Transcript The Patient with Dyspnea

First: Notes to the ECRN
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Changes have/are taking place this
fall
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Advocate Condell became a Level I
trauma center eff October 1, 2009
Grayslake Emergency Center will begin
to take BLS ambulance patients
effective November 1, 2009
 This is the Lake Forest Hospital facility
in Grayslake
All nurses need to be advised of
these changes
Condell as Level I Trauma Center
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Condell ECRN will be receiving calls from
farther out departments
Region IX and Region X (Lake County’s
Region) have similar criteria for Category
I trauma
If a department or helicopter service is
calling Condell, they have already decided
we are the best destination for the patient
 Take report, get an ETA, activate the
Trauma Alert
Category I Trauma Patient
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Any unstable patient and those
meeting criteria as a Category I
level trauma must be transported to
the highest level Trauma Center
within 25 minutes
Patients may be by-passing facilities
to get to a higher level trauma
center
Notes to the ECRN
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Grayslake Emergency Center
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Formerly referred to as the Lake Forest
Acute Care Center
Just west of the intersection of Routes
45 and 120
EMS may transport non-emergent
patients being treated with BLS
procedures
Will NOT transport patients with IV,
cardiac monitors, in labor, and others
with anticipation of the need for
admission
Notes to the ECRN
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Grayslake Emergency Center transport
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EMS to call their respective Resource
Hospital
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Condell is the Resource Hospital for:
Countryside
 Grayslake
 Lake Forest Fire
 Libertyville
 Mundelein
 Round Lake
 Wauconda
 Murphy
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Note to the ECRN
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EMS will alert Grayslake Emergency
Center to monitor 400
Resource Hospital will take report
on 400 and give orders, if needed,
including approval for the transport
destination requested
Report does not need to be called to
the Grayslake Emergency Center
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Grayslake Emergency Center will be
monitoring the call
Notes to ECRN
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If EMS was unable to contact
Grayslake Emergency Center, they
will advise the Resource Hospital
At that point in time, can determine
who will call Grayslake Emergency
Center with report
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The Resource Hospital will forward
report OR
EMS will repeat the report
Just be clear who is forwarding
report so it does get done
Note to the ECRN
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Your function is as a liaison between
the field personnel and the ED
Always think, “what is best for the
patient?”
Obtain and record report received
Ask for clarification, if necessary
Obtain ETA
ECRN Responsibilities
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EMS has an SOP to follow
EMS may still be calling Medical Control
for guidance (not all inclusive list)
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Minors with no parents available
Emancipated minor
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The girl under 18 that is pregnant is
emancipated and after delivery, if she remains
a parent, she remains emancipated
The person with alcohol on board
Questionable release situations
Psychiatric calls
Radio Etiquette
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Listen attentively
Fill in the radio log as completely as possible
Ask pertinent questions
 Do you really need to know which leg is
injured?
Respect field limitations
 Limited manpower
 Limited space to work in
 Driver needs to be focused on driving and
is not being used to communicate on the
radio
 This policy is now being followed by
most departments
The ECRN and Medical Control
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The ECRN can only give orders from
the SOP’s
If orders above and beyond the
SOP’s are necessary, the ED MD
must order them
Before leaving the radio to ask the
MD for orders, tell EMS to “standby”
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EMS may think you are not copying
their transmission if you do not
acknowledge them
Clarifications for Specific Calls
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Blood glucose levels
 EMS is required to obtain glucose levels in
the following populations:
 Known diabetic with diabetic related
problem
 Not appropriate for the hospital to
order a glucose level just because the
patient is a diabetic
 Unconscious unknown reasons
 Any altered level of consciousness
Not all patients require a blood glucose level
Clarifications for Specific Calls
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IV access
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Is it really necessary in the field?
Consider the less than ideal environment
in the field for invasive maneuvers
Indications IO access
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Shock, arrest, or impending arrest
Unconscious/unresponsive to verbal
stimuli
2 unsuccessful IV attempts or 90 second
duration
The Patient with Dyspnea
ECRN CE Packet Module II 2009
Site Code: 107200-E-1209
