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Respiratory Emergencies and the Rapid Response Team Lauri Stephens RRT-NPS, RPFT.

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Presentation on theme: "Respiratory Emergencies and the Rapid Response Team Lauri Stephens RRT-NPS, RPFT."— Presentation transcript:

1 Respiratory Emergencies and the Rapid Response Team Lauri Stephens RRT-NPS, RPFT

2 Why Was RRT Called? Patient not breathing enough Patient not breathing enough –Sedation –Central Nervous System Depression Patient increased WOB - Dyspnea Patient increased WOB - Dyspnea Dyspnea results from 3 generalized abnormalities of respiration: Dyspnea results from 3 generalized abnormalities of respiration: –Changes in ability to maintain normal respiratory “work” Neuromuscular disease-weakness Cachexia/Malnutrition Decreased respiratory muscle strength - deconditioning –An increase in effort/work load COPD Pleural Effusion Restriction –An increase in ventilatory requirements Anemia Metabolic acidosis Fever Hypercapnia

3 Evaluation of Dyspnea Pulmonary Causes Pulmonary Causes –Pulmonary Embolism –Pneumothorax –COPD/Asthma Exacerbation –Pleural Effusion –Pulmonary Edema –Airway Obstruction –Aspiration –Hypoxemia –Pneumonia –Infection –Fever Other- Sepsis Anemia (Hgb <10) Anemia (Hgb <10) Metabolic Acidosis Metabolic AcidosisHyperthyroidism Chronic Liver Failure Chronic Liver Failure Remember ABC’s Psychogenic Causes Psychogenic Causes –Panic Attack –Anxiety –“Spiritual Distress” –Hyperventilation Pain Fear Cardiac Causes Cardiac Causes –Acute MI –CHF –Unstable Angina –Pericarditis –Early Mitral Stenosis

4 46 yo male, 3 days post admission and treatment for pneumonia + acute on chronic renal failure. RRT called for tachypnea/SOB and fever. VS - HR 128, RR 30, BP 127/82 Temp 39.3 VS - HR 128, RR 30, BP 127/82 Temp % on 2 lpm 91% on 2 lpm Labs – RBC 1.85, WBC 9.44, HCT 21% Hgb 7.5 Labs – RBC 1.85, WBC 9.44, HCT 21% Hgb 7.5 Creatinine 1.7 Creatinine 1.7 ABG ABG Why is this patient dyspneic? Why is this patient dyspneic? Pt placed on 40% V-Mask Pt placed on 40% V-Mask Lasix given Lasix given

5 Second RRT called about 5 hours later. Patient having increased cough, sputum specimen obtained. VS about the same. ABG – ABG – Patient just wants to go home Patient just wants to go home Denies any increase in SOB or WOB Denies any increase in SOB or WOB Lungs have decent aeration, bronchial BS Lungs have decent aeration, bronchial BS Decision made to leave him on the floor Decision made to leave him on the floor Identify PNA pathogen to guide antibiotic tx Identify PNA pathogen to guide antibiotic tx

6 Third RRT in 24 hours called ~ 4 hours later. Pt moved to private room Pt moved to private room Now in isolation for “whooping cough” Now in isolation for “whooping cough” Initial presentation of pertussis presents as typical URI, runny nose, cough & conjunctival irritation (most contagious at this point) Initial presentation of pertussis presents as typical URI, runny nose, cough & conjunctival irritation (most contagious at this point) Characteristic cough occurs after 7-10 days Characteristic cough occurs after 7-10 days Many patients will not have the classic “whoop” Many patients will not have the classic “whoop” On the rise On the rise Most deadly in infants less than 6 months Most deadly in infants less than 6 months

7 Pertussis in the Adult Patient Up to 32% of adolescents & adults w/cough > 6 days have serologic evidence of pertussis Up to 32% of adolescents & adults w/cough > 6 days have serologic evidence of pertussis In adults w/confirmed pertussis, 80% had a cough for at least 3 weeks In adults w/confirmed pertussis, 80% had a cough for at least 3 weeks Vomiting post cough common Vomiting post cough common We become susceptible 6-10 years post vaccination We become susceptible 6-10 years post vaccination New strains emerging New strains emerging New DPT booster vaccines for adolescents and adults recently approved New DPT booster vaccines for adolescents and adults recently approved

