our agenda today
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“Sometimes a Wheeze is Not Just a Wheeze…” COPD and CHF Silver Cross EMS System February 2013 1 st Trimester CME. Our Agenda Today. Review airway anatomy and physiology Review the differences between COPD and CHF. Review use of CPAP and nitroglycerin in CHF and pulmonary edema. - PowerPoint PPT PresentationTRANSCRIPT
“Sometimes a Wheeze is Not Just a Wheeze…”
COPD and CHF
Silver Cross EMS SystemFebruary 2013 1st Trimester CME
Our Agenda Today
• Review airway anatomy and physiology• Review the differences between COPD and CHF.• Review use of CPAP and nitroglycerin in CHF
and pulmonary edema.• Take a look at some newer airway techniques
and gadgets on the market.• (ALS) EKG strip o’ the month: AV blocks/pacing
Quick A & P Review
Anatomy of the Upper Airway
Internal Anatomy of the Upper Airway
Anatomy of the Lower Airway
Anatomy of the Pediatric Airway
COPD vs. CHF
•One is respiratory•One is cardiac•They may seem the same, but their treatments are very different!
– Bronchitis– Emphysema– Asthma– Varying degrees/combination– Long-term tobacco abuse, exposure to inhaled
toxins
COPD
COPD - Bronchitis
–Mucus overproduction– Cell enlargement in lungs, airways– Productive cough 3+ months, 2+ years– Hypoventilation of alveoli, drops O2 level in blood
– Acidosis– Increased cardiac output, RBC production
Normal Lung Bronchitis
COPD - Emphysema– Involves alveoli– Alveolar destruction– Alveolar coalescence– Destruction of elastin fibers surrounding alveoli– Chronic hypoxia, hypercarbia
Emphysema
–Blebs on lung surface, possible pneumothorax–Polycythemia–Muscle wasting, malnourished appearance–Barrel chest
Emphysema
– Chronic dyspnea– Little/no cough, little mucus production– Tripod position–Mental status changes– Heart problems, cor pulmonale, ventricular failure
COPD-Asthma
–Bronchiole hyperstimulation, constriction–Wheezing, dyspnea–Mucus production
COPD
• Therapeutic interventions– Transport immediately
» Do all treatment en route if possible» IV option unless patient is near respiratory failure
– Albuterol (Ventolin) 2.5 mg via nebulizer (repeat x1)» Can give in-line via ET tube if necessary
– With medical control approval:» Epinephrine 1:1000 @ 0.01 mg/kg up to 0.3 mg IM (repeat in 15
min)» CPAP
– Consider Methylprednisolone (solu-medrol) 125 mg IVP.» No longer just for longer transports
Congestive Heart Failure - CHF
CHF
• Congestive heart failure can involve one side of the heart, or both.
Left Heart Failure• Left ventricle fails as an
effective forward pump• Causes backup of blood
into pulmonary circulation• Causes
– MI– Valvular disease– Chronic HTN– Dysrhythmias
• LV dysfunction– Causes LA pressure rise – Pulmonary HTN– PCP rises– Serum is forced into alveoli– Pulmonary Edema
LHF Signs & Symptoms• Severe Respiratory Distress– Orthopnea, dyspnea, spasmodic coughing, pink frothy
sputum– Paroxysmal Nocturnal Dyspnea (night time SOB)
• Severe Apprehension, Agitation and Confusion– Smothering feeling– As hypoxia worsens agitation
• Cyanosis• Diaphoresis
Prehospital Management of LHF
• Patients in LHF can decompensate rapidly• Goals– Decrease venous return to heart (preload)– Decrease myocardial oxygen demands– Improve ventilation and oxygenation
Prehospital management cont.
• CPAP!– Keeps more fluid from entering the alveoli– Forces those alveoli to exchange gases– In Region VII, ALS and BLS crews both can use
CPAP!• Nitroglycerin!– Vasodilates– Forces fluid out of alveoli further
Nitroglycerin
• One tablet or spray sublingual• Systolic blood pressure higher than 110
• May repeat x2 in 5 minutes.• If no IV, consider contacting medical control.
• Ask about ED drugs.
Continuous Positive Airway Pressure (CPAP)
What Is CPAP?
• CPAP is continuous positive airway pressure.• Designed to apply positive pressure to the
airways of a spontaneously breathing patient throughout the respiratory cycle.
• Airways are maintained in the open position during exhalation.
Goal of Therapy With CPAP?
