Region VIII EMS Systems July 2016

Transcription

1 Region VIII EMS Systems July 2016

2 Introduction SME video of the month Review of Respiratory SOPs Three scenarios

3 Announcements Region-None System- New SOP s In Effect July 1 st

4 Dyspnea Common type of emergency call in EMS Has various causes Is both a sign and a symptom Sensation of breathlessness or inadequate breathing Can be acute or chronic

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6 Differential Diagnosis of Dyspnea In disease states the cause is usually a result of cardiac, pulmonary pathology or trauma Severe dyspnea is a medical emergency if not treated appropriately respiratory failure and death can occur When eliciting a history it is helpful to determine if the dyspnea is acute or chronic utilizing Sample OPQRST

7 Dyspnea Acute Asthma Carbon monoxide poisoning Cardiac tamponade Heart failure Myocardial infarction Hypotension Pulmonary embolism Pneumothorax Pneumonia Upper airway obstruction Chronic Asthma COPD Deconditioning Heart dysfunction Interstitial lung disease Obesity

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9 Differential Diagnosis Dyspnea Common Respiratory Causes Foreign body Aspiration (upper / middle airway) Anaphylaxis (upper airway) Pulmonary Embolism (lower airway) Pneumothorax (lower airway) Tension pneumothorax (lower airway) Croup (upper airway) Acute epiglottitis (upper airway) Asthma (lower airway) COPD (lower airway) Pneumonia (lower airway)

10 Differential Diagnosis of Dyspnea Cardiac causes of dyspnea include Right and left heart failure Myocardial infarction Cardiomyopathy Valvar dysfunction Pericarditis Arrhythmias Hypovolemia H s & T s Hypoxia, Hydrogen ion (acidosis), Hyper- /hypokalemia Hypothermia Hypoglycemia Toxins/Tamponade Tension pneumothorax Thrombosis Trauma

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13 Dyspnea Scales

14 Location and lung sounds Location Sound Phase Disease Process Upper Airway Stridor Inspiration Viral Croup Epiglottitis Foreign Body Aspiration Lower Airway Rhonchi Primarily Expiration Frank Aspiration Bronchitis Cystic Fibrosis Wheeze Primarily Expiration Reactive airway disease Asthma Congestive heart failure Emphysema Endobronchial obstruction Crackles End Inspiration Pneumonia Exacerbation of congestive heart failure Pulmonary edema Diminished breath sounds Either or both Emphysema Atelectasis Pneumothorax (simple or tension) Flail chest Neuromuscular disease Pleural effusion Chest Wall Pleural rub Either Pleuritis Pleurisy Pleural effusion

15 Upper Airway Main symptoms of upper airway problem are Dyspnea Noisy breathing More prominent during exercise May be aggravated by change in body position Breathing is labored and increases if lying supine

16 Upper Airway Signs occur mostly during inspiration Change in voice: Hoarseness, barking cough Inspiratory stridor Cyanosis, drooling Nasal flaring Tachypnea Retractions Poor air entry on auscultation Prolonged inspiratory phase

17 Upper Airway Noisy breathing: Snoring: Indicates partial obstruction of the upper airway that causes a vibration of air as it passes thru the nasopharynx and oropharynx (tongue) Stridor: A harsh, continuous crowing sound. Mostly occur during inspiration

18 Upper Airway Conditions include Foreign body obstruction Pharyngeal edema Croup Epiglottitis Anaphylaxis

19 Angioedema Rapid swelling of the dermis, subcutaneous tissue mucosa and submucosal tissues Skin is swollen, tender and warm May last days or resolve spontaneously

20 Angioedema Substances known to trigger allergic angioedema Certain types of food particularly nuts, shellfish, milk, eggs Certain medication- penicillin, aspirin, NSAIDS Insect bites and stings Latex Cases without an identifiable cause are known as idiopathic angioedema. May be a problem with the immune system causing it to misfire. Triggers include: Anxiety - Hot or cold temps Stress - Exercise Minor infections

21 Angioedema Hereditary angioedema is caused by a genetic mutation in the C1 esterase inhibitor The body does not produce enough of this C1 protein C1 plays an important role in regulating the immune system Triggers include : Trauma- including surgery and infection, oral contraceptives, and pregnancy

22 Angioedema Acute episodes often involve the lip, eyes, and face. May also affect other parts of the body including respiratory and gastrointestinal mucosa. Laryngeal swelling can be life threatening Often associated with local burning sensation and pain Pronounced itchiness and local erythema