Prepared by: Lt. William Hoover, Wauconda Fire
Reviewed/revised by: Sharon Hopkins, RN, BSN,
EMT-P
Objectives
Upon successful completion of this module, the
ECRN will be able to:
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Identify the anatomy and physiology of the
respiratory system including
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The upper airway
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The lower airway
Identify clues which will assist in
determining the severity of a patient’s
respiratory distress.
Identify the components of the assessment
of patients with dyspnea.
Objectives
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Identify history and physical
assessment to be obtained for
patients with dyspnea.
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Initial assessment
SAMPLE history
OPQRST
Physical Assessment
Auscultation of Lung Sounds
12 Lead EKG
Objectives
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Identify abnormal respiratory
patterns and adventitious breath
sounds.
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Cheyne-Stokes
Kussmaul’s
Agonal respirations
Crackles
Wheezes
Rhonchi
Snoring
Objectives
Identify the main causes of dyspnea:
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Upper airway obstruction
Respiratory disease processes
Cardiovascular diseases
Neuromuscular diseases
Other causes
Psychogenic hyperventilation
Objectives
Identify treatment options for the main
causes of dyspnea
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Upper airway obstruction
Respiratory disease processes
Cardiovascular diseases
Neuromuscular diseases
Other causes
Psychogenic hyperventilation
Identify complications of different
treatments and procedures associated
with dyspnea
Objectives
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Identify the following medications and their EMS
field use for patients with dyspnea
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Albuterol
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Benadryl
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Benzocaine
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Epinephrine 1:1000
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Lasix
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Versed
List assessment post intubation in both the
adult and pediatric populations
Identify components of the regular
Albuterol kit and EMS in-line procedure
Anatomy & Physiology of Upper Airway
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Assists in heating, purifying, &
moistening inhaled air
 Nasal cavity
 Oral cavity
 Tongue
 Uvula
 Epiglottis – protects trachea
during swallowing
 Vocal cords
Anatomy and Physiology Lower Airway
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Trachea
Right and left mainstem bronchi
Bronchial tree
Lungs
Lobes
Alveoli – the functional unit of the
respiratory system where gas
exchange occurs
Upper
Airway
Larynx joins
upper and
lower airways
Lower
Airway
Alveoli are
the functional
units of the
respiratory
system and is
where gas
exchange takes
place
Difference With the Pediatric Airway
 Fundamentally
the same as an
adult
 Size and positioning differences
 Jaw smaller, tongue relatively
larger
 Epiglottis floppier and rounder
 Larynx more superior and
anterior (higher and more
forward) in children
Pediatric Considerations
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Anatomical differences between
adults & children dictate the
following:
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Oral airways slid in without turning
them – tongues are larger than adults
Preferable to use straight blade due to
floppy pediatric tongue
Before age 10, cricoid cartilage is the
narrowest part of the airway
 ETT are uncuffed
Determining the Severity of
Respiratory Distress
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Posture: Sitting up, leaning on
arms (Tripod)
Unable to speak in complete
sentences without pausing to
catch breath
Breathlessness when at rest
Imminent respiratory failure or
arrest indicated by bradycardia,
bradypnea, agonal respirations
or apnea
Tripod position – helps lungs expand
Pediatric Respiratory Distress
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Patient exhibits increased work of breathing
and the patient is using all resources to
compensate for self
 Child alert, irritable, anxious, restless
 Increased respiratory effort
 Use of accessory muscles
 Intercostal retractions
 Seesaw respirations (abdominal
breathing)
 Strained neck muscles
Pediatric Respiratory Failure
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Energy reserves exhausted
Patient cannot maintain adequate
oxygenation and ventilation
(breathing)
 Sleepy, less than alert
 Intermittently combative or agitated
 Bradycardic heart rate indicates
hypoxia
 Immediate attention to airway and
ventilation rate to fix the
bradycardia
Assessing Patients with Dyspnea
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Primary Assessment (ABC’s)
SAMPLE history
OPQRST
Physical Assessment
Lung Sounds
Minimally cardiac monitor; possibly
12 Lead EKG
Pulse oximetry
 Acceptable normal 95 – 99%
 Mild hypoxia 91 – 94%
 Severe hypoxia <91%
All Those Initials!!!
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ABC’s
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SAMPLE history
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Airway, breathing, circulation
Signs and symptoms, allergies, meds,
pertinent past history, last oral intake of
fluids or solids, events leading to the
incident
OPQRST of assessment
