1. Respiratory Emergencies: CHF, Pulmonary Edema, COPD, Asthma CPAP & Albuterol Nebulizer Condell Medical Center EMS System September, 2007 Site Code#10-7200E1207 Prepared by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives Upon successful completion of this program, the EMS provider should be able to: review the presentation and intervention for the patient presenting with CHF, pulmonary edema, COPD, and asthma. review criteria for the use of CPAP. discuss the set-up for CPAP. review the SOP for Acute Pulmonary edema, Asthma/COPD with Wheezing, and Conscious Sedation

3. Objectives cont’d review the Whisperflow patient circuit for CPAP. actively participate in return-demonstration of the albuterol nebulizer and in-line set-up. successfully complete the quiz with a score of 80% or better.

4. 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

5. 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

6. Deoxygenated Blood Flow Through The Heart Deoxygenated blood returns to the right heart via inferior and superior vena cavas Blood flow thru the right side of the heart –right atrium –right ventricle –pulmonary artery to the lungs arteries always carry blood away from the heart –pumped to the lungs to be oxygenated

7. Oxygenated Blood Flow Through The Heart Oxygenated blood from the lungs returns to the heart via the pulmonary veins to the left atrium Blood flow thru the left side of the heart –left atrium –left ventricle –thru aortic valve to the aorta –to aorta for distribution to the body

9. 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

10. 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)

11. 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

12. 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

13. 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

14. 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

15. 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)

16. 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

17. Acute Congestive Heart Failure Often presenting in the field as: Pulmonary edema Pulmonary hypertension Myocardial infarction

18. Chronic Congestive Heart Failure Often presenting in the field as: Cardiomegaly - enlargement of the heart Left ventricular failure Right ventricular failure

19. Patient Assessment Scene size-up Initial assessment –airway –breathing –circulation –disability AVPU GCS –expose to finish examining

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

21. Closest Appropriate Hospital Hospital of patient’s choice within the 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, you can communicate this to the patient to get your 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”)

22. 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 Document well the efforts taken to encourage transportation

23. 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

24. 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

25. 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

26. 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)

27. 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

28. ] 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)

29. 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

30. Acute Pulmonary Edema SOP Routine medical care –patient assessment –IV-O 2 -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

31. Stable Acute Pulmonary Edema 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

32. Pulmonary Edema Medications 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 –can repeat the drug (0.4 mg sl) every 5 minutes up to 3 doses total if blood pressure remains > 100 mmHg –onset 1 - 3 minutes sl (mouth needs to be moist for the tablet to dissolve & be absorbed)

33. 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 15 - 20 minutes

34. 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)

35. 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

36. 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

37. 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; SaO 2 - 88% Crackles are auscultated in the lower half of the lung fields.

38. 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:

39. Case Scenario #1 What is your impression? What will be your intervention(s)? What is the rationale for your interventions? What is this patient’s rhythm and do you need to administer any medications for the rhythm?

40. 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

41. 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-O 2 -monitor –Meds: NTG, Lasix, Morphine, consider CPAP

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

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

44. 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

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

46. 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)

47. 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

48. 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

49. Patient Monitoring During CPAP Use Patient tolerance; mental status Respiratory pattern –rate, depth, subjective feeling of improvement –B/P, pulse rate & quality, SaO 2, 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 SaO 2

50. 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

51. Patient Circuits Complete package includes mask tubing head strap Whisperflow CPAP valve corrugated tubing air entrapment filter

52. Patient Circuit

53. Oxygen Tank Duration D sized tank - 30 minutes* –typical small portable tank kept on patient cart H sized tank - 508 minutes* (8+ hours) –typical large tank kept in locker on rig Other tank sizes: E sized tank - 50 minutes* –typically used in hospitals during patient transports M sized tank - 253 minutes* * Based on 50 psi output & approx 30% FIO 2

54. Case Scenario #2 You have 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?

55. 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

56. 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 CO 2 ) that causes an acid-base imbalance

57. 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

58. 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

59. 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)

60. Alveolar Sac and Capillaries

61. Emphysema  in PaO 2 leads to  in red blood cell production (to carry more oxygen) Develop chronically elevated PaCO 2 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

