Condell Medical Center EMS System ECRN CE

Respiratory Emergencies: CHF, Pulmonary Edema, COPD, Asthma CPAP & Albuterol Nebulizer
Condell Medical Center EMS System ECRN CE Prepared by: Sharon Hopkins, RN, BSN, EMT-P

Objectives Upon successful completion of this program, the ECRN should be able to: review the signs and symptoms and field interventions for the patient presenting with CHF, pulmonary edema, COPD, and asthma. review criteria for the use of CPAP. review the SOP for Acute Pulmonary Edema, Asthma/COPD with Wheezing, and Conscious Sedation

Objectives cont’d review the Whisperflow patient circuit for CPAP used in the field. review the set up of the albuterol nebulizer kit and in-line Albuterol set-up. successfully complete the quiz with a score of 80% or better.

Heart Failure A clinical syndrome where the heart’s mechanical performance is compromised and the cardiac output cannot meet the demands of the body Considered a cardiac problem with great implications to the respiratory system Heart failure is generally divided into right heart failure and left heart failure

Heart Failure Etiologies are varied
valve problems, coronary disease, heart disease dysrhythmias can aggravate heart failure Variety of contributing factors to developing heart disease excess fluid or salt intake, fever (sepsis), history of hypertension, pulmonary embolism, excessive alcohol or drug usage

Left Side of the Heart High pressure system
Blood needs to be pumped to the entire body Left ventricular muscle needs to be significant in size to act as a strong pump Left sided failure results in backup of blood into the lungs

Right Side of the Heart Low pressure system
Blood needs to be pumped to the lungs right next to the heart Right ventricle is smaller than the left and does not need to be as developed Right sided failure results in back pressure of blood in the systemic venous system (the periphery)

Left Ventricular Heart Failure
Causes failure of effective forward pump back pressure of blood into pulmonary circulation heart disease MI valvular disease chronic hypertension dysrhythmias

Left Ventricular Failure
Pressure in left atrium rises increasing pressure is transmitted to the pulmonary veins and capillaries increasing pressure in the capillaries forces blood plasma into alveoli causing pulmonary edema increasing fluid in the alveoli decreases the lungs’ oxygenation capacity and increases patient hypoxia

As MI is a common cause of left ventricular failure:
Until proven otherwise, assume all patients exhibiting signs and symptoms of pulmonary edema are also experiencing an acute MI

Right Ventricular Heart Failure
Causes failure of the right ventricle to work as an effective forward pump back pressure of blood into the systemic venous circulation causes venous congestion most common cause is left ventricular failure systemic hypertension pulmonary embolism

Congestive Heart Failure
A condition where the heart’s reduced stroke volume causes an overload of fluid in the body’s other tissues Can present as edema pulmonary peripheral sacral ascites (peritoneal edema)

Compensatory Measures - Starling’s Law
The more the myocardium is stretched, the greater the force of contraction and the greater the cardiac output The greater the preload (amount of blood returning to the heart), the farther the myocardial muscle stretches, the more forceful the cardiac contraction After time or with too much resistance the heart has to pump against, the compensation methods fail to work

Acute Congestive Heart Failure
Often presents as: Pulmonary edema Pulmonary hypertension Myocardial infarction

Chronic Congestive Heart Failure
Often presents as: Cardiomegaly - enlargement of the heart Left ventricular failure Right ventricular failure

Patient Assessment Field & ED
Initial assessment airway breathing circulation disability AVPU (alert, responds to verbal, responds to pain, unresponsive) GCS expose to finish examining

Priority patients identified Additional assessment
vital signs, pain scale determine weight room air pulse ox, if possible, and oxygen PRN cardiac monitor; 12 lead ECG if applicable 0.9 NS IV established TKO determine blood glucose if indicated unconscious, altered level of consciousness, known diabetic with diabetic related call reassess initial assessment findings and interventions started

Closest Appropriate Hospital
Hospital of patient’s choice within the Fire Department’s transport area The patient who is alert and oriented has the right to request their hospital of choice EMS can have the patient sign the release for transport to a farther hospital If EMS does not feel comfortable transporting farther away, EMS can communicate this to the patient to get the point across in a diplomatic manner (ie: “I’m very concerned about your condition and I would feel more comfortable taking you to the closest hospital”)