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Onset – what was pt doing at the time;
provocation/palliation; quality; radiation;
severity on 0 – 10 scale; time of onset
Abnormal Respiratory Patterns
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Cheyne-Stokes
 Indicates brainstem injury
 Progressively deeper, faster
breathing alternating with shallow,
slower breathing
Kussmaul’s
 Commonly found in diabetic
ketoacidosis and can be seen in
Aspirin (acetylsalicylic acid)
overdose
 Deep, slow, or rapid & gasping
Abnormal Patterns cont’d
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Agonal
 Indicates brain anoxia
 Shallow, slow, or infrequent
breathing
Auscultating Lung Sounds
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Warm your stethoscope, have the
patient cough to clear their airway and
then you’re ready to auscultate
The patient should
take deep but easy
breaths breathing
in and out through
their mouth
Auscultating Anterior Lung Sounds
Auscultating Posterior Lung Sounds
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Start at the top and
move your
stethoscope
from the right to the
left comparing the
sides as you walk
your stethoscope
methodically
downward
Sounds are heard
better when
auscultated in the
posterior fields
directly over the skin
Abnormal Lung Sounds
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Crackles (rales)
 Fine, bubbling sound heard on inspiration;
indicates fluid in smaller airways
Wheezes
 Musical, squeaking, whistling sound heard
usually on inspiration & expiration; indicates
bronchial constriction
Rhonchi
 Coarse, rattling noise on inspiration,
indicates inflammation, mucous, or fluid in
bronchioles
Snoring
 Indicates partial upper airway obstruction
The patient with dyspnea:
Causes
Signs and Symptoms
EMS Field Treatment Options
Upper Airway Obstruction
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Foreign body
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Infections – causes airway swelling
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Sudden onset after exposure (eating or injection
common)
Laryngospasm – closure of glottic opening
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Croup – viral infection
Epiglottitis – bacterial infection
Anaphylaxis – severe reaction to allergen
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Airway blocked; food most common culprit
May be triggered by infection or irritants
Blood thinners (Coumadin, Plavix)
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Spontaneous hematomas in soft tissue of neck
Foreign Body Obstruction
Toe ring
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Esophageal
foreign
bodies can
also present
an airway
challenge
especially if
the foreign
body moves
Signs & Symptoms of Impaired
Airway
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Foreign body (FB)
 Sensation of a FB after eating
(food is the #1 cause of airway
obstruction)
 Stridor or wheezing respirations
Infection (epiglottitis, croup)
 Gradual onset
 Pain on swallowing, drooling
 Difficulty opening mouth
 Fever, cough, seal bark cough
Treatment Airway Obstruction
Foreign body
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Remove the object
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If patient can cough on own or rescuer needs to
apply the Heimlich or abdominal thrusts (back
slaps and chest thrusts for infants)
May need to use blade and handle and retrieve
object while using the magill forceps
Secure the airway if unable to relieve the
blockage (Quick Trach)
Infections – Croup or epiglottits
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Prehospital supportive care
Supplemental oxygen
6 ml normal saline in nebulizer kit
Albuterol if patient is wheezing with croup
Signs & Symptoms of Impaired
Airway Related to Anaphylaxis
Anaphylaxis
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Hives
Rash that itches
Wheezing
Hypotension – unique to anaphylaxis
Nausea
Abdominal cramps
Inability to urinate
Is quickly life-threatening
EMS Adult Anaphylaxis SOP
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Anaphylaxis – patient unstable
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Altered mental status & B/P <100 systolic
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Support airway; intubate as necessary
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IV wide open (1000 ml normal saline)
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Epi: 1:1000 IM 0.5 mg
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Benadryl 50 mg IVP slowly over 2 min or IM
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If wheezing, Albuterol 2.5mg/3ml
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May repeat
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If worsening, medical control contacted
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Medical Control may order Epi 1:10,000 IV/IO
EMS Pediatric Anaphylaxis SOP
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Anaphylaxis – patient unstable
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Altered mental status
Epi 1:1000 IM 0.01 mg/kg (max 0.3 mg or 0.3 ml per
dose)
May repeat every 15 minutes
Benadryl 1mg/kg slow IVP; max 50 mg
IV fluid challenge 20ml/kg
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May repeat as needed to max of 60 ml/kg
Albuterol 2.5mg/3ml
 May repeat Albuterol treatment
If worsening, medical control contacted
 To consider Epinephrine 1:10,000 at 0.01 mg/kg IV/IO
Respiratory Diseases - Asthma
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Bronchoconstriction
