Emt-B Intro To Emergency Care Respiratory Emergencies

Ch15: Respiratory Emergencies Respiratory system includes everything that contribute to breathing • Diaphragm • Chest wall and accessory muscles • Innervating nerves Brainstem senses blood’s CO2 levels. • Regulates breathing rate and depth Oxygen exchange can be hindered by: • Conditions in the anatomy of the airway • Disease processes • Traumatic conditions • Abnormalities in pulmonary vessels Hypoxic drive • Caused by chronic CO2 retention • Frequently found in end stage COPD Common causes of dyspnea • Pulmonary edema, Hay fever, pleural effusion, Airway obstruction, Hyperventilation syndrome, Environmental/industrial exposure, Drug overdose • AMS can be a result of hypoxic brain Dyspneic Pts can have: • Gas exchange obstructed ○ Damaged alveoli (atelectasis: collapsed lung due to fluid-filled alveoli) • Obstructed air passages (mucus, muscle spasm weakened airway walls) • Obstructed blood flow to the lungs • Excess fluid in pleural space • Severe pain can cause Pt to breathe shallowly without pulmonary dysfunction ○ When Pt complains of dyspnea, ask abt chest pain; when Pt complains abt chest pain, assess for dyspnea Airway infections • can cause dyspnea via: ○ Mucus and secretion obstructing airflow in major passages ○ Swelling of soft tissues in upper airways ○ Impaired exchange of gases in the alveoli Croup • Typical age range: 6 m/o to 3 y/o • Starts with cold, cough, low-grade fever • Hallmark symptom: seal-like bark • Responds well to humidified O2; bronchodilator may worsen symptoms Epiglottitis • Bacterial infection causing inflammation of epiglottis • Usually develops in otherwise-healthy children • Children are found in the tripod position (trying to open airway) and drooling. ○ Suspect if Pt presents with stridor/airway obstruction without a sign of mechanical obstruction • Position comfortably and provide oxygen. Don't put anything in their mouth Respiratory Syncytial Virus (RSV) • Suspect if infant is dehydrated/refuses liquid • Causes infection in the lungs and passages • Treat airway/breathing problems as needed, give humidified O2 • Often causes bronchiolitis ○ Bronchioles become inflamed and fill with mucus. ○ Usually affects newborns and toddlers ○ Give O2, CPAP if Pt goes into respiratory failure Pneumonia • Bacterial pneumonia will come on quickly and result in high fever. • Viral pneumonia presents more gradually and is less severe. • Often a secondary infection • Intubation/tracheostomy can cause pneumonia • Predisposing factors: institutional residence facilities, recent hospitalization, chronic diseases, COPD, immunocompromised • Assess temperature (pneumatic Pts will have fever) and provide airway support and supplemental O2 • Symptoms vary widely • Give O2 with appropriate adjuncts, transport Pertussis (whooping cough) • Bacterial infection • Children will be feverish and exhibit a “whoop” sound upon inspiration after a coughing attack • Adults • Watch for dehydration • suction as needed • Age range: <6 y/o Influenza Type A • Symptoms include fever, cough, sore throat, muscle aches, headache, and fatigue. • May lead to pneumonia or dehydration TB • Bacterial infection • Patients often complain of fever, coughing, fatigue, night sweats, and weight loss. • Predisposing factors: immunocompromised, Pts who inject drugs/alcohol • Wear gloves, eye protection, and an N-95 respirator. Acute pulmonary edema • Fluid builds up within alveoli and in lung tissue bc left side of heart can't pump out blood faster than right side receives it ○ Referred to as pulmonary edema ○ Usually result of congestive heart failure COPD • Slow process of dilation and disruption of airways and alveoli • Umbrella term for emphysema and chronic bronchitis ○ Tobacco smoke can cause chronic bronchitis (irritation of trachea and bronchi) • Excess mucus is produced, obstructing small airways and alveoli. • Emphysema is the most common type of COPD: loss of elastic material in lungs • Loss of elastic material in the lungs • Causes include inflamed airway and smoking. • Most patients with COPD have elements of both chronic bronchitis and emphysema. • Pts with COPD may also present with adventitious breath sounds like crackles, rhonchi, and wheezing and diminished breath sounds Wet lungs vs. dry lung sounds • COPD and CHF signs and symptoms commonly overlap • Patients with COPD will have “dry” lung sounds (wheezing) and typically present with sputum, chronic cough, wheezing • Pts with CHF/pulmonary edema have "wet" lung sounds like crackles • This isn't a perfect rule, so don't assume all COPD Pts have wheezing • Pts with wheezing can be caused by CHF: alveoli get so full that bubbles can't form (no crackles), and bronchi get constricted and cause wheezing (cardiac