prehospital emergency care · •indications of a critical asthma patient. title: slide 1 author:...

PREHOSPITALEMERGENCY CARE

CHAPTER

Copyright © 2014, 2010, 2008 by Pearson Education, Inc.All Rights Reserved

Prehospital Emergency Care, 10th editionMistovich | Karren

TENTH EDITION

Part I Respiratory Emergencies

16



Learning Readiness

• EMS Education Standards, text p. 445



Learning ReadinessObjectives

• Please refer to page 445 of your text to view the objectives for this chapter.



Learning ReadinessKey Terms

• Please refer to page 446 of your text to view the key terms for this chapter.



Setting the Stage

• Overview of Lesson Topics

▪ Respiratory Anatomy, Physiology, and Pathophysiology

▪ Respiratory Distress

▪ Pathophysiology of Conditions that Cause Respiratory Distress



Case Study Introduction

EMTs Jake Pratt and and Paul Berg arrive at a residence to find 62-year-old Margaret Brown sitting at the kitchen table, leaning forward on her hands to breathe. They immediately note that she is a thin woman with a barrel-shaped chest who is using accessory muscles to breathe.

continued on next slide



Case Study Introduction

Despite an increased respiratory rate and increased work of breathing, Mrs. Brown's skin color is pink. Jake notices a portable oxygen concentrator, as well as a nebulizer, nearby.



Case Study

• What is your general impression of this patient so far?

• What additional information will help you complete your general impression?

• What immediate actions should the EMTs take while completing the primary assessment?



Introduction

• Respiratory distress is frightening, and potentially life threatening.

• You must be able to recognize signs and symptoms of respiratory distress and provide immediate intervention.



Anatomy, Physiology, and Pathophysiology

• The respiratory system consists of the:

▪ Upper airway

▪ Lower airway

▪ Lungs





• Characteristics of normal breathing

▪ Open airway

▪ Normal respiratory rate

▪ Normal rise and fall of the chest

▪ Normal respiratory rhythm

▪ Breath sounds are present bilaterally

▪ Normal chest expansion and relaxation

▪ No use of accessory muscles





• Characteristics of normal breathing

▪ Normal mental status

▪ Normal muscle tone

▪ Pulse oximetry >94%

▪ Normal skin condition





• Conditions that impair gas exchange

▪ Increased space between alveoli and pulmonary capillaries

▪ Lack of perfusion of the pulmonary system from the right heart

▪ Fluid, blood, or pus in the alveoli





• Many findings associated with respiratory distress are associated with the use of accessory muscles.





• Breath sounds

▪ Place your stethoscope on the patient's skin with the patient in a sitting position.

▪ Listen in each place for an inhalation and exhalation.

▪ Compare each location to its mirror location on the other side.




EMT SKILLS 16-1

Auscultating the Chest




Auscultate the anterior chest at the second intercostal space at each midclavicular line.




Auscultate the lateral chest at the fourth to fifth intercostal space at each midaxillary line.




Auscultate the posterior chest below the tip of the scapula on each midscapular line.





• Abnormal breath sounds

▪ Wheezing

▪ Rhonchi

▪ Crackles





• Wheezing

▪ High-pitched whistling sound

▪ Indicates bronchoconstriction

▪ May be present in asthma, emphysema, bronchitis, pneumonia, and heart failure





• Rhonchi

▪ Rattling sound

▪ Indicate mucus secretions in the larger airways in the lungs

▪ Heard in chronic bronchitis, emphysema, aspiration, and pneumonia





• Crackles

▪ Bubbling, crackling sounds associated with fluid in or around the alveoli

▪ Associated with pulmonary edema and pneumonia



Respiratory Distress

• Inadequate breathing leads to hypoxemia (SpO2 <94%).

• Hypoxemia leads to cardiovascular failure and hypoperfusion.

• Untreated, inadequate breathing leads to death.





• Common findings in respiratory distress

▪ Complaint of shortness of breath

▪ Restlessness

▪ Increased or decreased pulse rate

▪ Changes in breathing rate or depth

▪ Skin color changes






▪ Abnormal breathing, lung, or airway sounds

▪ Difficulty or inability to speak

▪ Muscle retractions

▪ Altered mental status

▪ Abdominal breathing






▪ Excessive coughing

▪ Tripod positioning

▪ Decrease in pulse oximetry





• Causes

▪ Narrowing of the bronchioles from inflammation, swelling, or bronchoconstriction

▪ Bronchodilators can provide relief.