Stimulants cause inflammatory
response
Stimulants can include:
 Allergens
 Weather changes
 Exercise
 Respiratory infections
 Foods/medications
Signs & Symptoms of Asthma
Cough
Wheezes
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Heard first at the end of exhalation
Absent breath sounds = deadly implications
Shortness of breath
Chest tightness (not to be confused with chest
pain)
Use of accessory muscles in severe cases
Ask if the patient has ever needed intubation
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These patients tend to deteriorate faster
and need careful and close monitoring
EMS Asthma SOP
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Attempt pulse oximetry reading before
administration of oxygen
Assess & record VS, breath sounds,
pulse oximetry before/during/after
treatment
Oxygen by most appropriate route
Albuterol 2.5 mg/3ml (O2 flow at 6 L)
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Severe cases, treat while transporting
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EMS Treatment of Severe Asthma
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Patients with inadequate ventilations
or oxygenation are at risk of not being
able to continue to ventilate
themselves and will need intubation
In-line Albuterol therapy provided to
deliver medications to the lungs
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Albuterol can be delivered via BVM in-line
while preparing to intubate the patient
Once intubation is accomplished, continue
to deliver Albuterol via the in-line method
Respiratory Diseases - COPD
Blanket term for diseases that impede the
functioning of the lungs
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Chronic Bronchitis
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Increased mucous production in the
bronchial tree
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Decreased gas exchange in the alveoli
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Irreversible airway obstruction
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Emphysema
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Destruction of alveolar walls
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Loss of capacity for lungs to recoil
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Irreversible airway obstruction
COPD
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Most COPD patients have elements of both
chronic bronchitis and emphysema
Abnormal ventilation is a common feature
Often the cilia lining the respiratory tract are
destroyed
Common findings
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Bronchospasm
 Some elements are reversible, some not
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Inflammation of respiratory passages
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Air trapping distal to the obstruction
Desensitization to a chronic state of hypoxia
Patients susceptible to repeat respiratory
infection
COPD vs. Healthy Lungs
Signs & Symptoms of COPD
Chronic bronchitis
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Chronic productive cough
Tend to be obese with low blood oxygen levels
(referred to as blue bloaters)
Wheezing, crackles, or rhonchi can all be
auscultated
Rising carbon dioxide blood levels
Emphysema
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Typically thinner build with barrel chests
Hyperventilating to maintain blood oxygen levels
Color usually good (referred to as “pink puffers”)
Lungs sounds seem very distant
Use pursed lip breathing when exhaling
EMS Treatment of COPD with
Wheezing
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Albuterol treatment
 2.5 mg / 3 ml
 O2 flow rate at 6 l/min
 Need to generate a mist to
inhale and absorb the medication
 May repeat albuterol as needed
EMS may contact Medical Control to
obtain an order for CPAP in the
symptomatic patient
Respiratory Diseases - Pneumonia
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Infection of lower respiratory tract
Primarily a ventilation problem
Can be bacterial or non-bacterial
 Mycoplasma
 Chlamydia
 Viral
 Tuberculosis
Fluid and inflammatory cells collect in
the alveoli
5th leading overall cause of death in the
USA
Pneumonia
Signs & Symptoms of Pneumonia
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Patients generally appearing ill and feel ill
Shaking chills
Fever
Generalized weakness with gradual onset
Pleuritic chest pain
Shortness of breath with tachypnea
Tachycardia
Productive cough – yellow to brown
sputum
Crackles in involved lung segment
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May also hear wheezes and rhonchi
EMS Treatment of Pneumonia
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Supportive care
Supplemental oxygen
Patient usually dehydrated and fluid
therapy is supportive
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Need to be accurate on diagnosis
 Pneumonia needs fluid therapy
 CHF/Pulmonary edema needs fluid
restriction
CPAP may help patient in severe cases
Aspiration – A Deadly Complication
Protection Against Aspiration
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Positioning – patient on their side if
not contraindicated
Suctioning turned on and ready to
be used
Cricoid pressure used during
intubation attempts
Intubate the patient that is unable
to protect their own airway
Respiratory Disorders
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Pneumothorax
 Abnormal collection of air in the pleural
space
 Spontaneous or traumatic
Pulmonary embolism
 Arterial blockage to pulmonary
circulation
 Venous clots
Embolism can also be from fat, bone
