First: Notes to the ECRN

Changes have/are taking place this fall Advocate Condell became a Level I

trauma center eff October 1, 2009 Grayslake Emergency Center will begin

to take BLS ambulance patients effective November 1, 2009

This is the Lake Forest Hospital facility in Grayslake

All nurses need to be advised of these changes

Condell as Level I Trauma Center

Condell ECRN will be receiving calls from farther out departments

Region IX and Region X (Lake County’s Region) have similar criteria for Category I trauma

If a department or helicopter service is calling Condell, they have already decided we are the best destination for the patient Take report, get an ETA, activate the

Trauma Alert

Category I Trauma Patient

Any unstable patient and those meeting criteria as a Category I level trauma must be transported to the highest level Trauma Center within 25 minutes

Patients may be by-passing facilities to get to a higher level trauma center

Notes to the ECRN

Grayslake Emergency Center Formerly referred to as the Lake Forest

Acute Care Center Just west of the intersection of Routes

45 and 120 EMS may transport non-emergent

patients being treated with BLS procedures

Will NOT transport patients with IV, cardiac monitors, in labor, and others with anticipation of the need for admission

Notes to the ECRN Grayslake Emergency Center transport

EMS to call their respective Resource Hospital

Condell is the Resource Hospital for:CountrysideGrayslakeLake Forest FireLibertyvilleMundeleinRound Lake WaucondaMurphy

Note to the ECRN

EMS will alert Grayslake Emergency Center to monitor 400

Resource Hospital will take report on 400 and give orders, if needed, including approval for the transport destination requested

Report does not need to be called to the Grayslake Emergency Center Grayslake Emergency Center will be

monitoring the call

Notes to ECRN If EMS was unable to contact

Grayslake Emergency Center, they will advise the Resource Hospital

At that point in time, can determine who will call Grayslake Emergency Center with report The Resource Hospital will forward

report OR EMS will repeat the report

Just be clear who is forwarding report so it does get done

Note to the ECRN

Your function is as a liaison between the field personnel and the ED

Always think, “what is best for the patient?”

Obtain and record report received Ask for clarification, if necessary Obtain ETA

ECRN Responsibilities EMS has an SOP to follow EMS may still be calling Medical Control

for guidance (not all inclusive list) Minors with no parents available Emancipated minor

The girl under 18 that is pregnant is emancipated and after delivery, if she remains a parent, she remains emancipated

The person with alcohol on board Questionable release situations Psychiatric calls

Radio Etiquette Listen attentively Fill in the radio log as completely as possible Ask pertinent questions

Do you really need to know which leg is injured?

Respect field limitations Limited manpower Limited space to work in Driver needs to be focused on driving and is

not being used to communicate on the radio

This policy is now being followed by most departments

The ECRN and Medical Control

The ECRN can only give orders from the SOP’s

If orders above and beyond the SOP’s are necessary, the ED MD must order them

Before leaving the radio to ask the MD for orders, tell EMS to “stand-by” EMS may think you are not copying

their transmission if you do not acknowledge them

Clarifications for Specific Calls Blood glucose levels

EMS is required to obtain glucose levels in the following populations:

Known diabetic with diabetic related problem

Not appropriate for the hospital to order a glucose level just because the patient is a diabetic

Unconscious unknown reasons Any altered level of consciousness

Not all patients require a blood glucose level

Clarifications for Specific Calls

IV access Is it really necessary in the field? Consider the less than ideal environment

in the field for invasive maneuvers Indications IO access

Shock, arrest, or impending arrest Unconscious/unresponsive to verbal

stimuli 2 unsuccessful IV attempts or 90 second

duration

The Patient with Dyspnea

ECRN CE Packet Module II 2009Site Code: 107200-E-1209

Prepared by: Lt. William Hoover, Wauconda FireReviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P

Objectives

Upon successful completion of this module, the ECRN will be able to:

Identify the anatomy and physiology of the respiratory system including

The upper airway The lower airway

Identify clues which will assist in determining the severity of a patient’s respiratory distress.

