or
irregular
respirations
• Pursed lips
• Nasal flaring
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Dyspnea
• Shortness of breath or
difficulty breathing
• Patient may not be alert
enough to complain of
shortness of breath.
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Upper or Lower Airway Infection
• Infectious diseases may affect all
parts of the airway.
• The problem is some form of
obstruction to the air flow or the
exchange of gases.
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Acute Pulmonary Edema
• Fluid build-up in the lungs
• Signs and symptoms
–Dyspnea
–Frothy pink sputum
• History of chronic congestive heart
failure
• Recurrence high
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Chronic Obstructive Pulmonary Disease (COPD)
• COPD is the result of direct lung and
airway damage from repeated
infections or inhalation of toxic agents.
• Bronchitis and emphysema are two
common types of COPD.
• Abnormal breath sounds may be
present.
–Rhonchi and wheezes
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• Common but
serious disease
Asthma
• Asthma is an
acute spasm of
the bronchioles.
• Wheezing may
be audible
without a
stethoscope.
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Spontaneous Pneumothorax
• Accumulation of air
in the pleural space
• Caused by trauma
or some medical
conditions
• Dyspnea and sharp
chest pain on one
side
• Absent or
decreased breath
sounds on one side
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Anaphylactic Reactions
• An allergen can trigger an
asthma attack.
• Asthma and anaphylactic
(allergic) reactions can be
similar.
• Hay fever is a seasonal
response to allergens.
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Pleural Effusion/Edema
• Collection of fluid outside
lung
• Causes dyspnea
• Caused by irritation,
infection, or cancer
• Decreased breath sounds
over region of the chest
where fluid has moved the
lung away from the chest
wall
• Eased if patient is sitting up
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Mechanical Obstruction of the Airway
• Be prepared to treat quickly.
• Obstruction may result from the position of head, the
tongue, aspiration of vomitus, or a foreign body.
• Opening the airway with the head tilt-chin lift maneuver
may solve the problem.
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Pulmonary Embolism
• A blood clot that breaks off
and circulates through the
venous system
• Signs and symptoms
–Dyspnea
–Acute pleuritic pain
–Hemoptysis
–Cyanosis
–Tachypnea
–Varying degrees of
hypoxia
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Hyperventilation
• Overbreathing resulting in a decrease in the
level of carbon dioxide
• Signs and symptoms
–Anxiety
–Numbness
–A sense of dyspnea despite rapid
breathing
–Dizziness
–Tingling in hands and feet
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the partner
Provider
• You andYou
yourare
EMT-B
are dispatched
to 1465 Dalles Military Rd for a 33-year-old
woman with difficulty breathing.
• You arrive at the office building and an upset
man identifies himself as the patient’s
coworker.
• He tells you that the patient has had breathing
problems before, but he’s never seen it this
bad.
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You are the Provider (continued)
• He leads you to a woman who is
standing with her arms outstretched on
the desk with a metered-dose inhaler in
hand.
• She acknowledges your presence with a
nod. When you ask her what is wrong,
she answers with a two-word response,
“can’t breathe.”
• You hear audible wheezes.
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Scene Size-UP
• How significant is the person’s response
to your question and why?
• What should you do next? Should you
transport this patient or wait for ALS to
arrive on scene?
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Initial Assessment
• Perform initial assessment.
• Place the patient on oxygen.
• If patient is in respiratory
distress, ventilate.
• Check pulse.
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Signs and Symptoms (1 of 2)
•
•
•
•
•
•
•
Difficulty breathing
Altered mental status
Anxiety or restlessness
Increased or decreased respirations
Increased heart rate
Irregular breathing
Cyanosis
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Signs and Symptoms (2 of 2)
• Pale conjunctivae
• Abnormal breath
sounds
• Difficulty speaking
• Use of accessory
muscles
• Coughing
• Tripod position
• Barrel chest
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You
are thetoProvider
(continued)
• You
arrange
rendezvous
with ALS.
• You apply high-flow oxygen and
obtain the following vital signs:
–Pulse: 42 breaths/min
–Pulse oximetry: 90%
• The patient indicates that she has
used the inhaler twice already.
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You are the Provider (continued)
• What can you do before you meet
ALS?
• Another pulse oximetry reading
reveals a reading of 72%.
• The patient is using accessory
muscles to breathe.
• What do these signs indicate?