marrow, tumor fragments, amniotic
fluid, or air bubbles
Toxic inhalation
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Pneumothorax
Signs & Symptoms of
Spontaneous Pneumothorax
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Sudden sharp, pleuritic chest pain or
shoulder pain
May occur after coughing
Diminished lung sounds
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May be difficult to distinguish in smaller
sized lung collapse (<20%)
Young individuals with tall, thin body types
are most susceptible
Tachypnea
Diaphoresis
Possible subcutaneous emphysema
EMS Treatment of Spontaneous
Pneumothorax
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Majority of spontaneous pneumothorax
are not detected in the field – breath
sounds not appreciated to be diminished
Care is supportive
O2 via NRB mask
Assist patient in sitting upright
Monitor for change to tension
pneumothorax
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Tension pneumothorax needs needle
decompression
Pulmonary Embolism – Blood Flow Blocked
Signs and Symptoms of Pulmonary
Embolism
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Symptoms can be non-specific and
vary depending on the site and size of
obstruction
Sudden onset severe & unexplained
dyspnea
Pleuritic chest pain may be present
Cough, usually non-productive but
occasionally blood tinged
Tachycardia & tachypnea
In severe cases, confusion, hypoxia,
cyanosis, hypotension, death
EMS Treatment of Pulmonary
Embolism
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Supportive care
Rapid transport
High flow oxygen; possible
intubation
Rapidly fatal once patient arrests
Hospital treatment may include
anticoagulation or surgery to
remove clot
Cardiovascular Diseases
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CHF with acute pulmonary
edema
 Impaired pumping ability of
the heart
Acute Myocardial Infarction
 Death of heart muscle
Signs & Symptoms of
CHF/Acute Pulmonary Edema
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Dyspnea at rest
Unable to lie flat
Crackles in lungs – heard initially in the bases
Dependent edema – pedal edema in the
mobile patient
JVD especially in the upright position
Acute MI (AMI)
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Dyspnea may be the initial symptom
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At times difficult to determine which came
first – AMI affecting function of the heart or
hypoxia leading to AMI
CHF with
Pulmonary
Edema
EMS SOP Stable Pulmonary
Edema B/P >100 mmHg
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All therapies cause vasodilation and may
drop the B/P – monitor B/P carefully
Nitroglycerin 0.4 mg SL (max 3 doses)
Consider CPAP
Lasix 40 mg IVP (80 mg if on Lasix at
home)
Morphine 2 mg slow IVP; may repeat
every 2 minutes to max of 10 mg)
If wheezing, Medical Control contacted
for Albuterol order
EMS Interventions For Pulmonary Edema
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Nitroglycerin
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CPAP
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Prevents collapse of the alveoli; also lowers B/P
Lasix –
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Used for its venodilation effects to pool blood away
from the heart
Diuretic effect will take approximately 20 minutes
but venodilation effect evident in the field to pool
blood
Morphine
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Reduces anxiety level
Also a venodilator and will pool blood away from the
heart
EMS SOP For Cardiac Complaints
At minimum consider EKG monitoring
EMS to consider early 12 Lead EKG
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STEMI – ST elevation in 2 or more
contiguous leads (I, aVL, V5, V6; II,
III, aVF; V1 – V6)
Cardiac Alert
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Take 12 lead as soon as possible
ED contacted early to decrease door to
balloon time
Transmit 12 lead EKG to hospital
Abnormal rhythms treated
Neuromuscular Diseases
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Muscular dystrophy
 Wasting disease of the muscles
Amyotrophic lateral sclerosis (ALS)
 Lou Gehrig’s disease
 Muscular dystrophy caused by
degeneration of motor neurons of
the spinal cord
Guillain-Barre syndrome
Myasthenia gravis
Guillain-Barre Syndrome
Signs & Symptoms of
Neuromuscular Diseases
Amyotrophic Lateral Sclerosis (ALS)
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Chronic progressive wasting of muscles
Difficulty swallowing and speaking
Mental functions remain lucid
Guillian-Barre syndrome
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Weakness starting distally (hands/feet) moving
upward - “ascending” paralysis ending in temporary
paralysis
Sensory loss or decreased reflexes
Myasthenia Gravis
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Weakness that improves with rest, worsens with
activity
Crisis level can affect respiratory muscles
Treatment of Neuromuscular Disorders
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Conscious sedation intubation if
necessary
If lung muscles do not work, we
have to do it for them
Supportive care
 May have to assist patient with
BVM
In chronic cases, these patients
fatigue easily
These patients are prone to chronic
infection
Other Causes of Dyspnea
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Anemia
 Inadequate hemoglobin in the
blood
 Unable to supply body’s oxygen
demands
Hyperthyroid disease – increased
rate of metabolism
Metabolic acidosis
Psychogenic hyperventilation
 Psychological causes
Treatment of Hyperventilation