asthma due to left-sided heart failure) • COPD usually has slower onset of symptoms and is exacerbated by infections; CHF has faster onset due to failing pump • COPD usually has long history of dyspnea and sudden onset of SOB (rarely history of chest pain), BP usually normal, but pulse may not be Asthma, Hay Fever, and Anaphylaxis • Caused by allergies • Asthma is acute spasm of smaller air passages (bronchioles) • Characteristic wheezing • 5-17 y/o • Hay fever (allergic rhinitis) causes cold-like symptoms. • Allergens include pollen, dust mites, pet dander • Worst in spring/summer • Anaphylactic reaction can produce severe airway swelling. • Usually happens within 30 min of exposure • Total obstruction is possible. • Epinephrine is best treatment ▪ Adult dosage: .3 mg ▪ Child dosage: .15 mg • Oxygen and antihistamines are also helpful Spontaneous Pneumothorax • Pneumothorax is accumulation of air in pleural space, often caused by trauma • Vacuum-like pressure in pleural space is lost, lungs can't expand Can be caused by fractured rib puncturing lung, lung infections, older Pt coughing too hard, GSW Can cause sudden dyspnea Breath sounds may be absent on affected side May have pleuritic chest pain: sharp, stabbing pain on 1 side that's worse during inspiration and expiration • Other signs: sudden dyspnea, hypotension, JVD, cyanosis Pleural effusion • Collection of fluid outside the lung, compressing lung and causing dyspnea • Can be due to irritation, infection, CHF, cancer • Will hear decreased breath sounds where fluid has moved the lung away from chest wall • Pt feels better sitting upright • Fluid must be removed by doctor • • • • Pulmonary embolism (PE) • A blood clot that circulates to right side of heart to pulmonary artery ○ Circulation cut off, so no oxygenation despite Pt is ventilating ○ If large enough, can cause sudden death • Signs and symptoms: dyspnea, acute chest pain, hemoptysis (coughing up blood), cyanosis (from nipples up), tachypnea, tachycardia hypoxia Hyperventilation • Overbreathing causing arterial CO2 falls below normal • May be indicator of life-threatening illness like hyperglycemias ○ Can be due to acidosis • Can result in alkalosis (excess base in body fluids), causing anxiety, dizziness, numbness, tingling, carpopedal spasms • Hyperventilation syndrome is hyperventilating in absence of other physical problems (not due to acidosis, illness) ○ Can cause symptoms of panic attack: ▪ Anxiety ▪ Dizziness ▪ Numbness ▪ Tingling or painful spasms of the hands/feet • Don't have Pt breathe in a bag bc that recirculates CO2 Environmental/Industrial Exposure • Can cause aspiration pneumonia and then pulmonary edema • CO is produced by fuel-burning household appliances ○ Pts may present with flu-like symptoms (headache, dizziness, fatigue, nausea & vomiting) and possible dyspnea, chest pain, nervous system impairments, syncope, seizure Pt assessment Scene size-up 1. BSI/PPE 2. Is scene safe 3. Consider possibility of infectious disease or toxic substance. 4. MOI: ask why 911 was activated ○ Question the patient family, and/or bystanders to determine NOI (nature of illness) Primary assessment • Identify immediate life threats. • Form a general impression. ○ Note age and position of patient. ○ Use AVPU scale. ○ Ask patient about chief complaint. • ABC ○ Always check breath and lung sounds ○ Back unnecessary. Only need midclavicular and midaxillary ○ Make sure airway is patent and adequate. ○ Assess rate, rhythm, and quality. ○ Assess pulse rate, rhythm, and quality. ○ Evaluate for shock and bleeding. ○ Assess skin color, temperature, and condition • Transport decision ○ Needs to be decided upon w/in 10 min of patient assessment • Life threats: ABC issues, poor GI, unresponsiveness, shock, chest pain + hypotension, severe pain, excessive bleeding Primary assessment: Breath sounds • Snoring: partial upper airway obstruction • Wheezing: constriction/inflammation of bronchus • Crackles (rales): air passing through fluid in alveoli (heard on inspiration) ○ Fine crackles: High-pitched, coarse crackles: low-pitched • Ronchi: low-pithed rattling sounds caused by secretions in larger airway (heard on inspiration) ○ Indicates partial tracheal obstruction History taking • Investigate chief complaint • SAMPLE history, OPQRST assessment • PASTE assessment (for patients with dyspnea) ○ Progression (progression of symptoms), Associated chest pain, Sputum (has Pt been coughing up sputum), Talking tiredness (2-3 word dyspnea?), Exercise tolerance (ask if Pt could walk across a room before symptoms and ask if they could do it now) ▪ Pink, frothy sputum suggests fluid in lungs Secondary assessment • Look for overall chest symmetry, adequate rise and fall, work of breathing, auscultate • BP • Neurologic