9/25/2014. Medical Issues (Restrictive processes) Medical Issues (Obstructive processes) Respiratory Emergencies (Class 10)

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1 1 2 3 Respiratory Emergencies (Class 10) Respiratory distress accounts for approximately 60% of all ambulance calls There are greater than 300,000 deaths annually due to respiratory emergencies All respiratory problems impact at least 1 of 3 things: Ventilation (mechanical movement of air into and out of the lungs Diffusion (distribution of air throughout the alveoli) Perfusion (distribution of blood throughout the capillary beds of the lungs Three basic forms of respiratory problems Restrictive processes Obstructive processes Miscellaneous 4 Medical Issues (Restrictive processes) 5 Problems that limit lung volume Usually due to structural defects in chest wall or diseases of the lung tissue itself that minimizes lung volume Scoliosis Kyphosis Can also be caused by disesases of the lung tissue itself Pulmonary fibrosis Medical Issues (Obstructive processes) Problems that interfere with the ability to move air into and/or out of the lungs Usually due to behaviors or chronic diseases that damages the air passages and/or alveoli Smoking Environmental exposures One of the most common reasons for ambulance calls Bronchitis 1

2 Definition Inflammation of the respiratory epithelium (mucosa) Causes Exposure to irritants or infectious agents Cigarette smoke Air pollution Workplace exposure (becoming increasingly more rare due to worker safety regulations)» Dry cleaners» Industry Bacteria Viruses 12 Physiology Irritated mucosa Thickened mucosa Excessive mucous production Goblet cell Fibrous scarring Decreased ciliary action Signs and symptoms Productive cough At least three consecutive months for at least two consecutive years Usually in the morning Increases with seasonal change Dyspnea Exertional Resting (severe cases) Obesity (blue bloaters) Rales, rhonchi and wheezing Emphysema (COPD) Definition Numerous processes occurring in the lung as a result of continual airway irritation Causes Chronic bronchitis due to Cigarette smoke» Active» Passive Air pollution Workplace exposure (becoming increasingly more rare due to worker safety regulations) 2

3 » Industry» Dry cleaners Pathology Irritated & thickened mucosa Excessive mucous production Goblet cells Eventual goblet cell death Unusual to see completely "dry" emphysema patient Fibrous scarring Decreased ciliary action Cell death Prone to infection Loss of elasticity Pathology (cont.) Mucous plugs Retains CO 2 Distal airway collapse Retains CO 2 Confluency Decreases surface area Bullae formation CO 2 Narcosis Medulla (normally senses CO 2 ) Tolerance Chemoreceptors (senses O 2 ) High O 2 decreases drive to breath Respiratory arrest results if O 2 too high Signs and symptoms Initial productive cough, becoming more of a dry cough as disease progresses Dyspnea Resting Exertional (greater dyspnea) Patients typically end up living in one room having a bathroom and almost always on the ground floor Tachypnea Tripod posturing Retractions 3

4 Pursed lipped breathing 24 Signs and symptoms COPD personality Restless Anxious Irritable Angry Skin color usually remains pink ( Pink Puffers ) Barrel chest Rales Spontaneous pneumothorax for both chronic bronchitis and COPD Establish responsiveness Airway Positioning Modified jaw thrust Chin lift Adjuncts as needed Nasal airway Oral airway PTL Usually mechanical device not required Suction as needed Breathing Assist and supplement breathing as necessary, artificial ventilation as necessary Breathing patient Low flow O 2» 24% venturi mask (best)» Nasal cannula at 1-2 LPM DO NOT WITHHOLD OXYGEN IF PATIENT HAVING SIGNIFICANT BREATHING PROBLEMS Allow patient to use inhaler as prescribed Consider use of CPAP Non-breathing patient 100% O 2 by bag-valve-mask Assist with pre-prescribed Albuterol nebulizer 2.5 mg/3ml normal saline with 6LPM oxygen Circulation 4