Identify the components of the assessment of patients with dyspnea.

Objectives

Identify history and physical assessment to be obtained for patients with dyspnea.

Initial assessment SAMPLE history OPQRST Physical Assessment Auscultation of Lung Sounds 12 Lead EKG

Objectives Identify abnormal respiratory

patterns and adventitious breath sounds.

Cheyne-Stokes Kussmaul’s Agonal respirations Crackles Wheezes Rhonchi Snoring

Objectives

Identify the main causes of dyspnea: Upper airway obstruction Respiratory disease processes Cardiovascular diseases Neuromuscular diseases Other causes Psychogenic hyperventilation

Objectives

Identify treatment options for the main causes of dyspnea

Upper airway obstruction Respiratory disease processes Cardiovascular diseases Neuromuscular diseases Other causes Psychogenic hyperventilation

Identify complications of different treatments and procedures associated with dyspnea

Objectives

Identify the following medications and their EMS field use for patients with dyspnea

Albuterol Benadryl Benzocaine Epinephrine 1:1000 Lasix Versed

List assessment post intubation in both the adult and pediatric populations

Identify components of the regular Albuterol kit and EMS in-line procedure

Anatomy & Physiology of Upper Airway

Assists in heating, purifying, & moistening inhaled airNasal cavityOral cavityTongueUvulaEpiglottis – protects trachea

during swallowingVocal cords

Anatomy and Physiology Lower Airway

Trachea Right and left mainstem bronchi Bronchial tree Lungs Lobes Alveoli – the functional unit of the

respiratory system where gas exchange occurs

Upper Airway

Larynx joinsupper andlower airways

Lower Airway

Alveoli arethe functionalunits of therespiratorysystem and iswhere gasexchange takesplace

Difference With the Pediatric Airway

Fundamentally the same as an adult Size and positioning differences

Jaw smaller, tongue relatively larger

Epiglottis floppier and rounderLarynx more superior and anterior

(higher and more forward) in children

Pediatric Considerations

Anatomical differences between adults & children dictate the following: Oral airways slid in without turning

them – tongues are larger than adults Preferable to use straight blade due to

floppy pediatric tongue Before age 10, cricoid cartilage is the

narrowest part of the airway ETT are uncuffed

Determining the Severity of Respiratory Distress

Posture: Sitting up, leaning on arms (Tripod)

Unable to speak in complete sentences without pausing to catch breath

Breathlessness when at rest Imminent respiratory failure or arrest

indicated by bradycardia, bradypnea, agonal respirations or apnea

Tripod position – helps lungs expand

Pediatric Respiratory Distress

Patient exhibits increased work of breathing and the patient is using all resources to compensate for self Child alert, irritable, anxious, restless Increased respiratory effort Use of accessory muscles

Intercostal retractionsSeesaw respirations (abdominal

breathing)Strained neck muscles

Pediatric Respiratory Failure

Energy reserves exhausted Patient cannot maintain adequate

oxygenation and ventilation (breathing)Sleepy, less than alertIntermittently combative or agitatedBradycardic heart rate indicates

hypoxiaImmediate attention to airway and

ventilation rate to fix the bradycardia

Assessing Patients with Dyspnea

Primary Assessment (ABC’s) SAMPLE history OPQRST Physical Assessment Lung Sounds Minimally cardiac monitor; possibly 12

Lead EKG Pulse oximetry

Acceptable normal 95 – 99% Mild hypoxia 91 – 94% Severe hypoxia <91%

All Those Initials!!! ABC’s

Airway, breathing, circulation SAMPLE history

Signs and symptoms, allergies, meds, pertinent past history, last oral intake of fluids or solids, events leading to the incident

OPQRST of assessment Onset – what was pt doing at the time;

provocation/palliation; quality; radiation; severity on 0 – 10 scale; time of onset

