First: Notes to the ECRN

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: Countryside Grayslake Lake Forest Fire Libertyville Mundelein Round Lake Wauconda Murphy

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 2009 Site Code: E-1209 Prepared by: Lt. William Hoover, Wauconda Fire Reviewed/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 air Nasal cavity Oral cavity Tongue Uvula Epiglottis – protects trachea during swallowing Vocal cords The upper airway extends from the mouth and nose to the larynx. The larynx joins the upper and lower airways. The upper airway assists in heating, purifying, and moistening the inhaled air. The mouth and pharynx serve dual roles for respirations and for digestion. Protective mechanisms are in place to prevent foreign bodies from entering the trachea and the lungs. Sensitive nerves would stimulate the cough, swallowing, and gag reflexes. The epiglottis is cartilage that helps prevent food from entering the trachea by covering the trachea during swallowing.

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 The respiratory exchange of oxygen and carbon dioxide takes place in the lower airway system. The trachea connects the larynx to the 2 mainstem bronchi. The trachea is supported by a framework that maintains the trachea in an open position. The left mainstem bronchus is at a more acute angle then the right. The right mainstem bronchus is almost straight anatomically. Most aspirated foreign bodies will be in the right mainstem bronchus. Endotracheal tubes inserted too far almost always end up in the right mainstem bronchus. The alveoli are the functional unit of the respiratory system. Most oxygen and carbon dioxide exchange takes place in the alveoli. If the alveoli cannot be maintained in an open position or are filled with an alternate substance (ie: fluid, pus), gas exchange cannot take place.

Upper Airway Larynx joins upper and lower airways

Lower Airway Alveoli are the functional units of the respiratory
system and is where gas exchange takes place

Difference With the Pediatric Airway
Fundamentally the same as an adult Size and positioning differences Jaw smaller, tongue relatively larger Epiglottis floppier and rounder Larynx more superior and anterior (higher and more forward) in children Oral airways are placed in the same position they will be in when in place. There is no room in the oral cavity for flipping oropharyngeal airways around to seat them. Straight blade preferred over use of curved blade when intubating the pediatric patient due to the larger and floppier epiglottis. Cricoid cartilage is underdeveloped. Before age 10, the cricoid cartilage is the narrowest part of the airway in children. A small foreign body or minimal swelling could be life-threatening. The ribs and cartilage of the thoracic cage are softer and more pliable. Children rely more on their diaphragm for breathing than they do thoracic wall muscles. Adults suffer more fractured ribs than children but both populations will still suffer blunt trauma to underlying organs when recipients of chest wall trauma.

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 In the pediatric population, their response to hypoxia is bradycardia. When you notice the pediatric patient’s pulse rate dropping, turn your attention to their airway and improve oxygenation and ventilation. Ventilation attempts by the patient does not equal adequate oxygenation or ventilation (think agonal breathing). If the patient needs supportive (rescue) ventilations via BVM and has a heart beat, per the AHA the adult guidelines is to provide one breath every seconds (10 – 12 per minute); one breath every 6 – 8 seconds (8 – 10 per minute) if they are intubated. To provide rescue breathing via BVM for the pediatric patient, ventilate once every 3 seconds (20 breaths per minute). During CPR, once the patient is intubated the compressor does not pause compressions, the ventilator delivers one breath every 6 8 seconds (10 12 breaths per minute).

Tripod position – helps lungs expand
Tripod positioning is leaning forward which helps to allow lungs to expand to their fullest. Notice this patient’s appearance as typical of one having abnormal respiratory patterns – tripod position, pursed lip breathing (exhaling with lips pursed together creates a CPAP effect to keep the alveoli from fully collapsing), barrel chest (typical of chronic emphysema), thin build.

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 retractions Seesaw respirations (abdominal breathing) Strained neck muscles

Pediatric Respiratory Failure
Energy reserves exhausted Patient cannot maintain adequate oxygenation and ventilation (breathing) Sleepy, less than alert Intermittently combative or agitated Bradycardic heart rate indicates hypoxia Immediate attention to airway and ventilation rate to fix the bradycardia Once a child is in respiratory failure, respiratory arrest may quickly follow.