23 Angioedema Severe attacks can indicate the onset of systemic anaphylaxis Characterized initially by dyspnea Medications used in treating urticaria and anaphylaxis are also used in treating angioedema In severe cases of laryngeal edema a surgical airway may be needed

24 Angioedema

25 Upper Airway Condition Anaphylaxis Serious life threatening allergic reaction Most common causes Food Latex Medications Insect stings Envenomation

26 Signs and symptoms Upper Airway Condition Anaphylaxis A swollen tongue or throat, which can cause wheezing (wheezing is a lower condition) and dyspnea A weak and rapid pulse Nausea, vomiting or diarrhea Dizziness or fainting Abdominal pain

27 Upper Airway Condition Anaphylaxis Signs and symptoms (continued) Skin reactions, including hives itching, and flushed or pale skin A feeling of warmth The sensation of a lump in the throat Constriction of the airway Chest pain Headache

28 ADULT ALLERGIC REACTION / ANAPHYLAXIS BLS/ALS 1. Adult Initial Medical Care SOP, p Apply ice/cold pack to site 3. BLS: at the direction of Medical Control, administer one dose EPINEPHRINE autoinjector (EpiPen ) ALS Allergic reaction with systemic signs, i.e. wheezing, diffuse hives, or prior history of systemic reaction, without signs of hypoperfusion 4. Administer BENADRYL (diphenhydramine) 50 mg IM or slow IV/IO. Max dose 50 mg. 5. Administer EPINEPHRINE 1: mg IM. May repeat x 1 after 15 minutes if minimal response If age > 50 years old and/or cardiac disease history, contact Medical Control prior to administration of EPINEPHRINE 6. If wheezing, consider ALBUTEROL 2.5 mg (3 ml) via nebulizer ALS Anaphylaxis: multisystem reaction with signs of hypoperfusion; altered mental status or severe respiratory distress/wheezing/hypoxia 1. If signs of hypoperfusion, IV/IO FLUID BOLUS in 200 ml increments Administer EPINEPHRINE 1:10, mg slow IV/IO or EPINEPHRINE 1: mg IM. May repeat EPINEPHRINE q 3 minutes 2. Administer BENADRYL (diphenhydramine) 50 mg slow IV/IO If no IV, give BENADRYL (diphenhydramine) 50 mg IM No repeat dose 3. If wheezing, consider ALBUTEROL 2.5 mg (3 ml) via nebulizer 4. Consider DOPAMINE per CARDIOGENIC SHOCK SOP, p. 23, for refractory hypotension Note EPINEPHRINE may be given IM if IV/IO access delayed.

29 EpiPen

30 Auvi-Q Epinephrine auto injector Same dosing as the EpiPens 0.3mg IM 0.15mg IM Talks to the patient Walks them through the steps for injection

31 Change in epinephrine ratios

32 Epinephrine Confusion has been associated with numerous medication errors over the years The new epinephrine labeling will only be displayed on mass concentrations 1:1000 will be labeled 1mg/ml 1:10,000 will be labeled 0.1mg/ml Effective May 1, 2016

33 Epinephrine

34 Capnography Measures: Ventilation: for patient with a pulse Perfusion: When patient is pulseless Partial pressure (mmhg) or volume (% vol) of CO 2 in the airway at the end of exhalation Breath-to-breath measurement provides information within seconds Not affected by motion, artifact, poor perfusion or dysrhythmias

35 Capnography Reflects how effective our interventions are Can be utilized to more objectively determine a patient s respiratory distress Provides earliest, most accurate indication of respiratory distress Changes in capnography waveform provide earliest indication of apnea, upper airway obstruction and laryngospasm or worsening of patient s condition

36 Capnography Utilization in upper airway conditions Apnea: No waveform, no chest wall movement, no breath sounds Upper airway changes or obstruction: chest wall moving decrease or no breath sounds May be responsive to airway maneuvers with a return of waveform or improvement in waveform

37 Capnography

38 Lower airway Lung/Lower airway Causes Pneumonia Pneumothorax Pulmonary embolism Interstitial lung disease Adult Respiratory Distress Syndrome COPD Asthma

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40 Lower Airway Signs and Symptoms Tachypnea Wheezing (expiratory most common) Increased respiratory effort Retractions Prolonged expiration

41 Lower Airway Condition Pulmonary Embolism A sudden blockage in the lung usually caused by a clot that formed in the smaller vessels such as arms, legs, pelvis