Abnormal Respiratory Patterns Cheyne-Stokes

Indicates brainstem injury Progressively deeper, faster breathing

alternating with shallow, slower breathing

Kussmaul’s Commonly found in diabetic

ketoacidosis and can be seen in Aspirin (acetylsalicylic acid) overdose

Deep, slow, or rapid & gasping

Abnormal Patterns cont’d

Agonal Indicates brain anoxiaShallow, slow, or infrequent

breathing

Auscultating Lung Sounds Warm your stethoscope, have the

patient cough to clear their airway and then you’re ready to auscultate

The patient should take deep but easy breaths breathing in and out through their mouth

Auscultating Anterior Lung Sounds

Auscultating Posterior Lung Sounds Start at the top and

move your stethoscope from the right to the left comparing the sides as you walk your stethoscope methodically downward

Sounds are heard better when auscultated in the posterior fields directly over the skin

Abnormal Lung Sounds Crackles (rales)

Fine, bubbling sound heard on inspiration; indicates fluid in smaller airways

Wheezes Musical, squeaking, whistling sound heard

usually on inspiration & expiration; indicates bronchial constriction

Rhonchi Coarse, rattling noise on inspiration,

indicates inflammation, mucous, or fluid in bronchioles

Snoring Indicates partial upper airway obstruction

The patient with dyspnea:Causes Signs and SymptomsEMS Field Treatment Options

Upper Airway Obstruction Foreign body

Airway blocked; food most common culprit Infections – causes airway swelling

Croup – viral infection Epiglottitis – bacterial infection

Anaphylaxis – severe reaction to allergen Sudden onset after exposure (eating or injection

common) Laryngospasm – closure of glottic opening

May be triggered by infection or irritants Blood thinners (Coumadin, Plavix)

Spontaneous hematomas in soft tissue of neck

Foreign Body Obstruction

Esophageal foreign bodies can also present an airway challenge especially if the foreign body moves

Toe ring

Signs & Symptoms of Impaired Airway

Foreign body (FB) Sensation of a FB after eating

(food is the #1 cause of airway obstruction)

Stridor or wheezing respirations Infection (epiglottitis, croup)

Gradual onset Pain on swallowing, drooling Difficulty opening mouth Fever, cough, seal bark cough

Treatment Airway Obstruction Foreign body

Remove the object If patient can cough on own or rescuer needs to

apply the Heimlich or abdominal thrusts (back slaps and chest thrusts for infants)

May need to use blade and handle and retrieve object while using the magill forceps

Secure the airway if unable to relieve the blockage (Quick Trach)

Infections – Croup or epiglottits Prehospital supportive care Supplemental oxygen 6 ml normal saline in nebulizer kit Albuterol if patient is wheezing with croup

Signs & Symptoms of Impaired Airway Related to Anaphylaxis

Anaphylaxis Hives Rash that itches Wheezing Hypotension – unique to anaphylaxis Nausea Abdominal cramps Inability to urinate

Is quickly life-threatening

EMS Adult Anaphylaxis SOP

Anaphylaxis – patient unstable Altered mental status & B/P <100 systolic Support airway; intubate as necessary IV wide open (1000 ml normal saline) Epi: 1:1000 IM 0.5 mg Benadryl 50 mg IVP slowly over 2 min or IM If wheezing, Albuterol 2.5mg/3ml

May repeat If worsening, medical control contacted

Medical Control may order Epi 1:10,000 IV/IO

EMS Pediatric Anaphylaxis SOP

Anaphylaxis – patient unstable Altered mental status Epi 1:1000 IM 0.01 mg/kg (max 0.3 mg or 0.3 ml per

dose) May repeat every 15 minutes Benadryl 1mg/kg slow IVP; max 50 mg IV fluid challenge 20ml/kg