assessment bc LOC can change • Pulse ox • If Pt is breathing at 40 breaths/min and is wheezing, it's hard to determine if it's asthma or CHF. However, upon secondary assessment, you may find pedal edema or consistent hypertension. This leads you to CHF. Reassessment • Repeat the primary assessment (start at LOC). • Assess for changes in condition. • Possible interventions needed: • Oxygen via nonrebreathing mask at 15 L/min • Positive-pressure ventilations • Airway management techniques • Positioning • Assisting with respiratory medications Emergency Medical Care • Administer oxygen and monitor respirations. • Patient may have metered-dose inhaler (MDI) or small-volume nebulizer • Consult medical control and make sure medication is indicated. • Most medications are used to relax the muscles that surround the air passages in the lungs. Treatments for specific conditions • Airway infection: • Administer humidified oxygen (if available). • Do not attempt to suction the airway or place an oropharyngeal airway. • • • • • • • • • • • • Position comfortably. • Transport promptly. Acute pulmonary edema: • Provide 100% oxygen. • Suction if necessary. • Position comfortably. • Provide CPAP if indicated and allowed by protocol. • Transport promptly. Chronic obstructive pulmonary disease ○ Assist with prescribed inhaler. ▪ Watch for side effects from overuse. ○ Position comfortably. ○ Transport promptly. Asthma, hay fever, and anaphylaxis • Be prepared to suction. • Assist asthma patient with prescribed inhaler. • Provide aggressive airway management, oxygen, and prompt transport. • Hay fever is unlikely to need emergency treatment. • Anaphylaxis will respond to epinephrine. Spontaneous pneumothorax • Provide supplemental oxygen. • Transport promptly. • Monitor carefully. Pleural effusion • Fluid removal must be done in hospital. • Provide oxygen. • Transport promptly. Obstruction of airway • Partial obstruction ○ Provide supplemental oxygen and transport. • Complete obstruction ○ Clear obstruction and administer oxygen. • Transport rapidly to emergency department. Pulmonary embolism (PE) • Supplemental oxygen is mandatory. • Position comfortably. • If hemoptysis is present, clear airway. • Transport promptly. Hyperventilation • Complete primary assessment and gather history. • Do not have patient breathe into paper bag. • Reassure patient. • Provide supplemental oxygen. • Transport promptly. Environmental/industrial exposure • Ensure patients are decontaminated. • Treat with oxygen, adjuncts, and suction based on presentation. Foreign body aspiration • Clear the airway. • Provide oxygen and transport. Tracheostomy dysfunction • Position comfortably. • Suction. • Provide oxygen. • Asthma • Provide blow-by oxygen. • Use MDIs. • Cystic fibrosis • Genetic disorder that affects the lungs and digestive system • Suction and oxygenate as needed. CPAP helps clear out lung fluids • For Pts with respiratory distress associated with obstructive pulmonary disease and acute pulmonary edema • Uses O2 to deliver pos. pressure • Can be used for Pts who have moderate-severe respiratory distress from underlying disease, are alert and able to follow commands Review • Pursed lip breathing is sign of respiratory distress • • • • • • • • • When giving O2 during nebulizer, set O2 to 6 L/min Bronchitis also associated with wheezing Side effects of nebulized ede: muscle tremors, increased HR, nervousness COPD and emphysema commonly caused by smoking, tobacco smoke. Alveoli get inflamed, ability to remove foreign particles from airway diminishes Signs and symptoms of pulmonary embolism: A sudden onset of difficulty breathing, sharp chest pain, and cyanosis that persists despite supplemental oxygen Albuterol is the generic name for Ventolin (Proventil) A 70-year-old man recently had a heart attack and now complains of severe difficulty breathing, especially when lying flat. He is coughing up pink, frothy secretions. This is caused by left heart failure, which causes pulmonary edema Crackles (rales) are caused by air passing through fluid Pleural effusion: accumulation of fluid outside the lungs • CPAP is contraindicated by low BP. Increased pressure in chest diminishes blood return to the heart • CPAP is also contraindicated by Pts in respiratory arrest, with pneumothorax or chest trauma, decreased LOC, tracheostomy, inability to follow commands, GI bleeding • While auscultating an elderly woman's breath sounds, you hear low-pitched “rattling” sounds at the bases of both of her lungs. This suggests aspiration pneumonia: lung infection due to a relatively large amount of material from the stomach or mouth entering the lungs PASTE for respiratory distress: Progression of distress, asscoatied chest apin, sputum (color), talk time, exercise tolerance