5 Check and maintain appropriate pulse IV normal saline TKO (may use INT) Patient positioning Fowler's Semi-Fowler's Supine for CPR or airway management NPO (non per os) Frequent vital signs Emergency transport, if necessary 29 Asthma Definition - bronchospasm Causes Allergens Irritants Stress Exertion Physiology Irritated mucosa Thickened mucosa Excessive mucous production Bronchospasm Narrowed lumen Sustained contraction Episodic Signs and symptoms Dyspnea Sudden Resting Exertional Non-productive cough Tachypnea Tachycardia Retractions Wheezing and perhaps rales Cyanosis Low SpO2 95% or less Establish responsiveness Airway Positioning 5

6 Modified jaw thrust Chin lift Adjuncts as needed Nasal airway Oral airway PTL Usually mechanical device not required Suction as necessary Breathing Breathing patient High flow O 2 Non-rebreathing mask (best) Nasal cannula at 10 LPM as a last resort Bag-valve-mask assembled and ready»begin ventilations if SpO2 less than 90% even if patient is breathing on his/her own Assist with pre-prescribed metered dose inhaler Consider CPAP Non-breathing patient 100% O 2 by bag-valve-mask Assist with pre-prescribed Albuterol nebulizer 2.5 mg/3ml normal saline with 6LPM oxygen Consider epinephrine injection for patients in extreme distress who don t respond to inhaled medications MUST HAVE APPROVAL OF MEDICAL CONTROL Circulation Check and maintain appropriate pulse IV normal saline TKO (may use INT) Patient positioning Fowler's Semi-Fowler's Supine for CPR or airway management NPO (non per os) Frequent vital signs Emergency transport, if necessary Status Asthmaticus Definition Extended attacks Rapid, recurrent attacks Treatment Same as above Will probably have to bag the patient 6

7 36 Pneumoconiosis Definition Inflammatory response due to particulate matter lodging in lung tissue Pathology Inflammation Fibrous scarring Emphysematous changes Types Black lung or Coal Miner s disease (coal dust) White lung (cotton fibers) Farmer's lung (dust) Signs & symptoms & treatment Same as COPD Medical Issues (Miscellaneous problems) 39 Pneumonia Definition Infection of deep lung tissues Causes Bacteria Virus Frequency Very common in geriatric patients Very common in immuno-compromised patients AIDS Organ transplant patients Common cause of death in geriatric patients Signs and symptoms Fever Chest pain upon deep breathing or coughing Altered mental status Dyspnea Cough Tachypnea Tachycardia Wheezing, rales and perhaps rhonchi Cyanosis Low SpO2 7

8 95% or less Establish responsiveness Airway Positioning Modified jaw thrust Chin lift Adjuncts as needed Nasal airway Oral airway PTL Usually mechanical device not required Suction as necessary Breathing Breathing patient High flow O 2 Non-rebreathing mask (best) Nasal cannula at 10 LPM as a last resort Consider CPAP Non-breathing patient 100% O 2 by bag-valve-mask Circulation Check and maintain appropriate pulse IV normal saline TKO (may use INT) Patient positioning Fowler's Semi-Fowler's Supine for CPR or airway management NPO (non per os) Frequent vital signs Emergency transport, if necessary Hyperventilation Syndrome (Tachypnea) Definition Excessive rate and depth of breathing Excessive loss of CO 2 Causes Psychological Fright and anxiety Metabolic DKA 8

9 Signs and symptoms Tachypnea Rate greater than 20/min Usually 30 to 40/min Tingling Hands Feet Face Cramping Fingers Toes Anxiety Nervousness Restlessness Vertigo (unusual) Chest pain (unusual) Calm patient Slow breathing techniques Inhale slowly Hold breath Count to thousand five Exhale slowly Count to thousand five Repeat Rebreathing USE ONLY AT DIRECTION OF MEDICAL CONTROL Paper bag Partial rebreathing mask No O 2 Full or semi-fowler's position Transport Pulmonary embolism Definition Clot in arteries or capillary beds of the lungs Causes Immobility Recent surgery Childbirth Birth control pill use Signs and symptoms Sudden unexpected dyspnea without obvious cause Sharp, stabbing chest pain 9