May repeat as needed to max of 60 ml/kg Albuterol 2.5mg/3ml

May repeat Albuterol treatment If worsening, medical control contacted

To consider Epinephrine 1:10,000 at 0.01 mg/kg IV/IO

Respiratory Diseases - Asthma

Bronchoconstriction Stimulants cause inflammatory

response Stimulants can include:

Allergens Weather changes Exercise Respiratory infections Foods/medications

Signs & Symptoms of Asthma

Cough Wheezes

Heard first at the end of exhalation Absent breath sounds = deadly implications Shortness of breath Chest tightness (not to be confused with chest

pain) Use of accessory muscles in severe cases Ask if the patient has ever needed intubation

These patients tend to deteriorate faster and need careful and close monitoring

EMS Asthma SOP

Attempt pulse oximetry reading before administration of oxygen

Assess & record VS, breath sounds, pulse oximetry before/during/after treatment

Oxygen by most appropriate route Albuterol 2.5 mg/3ml (O2 flow at 6 L)

Severe cases, treat while transporting

EMS Treatment of Severe Asthma

Patients with inadequate ventilations or oxygenation are at risk of not being able to continue to ventilate themselves and will need intubation

In-line Albuterol therapy provided to deliver medications to the lungs Albuterol can be delivered via BVM in-line

while preparing to intubate the patient Once intubation is accomplished, continue

to deliver Albuterol via the in-line method

Respiratory Diseases - COPD

Blanket term for diseases that impede the functioning of the lungs

Chronic Bronchitis Increased mucous production in the

bronchial tree Decreased gas exchange in the alveoli Irreversible airway obstruction

Emphysema Destruction of alveolar walls Loss of capacity for lungs to recoil Irreversible airway obstruction

COPD

Most COPD patients have elements of both chronic bronchitis and emphysema

Abnormal ventilation is a common feature Often the cilia lining the respiratory tract are

destroyed Common findings

Bronchospasm Some elements are reversible, some not

Inflammation of respiratory passages Air trapping distal to the obstruction

Desensitization to a chronic state of hypoxia Patients susceptible to repeat respiratory

infection

COPD vs. Healthy Lungs

Signs & Symptoms of COPD Chronic bronchitis

Chronic productive cough Tend to be obese with low blood oxygen levels

(referred to as blue bloaters) Wheezing, crackles, or rhonchi can all be

auscultated Rising carbon dioxide blood levels

Emphysema Typically thinner build with barrel chests Hyperventilating to maintain blood oxygen levels Color usually good (referred to as “pink puffers”) Lungs sounds seem very distant Use pursed lip breathing when exhaling

EMS Treatment of COPD with Wheezing

Albuterol treatment2.5 mg / 3 mlO2 flow rate at 6 l/min

Need to generate a mist to inhale and absorb the medication

May repeat albuterol as needed EMS may contact Medical Control to

obtain an order for CPAP in the symptomatic patient

Respiratory Diseases - Pneumonia Infection of lower respiratory tract Primarily a ventilation problem Can be bacterial or non-bacterial

Mycoplasma Chlamydia Viral Tuberculosis

Fluid and inflammatory cells collect in the alveoli

5th leading overall cause of death in the USA

Pneumonia

Signs & Symptoms of Pneumonia

Patients generally appearing ill and feel ill Shaking chills Fever Generalized weakness with gradual onset Pleuritic chest pain Shortness of breath with tachypnea Tachycardia Productive cough – yellow to brown

sputum Crackles in involved lung segment

May also hear wheezes and rhonchi

EMS Treatment of Pneumonia

Supportive care Supplemental oxygen Patient usually dehydrated and fluid

therapy is supportive Need to be accurate on diagnosis

Pneumonia needs fluid therapy CHF/Pulmonary edema needs fluid

restriction CPAP may help patient in severe cases

Aspiration – A Deadly Complication

Protection Against Aspiration

- Positioning – patient on their side if not contraindicated

- Suctioning turned on and ready to be used

- Cricoid pressure used during intubation attempts

- Intubate the patient that is unable to protect their own airway

Respiratory Disorders

Pneumothorax Abnormal collection of air in the pleural

space Spontaneous or traumatic

Pulmonary embolism Arterial blockage to pulmonary circulation Venous clots Embolism can also be from fat, bone