Determine treatment based on situation
Could be deadly to assume these
patients are hyperventilating and a
“psych” patient
Do not have people “blow into a bag”
Inappropriate to place an O2 mask on
patient and not connect it to oxygen!!!
Use verbal counseling on patient to slow
their breathing down if possible
Additional EMS Field
Treatment Options
Procedure for Adult Intubation


Patient must be pre-oxygenated (100% O2)
Equipment checked





Blade and handle
 Straight blade preferred for pediatric
patients due to floppy epiglottis and large
sized tongue
 Light is bright and tight
ET tube and one back-up tube
Stylet – adult or pediatric
Syringe for adult ET tube cuff inflation
Mechanism to secure tube in place (ie: tape,
commercial tube holder device)
Confirming ET Tube Placement






Max of 30 seconds for intubation attempt time
Immediately after intubation, remove the style
to prevent delay in initiating ventilations
As ventilations are begun, perform 5 point
auscultation
 Auscultate 1st over the epigastrium
 Then auscultate 4 points over the lungs
Observe bilateral rise & fall of the chest
 Ventilate 1 breath every 6 – 8 seconds
Inflate the adult cuff until no air leak heard
Observe yellow coloring on ETCO2 device
Procedure for Pediatric Intubation

Steps nearly identical to the adult
 Straight blade preferable due to floppy
epiglottis and large sized tongue
 The pediatric ET tube up to and including
size 6 is uncuffed
 The pediatric patient somewhat has
their own cuff effect anatomically due
to the natural narrowing of the airway
at the cricoid cartilage
 Always watch for gentle chest rise and fall
to dictate the amount of volume to use
with the BVM
Respiratory Rates

BVM support to patient with a heart
beat – rescue breathing



Adults ventilate once every 5 - 6 sec
Infant & child ventilate once every 3 - 5
seconds
Once patient intubated, all patients
are ventilated once every 6 – 8
seconds
EMS SOP Conscious Sedation
Intubation

Indications





Failure to maintain adequate airway or for
risk of aspiration
Actual or impending respiratory failure
GCS <8 due to head injury
Inability to ventilate/oxygenate patient
after insertion of airway and/or BVM
Anticipated deterioration
EMS SOP Conscious Sedation
Intubation

Contraindication

Age less than 16




Need permission from Medical Control
B/P < 100mmHg
Known hypersensitivity or allergy to the
medication
Consider risk vs benefit if the patient is
pregnant
EMS SOP Conscious Sedation Medications

Lidocaine 1.5 mg/kg IVP one time only
 If head injury/insult, used prophylactically to
decrease risk of cough reflex


Coughing raises intrathoracic pressures which will
increase intracranial pressures
Versed 5 mg IVP – relaxes/sedates patient
 2 mg repeated every minute to relax and sedate
patient (1 mg every 5 minutes post procedure to
maintain sedation)
 Total dose used is 15 mg including postprocedure

Versed does not take away any painful stimulus
EMS SOP Conscious Sedation
Medications