42 Lower Airway Condition Pulmonary Embolism Signs and symptoms Sudden onset chest pain Sharp, knife like or deep ache that worsens with inspiration Dyspnea Anxiety Cough Diaphoresis Syncope Tachycardia Tachypnea Decrease ETCO2 (<20 mmhg) despite normal respiratory rate and perfusing rhythm

43 Lower Airway Condition Pulmonary Embolism A popular prehospital assessment tool for patient with respiratory complaints is end tidal CO2 (EtCO2) In patients with pulmonary embolism, expect to see normal (35-45mmHg) to slightly low EtCO2 resulting from tachypnea and a normal waveform Deliver oxygen to maintain SPO2 above 94%

44 12 lead changes with PE

45 12 Lead

46 Pulmonary Embolism

47 BLS Scenario Medic is dispatched for a 20 y/o female complaining of shortness of breath You arrive on the scene and observe the patient sitting in a chair in the tripod position States watching TV when developed sudden onset of pain between shoulder blades Pt is agitated, short of breath, and has faint cyanotic color to her face

48 BLS Scenario VS BP 98/62, HR 118, RR 32 and shallow SPO2 89% with decreased breath sounds on right and clear on left What are your priorities What information do you need What is your immediate treatment

49 Lower Airway Condition A pneumothorax occurs when the potential space between the parietal and visceral pleura of the lung fills with air and collapses the lung. It can occur spontaneously or following trauma or pathology Pneumothorax

50 Lower Airway Condition Primary Spontaneous Pneumothorax Risk factors Spontaneous Pneumothorax Age years old Male have higher incidence than women Tall thin stature

51 Lower Airway Condition Secondary Pneumothorax Secondary pneumothorax occurs in the presence of existing lung pathology Pneumonia is a possible cause of pneumothorax. Consider Pneumocystis jiroveci pneumonia (PCP), toxoplasmosis, and Kaposi sarcoma in patients with human immunodeficiency virus infection (HIV). A patient with HIV can have spontaneous pneumothorax as the presenting symptom of their illness. HIV carries a lifetime risk of 6% for pneumothorax, and about 85% of that number is related to PCP pneumonia.

52 Lower Airway Condition Secondary Pneumothorax Risk Factors History of Asthma, COPD, Cystic Fibrosis, TB, Whooping cough Previous history of pneumothorax Smoking Lung Cancer HIV

53 Lower Airway Condition Primary and Secondary Pneumothorax Signs and symptoms vary greatly depending on how much air enters the pleural space Sudden onset chest pain may describe as sudden, sharp, or stabbing increases when taking deep breath Dyspnea Tachycardia Tachypnea Pulses paradoxes Hypoxia and altered mental status Absent or diminished lung sounds on affected side

54 Pneumothorax

55 Obstructive lower airway diseases are characterized by diffuse obstruction to airflow within the lungs. Lower Airway Condition Asthma The most common obstructive airway diseases are emphysema, chronic bronchitis and asthma.

56 Lower Airway Condition Asthma Asthma prevalence is higher in children than adults Children who have wheezing that begins prior to 5 years old and persists into adulthood have increased risk of developing asthma Children who have a lower incidence of pulmonary disease even after age 5 have a lower incidence of pulmonary disease even if the wheezing persists into adulthood

57 Lower Airway Condition Asthma Signs and symptoms Wheezing Dyspnea Chest tightness Cough Signs of recent upper respiratory infection Rhinorrhea, congestion, headache, pharyngitis, and myalgia Signs of exposure to allergens Rhinorrhea Pharyngitis Hoarseness Cough Chest tightness, discomfort, or pain

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60 Capnography

61 Lower Airway Condition COPD COPD is an airflow obstruction caused by chronic bronchitis or loss of alveolar surface area associated with emphysema Characterized by some degree of wheezing and airway edema even though the mechanism is slightly different from asthma

62 Lower Airway Condition COPD Factors indicating severe exacerbation of COPD Oxygen saturation <90% Tachypnea Peripheral or central cyanosis Mental status changes caused by hypercapnia ETCO2 waveform ETCO2 readings

63 Lower Airway Condition COPD Signs and symptoms Dyspnea Exertion intolerance Wheezing Productive cough Chest pain or discomfort Diaphoresis Orthopnea Increased respiratory rate Decreased oxygen saturation

64 Capnography

65 Treatment COPD Emergency management Oxygen to maintain saturation of 92%* An oxygen saturation that falls into the 80 s and pale or cyanotic extremities requires aggressive airway and ventilation management CPAP has been shown to decrease work of breathing, increase oxygenation and decreasing the need for intubation NEVER WITHOLD OXYGEN FROM A HYPOXIC PATIENT