Refusals A conscious and alert patient has the right to refuse care and/or transportation A refusal, though, with a patient in CHF might prove devastating worsening of signs and symptoms increased and unnecessary myocardial damage severe pulmonary edema death Avoid refusals in these patients at all costs EMS to thoroughly document the efforts taken to encourage transportation

Signs and Symptoms CHF Progressive or acute shortness of breath
Labored breathing especially during exertion (ie: standing up, walking a few steps) Awakened from sleep with shortness of breath (paroxysmal nocturnal dyspnea) increasing episodes usually indicate the disease is worsening Positioning tripod - resting arms on thighs, leaning forward inability to recline in bed without multiple pillows using more pillows to be comfortable in bed

Changes in skin parameters
pale, diaphoretic, cyanotic mottling present in severe CHF Increasing edema or weight gain over a short time early edema in most dependent parts of the body first (ie: feet, presacral area) Generalized weakness Mild chest pain or pressure Elevated blood pressure sometimes to compensate for decreased cardiac output

Typical home medication profile
diuretic - to remove excess fluids hypertension medications - to treat a typical co-morbid factor digoxin - to increase the contractile strength of the heart oxygen Worst of the worst complications - pulmonary edema

Progression of Acute CHF
Left ventricle fails as a forward pump Pulmonary venous pressure rises Fluid is forced from the pulmonary capillaries into the interstitial spaces between the capillaries and the alveoli Fluid will eventually enter & fill the alveoli Pulmonary gas exchange is decreased leading to hypoxemia ( oxygen in blood) & hypercarbia ( carbon dioxide in blood)

Progression of CHF cont’d
Hypercarbia ( carbon dioxide retained in the blood) can cause CNS depression slowing of the respiratory drive slowing of the respiratory rate

Wheezes heard in any geriatric patient should be considered pulmonary edema until proven otherwise (especially in the absence of any history of COPD or asthma)

Progression of Pulmonary Edema
Untreated, leads to respiratory failure Oxygen exchange inhibited due to excess serum fluid in alveoli hypoxia  death Presentation tachypnea abnormal breath sounds crackles (rales) at both bases rhonchi - fluid in larger airways of the lungs wheezing - lungs’ protective mechanisms bronchioles constrict to keep additional fluid from entering the airway

Acute Pulmonary Edema Region X SOP
Routine medical care patient assessment IV-O2-monitor cautiously monitor IV fluid flow rates Place patient in position of comfort often patient will choose to sit upright dangle the feet off the cart to promote venous pooling Determine if the patient is stable or unstable evaluate mental status, skin parameters, and blood pressure

Stable Acute Pulmonary Edema
Region X SOP Patient alert Skin warm & dry Systolic B/P > 100 mmHg Nitroglycerin 0.4 mg sl - maximum 3 doses Consider CPAP Lasix 40 mg IVP (80 mg if already taking) If systolic B/P remains >100 mm Hg give Morphine Sulfate 2 mg IVP slowly If wheezing, obtain order from Medical Control for Albuterol nebulizer

Pulmonary Edema Medications Used in Region X SOP
Nitroglycerin venodilator; reduces cardiac workload and dilates coronary vessels do not use in the presence of hypotension or if Viagra or Viagra-type drug has been taken in the past 24 hours (may get resistant hypotension) can repeat the drug (0.4 mg sl) every 5 minutes up to 3 doses total if blood pressure remains > 100 mmHg onset minutes sl (mouth needs to be moist for the tablet to dissolve & be absorbed)

Lasix® (Furosemide) diuretic; causes venous dilation which decreases venous return to the heart avoid in sulfa allergies & in the presence of hypotension dose 40 mg IVP 80 mg IVP if the patient is taking the drug at home vascular effect onset within 5 minutes; diuretic effects within minutes

Morphine sulfate narcotic analgesic (opioid)
causes CNS depression; causes euphoria increases venous capacity and decreases venous return to the heart by dilating blood vessels used to decrease anxiety and to decrease venous return to the heart in pulmonary edema give 2 mg slow IVP; titrate to response and vital signs and give 2 mg every 2 minutes to a maximum of 10 mg IVP effects could be increased in the presence of other depressant drugs (ie: alcohol)

Albuterol bronchodilator reverses bronchospasm associated with COPD
dose is 2.5 mg in 3 ml solution administered in the nebulizer the patient may be aware of tachycardia and tremors following a dose Albuterol must be ordered by Medical Control for the acute pulmonary edema patient