Morphine 2 mg IVP slow over 2 minutes –
relaxes pt
 Repeated every 3 minutes to a max of
10 mg
Benzocaine spray – eliminates gag reflex
 Limited to 1-2 short sprays to
posterior pharynx
 Can stroke the eyelashes to
determine presence of a gag reflex
 The blink reflex disappears at the
same time as the gag reflex
In-line Albuterol Kit






Albuterol can be delivered via BVM or
through ET tube to be delivered into lungs
Kit prepared as usual but mouthpiece
taken off
BVM placed where mouthpiece was
Adaptor added to distal end of corrugated
tube in preparation to connect the adaptor
to ET tube
Need to confirm ET tube placement in the
usual manner
Can start to bag patient delivering
Albuterol prior to ET tube placement
In-line
Albuterol Kit



Mouthpiece
taken off and
replaced with
BVM
Adaptor added
to end of blue
corrugated
tubing and
attached to
mask (or ET
tube)
Can begin to
ventilate patient
before
intubation
CPAP Device for Pulmonary Edema





Oxygen started via non-rebreather mask
while equipment being set up
Medications are administered
simultaneously with CPAP
Medications used and CPAP can all cause
a drop in blood pressure; monitor B/P
carefully
CPAP will give time fort he medications to
take effect
ED will usually call respiratory therapy
when expecting a patient on CPAP

Resp therapy to set up equipment for patient
CPAP Device


In under 5 minutes
patients will feel
better
Patients need
psychological
support to get over
the suffocating
feeling from the
tight fitting mask
Advanced Airway Alternative - Combitube


Indications
 Arrested patient, unresponsive medical or
trauma patient with no gag reflex and ET
tube placement cannot be achieved
Contraindications
 Age less than 16
 This tube is a one size fits all so
limited use in pediatric patients and
short adults (less than 5 feet)
 Gag reflex present
 Known esophageal disorder/caustic
ingestion
Combitube





Patient hyperventilated prior to insertion
Equipment checked and prepared and
distal tip lubricated
Device is inserted mid-line and to depth
of printed ring level with teeth
Pharyngeal cuff inflated with 100 ml of air
Distal cuff inflated with 15 ml of air
Combitube


Placement
shown is in
the
esophagus
Proximal
and distal
balloons
both get
inflated
Combitube cont’d


Ventilations begin via tube #1
Placement confirmed



If unable to confirm tube placement,
then attach BVM to tube #2 and
ventilate


Observe gentle rise and fall of the chest wall
Perform 5 point auscultation over the
epigastrium and bilaterally over the lungs
Repeat confirmation steps
Secure device
Combitube in the ED

If patient arrives with combitube in
place


Use this advanced airway device until
adequate staffing and competence to
change to an ETT
When ready to intubate the patient
with ETT, deflate the combitube cuffs
 Cuff balloons are marked with amount
of air
 Blue cuff balloon – 100 ml
 White cuff balloon – 15 ml
Case Scenario Review




Read the cases
Treatment is based on the EMS
SOP’s
Determine what your response
would be on the radio call
Check your own answers with the
power point slides
Case Scenario #1




911 was called to the scene for a 72
year-old obese male with complaints of
increased shortness of breath today and
with fever
VS: B/P 152/94; P – 104; R – 26; SpO2
92%
Meds: Ventolin, Prednisone, Glucophage,
Verapamil, Isordil, Hydrochlorathiazide
Observation: Patient’s color is dusky,
slightly diaphoretic, cannot talk in
complete sentences, productive cough
Case Scenario #1





What else needs to be done during the
assessment phase?
History – is this problem old or new?
What are the lung sounds?
EKG monitor – possibly obtain a 12 lead
based on assessment findings
Sputum is dark brown
Case Scenario #1


Patient found to have exacerbation of
signs and symptoms of COPD with
wheezing; possibly a secondary lung
infection
EMS Field treatment:


Oxygen starting at 2-6 L/minute per nasal
cannula
IV TKO – for access if necessary



Carefully monitor flow rate not to over hydrate
Albuterol 2.5 mg/3ml attached to O2 at 6L flow
Reassess frequently watching for
deterioration and hoping for improvement
Case Scenario #2