• Causes

▪ Injuries to the head, neck, face, spine, chest, or abdomen

▪ Cardiac compromise

▪ Hyperventilation

▪ Abdominal conditions





• Causes

▪ Dysfunction of the respiratory system by:

• Mechanical disruption to the airway, lung, or chest wall

• Stimulation of receptors in the lungs

• Inadequate gas exchange related to a ventilation or perfusion disturbance





• Respiratory distress

▪ Adequate rate and tidal volume

▪ Patient is compensating.

▪ Administer oxygen to maintain an SpO2

of 94% or higher.

▪ Consider CPAP.





• Respiratory distress

▪ Rate, tidal volume, or both are inadequate.

▪ Assist ventilations with bag-valve-mask.

▪ Provide supplemental oxygen.

▪ May deteriorate to respiratory arrest





• Respiratory arrest

▪ Cessation of respiratory effort

▪ Leads to cardiac arrest in minutes

▪ Immediately intervene with bag-valve-mask ventilations and supplemental oxygen.



Pathophysiology of Conditions that Cause Respiratory Distress

• There are many causes of respiratory distress, but assessment and basic emergency care is the same.





• Obstructive pulmonary diseases

▪ Emphysema

▪ Chronic bronchitis

▪ Asthma





• Emphysema

▪ Destruction of alveolar walls and distention of alveoli

▪ Increased resistance to air flow

▪ Severe reduction in gas exchange

▪ Caused primarily by smoking




Emphysema and chronic bronchitis are chronic obstructive pulmonary diseases.





• Emphysema signs and symptoms

▪ Anxious

▪ Dyspneic

▪ Accessory muscle use

▪ Thin, barrel-chested appearance

▪ Coughing

▪ Prolonged exhalation






▪ Diminished breath sounds

▪ Wheezing and rhonchi

▪ Pursed-lip breathing

▪ Difficulty breathing with exertion

▪ Pink complexion






▪ Tachypnea

▪ Tachycardia

▪ Diaphoresis

▪ SpO2 >94% unless in respiratory failure

▪ Tripod position

▪ Home oxygen




Man suffering respiratory distress (indicated by tripod position) from obstructive lung disease.




CPAP or BiPAP may be used to improve oxygenation.





• Chronic bronchitis

▪ Affects bronchi and bronchioles

▪ Persistent productive cough

▪ Associated with smoking

▪ Narrowed bronchioles reduce airflow

▪ Reduced lung ventilation with increased lung perfusion





• Chronic bronchitis signs and symptoms

▪ Productive cough

▪ Overweight with edema and JVD

▪ Cyanotic complexion

▪ Minimal difficulty breathing and anxiety unless in respiratory failure





• Chronic bronchitis signs and symptoms

▪ SpO2 <94%

▪ Scattered rales and rhonchi

▪ Wheezes, crackles at bases of lungs

▪ Asterixis in respiratory failure





• COPD patients may develop a hypoxic drive as an adaptation to chronically increased CO2 levels.

• Prolonged administration of high-flow oxygen can suppress breathing.

• Do not withhold oxygen in prehospital care.





• COPD treatment

▪ Supplemental oxygen to maintain SpO2

of 94% or above

▪ Consider CPAP for severe respiratory distress.

▪ Monitor for signs of improvement or deterioration.



Case Study

Jake quickly notes the following as Paul applies oxygen by nasal cannula and begins asking Mrs. Brown's friend some questions. Mrs. Brown is in tripod position, using pursed-lip breathing. She is anxious, and is able to speak three to four words at a time. Her respiratory rate is 28, with adequate tidal volume.




Case Study

Auscultation reveals scattered wheezing and rhonchi throughout both lungs. Mrs. Brown's SpO2 is 94%. The friend states that Mrs. Brown has emphysema, and has been more short of breath than usual since early this morning.




Case Study

• Would you characterize Mrs. Brown's condition as respiratory distress, respiratory failure, or respiratory arrest?

• What treatments may be appropriate for Mrs. Brown?

• How should treatments be integrated with plans for transport?




• Asthma

▪ Increased sensitivity of lower airways leads to narrowing of the bronchioles and increased resistance to airflow.

• Bronchospasm

• Edema of the airways

• Increased mucus production




Conditions contributing to airflow resistance in asthma.