Assessing Patients with Dyspnea
Primary Assessment (ABC’s) SAMPLE history OPQRST Physical Assessment Lung Sounds Minimally cardiac monitor; possibly Lead EKG Pulse oximetry Acceptable normal 95 – 99% Mild hypoxia 91 – 94% Severe hypoxia <91% ABC’s – airway (is it open?); breathing (is it adequate?); circulation (do they have a pulse and if so, what kind?). SAMPLE history – signs & symptoms; allergies; current medications; past pertinent medical history; last oral intake of fluids and/or food; events leading up to the call. OPQRST – Onset (what was the patient doing when the issue began); Palliation/provocation (what makes it worse/better); Quality (in patient’s own words); Radiation (does the pain travel anywhere else); Severity (on a scale of 0 – 10); Time (of onset). Physical assessment: inspection, auscultation, palpation Hypoxia can induce cardiac dysrhythmias (or did the dysrhythmia have a negative effect on the respiratory system causing the respiratory complaints?). A 12 lead EKG can be helpful and diagnostic in the patient with respiratory distress. Pulse oximetry – non-invasive measure to evaluate the hemoglobin oxygen saturation in peripheral tissues. As a guideline, normal SpO2 is %. Mild hypoxia is indicated at 91 – 94% and indicates the need for further assessment and possible intervention may be necessary. Readings less than 91% indicate moderate hypoxia and less than 85% is severe hypoxia and require your intervention.

All Those Initials!!! ABC’s SAMPLE history OPQRST of assessment
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 Provocation – what provokes the complaint? Palliation – what makes the complaint better? Quality – in the patient’s own words

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 Cheyne-stokes – progressively deeper, faster breathing alternating with gradually shallow, slower breathing Kussmaul’s – deep, slow, or rapid, gasping breathing. Usually an attempt to blow off excess CO2 to reduce the acid level in the body.

Abnormal Patterns cont’d
Agonal Indicates brain anoxia Shallow, 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 Listen to breath sounds audibly first and then listen with a stethoscope. The anterior and lateral surfaces are most accessible. Auscultate the right and left apex (just beneath the clavicle). The right and left bases (approximately the 8th or 9th intercostal space, midclavicular line) And finally the right and left lower thoracic back right and left of the midaxillary line on the sides of the chest wall. If you have access to the posterior surface of the chest wall, auscultate in 6 positions – 3 on the right and 3 on the left for comparison. Heart sounds do not interfere when auscultating the posterior surface so auscultating posterior sounds produce the best sounds.

Auscultating Anterior Lung Sounds
Moving methodically is helpful when comparing one side to the next and then moving down. The right lung has 3 lobes, the left lung has 2 lobes.

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 When listening for breath sounds over clothing, the rubbing of clothing on the stethoscope may lead you to hear abnormal breath sounds when it is just the effect of the clothing rubbing.

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 Symptoms EMS 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
Toe ring Esophageal foreign bodies can also present an airway challenge especially if the foreign body moves This is a toe ring that may have been present for 5 days (7 year old with drooling and difficulty swallowing). Child is mentally challenged and drooling was not unusual for him. No respiratory signs or symptoms.

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 Foreign body could cause incomplete or complete obstruction. In complete obstruction, the patient can no longer talk or cough and will lose consciousness soon if obstruction is not relieved. Croup – most common in persons under the age of 3. Patient presents with low grade fever with seal-like bark and stridor. The patient may also have retractions, tachypnea, and exhibit acute respiratory distress. Often symptoms exaggerate in the middle of the night. Epiglottitis – true airway emergency that can affect persons of all ages with no age limit. Patients usually present with difficulty talking, drooling, hoarseness, and respiratory distress. They may also have stridor, fever, sore throat and the patient looks ill. An increase in immunizations given against the most common bacteria has reduced the incidence of this disease.

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 Conscious choking victim – For adult and child perform the Heimlich maneuver until the obstruction is relieved or the patient becomes unconscious. For infants, perform 5 back slaps alternating with 5 chest thrusts. If the patient is unconscious, perform the steps of CPR adding the additional step of looking into the airway for the object before administering breaths. Croup - Treatment initiated at home is a cool mist. EMS can administer 6 ml normal saline in a nebulizer kit. If wheezing is present, Albuterol 2.5 mg/3ml may be administered. Epiglottitis treatment - EMS can administer 6 ml normal saline in a nebulizer kit.

Signs & Symptoms of Impaired Airway Related to Anaphylaxis
Hives Rash that itches Wheezing Hypotension – unique to anaphylaxis Nausea Abdominal cramps Inability to urinate Is quickly life-threatening In anaphylaxis versus allergic reaction, the blood pressure will drop due to vasodilation. Patients with an allergic reaction and those with anaphylaxis can both have hives, itching, wheezing, coughing – it is the drop in blood pressure that points to anaphylaxis.

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 In anaphylaxis versus allergic reaction, the blood pressure will drop due to vasodilation. Patients with an allergic reaction and with anaphylaxis can both have hives, itching, wheezing, cough – it is the drop in blood pressure that points to anaphylaxis.

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 Signs and symptoms of asthma are often triggered by allergens, weather changes, exercise, respiratory infections, and by certain food or medications. Asthma is a reversible airway obstruction. Asthma can be deadly if the attack is severe enough to cause hypoxia leading to hypoxemia and fatigue of the respiratory system.

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 Patients in an asthma attack get very dry and dehydrated due to their rapid respiratory pattern. They would benefit from receiving IV therapy hydration.

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 Patients can get exhausted during their asthma attack and may need to be intubated.

