Respiratory Distress/Failure - General Criteria: Dyspnea WITHOUT a clear etiology O 2 V/S and SpO 2 (with and without Oxygen therapy if possible) Blood glucose analysis: if less than 80 mg/dl, refer to hypoglycemia protocol Albuterol 2.5 mg via nebulizer (6L/min.) IV NS at TKO (if hypotensive, titrate to SBP of greater than 100 mmhg) As soon as reasonably possible, reference a more specific protocol. Consider these differentials: Foreign Body Airway Obstruction - sudden onset, stridor or snoring, cyanosis, no air movement Asthma - relatively rapid onset, wheezing or silence, history of asthma COPD - gradual onset, history of COPD or long-term cigarette use Pneumonia - gradual onset, recent history of upper respiratory infection, fever, chest wall pain Pulmonary edema - sudden onset, history of hypertension, or cardiac or renal problems, presents with hypertension and/or irregular HR Pulmonary embolus - sudden onset, chest or back pain, history of recent surgery, childbirth, long-term immobility, or irregular HR Allergic reaction - sudden onset, urticaria, itching, edema, history of allergies Hyperventilation - recent history of anxiety/emotional upset, facial tingling and/or carpopedal spasms Myocardial infarction - chest pain, accompanied by nausea, diaphoresis, radiating pain PEDIATRIC Consideration: Cardiopulmonary arrest in infants and children is not usually a sudden event. Instead, it is often the end-result of a progressive deterioration in respiratory and circulatory function, the common pathway of which is cardiopulmonary failure, regardless of the underlying disease. Respiratory failure and shock may begin as two distinct syndromes, but they progress to an indistinguishable state of cardiopulmonary failure in the final moments before arrest. Their common denominator lies in the insufficient oxygen delivery to tissues and reduced clearance of metabolites. In shock, low cardiac output rates may deliver well-oxygenated blood to the tissues, but it is delivered too slowly to meet the tissues' metabolic demand. In advanced respiratory failure, poorly oxygenated blood may be delivered at a normal or elevated flow rate to the tissues. In both cases, hypoxia is present. 47
Respiratory Distress/Failure (continued) Respiratory failure may occur because of intrinsic lung or airway disease or because of inadequate respiratory effort. As with shock, respiratory failure is often preceded by a "compensated" state (respiratory distress) in which the patient is able to maintain adequate gas exchange at the expense of an increase in the work of breathing. This is seen in the use of accessory muscles of respiration, inspiratory retractions, tachypnea, and tachycardia. Any child manifesting the following conditions requires immediate attention and treatment: Respiratory rate greater than 60 Heart rate greater than 180 or less than 80 (under 5 years) Greater than 160 or less than 60 (over 5 years) Persistent respiratory distress Cyanosis Diminished level of consciousness Failure to recognize parents Seizures Fever with petechiae Fever with rash EVERY EMS PROVIDER WORKING WITH SICK CHILDREN SHOULD BE ABLE TO DIAGNOSE PULMONARY AND CIRCULATORY FAILURE AND IMPENDING CARDIOPULMONARY ARREST BASED ON A RAPID CARDIOPULMONARY ASSESSMENT. This assessment should take less than half a minute to complete and, by integrating important physical findings, is designed to evaluate pulmonary and cardiovascular integrity. 48
Asthma/ COPD /Pneumonia Criteria: Shortness of breath AND Auscultated findings of bronchospasm (wheezes or silence) Exacerbation of chronic bronchitis or emphysema WITH: Shortness of breath or dyspnea History of COPD O 2 V/S Albuterol 2.5 mg via nebulizer. May repeat once in 5 min if dyspnea not relieved. Pediatric treatment: Albuterol 2.5 mg via nebulizer. Blood glucose analysis: if less than 80 mg/dl refer to hypoglycemia protocol If febrile (greater than 100.5º F), Acetaminophen (see dosage chart) IV NS TKO Consider endotracheal intubation if patient condition warrants (especially when SpO2 <90%) See BRONCHIOLITIS/PNEUMONIA: PEDIATRIC for further pediatric treatment details. Asthma: The asthma treatment regimen may be thought of as oxygenate, dilate, and hydrate. o IV should be NS at 250-500 ml/hr. o Bronchial/alveolar dehydration (due to tachypnea) is a component of an "asthma attack". o Hydration will often allow the patient to clear mucous plugs and may result in as much relief as bronchodilation. The severely dyspneic and hypoxic asthma patient may require intubation. COPD: CO 2 retention and hypercarbia resulting in a respiratory acidosis are major culprits in COPD. Hypercarbia can be managed ONLY by increasing tidal volume by PPV with a BVM. BVM assist should be used in the patient with marked obtundation or respiratory insufficiency (rate less than 12/min or greater than 40/min). COPD patients can be very difficult to "wean" from the ET tube and/or ventilator. If the patient's airway and ventilatory status can be managed without intubation, try to do so. DO NOT, however, jeopardize the patient's survival in order to avoid intubation. 49