marrow, tumor fragments, amniotic fluid, or air bubbles

Toxic inhalation

Pneumothorax

Signs & Symptoms of Spontaneous Pneumothorax

Sudden sharp, pleuritic chest pain or shoulder pain

May occur after coughing Diminished lung sounds

May be difficult to distinguish in smaller sized lung collapse (<20%)

Young individuals with tall, thin body types are most susceptible

Tachypnea Diaphoresis Possible subcutaneous emphysema

EMS Treatment of Spontaneous Pneumothorax

Majority of spontaneous pneumothorax are not detected in the field – breath sounds not appreciated to be diminished

Care is supportive O2 via NRB mask Assist patient in sitting upright Monitor for change to tension

pneumothorax Tension pneumothorax needs needle

decompression

Pulmonary Embolism – Blood Flow Blocked

Signs and Symptoms of Pulmonary Embolism

Symptoms can be non-specific and vary depending on the site and size of obstruction

Sudden onset severe & unexplained dyspnea

Pleuritic chest pain may be present Cough, usually non-productive but

occasionally blood tinged Tachycardia & tachypnea In severe cases, confusion, hypoxia,

cyanosis, hypotension, death

EMS Treatment of Pulmonary Embolism

Supportive care Rapid transport High flow oxygen; possible

intubation Rapidly fatal once patient arrests Hospital treatment may include

anticoagulation or surgery to remove clot

Cardiovascular Diseases

CHF with acute pulmonary edema

Impaired pumping ability of the heart

Acute Myocardial Infarction Death of heart muscle

Signs & Symptoms of CHF/Acute Pulmonary Edema

Dyspnea at rest Unable to lie flat Crackles in lungs – heard initially in the bases Dependent edema – pedal edema in the

mobile patient JVD especially in the upright position Acute MI (AMI)

Dyspnea may be the initial symptom At times difficult to determine which came

first – AMI affecting function of the heart or hypoxia leading to AMI

CHF with Pulmonary Edema

EMS SOP Stable Pulmonary Edema B/P >100 mmHg

All therapies cause vasodilation and may drop the B/P – monitor B/P carefully

Nitroglycerin 0.4 mg SL (max 3 doses) Consider CPAP Lasix 40 mg IVP (80 mg if on Lasix at

home) Morphine 2 mg slow IVP; may repeat

every 2 minutes to max of 10 mg) If wheezing, Medical Control contacted

for Albuterol order

EMS Interventions For Pulmonary Edema

Nitroglycerin Used for its venodilation effects to pool blood away

from the heart CPAP

Prevents collapse of the alveoli; also lowers B/P Lasix –

Diuretic effect will take approximately 20 minutes but venodilation effect evident in the field to pool blood

Morphine Reduces anxiety level Also a venodilator and will pool blood away from the

heart

EMS SOP For Cardiac Complaints

At minimum consider EKG monitoring EMS to consider early 12 Lead EKG

Take 12 lead as soon as possible STEMI – ST elevation in 2 or more

contiguous leads (I, aVL, V5, V6; II, III, aVF; V1 – V6)

Cardiac Alert ED contacted early to decrease door to

balloon time Transmit 12 lead EKG to hospital

Abnormal rhythms treated

Neuromuscular Diseases

Muscular dystrophy Wasting disease of the muscles

Amyotrophic lateral sclerosis (ALS) Lou Gehrig’s disease Muscular dystrophy caused by

degeneration of motor neurons of the spinal cord

Guillain-Barre syndrome Myasthenia gravis

Guillain-Barre Syndrome

Signs & Symptoms of Neuromuscular Diseases

Amyotrophic Lateral Sclerosis (ALS) Chronic progressive wasting of muscles Difficulty swallowing and speaking Mental functions remain lucid