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COPD Patients
• COPD patients cannot handle
pulmonary infections well
• Usually age 50 or older
• History of recurring lung problems
• Long-term smokers
• Tightness in chest/constant fatigue
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Focused History and Physical Exam
• Abnormal breath sounds are symptomatic of
COPD
• Long history of dyspnea with sudden increase
in shortness of breath
• Recent chest cold with fever
• Vital signs
– Normal blood pressure
– Rapid, occasionally irregular pulse
– Respirations rapid or very slow
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Interventions
• Treat immediate life threats
• Possible interventions
– Oxygen via nonrebreathing mask at 15
L/min
– Positive pressure ventilations
– Airway adjuncts
– Positioning
– Respiratory medications
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Detailed Physical Exam
• Performed only once life threats
are addressed.
• May not be able to do if busy
treating airway or breathing
problems.
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Ongoing Assessment
• Carefully watch patients for
shortness of breath.
• Reassess vital signs.
• Ask patient if treatment has made a
difference.
• Check for accessory muscle use.
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Emergency Medical Care
• Give supplemental oxygen at 10 to
15 L/min via nonrebreathing mask.
• Patients with longstanding COPD
may be started on low-flow oxygen
(2 L/min).
• Assist with inhaler if available.
• Consult medical control.
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Medications in MDI
• Trade names
–Proventil
–Ventolin
–Alupent
–Metaprel
–Brethine
• Generic names
–Albuterol
–Metaproterenol
–Terbutaline
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Prescribed Inhalers
• Actions
– Relax the muscles surrounding the
bronchioles
– Enlarge the airways leading to easier
passage of air
• Side effects
– Increased pulse rate
– Nervousness
– Muscle tremors
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Prior to Administration
• Read label carefully.
• Verify it has been prescribed by a
physician for this patient.
• Consult medical control.
• Make sure the medication is
indicated.
• Check for contraindications.
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Contraindications for MDI
• Patient unable to help coordinate
inhalation
• Inhaler not prescribed for patient
• No permission from medical control
• Maximum dose prescribed has been
taken.
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Administration of MDI (1 of 3)
• Obtain order from medical control or
local protocol.
• Check for right medication, right
patient, right route.
• Make sure the patient is alert.
• Check the expiration date.
• Check how many doses have been
taken.
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Administration of MDI (2 of 3)
•
•
•
•
Make sure inhaler is at room temperature or warmer.
Shake inhaler.
Stop administration of oxygen.
Ask the patient to exhale deeply and put lips around
opening.
• If the inhaler has a spacer, use it.
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Administration of MDI (3 of 3)
• Have the patient depress
the inhaler and inhale
deeply.
• Instruct the patient to hold
his or her breath.
• Continue administration of
oxygen.
• Allow the patient to breathe
a few times then repeat
dose according to protocol.
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Reassessment
• Carefully watch for shortness of
breath.
• 5 minutes after administration:
–Obtain vital signs again.
–Perform focused reassessment.
• Transport and continue to assess
breathing.
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Upper or Lower Airway Infection
• Administer warm, humidified oxygen.
• Do not attempt to suction the airway or
insert an oropharyngeal airway in a
patient with suspected epiglottitis.
• Transport patient in position of comfort.
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Acute Pulmonary Edema
• Administer 100% oxygen.
• Suction secretions.
• Transport in position of comfort.
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Chronic Obstructive Pulmonary Disease
(COPD)
• Assist with prescribed inhaler if
patient has one.
• Transport promptly in position of
comfort.
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Spontaneous Pneumothorax
• Administer oxygen.
• Transport in position of comfort.
• Monitor closely.
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Asthma
• Obtain history.
• Assess vital signs.
• Assist with inhaler if patient has
one.
• Administer oxygen.
• Transport promptly.
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Pleural Effusion
• Definitive treatment is
performed in a hospital.
• Administer oxygen and support
measures.
• Transport promptly.
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Obstruction of the Airway
• Clear airway.
• Administer oxygen.
• Transport promptly.
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Pulmonary Embolism
• Administer oxygen.
• Place patient in comfortable position,
usually sitting.
• Assist breathing as necessary.
• Keep airway clear.
• Transport promptly.
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Hyperventilation
• Complete initial assessment and
history of the event.
• Assume underlying problems.
• Do not have patient breathe into a
paper bag.
• Give oxygen.
• Reassure patient and transport.
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