Home | Index | Next                         RESPIRATORY EMERGENCIES

 

INTRODUCTION

Optimal patient care requires that the EMT-I understand the pathophysiology and management of

respiratory emergencies.  The following topics will be discussed during this lesson:

 

·                      Pathophysiology of Common Respiratory Emergencies

 

·                      Field management of respiratory emergencies

 

·                      Patient transport decisions

 

 

LESSON OBJECTIVES

At the end of this lesson the participants will be able to:

 

1.                  Describe the pathophysiology, signs and symptoms, and field management of foreign

body obstruction.

 

2.         Discuss the pathophysiology, signs and symptoms, and field management of allergic        reactions.

 

3.         Describe the pathophysiology, signs and symptoms, and field management of asthma.

 

4.                  Discuss the pathophysiology, signs and symptoms, and field management of obstructive

            lung disease.

 

5.                  Describe the pathophysiology, signs and symptoms, and field management of congestive           

            heart failure/pulmonary edema.

 

6.                  Describe the pathophysiology, signs and symptoms, and field management of

spontaneous pneumothorax.

 

7.         Discuss the pathophysiology, signs and symptoms, and field management of pulmonary embolus.

 

8.         Describe the pathophysiology, signs and symptoms, and field management of pneumonia.

 

9.         Understand the transport decisions for respiratory emergencies.

 

SKILLS

 

Patient assisted inhalers

Patient assisted auto-injectors

 

KEY VOCABULARY

The following terms will be used during this lesson:

 

·        Anaphylaxis - an acute, generalized, and violent allergic reaction that can be rapidly fatal

 

·        Angioedema - swelling to face and mucous membranes

 

·        C.O.P.D. - abbreviation for “Chronic Obstructive Pulmonary Disease”.  Used for a group of commonly encountered lung diseases, including emphysema and chronic bronchitis

 

·        Hemoptysis: coughing up blood from the respiratory tree

 

·        Pleuritic: chest pain that worsens with respiration

 

KEY CONCEPTS

The following section provides information and space for taking notes on the key concepts discussed by the instructor.

 

FOREIGN BODY OBSTRUCTION

 

Pathophysiology

·          Any foreign material that enters the trachea has the potential to cause either a partial or complete airway obstruction. The foreign body may be from the victims own body (vomitus, teeth, mucous) or from an outside source (food, toys, balloons).

 

 

Signs/ Symptoms

·        Hand to throat (universal sign)

 

·        Coughing and stridor (partial obstruction)

 

·        Aphonia (complete obstruction)

 

·        Apnea (complete obstruction)

 

·        Tracheal indrawing

 

·        Altered level of consciousness (consider hypoxia)

 

 

 

Field Management

·        BLS procedures

·          High flow O2 by mask

·          Reassure the patient

·          Partial: encourage coughing, position of comfort, observation, transport

·          Complete:  abdominal thrusts until airway is open

·          Assist with ALS procedures

 

·        ALS procedures

·          Laryngoscopy to guide direct foreign body removal using the Magill Forceps

·          Advanced airway maneuvers as indicated

·          Venous access

·          Monitor

·          Rapid transport if unsuccessful in securing a patent airway

 

ALLERGIC REACTION

 

Pathophysiology

·          Overreaction of the immune system to a given stimulus

·          Immune system releases histamine causing arterioles and capillaries to dilate and increase permeability of the capillary membranes

·          Intravascular fluid leaks into the interstitial space causing decreased circulating blood volume.

·          Immune system response also leads to bronchoconstriction, with the potential for complete airway obstruction.