• Goal– to increase amount of inspired oxygen and
decrease the work load of breathing– to reduce the need for emergent intubations of
the patient in pulmonary edema– to increase the oxygenation levels of the patient– to reduce mortality and decrease hospital length
of stay
Indications For Use of CPAP
• Patient with acute pulmonary edema/CHF• Alert, cooperative adult patient• Systolic blood pressure >90• No presence of nausea or vomiting• No major trauma• Patent airway• SaO2 <95
• Lung sounds - crackles
CPAP And Pulmonary Edema
Severe pulmonary edema is a frequent cause of respiratory failure
CPAP increases functional residual capacity CPAP increases transpulmonary pressure CPAP improves lung compliance CPAP improves arterial blood oxygenation CPAP redistributes extravascular lung water
When Not To Use Mask CPAP
Hypercapnia
Pneumothorax
Hypovolemia
Severe facial injuries
Patients at risk of vomiting
Common Complications With CPAP
Pressure sores Gastric distension Pulmonary barotrauma Reduced cardiac output Hypoventilation Fluid retention
Patient Monitoring During Use of CPAP
• Patient tolerance, mental status• Respiratory pattern – rate, depth, subjective feeling of improvement
• Lung sounds• B/P, pulse rate and quality, SaO2, EKG pattern
• Complications to monitor for:– gastric distention– nausea & vomiting
Criteria For Discontinuing Use of CPAP
• Emergent need to intubate the patient• Inability of the patient to tolerate the tight
fitting mask– success of tolerance to the treatment increased
with proper coaching by EMS crew
• Hemodynamic instability (B/P drops below 90 systolic)
More treatments if necessary…
• Albuterol if wheezing continues from co-morbid COPD– Make sure it’s wheezing, not crackles/rales– Albuterol can increase workload of heart
• Lasix/Morphine if medical control approves– Research showing these may not do what we
thought they always did
Right Heart Failure
• Right Ventricle fails as an effective forward pump• Results in backpressure of blood into systemic
venous circulation• Causes– The most common cause of right heart failure is left
heart failure– Systemic HTN
• Pulmonary HTN RV / RA enlargement– Pulmonary Emboli
• Causes pulmonary HTN
RHF Signs & Symptoms
• Tachycardia– Attempt to compensate
• Venous Congestion– Peripheral Edema
• Ankles in ambulatory pts• Presacral in bedridden
• Severe pitting edema
– JVD– Fluid accumulation in serous
cavities• Abdominal (ascites)• Pleural Space (effusion)• Pericardium (effusion)
– Liver engorgementHistory Prior MI / Chronic Pump Failure Lasix / Lanoxin
Prehospital Management of RHF
• Not usually emergent, unless accompanied by LHF• Limit IV fluids
A good time for a saline lock, if you have them.
• IMC• Treat signs and symptoms of respiratory distress
COPD vs. CHF
• COPD• Expiratory wheeze• Skinny w/barrel
chest• History of
asthma/emphasema/bronchitis
• Treat w/neb
•CHF•Crackles/rales•Retaining fluid•Blood-tinged sputum (pink puffers)•History of afib/heart failure/edema/•Treat w/CPAP, nitro
Some New Airway Procedures and Gadgets
• Wave-form capnography• Quick-trach• King vision laryngoscope
Using capnography in intubation…
Capnography
• Phase I– Beginning of exhalation when air from anatomic dead space being
exhaled– Baseline
Capnography
• Phase II– CO2 from larger bronchi begins to pass sensor
– Expiratory upslope– Sharp increase in CO2 concentration passing sensor, rapid departure
of waveform from baseline– Rapidly departs from Phase I, vertical line
Capnography
• Phase III– Alveolar plateau– CO2-rich alveolar air passing sensor
– Flat, straight/slightly angled upward
Capnography
• Phase 0– End of exhalation, beginning of inhalation– CO2 levels passing sensor quickly drop to 0
– Quick return of waveform to baseline– Straight line, rapidly returns to baseline
Approach to PatientNormal Capnogram
Important Points
• Capnography is a dynamic monitoring mechanism. – The therapeutic range for CO2 levels is 35-45.– It’s a positive/negative feedback system for how
resuscitation efforts are going.– Not just an initial tool for intubation
• Can hit record on monitors to chart CO2 levels.– If tube dislodged during transfer to ER bed, medics have
proof that tube was in trachea during transport.
Inline Capnography
Bottom Line
There are too many esophageal intubations in the field. If you have access to waveform capnography, use it!
A short video
• http://youtu.be/p4TkeCkBeHw
• This is made by Medtronics but is applicable information no matter what capnography/monitor combo you plan to use.
Colorimetric end-tidal COColorimetric end-tidal CO22 detector. detector.
Quick Trach
CricothyroidotomyIndications
• Upper airway obstruction which cannot be dislodged by back blows or direct larygoscopy and Magill forceps.
• Inability to insert an ETT past edema• Destructive facial injury precluding the use of
ALS upper airway adjuncts.
Anatomical Landmarksfor Cricothyroidotomy
Thyroid CartilageCricothyroid
Membrane
Cricoid Cartilage
Quicktrach
• More expensive than needle crichs, but really easy to use!
• Silver Cross EMS only allows the 4mm size, no pediatric Quicktrachs in this system.