EMS arrived at the scene of a local fast food
chain for a 3 year-old choking victim
Upon EMS arrival they noted a conscious
patient who appears exhausted and is
clutching at their throat, color is pale, and they
had a weak cough
As EMS approached, the child looks at them
with wide eyes and is trying to cough but was
no longer making any sound
What is your assessment & what action plan
should be started?
Case Scenario #2



Impression – partially obstructed airway that
is now a completely obstructed airway
 If the patient can speak or cough, you are
to allow them to try to relieve the
obstruction with coughing
In a conscious child, you perform the
Heimlich maneuver (abdominal thrusts) until
the patient is unconscious or the obstruction
is relieved
Equipment to prepare and have on stand-by
 Intubation equipment
 Child BVM
 Magill forceps
Case Scenario #2



If the patient has a history of asthma
and is wheezing, short of breath, and
has an increased respiratory rate, how
do you tell the difference between an
asthma attack and an obstructed
airway?
Don’t let patient history steer you
wrong
Assess the patient


Asthma – bilateral wheezing, usually
identifiable trigger evident
FB – wheezing on obstructed side, patient
usually eating or child playing with small
objects at onset of incident
Case Scenario #3




EMS is called to the scene of 32 year-old
female having an asthma attack
The episode started approximately 3
hours ago and the patient has used her
inhaler with no success
Appearance: Anxious, pale, dry oral
mucous membranes (mouth), unable to
talk in complete sentences, appears
exhausted, using accessory muscles
What is your impression? What else
should be assessed? What treatment by
EMS is appropriate?
Case Scenario #3


Initial impression – acute asthma attack
Assessment to obtain





Lung sounds, pulse oximetry
List of medications
Verification of allergies
EKG monitor to check rhythm
Treatment


Set up the Albuterol kit
Need to coach patient in her ear to talk her
through slowing down her breathing, then
taking deeper breaths, and finally holding the
deeper breath to get the medication into the
lungs
Case Scenario #3



The patient is so exhausted, their level of
consciousness is deteriorating and SpO2
is falling
EMS will prepare for in-line Albuterol
administration and intubation
Upon ED arrival, continue administration
of Albuterol until the dose is completed
 The chamber will be empty of liquid
Case Scenario #4



911 was called to the scene for a
year-old male with sudden onset of
difficulty breathing
Patient is sitting upright on a chair,
leaning forward resting their arms on
their thighs (tripod position)
Appearance




68
Rapid respirations with noisy ventilations
Cyanotic finger tips and pale, diaphoretic face
Using accessory muscles
Your impression? Further assessment?
EMS intervention?
Case Scenario #4


Further assessment to be obtained
 History
 Allergies & medications
 Lung sounds
 Bilateral crackles and wheezing
 Vital signs and SpO2 reading
 B/P 180/110; P – 110; R- 32; SpO2 89%
 EKG monitor and 12 lead EKG
 Atrial fibrillation; no ST elevation
Impression
 Acute pulmonary edema
Case Scenario #4

EMS interventions
 Is patient stable or unstable?
 Stable – B/P 180/110
 Medications to be given:
 Nitroglycerin 0.4 mg sl
 Vasodilator
 Lasix 40 mg IVP (80 mg if used at home)
 Morphine 2 mg IVP
 If

wheezing, Albuterol needs to be requested
from Medical Control
Device
 CPAP – keep alveoli open
Bibliography
Campbell, J. Basic Trauma Life Support, 5th Edition,
Brady. 2004
Dalton, Limmer, Mistovich, Werman. Advance Medical
Life Support, 3rd Edition. Brady. 2007.
Region X Standard Operating Procedures, March 2007
Amended version May 1, 2008
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Conscious Sedation (Page 7)
Acute Pulmonary Edema (Page 19)
Airway Obstruction (Page 22)
Adult Allergic reaction/Anaphylactic Shock (Page 23)
Asthma/COPD (Page 25)
Pediatric Respiratory Failure (Page 53)
Pediatric Acute Asthma (Page 55)
Pediatric Airway Obstruction (Page 56)
Croup/Epiglottitis (Page 64)
Pediatric Allergic Reaction/Anaphylaxis (Page 70)
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