 

Signs/Symptoms

·          Hives, itching

 

·          Angioedema

 

·          Hypotension

 

·          Dyspnea, stridor, wheezing

 

·          Cough, sneezing

 

·          Rales

 

·          Nausea, vomiting, abdominal cramping or diarrhea

 

·          Altered level of consciousness

 

Field Management

·        BLS procedures

·          High flow O2 by mask

·          Assist with patients own auto-injector device

·          Position of comfort (shock position if hypotensive)

·          Assist with ALS procedures

 

·        ALS procedures

·          Advanced airway may be necessary to prevent airway obstruction due to edema

·          Venous access (large bore)

·          Monitor

·          Fluid challenge if hypotensive

·          Drug therapy

·          Epinephrine

·          Benadryl

·          Dopamine prn

·          Albuterol via hand held nebulizer for wheezing

·          Transport

 

 

Allergic Reactions vs. Anaphylaxis

 

                     Mild

                 Moderate

        Severe (Anaphylaxis)

Onset of symptoms 1 - 10 hrs after exposure

 

Hives, itching

 

Sneezing

Onset of symptoms 1 - 10 hrs after exposure

 

Hives, itching, angioedema

 

Mild to mod. respiratory involvement

 

Mild to mod. GI involvement

Onset of symptoms within 30 min.

 

Flushed skin

 

Severe respiratory involvement, i.e., laryngospasm, stridor, pulmonary edema, wheezing

 

Severe GI involvement

 

Syncope, shock, dysrhythmias

 

 anxiety, altered LOC, "feeling of impending            doom"

 

 

ASTHMA

 

Pathophysiology

·        A chronic inflammatory disorder of the airways.

·        Widespread, usually reversible, bronchospasm usually due to an allergy or irritant.  Environmental allergens are a major cause of inflammation.

·        The allergen causes a release of histamines which results in leakage of fluid from the peribronchiolar capillaries.

·        This fluid leads to bronchospasm and bronchial edema.

 

 

Signs and Symptoms

·        Dyspnea

 

·        Wheezing

 

·        Tachypnea

 

·        Diminished breath sounds

 

·        Nonproductive cough

 

·        Accessory muscle use

·        Hypoxia may lead to anxiety, agitation, and confusion

 

 

Field Management

·        BLS procedures

·          High flow O2 by mask

·          Position of Comfort

·          Assist patient with their own inhaler

·          Assist with ALS procedures

 

·        ALS procedures

·          Venous access

·          Monitor

·          Drug therapy

·          Albuterol via hand held nebulizer

·          Epinephrine if Albuterol is ineffective

·          Transport

 

OBSTRUCTIVE LUNG DISEASE (CHRONIC BRONCHITIS AND EMPHYSEMA)

 

Pathophysiology

Emphysema

·          Results from the destruction of the alveolar walls (usually associated with cigarette smoking).

·          Destruction of the alveoli reduces the area of gas exchange and the pulmonary capillary blood flow.

·          Chronic resistance to pulmonary blood flow results in Pulmonary hypertension and right heart failure

 

Chronic Bronchitis

·          Results from an increase in the number of mucous producing cells in the respiratory tree.

·          It is characterized by excessive mucous production.

·          Chronic obstruction results in hypoxia and CO2 retention.

·          Chronic retention of CO2 results in reduced pulmonary capillary blood flow, which eventually will lead to right heart failure.

 

Signs and Symptoms

·          Dyspnea

·          Cyanosis

·          Neck vein distension

·          Diminished breath sounds

·          Wheezing

·          Chronic productive cough

·          Accessory muscle use

·          Barrel shaped chest

·          “Pursed lip” breathing

·          Right Heart Failure is characterized by

·          neck vein distension

·          pedal edema

·          liver engorgement

 

Field Management

·        BLS procedures

·          Without distress

·          Low flow O2 at 2 L. per nasal cannula

·          With distress

·          High flow O2 per mask at 12 - 15 liters

·          Position of comfort

·          Assist patient with their own inhaler

·          Assist with ALS procedures

 

·        ALS procedures

·          Venous access

·          Monitor

·          Advanced airway management prn

·          Drug therapy

·           Albuterol by hand held nebulizer

·           Epinephrine if patient is severe

·           Transport

 

CONGESTIVE HEART FAILURE/PULMONARY EDEMA

 

Pathophysiology

·          Failure of the left ventricle to pump effectively.  Results in a back up of blood into the pulmonary system.