Quicktrach
neck strap
syringe
stopper
hub of catheter
Picture courtesy Christ Medical Center
Quicktrach Procedure
• Patient supine with head slightly extended if no cervical spine trauma suspected
• Locate the cricothyroid membrane• Cleanse the overlying skin
Quicktrach Procedure cont’d• Puncture cricothyroid membrane at 90 degree angle• Aspirate air through syringe• Change the angle of insertion to 60 degrees• Slide catheter sheath forward to level of stopper• Remove stopper – may be a bit tight.• Advance plastic cannula while removing needle and
syringe
Quicktrach Procedure cont’d
• Ventilate the patient• Secure catheter in place using the strap provided• Confirm placement– Auscultation, bilateral chest rise and fall
King Vision Video Laryngoscope
From the brochure…
• Durable• The King Vision is designed to be your primary tool for intubations• The display comes with a 1-year warranty• The robust, full-color, non-glare display can resist repeated cleaning and normal use wear and tear• The camera and light source are enclosed in the disposable blade, keeping the display free of fragile optics
• Portable• The King Vision is light weight, self-contained and battery operated• Assembled, the device is water resistant• Reusable display comes packaged in a protective, foam case• Blades are individually packaged so that the King Vision can be taken anywhere
• Affordable• The disposable blades allow economical use of the King Vision for all of your intubations• Low cost per use procedure• High performance visualization capabilities
In the pyxis now…
• Silver Cross stocks unchanneled #3 King Vision video laryngoscope blades in the pyxis now.
• Not an endorsement of the product, just an accommodation for providers who use them.
• Good intubation techniques and practice still trump gadgets.
EKG Strip O’ the Month
• AV Blocks
Review - AV Junction
62
• AV Junction = AV Node and Bundle of His• Pacemaker cells located throughout AV
Junction
Review - Functions of AV Node
63
• Backup pacemaker for SA Node• Creates delay between atrial and ventricular
depolarizations• Physiologic block for rapid supraventricular
rhythms
Degrees of AV Blocks
64
• First Degree - Delay in conduction• Second Degree - Some impulses blocked• Third Degree - All impulses blocked
First Degree AV Block
65
• An abnormal slowing of AV Junction conduction
First Degree AV Block ECG Criteria
66
• Rate - Dependent on underlying rhythm– Interpretation must include underlying rhythm
• Rhythm - Dependent on underlying rhythm• P-Waves - Normal morphology with one P-
Wave for each QRS• PRI - > .20 seconds and constant• QRS - Dependent on underlying rhythm
First Degree AV Block Clinical Significance
67
• Not usually detrimental and often resolves when ischemia corrected
• Must consider entire patient
Second Degree AV Blocks
68
• Type I– Also called “Wenckebach”– Also called Mobitz I
• Type II– Also called Mobitz II
Second Degree AV Block, Type I
69
• Intermittent block in which AV conduction gradually slows until an impulse is blocked
• “Long, longer, longer, drop! Long, longer, longer, drop!”
Second Degree AV Block, Type I ECG Criteria
70
Rate - Atrial rate unaffected but ventricular rate is less than atrial rate
Rhythm - Atrial rhythm usually regular. Ventricular rhythm is irregular with more P-Waves than QRS Complexes.
P-Waves - Unaffected with more P-Waves than QRS Complexes
PRI - Progressively increases for consecutively conducted P-Waves until QRS Complex is dropped
QRS - Unaffected
Second Degree AV Block, Type I Etiology
71
• Often caused by increased parasympathetic tone or drug effect
• Can be caused by MI
Second Degree AV Block, Type I Clinical Significance
72
• Usually transient with good prognosis• Can reduce cardiac output due to bradycardia
Second Degree AV Block, Type II
73
• Intermittent block in which not all P-Waves are conducted to ventricles but there is no progressive prolongation of PRI
• “Extra” p-waves.
Second Degree AV Block, Type II Etiology
74
• Usually due to MI or other organic heart disease
• Rarely the result of increased parasympathetic tone or drug effect
Second Degree AV Block, Type II Clinical Significance
75
• Poorer prognosis than Type I• Usually requires pacemaker• Frequently develops into Complete Block
Second Degree AV Block, Type II ECG Criteria
76
Rate - Atrial rate is unaffected but ventricular rate is less than atrial
Rhythm - Atrial rhythm regular, Ventricular irregular with more P-waves than QRS Complexes
P-Waves - Normal morphology with more P-Waves than QRS Complexes
PRI - Constant for consecutively conducted P-Waves
QRS - Usually wide but may be narrow if block is at His level or above
Second Degree AV Block, Type II Example
77
Third Degree AV Block
78
• Complete blockage of impulse conduction through AV Junction
• Results in “AV dissociation” (very very bad thing)
• P’s and QRS’s “march to their own drummer”
AV Dissociation
79
• No relationship between P-waves and QRS complexes
Third Degree AV Block Etiology
80
• MI• Increased parasympathetic tone• Drug toxicity
Third Degree AV Block ECG Criteria
81
• Rate - Atrial > 60, Ventricular based on escape• Rhythm - Atrial and ventricular regular• P-Waves - Normal• PRI - No association between P-Waves and
QRS complexes (P’s and QRS’s are divorced and do their own thing)
• QRS - Narrow if intranodal, Wide if infranodal
Questions?
• Recording of this session will be sent out shortly.
• Please feel free to type questions in the text box to the right before we sign off.
• Or email questions to [email protected]• Thank you!