66 CPAP Improves respiratory function in asthma/copd Improvement seen due to: Decrease work of breathing/ reduction in fatigue Improved oxygenation Splinting of larger airways and bronchioles to reduce airway collapse and mucous plugging

67 ADULT ACUTE ASTHMA COPD WITH WHEEZING REACTIVE (LOWER) AIRWAY DISEASE BLS 1. Adult Initial Medical Care SOP, p If patient has prescribed inhaler, obtain time of last usage. If appropriate, assist patient with prescribed inhaler. 3. Reassess patient's respiratory status and begin transport 4. At discretion of Medical Control, additional doses of inhaler may be given 5. ALBUTEROL 2.5 mg (3 ml) via nebulizer per System-specific procedure 6. Consider possibility of congestive heart failure (CHF) / pulmonary edema in wheezing patient, if patient has a history of CHF, and/or pulmonary edema. If so, treat per PULMONARY EDEMA SOP, p. 22. ALS 1. Adult Initial Medical Care SOP, p ALBUTEROL 2.5 mg (3 ml) via nebulizer 3. Partial response: repeat ALBUTEROL immediately 4. If no response to ALBUTEROL or patient in severe respiratory distress: consider NIPPV / CPAP per System-specific procedure If age 50 and patient has no history of cardiac disease, consider EPINEPHRINE 1: mg IM If age > 50 and/or cardiac disease history, contact Medical Control 5. If imminent respiratory arrest, INTUBATE and use in-line ALBUTEROL 2.5 mg (3 ml)

68 Hyperventilation syndrome Respiratory disorder, psychologically or physiologically based, involving breathing to deeply or too rapidly Causes are unknown Sudden and everyday are two forms Causes carbon dioxide levels to decrease

69 Hyperventilation syndrome Lower levels of carbon dioxide reduce blood flow to the brain resulting in nervous system and emotional symptoms Weakness Fainting Dizziness Confusion Agitation Feeling as if you can t breathe

70 Hyperventilation Over breathing can also cause Calcium levels to drop in your blood which results in these CNS symptoms Numbness and tingling (in arms and around mouth) Spasms or cramps in hands and feet Muscle twitching May also cause cardiac symptoms Chest pain or tenderness Shortness of breath Wheezing

71 Hyperventilation Syndrome Symptoms usually last longer (hours as apposed to minutes) Usually happens in younger people Improves with exercise Pain does not improve with medication

72 Hyperventilation Syndrome Medical conditions can cause hyperventilation In children a medical cause is more likely than stress Administer oxygen Paper bag treatment is no longer considered appropriate Tetany, paresthesia and carpopedal spasm may occur

73 Hyperventilation syndrome

74 Hyperventilation Syndrome

75 ALS Scenario Medic is dispatched for the 60 year old female with shortness of breath Pt is in tripod position with increased work of breathing and accessory muscle use, breathing at a rate of 40 and unable to speak more than one word/sentence She tells to you I..can t.breathe

76 ALS Scenario HPI= per patient s husband, patient awoke this morning with shortness of breath and has experienced increased work of breathing with exertion Patient has recent history of a cold, but husband concerned she may now have pneumonia PMHX- diabetes, heart failure, hypertension Medications: Lasix 80 mg bid, digoxin 0.125mg daily, Regular insulin 30u twice daily, Levaquin and an albuterol inhaler

77 ALS Scenario VS 170/104 HR 118 RR 28 SPO2 87% RA ECG What are your treatment priorities

78 Case Scenario You are dispatched for the patient complaining of shortness of breath at the local rehab facility You find a 40 year old, obese female, lying supine on her bed with very labored respirations audible from outside the room The patient is staring at the ceiling and does not respond to your presence Patient is pale with cyanosis around the lips. Staff disappears when you get there

79 Scenario Assessment reveals Airway- Patent, no vomitus or obstruction Breathing- Shallow, very labored and rapid at 36 bpm with lung sounds diminished and audible rales in all fields Perioral and peripheral cyanosis present Circulation- Skin is pale, cool, diaphoretic No trauma or bleeding Pulse difficult to palpate GCS = 3 History CHF, COPD, recent hip replacement surgery

80 Initial Capnography waveform Case Scenario Placed on Hi flow oxygen at 15 L/m via BVM

81 Scenario Potential causes Treatment Rapid transport

82 Questions?