8 17 yo male, fractured tib/fib sustained in a soccer game. Family visiting re-positioned patient’s leg because he was uncomfortable. Pale appearance, normal build Pale appearance, normal build Respiratory rate 36 HR 140 Respiratory rate 36 HR 140 BS clear, diminished in bases BS clear, diminished in bases Patient c/o severe SOB “I can’t breathe” Patient c/o severe SOB “I can’t breathe” Patient c/o chest pain “Someone sitting on chest” Patient c/o chest pain “Someone sitting on chest” Patient placed on 100% NRB Mask, SpO2 100% Patient placed on 100% NRB Mask, SpO2 100%

9 Patient now c/o “I can’t feel my legs” “My face hurts, I can’t open my mouth” “Am I going to die?” ABG

10 Family asked to leave the room Pain meds and anti-anxiety Rx given Patient relaxed, dyspnea relieved Symtoms of hyperventilation: Symtoms of hyperventilation: –Numbness or tingling in hands, feet or lips –Lightheadedness/dizziness –Cofusion –SOB –Slurred speech –Headache –Chest pain –Spasms & cramps –Muscle twitching –Trismus Causes of hyperventilation Causes of hyperventilation –Stress or anxiety –Pain –Hypoxia –Sepsis –Head injury –Metabolic acidosis –Fever

11 66 yo, restrained passenger involved in a MVC w/ multiple trauma and fractured pelvis. 11 days out. Patient became very SOB and desaturated post working with PT. HR 136, RR 32, SpO2 90% on 100% NRB Temp 38 HR 136, RR 32, SpO2 90% on 100% NRB Temp 38 BS unremarkable BS unremarkable Pt c/o stomach pain and it hurts to take a deep breath Pt c/o stomach pain and it hurts to take a deep breath Pt has occasional spontaneous dry cough Pt has occasional spontaneous dry cough Edema noted in left leg Edema noted in left leg Pt is in isolation, wants something to drink Pt is in isolation, wants something to drink

12 What would you recommend at this point? ABG ABG CXR unchanged from previous CXR unchanged from previous CT ordered – Will patient fit in scanner? Can she lay flat? CT ordered – Will patient fit in scanner? Can she lay flat? ???? Isolation ???? Isolation Patient just wants apple juice Patient just wants apple juice Risk Factors for PE Risk Factors for PE –Prior History DVT or PE –Recent Surgery, Pregnancy, Trauma, Fractures or Immobilzation –Malignancy, Chemotherapy –CHF or MI –Burns –Old Age, Obesity, Oral Contraceptives or Estrogen Replacement –Varicose Veins –IV Drug Abuse –Polycythemia, Hemolytic Anemia, Fibrinogen Abnormality, Early Coumadin Therapy and Heparin Associated Thrombocytopenia –Type A blood

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14 Pulmonary Emboli Facts First or second most common cause of unexpected death in most age groups First or second most common cause of unexpected death in most age groups Most commonly (80%) diagnosed on autopsy (~60% of pt’s dying in the hospital + for PE) Most commonly (80%) diagnosed on autopsy (~60% of pt’s dying in the hospital + for PE) 10% of patients diagnosed w/PE will die within 1 hour 10% of patients diagnosed w/PE will die within 1 hour Only 1/3 of the rest will be diagnosed & treated Only 1/3 of the rest will be diagnosed & treated Incidence & findings of massive PE Incidence & findings of massive PE –96% Tachypnea –58% Rales/Crackles –53% Accentuated 2 nd Heart Sound –44% Tachycardia –43% Fever (>37.8C) –36% Diaphoretic –24% LE Edema –23% Cardiac Murmur –19% Cyanosis

15 640# Paraplegic in for treatment of decubitus ulcers, history of ostructive sleep apnea. 640# Paraplegic in for treatment of decubitus ulcers, history of ostructive sleep apnea. RRT called for acute desaturation and patient decreased LOC RRT called for acute desaturation and patient decreased LOC Patient supine in FluidAir/Clinitron bed Patient supine in FluidAir/Clinitron bed Patient recently had “wound care” Patient recently had “wound care”

16 Patient lethargic, with shallow respirations. Will take deep breaths when stimulated and then falls asleep and RR decreases to 4. On 100% NRB Mask SpO2 =82% Do we need a gas? Do we need a gas? What do you want to do now? What do you want to do now? Stay on floor or transfer to unit? Stay on floor or transfer to unit?