Guillian-Barre syndrome Weakness starting distally (hands/feet) moving

upward - “ascending” paralysis ending in temporary paralysis

Sensory loss or decreased reflexes Myasthenia Gravis

Weakness that improves with rest, worsens with activity

Crisis level can affect respiratory muscles

Treatment of Neuromuscular Disorders

Conscious sedation intubation if necessary If lung muscles do not work, we have to do

it for them Supportive care

May have to assist patient with BVM In chronic cases, these patients fatigue

easily These patients are prone to chronic

infection

Other Causes of Dyspnea

Anemia Inadequate hemoglobin in the

blood Unable to supply body’s oxygen

demands Hyperthyroid disease – increased

rate of metabolism Metabolic acidosis Psychogenic hyperventilation

Psychological causes

Treatment of Hyperventilation

Determine treatment based on situation Could be deadly to assume these

patients are hyperventilating and a “psych” patient

Do not have people “blow into a bag” Inappropriate to place an O2 mask on

patient and not connect it to oxygen!!! Use verbal counseling on patient to slow

their breathing down if possible

Additional EMS Field Treatment Options

Procedure for Adult Intubation Patient must be pre-oxygenated (100% O2) Equipment checked

Blade and handleStraight blade preferred for pediatric

patients due to floppy epiglottis and large sized tongue

Light is bright and tight ET tube and one back-up tube Stylet – adult or pediatric Syringe for adult ET tube cuff inflation Mechanism to secure tube in place (ie: tape,

commercial tube holder device)

Confirming ET Tube Placement

Max of 30 seconds for intubation attempt time Immediately after intubation, remove the style

to prevent delay in initiating ventilations As ventilations are begun, perform 5 point

auscultation Auscultate 1st over the epigastrium Then auscultate 4 points over the lungs

Observe bilateral rise & fall of the chest Ventilate 1 breath every 6 – 8 seconds

Inflate the adult cuff until no air leak heard Observe yellow coloring on ETCO2 device

Procedure for Pediatric Intubation

Steps nearly identical to the adult Straight blade preferable due to floppy

epiglottis and large sized tongue The pediatric ET tube up to and including

size 6 is uncuffedThe pediatric patient somewhat has

their own cuff effect anatomically due to the natural narrowing of the airway at the cricoid cartilage

Always watch for gentle chest rise and fall to dictate the amount of volume to use with the BVM

Respiratory Rates

BVM support to patient with a heart beat – rescue breathing Adults ventilate once every 5 - 6 sec Infant & child ventilate once every 3 - 5

seconds Once patient intubated, all patients

are ventilated once every 6 – 8 seconds

EMS SOP Conscious Sedation Intubation

Indications Failure to maintain adequate airway or for

risk of aspiration Actual or impending respiratory failure GCS <8 due to head injury Inability to ventilate/oxygenate patient

after insertion of airway and/or BVM Anticipated deterioration

EMS SOP Conscious Sedation Intubation

Contraindication Age less than 16

Need permission from Medical Control B/P < 100mmHg Known hypersensitivity or allergy to the

medication Consider risk vs benefit if the patient is

pregnant

EMS SOP Conscious Sedation Medications

Lidocaine 1.5 mg/kg IVP one time only If head injury/insult, used prophylactically to

decrease risk of cough reflex Coughing raises intrathoracic pressures which will

increase intracranial pressures Versed 5 mg IVP – relaxes/sedates patient

2 mg repeated every minute to relax and sedate patient (1 mg every 5 minutes post procedure to maintain sedation)

Total dose used is 15 mg including post-procedure Versed does not take away any painful stimulus

EMS SOP Conscious Sedation Medications

Morphine 2 mg IVP slow over 2 minutes – relaxes pt Repeated every 3 minutes to a max of