 

Signs and Symptoms

·        Dyspnea

 

·        Tachypnea

 

·        Orthopnea

 

·        Rales

 

·        Wheezes

 

·        Cough

 

·        Frothy, pink tinged sputum

 

·        Cool, pale, moist skin signs

 

·        Accessory muscle use

 

·        Anxiety, agitation, fatigue

 

·        May have chest pain or have had chest pain

 

Field Management

·        BLS procedures

·          High flow O2 by mask

·          Position of comfort (high fowlers - legs dependent)

·          Assist with ALS procedures

·        ALS procedures

·          Advance airway management if severe

·          Venous access (saline lock)

·          Monitor

·          Drug therapy

·          Nitroglycerin sublingual tablets or spray

·          Lasix 40-80 mg IVP

·          Morphine 4-10 mg IVP

·          Transport

 

SPONTANEOUS PNEUMOTHORAX

 

Pathophysiology

·          Spontaneous rupture of the lung allows air to enter the pleural space.  Air cannot escape from the enclosed pleural space.  More air is trapped in the pleural space with each inspiration, causing collapse of the lung on the affected side.

 

 

Signs and Symptoms

 

·        Dyspnea/Tachypnea

 

·        Decreased or absent lung sounds on the affected side

 

·        May progress to a tension pneumothorax

 

·        Cyanosis

 

·        Hypotension

 

·        Cool, moist skin

 

·        Anxiety

 

·        Confusion

 

·        Neck vein distension

 

·        Tracheal shift

 

·        Subcutaneous emphysema

 

·        Hyper-resonance on percussion

Field Management

·        BLS procedures

·          Reassurance

·          High flow O2 by mask

·          Position of Comfort (usually high fowlers)

·          Assist with ALS procedures

 

·        ALS procedures

·          Monitor

·          Venous access

·          Needle thoracostomy if signs and symptoms of tension pneumothorax

·          Transport

 

PULMONARY EMBOLUS

 

Pathophysiology

·          Sudden blockage of a pulmonary artery or one of its branches by a blood clot or other small particle. 

·          Risk factors associated with pulmonary embolus include

·          Prolonged bed rest

·          Thrombophlebitis

·          Atrial fibrillation

·          Oral contraceptives

·          Long bone fractures

 

Signs and Symptoms

·        Dyspnea/Tachypnea

 

·        Anxiety

 

·        Cyanosis

 

·        Hypotension

 

·        Hemoptysis

 

·        Pleuritic chest pain

 

·        Cough

 

·        Rales or wheezes

Field Management

·        BLS procedures

·          Reassurance

·          High flow O2 by mask

·          Position of Comfort (usually high fowlers)

·          Assist with ALS Procedures

 

·        ALS procedures

·          Venous access

·          Albuterol if wheezing

·          Advance airway prn

·          Transport

 

PNEUMONIA

 

Pathophysiology

·          A viral or bacterial infection affecting the lungs.  Pus and fluid from the inflammatory process accumulate in the lungs resulting in poor oxygenation.

 

Signs and Symptoms

 

·        Dyspnea/Tachypnea

 

·        Recent Upper Respiratory Infection

 

·        Fever/Chills

 

·        Pleuritic chest pain

 

·        Productive cough

 

·        Restlessness/confusion

 

Field Management

BLS Procedures

·          Position of Comfort

·          High flow O2 by mask

·          Assist with ALS procedures

 

ALS Procedures

·          Monitor/venous access

·          Albuterol if wheezing

·          Advance airway prn

·          Transport

INITIAL ASSESSMENT AND FOCUSED HISTORY AND DETAILED PHYSICAL

EXAMINATION  OF RESPIRATORY EMERGENCIES

 

1).  Assess environment:  (may need to manipulate the environment)