Using CPAP With Medications
Medications and CPAP are to be administered simultaneously The use of CPAP buys time for the medications to exert their effect CPAP and medications used (Nitroglycerin, Lasix, and Morphine) can all cause a drop in blood pressure CPAP and medications must be discontinued if the blood pressure falls < 100 mmHg

Case Scenario #1 A 68 year-old female calls 911 due to severe respiratory distress which suddenly woke her up from sleep. She is unable to speak in complete sentences and is using accessory muscles to breathe. Lips and nail beds are cyanotic; ankles are swollen. B/P 186/100; P - 124; R - 34; SaO2 - 88% Crackles are auscultated in the lower half of the lung fields.

Case Scenario #1 History: angina and hypertension; smokes 1 pack per day for the past 30 years Meds: Cardizem, nitroglycerin PRN; 1 baby aspirin daily; furosemide, Atrovent inhaler as needed Rhythm:

Case Scenario #1 What is your impression?
What intervention(s) are appropriate following Region X SOP’s? What is the rationale for these interventions? What is this patient’s rhythm and do you need to administer any medications for the rhythm?

Case Scenario #1 Impression: congestive heart failure with pulmonary edema paroxysmal nocturnal dyspnea (sudden shortness of breath at night) bilateral crackles in the lungs peripheral edema cardiac history - hypertension and angina Rhythm - sinus tachycardia do not treat this rhythm with medication determine and treat the underlying cause

Case Scenario #1 Interventions
Sit the patient upright, have their feet dangle off the sides of the cart promotes venous pooling of blood and decreases the volume of return to the heart Oxygen via non-rebreather face mask Prepare to assist breathing via BVM have BVM reached out and ready for use IV-O2-monitor Meds: NTG, Lasix, Morphine, consider CPAP

Unstable Acute Pulmonary Edema
Region x SOP Altered mental status Systolic B/P < 100 mmHg EMS to contact Medical Control medications given in the stable patient are now contraindicated due to a lowered blood pressure CPAP on orders of Medical Control (MD order) Consider Cardiogenic Shock protocol Treat dysrhythmia as they are presented EMS to contact Medical Control for Albuterol if wheezing; possibly in-line with intubation

Continuous Positive Airway Pressure CPAP
A means of providing high flow, low pressure oxygenation to the patient in pulmonary edema

CPAP CPAP, if applied early enough, is an effective way to treat pulmonary edema and a means to prevent the need to intubate the patient CPAP increases the airway pressures allowing for better gas diffusion & for reexpansion of collapsed alveoli CPAP allows the refilling of collapsed, airless alveoli CPAP allows/buys time for administered medications to be able to work

CPAP expands the surface area of the collapsed alveoli allowing more surface area to be in contact with capillaries for gas exchange Before CPAP With CPAP

The patient is assisted into an upright position
CPAP is applied during the entire respiratory cycle (inhalation & exhalation) via a tight fitting mask applied over the nose and mouth The patient is assisted into an upright position The lowest possible pressure should be used the higher the pressure, the risk of barotrauma (pneumothorax, pneumomediastinum) rises increased pressures in the chest decrease ventricular filling worsening cardiac output (less coming into the heart, less going out of the heart)

Goal of Therapy With CPAP
Increase the amount of inspired oxygen Decrease the work load of breathing In turn to: Decrease the need for intubation Decrease the hospital stay Decrease the mortality rate

Region X SOP Indications & Criteria for CPAP Use
Patient identified with signs & symptoms of pulmonary edema or, in consultation with Medical Control, exacerbation of COPD with wheezing Patient must be alert & cooperative Systolic B/P >100 mmHg No presence of nausea or vomiting; absence of facial or chest trauma

Patient Monitoring During CPAP Use
Patient tolerance; mental status Respiratory pattern rate, depth, subjective feeling of improvement B/P, pulse rate & quality, SaO2, EKG pattern Indications the patient is improving (can be noted in as little as 5 minutes after beginning) reduced effort & work of breathing increased ease in speaking slowing of respiratory and pulse rates increased SaO2

Discontinuation of CPAP
Hemodynamic instability B/P drops below 100 mmHg The positive pressures exerted during the use of CPAP can negatively affect the return of blood flow to the heart Inability of the patient to tolerate the tight fitting mask Emergent need to intubate the patient

CPAP Patient Circuits Complete package used in the field (and similar to in-hospital use) includes mask tubing head strap Whisperflow CPAP valve corrugated tubing air entrapment filter

Patient Circuit

Case Scenario #2 EMS has initiated CPAP and simultaneous medication administration (NTG, Lasix and Morphine) to a 76 year-old patient who EMS has assessed to be in acute pulmonary edema The patient begins to lose consciousness and the blood pressure has fallen to 86/60. What is the appropriate response for EMS to take?