17 Patient Outcome Transferred to unit Transferred to unit Placed in Bariatric air bed Placed in Bariatric air bed BiPAP 25/8 BiPAP 25/8 Patient woke up ~6hours later Patient woke up ~6hours later Patient recognized RCP from previous episode Patient recognized RCP from previous episode Patient reported that he had lost ~150 since last hospitalization Patient reported that he had lost ~150 since last hospitalization

18 68yo male, chronic renal failure, Hx IVDA & ETOH, Hep C+, admitted via the ED overnight with a nosebleed. RRT called for inability to awaken patient RRT called for inability to awaken patient Respirations very irregular, with frequent apnea and no respiratory effort observed (was not obstructing) Cheyne-Stokes respirations Respirations very irregular, with frequent apnea and no respiratory effort observed (was not obstructing) Cheyne-Stokes respirations BS essentially clear BS essentially clear SpO2 93% on 3 Lpm SpO2 93% on 3 Lpm HR 130. BP 90/52 HR 130. BP 90/52

19 What do you want to know? Any labs? CXR? Received Xanax ~ 8 hours ago for agitation Received Xanax ~ 8 hours ago for agitation ABG ABG Pinpoint pupils Pinpoint pupils Arouses with stimulation and becomes very agitated Arouses with stimulation and becomes very agitated Mumbling about his friend who visited ‘this morning” Mumbling about his friend who visited ‘this morning” RN wants nasal airway placed RN wants nasal airway placed

20 Decision made to try Narcan/Naloxone (opioid antagonist). Patient responded, becoming combative and agitated, but breathing. Should he stay on floor or transfer to unit? Should he stay on floor or transfer to unit? Narcan takes effect in about 2 minutes and lasts ~45 minutes Narcan takes effect in about 2 minutes and lasts ~45 minutes Duration of action of narcotics may exceed that of Narcan Duration of action of narcotics may exceed that of Narcan Dose to response-.4mg- 2mgQ2-3 minutes up to 10mg Dose to response-.4mg- 2mgQ2-3 minutes up to 10mg

21 88 yo edentulous male, status post CVA. RRT called for SpO2 of 77% on 3 LPM and increased WOB. Rhonchorus BS heard from bedside Rhonchorus BS heard from bedside Loose, wet cough Loose, wet cough Intercostal retractions and use of accesory muscles present Intercostal retractions and use of accesory muscles present Patient lethargic, breathing with mouth “open ” Patient lethargic, breathing with mouth “open ” RR 28, HR 112 BP 102/70 RR 28, HR 112 BP 102/70

22 What is your first “move”? “A” for airway! “A” for airway! Secretions pooling back of throat Secretions pooling back of throat Oral mucosa noted to be very dry Oral mucosa noted to be very dry Huge oral cast cleared from pharynx Huge oral cast cleared from pharynx Patient needs hydration & frequent oral care Patient needs hydration & frequent oral care

23 44yo 5 days post motorcycle vs car. C-2 fracture, pelvic fracture and left clavicle fracture. Some concern over possible vertebral artery injury. RRT called for Mental status changes RRT called for Mental status changes –Doesn’t recognize wife –Speaking gibberish –Vital signs all WNL –Difficult to assess BS/Chest due to Halo –Wife reports difficult night and patient being very anxious

24 What are your concerns? ABG on room air ABG on room air Now what? Now what? Head CT normal Head CT normal Can he stay on floor or does he need to transfer? Can he stay on floor or does he need to transfer?

25 The End


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