10 Hemoptysis Tachypnea Retractions Cyanosis Atypical chest pain Establish responsiveness Airway Positioning Modified jaw thrust Chin lift Adjuncts as needed Nasal airway Oral airway Double lumen airway Suction as necessary Breathing Breathing patient High flow O 2 Non-rebreathing mask (best) Nasal cannula at 6 LPM as a last resort Bag-valve-mask assembled and ready Non-breathing patient 100% O 2 by bag-valve-mask Circulation Check and maintain appropriate pulse IV normal saline TKO (may use INT) Patient positioning Fowler's or Semi-Fowler's if breathing Supine for CPR or airway management NPO (non per os) Frequent vital signs Emergency transport Pulmonary edema Definition Abnormal accumulation of interstitial fluid in the lungs 10

11 Causes Congestive heart failure Pneumonia Smoke inhalation Further discussion in cardiac emergencies lecture Always consider CPAP!! CPAP (Continuous Positive Airway Pressure) Increased pressure in the airways designed to keep them open Pursed-lipped breathing is self-cpap Now considered standard of care Indications Patient awake and able to follow commands Systolic pressure >90 mmhg Ability to maintain airway CPAP (Cont.) Two or more of the following: Respiratory rate > 25/min O2 saturation < 94% Use of accessory muscles (expiration becomes a muscular act) Contraindications Cardiac or respiratory arrest Pneumothorax Agonal breathing Typical starting pressure is 5 cm H 2 0 Open 0 2 regulator WIDE 57 CPAP Machine 58 Medical or Trauma Issues 59 Simple pneumothorax Air between visceral and parietal pleura May be caused by trauma or medical problem Assessment Dyspnea Absent or decreased breath sounds on affected side 11

12 Trachea MAY deviate toward injured side when patient inhales Simple pneumothorax (Cont.) Treatment Airway with Spinal Precautions Manual immobilization Ask patient to remain motionless Adjuncts as needed» Nasal airway» Oral airway» PTL Breathing High flow oxygen» Non-rebreathing mask» 15 LPM Bag-valve-mask assembled and ready Assist and supplement breathing as necessary Artificial ventilation as necessary Simple pneumothorax (Cont.) Circulation Stop Major Hemorrhage IV normal saline TKO» 20 cc/kg bolus if hypotension present Spinal precautions NPO (non per os) Frequent vital signs Emergency transport, if necessary 63 Trauma Issues 64 Sucking chest wound Movement of air through open chest wall wound Always causes pneumothorax Assessment Most rib fracture signs and symptoms Open chest wall laceration or puncture Air movement through wound Whistling Bubbling Foaming 12

13 "Spurting" with breathing, not pulse Pneumothorax signs and symptoms Sucking chest wound (Cont.) Treatment Airway with Spinal Precautions Manual immobilization Ask patient to remain motionless Adjuncts as needed» Nasal airway» Oral airway» PTL Breathing High flow oxygen» Non-rebreathing mask» 15 LPM Bag-valve-mask assembled and ready Assist and supplement breathing as necessary Artificial ventilation as necessary Circulation Check and maintain a central pulse Stop major hemorrhage IV normal saline TKO» 20 cc/kg bolus if hypotension present Sucking chest wound (Cont.) Treatment (Cont.) Close the sucking wound Occlusive dressing» Aluminum foil» Vaseline gauze» Plastic wrap Close on exhalation Sterility Three sides to avoid tension pneumothorax Patient positioning Fowler's, if no spinal injury Semi-Fowler's, if no spinal injury Supine for CPR Spinal precautions NPO (non per os) Frequent vital signs and monitoring Observe for the development of a tension pneumothorax 13

14 Emergency transport Tension pneumothorax Pressurized air between visceral and parietal pleura Usually caused by trauma Tension pneumothorax (Cont.) Assessment Dyspnea Absent or decreased breath sounds on affected side Narrowed pulse pressure Moves air poorly even with adequate airway Tracheal deviation AWAY from the injured side (LATE SIGN) Jugular vein distention (LATE SIGN) Unilaterally toward injury Bilateral as tension increases Tension pneumothorax Treatment Airway with Spinal Precautions Manual immobilization Ask patient to remain motionless Adjuncts as needed» Nasal airway» Oral airway» PTL Breathing High flow oxygen» Non-rebreathing mask» 15 LPM Bag-valve-mask assembled and ready» Assist and supplement breathing as necessary» Artificial ventilation as necessary Circulation Check and maintain a central pulse IV normal saline TKO» 20 cc/kg bolus if hypotension present 14