10 mg Benzocaine spray – eliminates gag reflex

Limited to 1-2 short sprays to posterior pharynx

Can stroke the eyelashes to determine presence of a gag reflex

The blink reflex disappears at the same time as the gag reflex

In-line Albuterol Kit

Albuterol can be delivered via BVM or through ET tube to be delivered into lungs

Kit prepared as usual but mouthpiece taken off

BVM placed where mouthpiece was Adaptor added to distal end of corrugated

tube in preparation to connect the adaptor to ET tube

Need to confirm ET tube placement in the usual manner

Can start to bag patient delivering Albuterol prior to ET tube placement

In-line Albuterol Kit

Mouthpiece taken off and replaced with BVM

Adaptor added to end of blue corrugated tubing and attached to mask (or ET tube)

Can begin to ventilate patient before intubation

CPAP Device for Pulmonary Edema

Oxygen started via non-rebreather mask while equipment being set up

Medications are administered simultaneously with CPAP

Medications used and CPAP can all cause a drop in blood pressure; monitor B/P carefully

CPAP will give time fort he medications to take effect

ED will usually call respiratory therapy when expecting a patient on CPAP Resp therapy to set up equipment for patient

CPAP Device

In under 5 minutes patients will feel better

Patients need psychological support to get over the suffocating feeling from the tight fitting mask

Advanced Airway Alternative - Combitube

Indications Arrested patient, unresponsive medical or

trauma patient with no gag reflex and ET tube placement cannot be achieved

Contraindications Age less than 16

This tube is a one size fits all so limited use in pediatric patients and short adults (less than 5 feet)

Gag reflex presentKnown esophageal disorder/caustic

ingestion

Combitube

Patient hyperventilated prior to insertion Equipment checked and prepared and

distal tip lubricated Device is inserted mid-line and to depth

of printed ring level with teeth Pharyngeal cuff inflated with 100 ml of air Distal cuff inflated with 15 ml of air

Combitube

Placement shown is in the esophagus

Proximal and distal balloons both get inflated

Combitube cont’d

Ventilations begin via tube #1 Placement confirmed

Observe gentle rise and fall of the chest wall Perform 5 point auscultation over the

epigastrium and bilaterally over the lungs If unable to confirm tube placement,

then attach BVM to tube #2 and ventilate Repeat confirmation steps

Secure device

Combitube in the ED

If patient arrives with combitube in place Use this advanced airway device until

adequate staffing and competence to change to an ETT

When ready to intubate the patient with ETT, deflate the combitube cuffs

Cuff balloons are marked with amount of air

Blue cuff balloon – 100 mlWhite cuff balloon – 15 ml

Case Scenario Review

Read the cases Treatment is based on the EMS

SOP’s Determine what your response

would be on the radio call Check your own answers with the

power point slides

Case Scenario #1

911 was called to the scene for a 72 year-old obese male with complaints of increased shortness of breath today and with fever

VS: B/P 152/94; P – 104; R – 26; SpO2 92%

Meds: Ventolin, Prednisone, Glucophage, Verapamil, Isordil, Hydrochlorathiazide

Observation: Patient’s color is dusky, slightly diaphoretic, cannot talk in complete sentences, productive cough

Case Scenario #1

What else needs to be done during the assessment phase?

History – is this problem old or new? What are the lung sounds? EKG monitor – possibly obtain a 12 lead

based on assessment findings Sputum is dark brown

Case Scenario #1 Patient found to have exacerbation of signs

and symptoms of COPD with wheezing; possibly a secondary lung infection

EMS Field treatment: Oxygen starting at 2-6 L/minute per nasal

cannula IV TKO – for access if necessary

Carefully monitor flow rate not to over hydrate Albuterol 2.5 mg/3ml attached to O2 at 6L flow

Reassess frequently watching for deterioration and hoping for improvement

Case Scenario #2

EMS arrived at the scene of a local fast food chain for a 3 year-old choking victim

Upon EMS arrival they noted a conscious patient who appears exhausted and is clutching at their throat, color is pale, and they had a weak cough

As EMS approached, the child looks at them with wide eyes and is trying to cough but was no longer making any sound

What is your assessment & what action plan should be started?