63. 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

64. 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

65. 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 - 116 & irregular; R - 26; SaO 2 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

66. Case Scenario 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? Case Scenario #3 Atrial fibrillation diminishes the efficiency of the pumping of the heart which can further compromise the cardiac output

67. 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 100.6 0 F) –rhonchi & rales in the right lung field base Routine medical care –supplemental oxygen –  heart rate most likely due to pneumonia and does not need specific treatment

68. 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

69. 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

70. Drive to Breath & COPD Normal driving force to breathe –decreased oxygen (O 2 ) level –increased carbon dioxide (CO 2 ) level Chemoreceptors sense: –too little O 2 (  resp rate to improve) or –too much CO 2 (  resp rate to blow off more CO 2 ) Patients with COPD have retained excess CO 2 for so long that their chemoreceptors are no longer sensitive to the elevated CO 2 levels –COPD patients breathe to pull in O 2

71. O 2 Administration & COPD Never withhold oxygen therapy from a patient who clinically needs it Monitor all patients receiving O 2 but especially the patient with COPD Normal O 2 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

72. 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

73. 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

75. 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

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

77. 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

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

79. 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 Contact Medical Control for possible CPAP in patient with COPD

80. 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

81. Add medication to the chamber

82. Connect the mouthpiece to the T-piece

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

84. Encourage slow, deep breathing

85. 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

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

87. 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 - 20; SaO 2 - 97% Upon auscultation, left lung is clear and wheezing is present on the right side Impression and intervention?

88. 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?

89. 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 Transport with supplemental oxygen if indicated, position of comfort, reassessment watching for increase in airway obstruction

90. Aerosol Medication via BVM or ETT with BVM (In-line) Place Albuterol in the chamber as usual Connect the chamber to the T-piece Once the nebulizer kit is assembled and the clear adaptor(s) are in place, you may begin to bag the patient prior to completion of intubation –the clear adaptor on the corrugated tubing is attached to the BVM’s mask –any medication that can be delivered as soon as possible to the target organ (the lungs) will be helpful in promoting bronchodilation

91. Nebulizer with white T-piece (CMC pyxis) –Remove the white mouth piece; the BVM will be connected to this port –Add a clear adaptor to the distal end of the corrugated tubing –Intubate the patient as usual and connect the clear adaptor on the corrugated tubing to the proximal end of the ETT placed in the patient –Begin to bag the patient –Supplemental oxygen must be connected to the nebulizer and the BVM

92. Nebulizer with blue T-piece –Remove the mouthpiece from the T-piece and connect a clear adaptor in it’s place –The BVM will attach to the clear adaptor on the T- piece –Add a second clear adaptor to the distal end of the corrugated tubing –This clear adaptor will be connected to the proximal end of the ETT after intubation is performed in the usual manner –Supplemental oxygen must be connected to the nebulizer and the BVM

93. Remove mouthpiece from T-piece and replace with BVM Connect nebulizer to oxygen source Place clear adaptor at distal end of corrugated tubing (to connect to ETT)

94. Intubate the patient Connect the clear adaptor on the distal end of the corrugated tubing to the proximal end of the ETT Confirm placement in the usual manner –visualization –chest rise & fall –5 point auscultation –ETCO 2 detector

95. 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?

96. 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

97. 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

98. Conscious Sedation Would Lidocaine bolus be indicated? What is the dose of Versed and the purpose of Versed? What would be the effects of Morphine? How do you know if the patient needs Benzocaine (Hurricaine, Cetacaine)?

99. Conscious Sedation Lidocaine is not indicated –there is no presence of head injury or insult Versed is an amnesic and will relax the patient Versed does not take away any pain The dose of Versed is 5 mg slow IVP –If not sedated within 60 seconds, Versed 2 mg slow IVP every minutes until sedated –Following sedation, may give Versed 1 mg IVP every 5 minutes for agitation (total dose 15 mg)

100. Conscious Sedation 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 every 3 minutes –Max dose Morphine 10 mg 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 The gag reflex disappears with the blink reflex –Minimize the duration of spray (<2 seconds)

101. 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. 2007. Via Google: Respiratory Module Part I Via Google: Respiratory Module Part II