• Asthma signs and symptoms

▪ Dyspnea

▪ Cough

▪ Wheezing

▪ Tachypnea

▪ Tachycardia






▪ Use of accessory muscles

▪ Diaphoresis

▪ Anxiety and apprehension

▪ Difficulty speaking in sentences

▪ Fever






▪ Allergic signs

▪ Runny nose

▪ Chest tightness

▪ Inability to sleep

▪ SpO2 <94%






▪ Gastroesophageal reflux

▪ Pulsus paradoxus

▪ Reduced peak expiratory flow rate





• Indications of a critical asthma patient

▪ Upright position

▪ Severe respiratory distress

▪ Tachypnea

▪ Tachycardia

▪ Pulsus paradoxus






▪ Diaphoresis

▪ Accessory muscle use

▪ Speaks in single words or syllables

▪ Wheezing may be absent






▪ Decreasing consciousness

▪ Bradypnea

▪ Exhaustion

▪ SpO2 <90% with supplemental oxygen





• Emergency medical care for asthma

▪ Primary assessment interventions


of 94% or above

▪ Allow sufficient time for exhalation when providing positive pressure ventilation.

▪ Consider CPAP.

▪ Beta2 agonist





• Pneumonia

▪ Acute infectious disease of the lower respiratory tract

▪ Causes lung inflammation and fluid- or pus-filled alveoli

▪ Leads to a ventilation disturbance and poor gas exchange




Pathophysiology of pneumonia.





• Pneumonia signs and symptoms

▪ Malaise, decreased appetite

▪ Fever

▪ Cough

▪ Dyspnea

▪ Tachypnea and tachycardia






▪ Sharp, localized chest pain

▪ Decreased chest wall movement

▪ Splinting the thorax with arm

▪ Crackles, wheezing, rhonchi






▪ Altered mental status

▪ Diaphoresis

▪ Cyanosis

▪ SpO2 <94%





• Pneumonia treatment


of 94% or higher

▪ Follow protocols for use of beta2

agonists and CPAP.





• Pulmonary embolism

▪ Obstruction to blood flow in the pulmonary arteries

▪ Several factors increase the risk, including immobility

▪ Usually caused by a blood clot




A blood clot, air bubble, fat particle, foreign body, or amniotic fluid can cause an embolism, blocking blood flow through a pulmonary artery.





• Pulmonary embolism leads to cellular hypoxia by creating a lung perfusion disturbance.





• Pulmonary embolism signs and symptoms

▪ Sudden onset of unexplained dyspnea

▪ Signs of difficulty breathing

▪ Sharp, stabbing chest pain

▪ Cough

▪ Tachypnea






▪ Tachycardia

▪ Syncope

▪ Cool, moist skin

▪ Restlessness, anxiety, sense of doom

▪ Hypotension

▪ Cyanosis






▪ Distended neck veins

▪ Crackles

▪ Fever

▪ SpO2 <94%

▪ Signs of complete circulatory collapse



Click on the item that best characterizes emphysema.

A. Destruction of alveolar walls with distention of the alveoli

B. An obstruction to blood flow in the pulmonary arteries

C. Inflammation of the bronchi and bronchioles with increased mucus production

D. Sudden collapse of the lung without history of injury




• Acute pulmonary edema

▪ Often due to cardiac dysfunction

▪ Results in hypoxia

▪ Occurs when excessive fluid collects between the alveoli and pulmonary capillaries

▪ Gas exchange is impaired




Fluid that collects between the alveoli and capillaries, preventing normal exchange of oxygen and carbon dioxide. The fluid may also invade the alveolar sacs.





• Pulmonary edema signs and symptoms

▪ Dyspnea

▪ Orthopnea

▪ Frothy sputum

▪ Tachycardia

▪ Anxiety, combativeness, confusion






▪ Tripod position

▪ Fatigue

▪ Crackles, possibly wheezing

▪ Cyanosis

▪ Pale, moist skin






▪ Distended neck veins

▪ Swollen lower extremities

▪ Cough

▪ Cardiac compromise

▪ SpO2 <95%





• Pulmonary edema treatment

▪ Positive pressure ventilation may be necessary.

▪ CPAP may be beneficial.

▪ Administer oxygen.

▪ Keep the patient in an upright sitting position.





• Spontaneous pneumothorax

▪ Sudden rupture of visceral lining of lung with partial collapse of lung

▪ Gas exchange is impaired.

▪ Risk factors include smoking, connective tissue disorders, and COPD.




A ruptured bleb, or weakened area of lung tissue, causes a spontaneous pneumothorax in which air enters the pleural cavity and travels upward, beginning collapse of the lung from the top.





• Spontaneous pneumothorax signs and symptoms

▪ Sudden onset of shortness of breath

▪ Sudden sharp chest or shoulder pain

▪ Decreased breath sounds on one side

▪ Subcutaneous emphysema

▪ Tachypnea





• Spontaneous pneumothorax signs and symptoms

▪ Diaphoresis

▪ Pallor

▪ Cyanosis

▪ SpO2 <94%





• Spontaneous pneumothorax treatment

▪ If positive pressure ventilation is required, use the minimum tidal volume necessary.