15 78 79 Tension pneumothorax (Cont.) Treatment (Cont.) If tension pneumothorax is due to a sucking chest wound, open the sucking wound Raise the occlusive dressing Allow pressure to escape Reclose the sucking wound» Close on exhalation Patient positioning Fowler's, if no spinal injury Semi-Fowler's, if no spinal injury Shock precautions Spinal precautions NPO (non per os) Frequent vital signs and monitoring Observe for the redevelopment of a tension pneumothorax Emergency transport Hemothorax Blood between visceral and parietal pleura Usually caused by trauma Assessment Dyspnea Absent or decreased breath sounds on affected side Shock may be present Flat neck veins Treatment Same as pneumothorax Patients are usually extremely difficult to ventilate Treat for shock Pneumo-hemothorax Blood and air between visceral and parietal pleura Usually caused by trauma Assessment Dyspnea Absent or decreased breath sounds on affected side Shock may be present Treatment Same as pneumothorax Treat for shock Pulmonary Contusion 75% of chest trauma patients also have pulmonary contusion (bruising of the lung). 15

16 The bruising results in alveolar edema, alveolar hemorrhage and atelectasis (deflation of the alveoli) This causes hypoxia and hypercarbia due to poor perfusion and reduced gas exchange in the affected area (ventilation/perfusion mismatch) Most common potentially life-threatening pulmonary injury Assessment Small movements of the stethoscope identify areas of present then absent breath sounds Treatment High flow oxygen Medications Metered Dose Inhaler (MDI) Nebulizer (Small Volume Nebulizer/SVN) Bronchiodilator Albuterol (Proventil, Ventolin, Bronkosol, Alupent, Metaprel, etc) Description A commonly prescribed bronchiodilator in pre-hospital care, Albuterol is administered with a small volume nebulizer, or metered dose inhaler. Actions Causes bronchiodilation with minimal side effects, reduces airway resistance, and duration is approximately five hours. Indications Exhibits signs and symptoms of respiratory emergency (Bronchial asthma or signs and symptoms of respiratory distress; reversible bronchospasm associated with chronic bronchitis and cases of emphysema). Third drug for anaphylaxis. Has physician prescribed inhaler or nebulizer medication, and Specific authorization by medical direction. Contraindications Patients with a known hypersensitivity to the drug. Inability of patient to use device However, nebulizers are occasionally used with a mask. Inhaler/nebulization medication is not prescribed for the patient. No permission from medical direction. 16

17 Patient has already met maximum prescribed dose prior to your arrival. Precautions Palpitations, anxiety, nausea, and dizziness may be seen. Monitor vital signs Use caution when administering to patients with history of cardiovascular disease or hypertension. Side effects Increased pulse rate. May increase systolic pressure. Tremors. Nervousness Dosage Nebulizer Amount of medication or duration of treatment based upon medical direction's order or physician's order based upon consultation with the patient Typical order is 2.5 mg of the drug placed in 3 ml of normal saline for inhalation and administered by a nebulizer running at the flow rate established in the nebulizer s manufacturer s recommendations until appropriate mist is achieved (usually about six liters per minute). Metered Dose Inhaler Shake inhaler vigorously several times and administer to the patient upon deep inhalation. The patient should hold their breath as long as comfortably possible (at least 10 seconds or more) to assure more effective distribution of medication. Number of inhalations based upon medical direction's order or physician's order based upon consultation with the patient. Route Inhalation only Infant & child considerations Use of handheld inhalers is very common in children Retractions are more commonly seen in children than adults Cyanosis is a late finding in children Very frequent coughing may be present rather than wheezing in some children Emergency care with usage of handheld inhalers is the same if the indications for usage of inhalers are met by the ill child Skills Metered Dose Inhaler Administration Skills Manual pages 15 & 16 Video Skills Nebulized Medication Administration 17

18 Skills Manual pages 17 & 18 Video 95 18