Case Scenario #2 This patient is showing signs of deterioration
The CPAP needs to be discontinued No further medications (NTG, Lasix, Morphine) can be administered due to the lowered B/P Prepare to intubate the patient following the Conscious Sedation SOP support ventilations with BVM prior to intubation attempt

COPD Chronic obstructive pulmonary disease - a progressive and debilitating collection of diseases with airflow obstruction and abnormal ventilation with irreversible components (emphysema & chronic bronchitis) Exacerbation of COPD is an increase in symptoms with worsening of the patient’s condition due to hypoxia that deprives tissue of oxygen and hypercapnia (retention of CO2) that causes an acid-base imbalance

Obstructive Lung Disease - COPD & Asthma
Abnormal ventilation usually from obstruction in the bronchioles Common changes noted in the airways bronchospasm - smooth muscle contraction increased mucous production lining the respiratory tree destruction of the cilia lining resulting in poor clearance of excess mucus inflammation of bronchial passages resulting in accumulation of fluid and inflammatory cells

The Ventilation Process
Normal inspiration - the working phase bronchioles naturally dilate Normal exhalation - the relaxation phase bronchioles constrict Exhalation with obstructive airway disease exhalation is a laborous process and not efficient or effective air trapping occurs due to bronchospasm, increased mucous production, and inflammation

Emphysema Gradual destruction of the alveolar walls distal to the terminal bronchioles Less area available for gas exchange Small bronchiole walls weaken, lungs cannot recoil as efficiently, air is trapped  in number of pulmonary capillaries which  resistance to pulmonary blood flow which leads to pulmonary hypertension may lead to right heart failure & cor pulmonale (disease of the heart because of diseased lungs)

Alveolar Sac and Capillaries
Bronchioles capillary alveolus Interior of alveolus

Emphysema  in PaO2 leads to  in red blood cell production (to carry more oxygen) Develop chronically elevated PaCO2 from retained carbon dioxide Loss of elasticity/recoil; alveoli dilated More common in men; major contributing factor is cigarette smoking; another contributing factor is environmental exposures Patients more susceptible to acute respiratory infections and cardiac dysrhythmias

Assessment of Emphysema
“Pink puffer” - due to excess red blood cells Recent weight loss; thin bodied Increased dyspnea on exertion Progressive limitation of physical activity Barrel chest (increased chest diameter) Prolonged expiratory phase (usually pursed lip breathing noted on exhalation) Rapid resting respiratory rate Clubbing of fingers

Diminished breath sounds Use of accessory muscles
One-to-two word dyspnea Wheezes and rhonchi depending on amount of obstruction to air flow May have signs & symptoms of right heart failure jugular vein distention peripheral edema liver congestion

Case Scenario #3 The patient is a conscious, restless, and anxious 68 year-old male with respiratory distress that has progressively worsened during the past 2 days. The patient has cyanosis of the lips and nail beds B/P 138/70; P & irregular; R - 26; SaO2 82% Rhonchi and rales are auscultated in the lower right lung field; patient feels warm to the touch The patient has had a cold for 1 week with a productive cough of yellow-green sputum Hx: emphysema, angina, osteoarthritis

Case Scenario Case Scenario #3 What is this patient’s rhythm?
What influence would this rhythm have on this patient’s health history & current condition? Do you need to intervene? Atrial fibrillation diminishes the efficiency of the pumping of the heart which can further compromise the cardiac output

Case Scenario #3 Impression & intervention?
The patient has COPD most likely complicated by pneumonia a “cold” over the last week productive cough of yellow-green sputum warm to the touch (temperature F) rhonchi & rales in the right lung field base Routine medical care for EMS to follow supplemental oxygen  heart rate most likely due to pneumonia and does not need specific treatment