▪ CPAP is contraindicated.





• Hyperventilation syndrome

▪ Associated emotional upset, excitation, and panic attacks

▪ Breathing is faster and deeper than normal.

▪ Carbon dioxide levels decrease.

▪ Muscle cramps may occur in feet and hands.





• Hyperventilation syndrome signs and symptoms

▪ Fatigue

▪ Nervousness, anxiety

▪ Dizziness

▪ Shortness of breath

▪ Chest tightness





• Hyperventilation syndrome signs and symptoms

▪ Numbness and tingling around the mouth, and in the hands and feet

▪ Tachypnea

▪ Tachycardia

▪ Spasms of fingers and feet

▪ Seizures, in patients with a seizure disorder





• Hyperventilation syndrome emergency medical care

▪ Calm the patient and get him to slow his breathing.

▪ Administer oxygen if the SpO2 is <94%.





• Epiglottitis

▪ Infection of the epiglottis leads to swelling that can obstruct the airway.




Pathophysiology of epiglottitis.





• Epiglottitis signs and symptoms

▪ History of upper respiratory infection

▪ Dyspnea

▪ Fever

▪ Sore throat

▪ Inability to swallow, drooling

▪ Anxiety





• Epiglottitis signs and symptoms

▪ Tripod position

▪ Fatigue

▪ Inspiratory stridor

▪ Cyanosis

▪ Difficulty or pain with speaking

▪ SpO2 <94%





• Epiglottitis emergency care

▪ Administer oxygen.

▪ Keep the patient calm and comfortable.

▪ Do not inspect the airway.

▪ If ventilation is required, squeeze the bag slowly.





• Pertussis

▪ Contagious disease characterized by uncontrollable coughing followed by a "whooping" sound

▪ Severe complications can lead to death.

▪ Preceded by signs and symptoms of upper respiratory infection.





• Cystic fibrosis

▪ Hereditary disease affecting lungs, digestive system, and sweat glands

▪ Death occurs in young adulthood, usually from pulmonary failure.

▪ Production of thick mucus leads to repeated respiratory infection.





• Poisonous exposure

▪ Inhalation of toxins leads to hypoxia by various mechanisms, including:

• Upper airway swelling

• Displacement of oxygen in the atmosphere

• Damage to the alveoli

• Effects on the body upon entering the bloodstream





• Poisonous exposure signs and symptoms

▪ History of inhalation injury

▪ Presence of chemicals on face

▪ Respiratory distress

▪ Cough, stridor, wheezing, crackles

▪ Oral or pharyngeal burns

▪ Dizziness, malaise





• Poisonous exposure signs and symptoms

▪ Headache, altered mental status

▪ Seizures

▪ Cyanosis

▪ Nausea, vomiting, abdominal pain

▪ Copious secretions

▪ Changes in vital signs





• Poisonous exposure emergency medical care

▪ Be aware of hazards to rescuers.

▪ Remove the patient from the exposure, if safe to do so.

▪ Manage the airway.

▪ Provide oxygen.

▪ Ventilate if necessary.





• Viral respiratory infections

▪ Includes colds, the flu, and bronchiolitis

▪ Usually mild, but significant infections can occur.

▪ Assess for and treat hypoxia and respiratory distress.



Case Study Conclusion

Paul locates Mrs. Brown's medications, finding that she has both metered-dose inhalers and medications for use in a small-volume nebulizer. Jake questions Mrs. Brown about her recent use of the medications to determine if she is eligible for additional treatment, as Paul consults a drug reference to confirm the nature of the medications.





Jake consults medical direction, and receives an order to administer medication from the metered-dose inhaler. As Jake assists Mrs. Brown with the medication, Paul completes baseline vital signs. They then assist Mrs. Brown to the stretcher and prepare for transport.





Jake reassesses Mrs. Brown en route to the hospital, noticing some decrease in wheezing and a respiratory rate of 24, with an SpO2 of 96% on 4 lpm of oxygen.



Lesson Summary

• Respiratory emergencies range from respiratory distress, to respiratory failure, to respiratory arrest.

• There are many causes of respiratory emergencies.




Lesson Summary

• No matter the underlying cause, respiratory emergencies have many signs and symptoms in common.

• EMTs must know when to administer oxygen and must recognize when to provide positive pressure ventilation.

prehospital emergency care · •indications of a critical asthma patient. title: slide 1 author:...

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