·        Safety of rescuers and environment

  • Environmental factors
    • Patient location (home, street, convalescent, etc.)
    • Weapons (may indicate trauma mechanism)
    • Medications (may offer clues to past medical history)
    • Witnesses (may help to explain circumstances)

 
 
 

 

 

 

 

 

 

 

 

 

 

2).  Airway  (determine responsiveness and patency of airway)

  • Introduce self to patient
  • Obtain patient’s name and age
  • Determine LOC:  day/time/place
  • Open the airway using the chin lift/head tilt or jaw thrust maneuver
  • Remove any obstruction
  • BLS Maneuvers until open airway is achieved
  • Patient may be altered or unconscious and unable to protect or maintain their airway
 
 

 

 

 

 

 

 

 

 

 

 

 

3).  Breathing:  assess rate, rhythm, and tidal volume

  • If the patient is not breathing, begin rescue breathing using mouth to mouth, mouth to mask, or bag-valve-mask
  • Is the breathing labored or unlabored

·        If labored, place the patient on oxygen

  • Assess the lung sounds of trauma patients during the initial assessment to detect tension pneumothorax
 
 

 

 

 

 

 

 

 

 

 

 

4).  Circulation:    

a).  Palpate for pulse noting: rate/rhythm/quality

b).  Control obvious bleeding

c).  Check capillary refill

·        Cyanosis-indicates a lack of oxygenated blood
 
 

 

 

 

 

 

 

 

5). Skin signs:  assess color, temperature and moisture

  • Pale, cool, moist skin and delayed capillary refill are due to peripheral vasoconstriction
  • If signs of poor perfusion, consider placing patient supine
 
 

 

 

 

 


                                                                                                                                               

6).  Assess neurological status:  assess level of consciousness                 

       (Glasgow Coma Score) and neuro deficits

  • Restlessness, agitation, and lethargy may be due to hypoxia and decreased cerebral perfusion.

 
 
 

 

 

 

 

 

 

GOLDEN RULE:     Noisy breathing is obstructed breathing
 
 

 

 


7).  Determine chief complaint
 
                                                      

 

 

Focused History and Detailed Physical Examination

1).  Elicit history of chief complaint or problem

·        Dyspnea:  does the patient feel short of breath?

·        Provoking factors:  what were they doing when this started?

·        Palliating factors:  what helps them feel better?

  • Have they had this in the past? When? What made it better?
  • How long has it been going on?
  • Any associated symptoms?  Chest pain?  Nausea?  Vomiting?
 
 

 


                                                                   

 

 

 

 

 

 

 

 

2).  Elicit personal history (HAM)

  • H   medical history/under a doctors care
  • A   allergies/age
  • M   medications-current over the counter and prescription                                              
 
 


                             

 

 

 

 

 

3). Vital Signs

  • Assess the rate, quality, and depth of respiration
  • Assess the rate, quality, and bilateral equality of pulses
  • Obtain base line blood pressure
 
 

 


                                 

 

                                                                                                                                                     

 

 

4). Special Questions

  • Ask questions specific to chief complaint
 
 

 

 

5).  Pertinent Body Check:

  • Medical:     perform body check pertinent to chief complaint
 
 

 

 

 

 

 

 

Head to Toe Examination:

  • Position:
    • Tripod position is typically assumed by patients that are short of breath.
  • Mental Status:

o       Anxiety, restlessness, and confusion are typically associated with hypoxia.

  • Lung Sounds:

o       Wheezes

o       Rales

o       Crackles

o       Rhonchi

o       Diminished breath sounds

o       Absent breath sounds

  • Other Signs and Symptoms of Respiratory Distress

o       Tachypnea:   is the patient obviously short of breath

o       Tachycardia: rapid heart rate may be a sign of tissue hypoxia

o       Cyanosis:      a sign of tissue hypoxia

o       Accessory muscle use:  a sign of increased work of breathing

o       Nasal flaring:  a sign of air hunger

Home | Index | Next