Pneumonia: Signs and symptoms of pneumonia are as follows: Dyspnea WITH one or more of the following: o Fever o Productive cough o Chest wall or pleuritic pain Pneumonia has a high mortality rate, especially among the elderly. EMS personnel must recognize this as a serious chief complaint. EMS personnel often confuse pneumonia, especially severe cases, with pulmonary edema. Pneumonia may present with a wide variety of auscultated breath sounds, including rales. History and associated signs/symptoms are the best tools to differentiate pneumonia from other sources of respiratory distress. Pneumonia is characterized by: o Gradual onset of symptoms, usually over a few days o A recent history of upper respiratory infection symptoms, including a productive (sometimes purulent) cough, fever, and chest wall pain Some pneumonia patients may present with wheezing (as may acute MI, severe allergic reactions, etc.); this may be a product of reactive bronchospasm (in response to the presence of the bacteria), or (more likely) an indication of narrowing of the small airways from the physical obstruction of infectious material. o Occasionally, these patients may show some improvement with the administration of bronchodilators. Most often, however, the bronchodilators will have no appreciable affect, as these are usually not true cases of reversible bronchospasm. 50
Bronchiolitis/Pneumonia: Pediatric Criteria: Pediatric patient with: Dyspnea WITHOUT evidence of upper airway obstruction WITH evidence of lower airway involvement (wheezes, crackles, forced exhalation) O 2 with SpO 2 V/S Maintain normothermia Albuterol 2.5 mg via nebulizer for mild to moderate dyspnea If febrile, administer Acetaminophen (see reference for medication doses) IV: NS, titrated to resolve dehydration (initial 20 ml/kg bolus for the child, 10 ml/kg for infant) Typically, an affected child has had a preceding upper respiratory infection, followed by rapid onset of respiratory distress with tachypnea, tachycardia, and a hacking cough. Increasing distress is evidenced by circumoral cyanosis and audible wheezing. The child often appears markedly lethargic, but fever is not always present. Dehydration may develop from vomiting and decreased oral intake. Bronchiolitis is a viral or bacterial infection of the bronchioles themselves. It generally occurs in children under 2 years of age. Pneumonia is a more general infection of the lung, including the large airways and the alveoli. It may occur at any age. In severe cases, it can be confused with pulmonary edema. It may present with a wide variety of breath sounds on auscultation, including rales. History and associated signs/symptoms are the best tools to differentiate pneumonia from other sources of respiratory distress. Pneumonia is characterized by: o Gradual onset of symptoms, usually over a few days o Recent history of upper respiratory infection symptoms, including a productive (sometimes purulent) cough o Fever o Chest wall pain 51
Croup: Pediatric Criteria: Pediatric patient with: Dyspnea AND Inspiratory stridor AND Recent history or current symptoms of URI O 2 V/S with SpO 2 if available Maintain normothermia If febrile, Acetaminophen or Ibuprofen (see reference for medication doses) Croup is usually preceded by an upper respiratory infection. A "barking," often spasmodic cough and hoarseness may mark the acute onset of inspiratory stridor, which commonly occurs at night. The child often awakens during the night with respiratory distress and tachypnea. The obvious respiratory distress and the harsh inspiratory stridor are the most dramatic physical findings. Auscultation reveals prolonged inspiration and stridor, often with some expiratory rhonchi and wheezes. Rales also may be present. Fever is present in about 1/2 of the children. The illness usually lasts 3-4 days and generally occurs in children between the ages of 6 months and 4 years. IF THERE IS ANY DOUBT AS TO WHETHER THE PATIENT IS SUFFERING FROM CROUP OR EPIGLOTTITIS, TREAT AS EPIGLOTTITIS, and do everything possible to minimize the child's agitation. 52