Chronic Bronchitis An increase in the number of mucous-secreting cells in the respiratory tree Large production of sputum with productive cough Diffusion remains normal because alveoli not severely affected Gas exchange decreased due to lowered alveolar ventilation which creates hypoxia and hypercarbia

Assessment of Chronic Bronchitis
“Blue bloater” - tends to be cyanotic Tends to be overweight Breath sounds reveal rhonchi (course gurgling sound) due to blockage of large airways with mucous plugs Signs & symptoms of right heart failure jugular vein distention ankle edema liver congestion

Drive to Breath & COPD Normal driving force to breathe
decreased oxygen (O2) level increased carbon dioxide (CO2) level Chemoreceptors sense: too little O2 ( resp rate to improve) or too much CO2 ( resp rate to blow off more CO2) Patients with COPD have retained excess CO2 for so long that their chemoreceptors are no longer sensitive to the elevated CO2 levels COPD patients breathe to pull in O2

O2 Administration & COPD
Never withhold oxygen therapy from a patient who clinically needs it Monitor all patients receiving O2 but especially the patient with COPD Normal O2 sat for COPD patient is around 90% If the patient with COPD is supplied all the oxygen they need, this might trigger them not to work at breathing anymore and may result in hypoventilation and/or respiratory arrest

Asthma Chronic inflammatory disorder of the airways
Airflow obstruction and hyperresponsiveness are often reversible with treatment Triggers vary from individual environmental allergens cold air; other irritants exercise; stress food; certain medications

Asthma’s Two-Phase Reaction
Phase one - within minutes Release of chemical mediators (ie: histamine) contraction of bronchial smooth muscle (bronchoconstriction) leakage of fluid from bronchial capillaries (bronchial edema) Phase two - in 6-8 hours Inflammation of the bronchioles from invasion of the mucosa of the respiratory tract from the immune system cells additional swelling & edema of bronchioles

Assessment of Asthma Presentation Dyspnea
Wheezing - initially heard at end of exhalation Cough - unproductive, persistent may be the only presenting symptom Hyperinflation of chest - trapped air Tachypnea - an early warning sign of a respiratory problem Use of accessory muscles

Severe Asthma Attack One and two word dyspnea Tachycardia
Decreased oxygen saturation on pulse oximetry Agitation & anxiety with increasing hypoxia

Obtaining a History Very helpful in forming an accurate impression
Will have a history of asthma Home medications indicate asthma A prior history of hospitalization with intubation makes this a high-risk patient for significant deterioration Note: unilateral wheezing is more likely an aspirated foreign body or a pneumothorax than an asthma attack

Treatment Goals - COPD & Asthma
Relieve and correct hypoxia Reverse any bronchospasm or bronchoconstriction

Asthma/COPD with Wheezing SOP
Routine medical care Pulse oximetry (on room air if possible) Albuterol 2.5 mg / 3ml with oxygen adjusted to 6 l/minute May repeat Albuterol treatments if needed May need to consider intubation with in-line administration of Albuterol based on the patient’s condition EMS to contact Medical Control for possible CPAP in patient with COPD

Albuterol Nebulizer Procedure
Medication is added to the chamber which must be kept upright The T-piece is assembled over the chamber The patient needs to be coached to breath slowly and as deeply as possible this will take time and several breathes before the patient can slow down and start breathing deeper; the patient needs a good coach to talk them through the slower/deeper breathing the medication needs to be inhaled into the lungs to be effective the patient should be sitting upright

Add medication to the chamber

Connect the mouthpiece to the T-piece

Connect the corrugated tubing to the T-piece
Kit connected to oxygen and run at 6 l/minute (enough to create a mist)

Encourage slow, deep breathing

Albuterol Nebulizer Mask
For the patient who is unable to keep their lips sealed around the mouthpiece, take the top T-piece off the kit and replace with an adult or pediatric nebulizer mask

Pediatric patient using nebulizer mask
Pediatric patient using nebulizer mask. Caregiver may assist in holding the mask.

Case Scenario #4 7 year-old with history of asthma has sudden onset of difficulty breathing and wheezing while playing outside Patient has an increased respiratory rate and is using accessory muscles B/P - 108/70; P - 90; R - 24; SaO2 - 97% Upon auscultation, left lung is clear and wheezing is present on the right side Impression and intervention?