Case Scenario #2

Impression – partially obstructed airway that is now a completely obstructed airway If the patient can speak or cough, you are

to allow them to try to relieve the obstruction with coughing

In a conscious child, you perform the Heimlich maneuver (abdominal thrusts) until the patient is unconscious or the obstruction is relieved

Equipment to prepare and have on stand-by Intubation equipmentChild BVMMagill forceps

Case Scenario #2

If the patient has a history of asthma and is wheezing, short of breath, and has an increased respiratory rate, how do you tell the difference between an asthma attack and an obstructed airway?

Don’t let patient history steer you wrong

Assess the patient Asthma – bilateral wheezing, usually

identifiable trigger evident FB – wheezing on obstructed side, patient

usually eating or child playing with small objects at onset of incident

Case Scenario #3

EMS is called to the scene of 32 year-old female having an asthma attack

The episode started approximately 3 hours ago and the patient has used her inhaler with no success

Appearance: Anxious, pale, dry oral mucous membranes (mouth), unable to talk in complete sentences, appears exhausted, using accessory muscles

What is your impression? What else should be assessed? What treatment by EMS is appropriate?

Case Scenario #3

Initial impression – acute asthma attack Assessment to obtain

Lung sounds, pulse oximetry List of medications Verification of allergies EKG monitor to check rhythm

Treatment Set up the Albuterol kit Need to coach patient in her ear to talk her

through slowing down her breathing, then taking deeper breaths, and finally holding the deeper breath to get the medication into the lungs

Case Scenario #3

The patient is so exhausted, their level of consciousness is deteriorating and SpO2 is falling

EMS will prepare for in-line Albuterol administration and intubation

Upon ED arrival, continue administration of Albuterol until the dose is completedThe chamber will be empty of liquid

Case Scenario #4

911 was called to the scene for a 68 year-old male with sudden onset of difficulty breathing

Patient is sitting upright on a chair, leaning forward resting their arms on their thighs (tripod position)

Appearance Rapid respirations with noisy ventilations Cyanotic finger tips and pale, diaphoretic face Using accessory muscles

Your impression? Further assessment? EMS intervention?

Case Scenario #4 Further assessment to be obtained

History Allergies & medications Lung sounds

Bilateral crackles and wheezing Vital signs and SpO2 reading

B/P 180/110; P – 110; R- 32; SpO2 89% EKG monitor and 12 lead EKG

Atrial fibrillation; no ST elevation Impression

Acute pulmonary edema

Case Scenario #4

EMS interventions Is patient stable or unstable?

Stable – B/P 180/110 Medications to be given:

Nitroglycerin 0.4 mg slVasodilator

Lasix 40 mg IVP (80 mg if used at home)Morphine 2 mg IVP If wheezing, Albuterol needs to be requested

from Medical Control Device

CPAP – keep alveoli open

Bibliography

Campbell, J. Basic Trauma Life Support, 5th Edition, Brady. 2004

Dalton, Limmer, Mistovich, Werman. Advance Medical Life Support, 3rd Edition. Brady. 2007.

Region X Standard Operating Procedures, March 2007 Amended version May 1, 2008

Conscious Sedation (Page 7) Acute Pulmonary Edema (Page 19) Airway Obstruction (Page 22) Adult Allergic reaction/Anaphylactic Shock (Page 23) Asthma/COPD (Page 25) Pediatric Respiratory Failure (Page 53) Pediatric Acute Asthma (Page 55) Pediatric Airway Obstruction (Page 56) Croup/Epiglottitis (Page 64) Pediatric Allergic Reaction/Anaphylaxis (Page 70)

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