Epiglottitis: Pediatric Criteria: Pediatric Patient with Dyspnea Evidence of upper airway obstruction (inspiratory stridor, drooling, or hoarseness) AND any one or more of the following: o Fever o Recent history of upper respiratory infection symptoms o Dysphagia or severe sore throat EMT-B/ O 2 V/S with SpO 2 if available Maintain normothermia Onset of epiglottitis is frequently acute and fulminating. Sore throat, hoarseness, and usually high fever develop abruptly in a previously well child. Dysphagia and respiratory distress characterized by drooling, dyspnea, tachypnea, and inspiratory stridor develop rapidly and cause the child to lean forward and hyperextend the neck. Acute epiglottitis usually presents before 5 years of age. It is IMPERATIVE that oxygen administration not result in increased agitation. Great care must be taken not to agitate the child, as agitation may result in sudden, complete airway obstruction. As long as the child has adequate respiratory volume, DO NOT place any instrument in the child's mouth or attempt to visualize the epiglottis with a laryngoscope or tongue blade, since severe laryngospasm and swelling may result. Respiratory arrest can occur from total airway obstruction or a combination of partial airway obstruction and fatigue. If respiratory arrest occurs, PPV with a BVM with 100% oxygen should precede any attempt to intubate the patient. 53
Foreign Body Airway Obstruction Criteria: Pediatric Patient with Partial or complete airway obstruction secondary to foreign body aspiration WITH: o Decreased LOC o Cyanosis OR o Obvious inadequate air exchange Abdominal/chest thrusts Reassess airway Direct laryngoscopy Attempt to visualize object and remove with Magill forceps Intubate as needed Foreign body aspiration is the most common cause of sudden respiratory distress or arrest in a previously healthy child and should be the provider's initial suspicion in such patients. In the conscious patient, chest or abdominal thrusts are used (as per AHA guidelines). In the unconscious patient, appropriately certified EMS personnel should attempt to ventilate and intubate. If unable to ventilate with the BVM, go directly to direct laryngoscopy and Magill forceps to remove the foreign object. 54
Pulmonary Edema Criteria: Shortness of breath WITH Evidence of pulmonary edema (auscultated findings, history, etc.) AND Cardiac history WITH Systolic BP of greater than 100 mmhg CABC s O 2 V/S with SpO2 if available If hypotensive, place in modified Trendelenburg (elevated feet while sitting upright) IV NS at TKO rate Consider intubation via endotracheal or alternative airway device, if indicated Pulmonary edema often presents as simply dyspnea with wheezes or silence on auscultation; rales may not be heard. Use other signs and history to differentiate CHF from other etiologies. Pulmonary edema is often associated with these indicators: Sudden onset, frequently at night Hypertension Previous cardiac history Be aware that hypotensive patients (systolic BP of less than 90 mmhg) with pulmonary edema may actually be in cardiogenic shock. Oxygen must be by NRB at 10-15 L/min or by BVM. IV fluid should be NS at TKO rate. Watch the fluid administration rate carefully. 55
Seizures Criteria: Patient experiencing active seizures or in a postictal state CABCs O 2, assist with BVM if necessary V/S with SpO 2 if available Temperature Blood glucose analysis: if less than 80 mg/dl refer to hypoglycemia protocol If actively seizing, protect head from trauma Position patient in left lateral recumbent position if decreased level of consciousness IV NS TKO Naloxone for persistent altered mental status o 0.4-2 mg IV in the adult May repeat every 2-5 min if patient responds to initial dose. Maximum total dosage of 4 mg Consider Thiamine 50 mg IV and 50 mg IM OR 100 mg IV in suspected alcohol abuse patients Active airway maintenance, the use of airway adjuncts, and ventilatory support with the BVM are essential to the early management of the actively seizing patient. Temperature can be a major factor in seizures. Increased body temperature lowers the seizure threshold (makes a seizure more likely), while lowered temperature raises it. The seizure patient who is hyperthermic or febrile will benefit from external cooling procedures. Seizures generally are classed into four categories: Tonic-Clonic (generalized, "grand-mal" convulsion) Absence ("petit mal") Focal (non-generalized or localized convulsion) Psychomotor (behavioral/personality manifestation) Aggressive, early oxygenation is a must in the seizure patient. Oxygen alone will shorten the postictal state and raise the seizure threshold. Blood glucose should always be assessed in the seizure patient. Hypoglycemia will significantly lower seizure threshold and represents a life-threatening cause of convulsions. Additionally, convulsions may cause hypoglycemia in an otherwise normoglycemic patient. Thiamine is to be given as 50 mg IV and 50 mg IM OR 100 mg IV only in the event of suspected alcohol abuse. 56