Case Scenario #4 Sounds like asthma, looks like asthma, has a history of asthma but why should you not suspect asthma? Asthma is not a selective disease - the patient will have widespread, not localized, bronchoconstriction and have bilateral wheezing, not unilateral Dig into the history more - what was the patient doing prior to the development of symptoms?

Case Scenario #4 This patient was playing with friends, running around while eating food Possibly aspirated a foreign body sudden onset of unilateral wheezing Albuterol would not be indicated in this situation Supplemental oxygen if indicated, position of comfort, reassessment watching for increase in airway obstruction

What To Do in Extreme Asthma Attack
At times, the asthma attack is so severe the patient is at risk of dying To relieve the bronchoconstriction, Albuterol needs to be delivered right into the lungs To assist with this, the patient may need to be bagged or intubated to deliver the medication Abuterol is delivered via in-line technique

Aerosol Medication via BVM or ETT with BVM (In-line)
Albuterol placed in the chamber as usual The chamber is connected to the T-piece Adaptor(s) are used to accommodate bagging the patient with in-line Albuterol as soon as possible any medication that can be delivered as soon as possible to the target organ (the lungs) will be helpful in promoting bronchodilation

Mouthpiece removed from T-piece and replaced with BVM
Nebulizer still connected to oxygen source Adaptor placed at distal end of corrugated tubing to connect to BVM mask or ETT

Albuterol Delivered Via BVM
#1 #1 Disconnect reservoir bag with L valve from mask #2 Connect L shaped valve with bag where mouthpiece of albuterol kit would fit #3 Place corrugated tubing of albuterol kit to the mask over the patient’s mouth #4 Begin to bag to “blow” the drug into the lungs while waiting to complete intubation #2 #3, #4 To 6l O2

Adaptor connected to the distal end of the corrugated tubing of Albuterol kit connected to the proximal end of the ETT ETT placement confirmed in the usual manner visualization chest rise & fall 5 point auscultation ETCO2 detector Intubated patient

Case Scenario #5 EMS has responded to a 14 year-old child in severe respiratory distress with audible wheezing. The complaints have been present for the past 3 hours. Inhalers used have not been effective. B/P - 112/60; P - 120; R - 32; SaO2 - 89% Patient is very anxious, pale, cool, and diaphoretic. The lips and nail beds are cyanotic. What is your impression? What is your greatest concern?

Case Scenario #5 This patient is experiencing a severe asthma attack that is not responding to medication - status asthmaticus This patient is in danger of going into respiratory arrest due to exhaustion Begin supportive oxygen therapy Set up the albuterol nebulizer kit and simultaneously the BVM Anticipate intubation with administration of Albuterol via the in-line method

Case Scenario #5 Patients experiencing an asthma attack are in need of bronchodilators (Albuterol) and IV fluids (they are usually dry from the rapid respirations and inability to have been taking in fluids) If the patient is losing consciousness, you may need to follow the Conscious Sedation SOP to intubate and administer Albuterol via in-line

Region X SOP - Conscious Sedation
Lidocaine is not indicated Lidocaine is used to eliminate the cough reflex that would increase ICP in head insults/trauma There is no presence of head injury or head insult Versed is an amnesic and will relax the patient Versed does not take away any pain Region X SOP dose of Versed is 5 mg slow IVP If not sedated within 60 seconds, Versed 2 mg slow IVP every minute until sedated Following sedation, may give Versed 1 mg IVP every 5 minutes for agitation (total sedation dose is 15 mg)

Conscious Sedation cont’d
Morphine can help increase the effects of Versed and assist in improving patient sedation Morphine 2 mg slow IVP over 2 minutes May repeat Morphine 2mg IVP every 3 minutes Max dose Morphine 10 mg IVP Benzocaine eliminates the gag reflex The conscious patient will have a gag reflex For the unconscious patient, stroke at the eyelashes or tap the space between the eyes to check for gag The gag reflex disappears with the blink reflex Minimize the duration of spray (<2 seconds)

Bibliography Bledsoe, B., Porter, R., Cherry, R.
Essentials of Paramedic Care. Brady. 2007. Kohlstedt, D. Sales Representative. Tri-Anim. Region X SOP’s, March 1, 2007. Sanders, M. Mosby’s Paramedic Textbook, Revised Third Edition Via Google: Respiratory Module Part I Via Google: Respiratory Module Part II

Condell Medical Center EMS System ECRN CE

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