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 Obstructive lung disease is wide spread. The common factor is abnormal ventilation primarily in the bronchioles. The most common obstructive diseases EMS will take care of include asthma, emphysema and chronic bronchitis. Emphysema and chronic bronchitis are referred to chronic obstructive pulmonary diseases (COPD). COPD is known to have a direct link to cigarette smoking and environmental toxins. Asthma may have a genetic tendency.

COPD Some elements are reversible, some not
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 COPD patients function at lower than normal O2 levels. They have adjusted to the decrease oxygen levels over time.

EMS Treatment of COPD with Wheezing
Albuterol treatment 2.5 mg / 3 ml O2 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
Aspiration occurs when foreign material is inhaled into the lungs. This often occurs when the patient is unable to protect their own airway as can happen in patients with an altered level of consciousness (ie: drug and alcohol overdose, head injury, stroke, trauma). The mortality rate is extremely high for any patient that has aspirated. EMS must be constantly vigilant against the chances of aspiration. What can EMS do? Positioning – patient on their side if not contraindicated Suctioning turned on and ready to be used Cricoid pressure used during intubation attempts Intubation in the patient that is unable to protect their own airway

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 Toxic exposure needs to be suspected in chemical factory workers and at Haz-mat and fire scenes. The chemical needs to be identified. Some exposures can cause fluid build-up in the lungs.

Pneumothorax Spontaneous pneumothorax occurs more often in males. Additional risk factors include a tall, thin build and history of cigarette smoking. The lung cannot properly expand and ventilation is affected. A pneumothorax up to 15 – 20% can often be well tolerated especially in the relatively healthy patient.

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 Pleuritic chest pain is described as a sharp or tearing sensation. A spontaneous pneumothorax can become a tension pneumothorax.

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
Blood flow to the pulmonary artery is blocked by a clot. This is a life-threatening event decreasing pulmonary blood flow and leading to hypoxemia. Immobility of the extremities increases the risk factor (recent surgery, long-bone fractures immobilized in casts or splints, bed ridden conditions, prolonged immobilization with long distance travel (especially by car or airplane). Also a risk factor are females on birth control pills and especially if they are smokers.

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 Immobility of the extremities increases the risk factor (recent surgery, long-bone fractures immobilized in casts or splints, bed ridden conditions, prolonged immobilization with long distance travel (especially by car or airplane). Also a risk factor are females on birth control pills and especially if they are smokers.

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 Muscular dystrophy – a group of inherited muscle diseases where primarily, the voluntary muscles are affected and become progressively weaker. Some types of MD can affect heart muscles, other involuntary muscles, and some organs. There is no cure but medications and therapy can slow the course of the disease. ALS – A rapidly progressive and fatal disease. Attacks the nerve cells responsible for controlling voluntary muscles. Muscles gradually weaken, waste away, and twitch. When muscles of the diaphragm and chest wall become affected, the patient will need ventilatory support. The average life expectancy after the onset of symptoms is 3 – 5 years. The patient’s cognitive function and senses are not affected – they can still hear, see, smell, taste, and recognize touch. Guillain-Barre – a rare disorder striking at any age and equally among the sexes. The body’s immune system attacks a part of the peripheral nervous system. There is an ascending paralysis. The first symptoms are varying weakness or tingling sensations in the legs eventually spreading to the arms and upper body. The patient becomes almost totally paralyzed which will interfere with ventilations and at times can affect the blood pressure and heart rate. Most patients will recover. Myasthenia gravis – This is a chronic autoimmune neuromuscular disease with varying degrees of weakness of skeletal (voluntary) muscles of the body. Often the affected muscles include those that control eye and eyelid movement, facial expressions, chewing, talking, and swallowing. Myasthenia gravis can affect persons at any age but most commonly affects women under 40 and men over 60. Life expectancy is not affected and medications can help improve symptoms of muscle weakness. Patients can expect to lead a normal to nearly normal life.

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 Hyperthyroid disease – overproduction of thyroid hormones (T3 and T4) that increase the rate of metabolism. In severe disease, the patient may have shortness of breath. Metabolic acidosis – as a by-product, carbon dioxide is formed in the lungs. The body attempts to decrease the levels of carbon dioxide (CO2) by increasing the depth and rate of respirations. Metabolic acidosis can result from chronic renal failure, in diabetic ketoacidosis, following massive and severe crush injuries with destruction of a large amount of muscle, and in overdoses such as aspirin (salicylate acid), ethanol, and ethylene glycol (antifreeze). Psychogenic hyperventilation – these patients need to be carefully screened and assessed – they may have a medical problem for hyperventilation masquerading as a psychogenic cause.

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 handle Straight 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) Adequate volume for ventilation is measured by visually observing for gentle rise and fall of the chest. The BVM needs to be connected to an oxygen source in order to deliver 100% O2. Stylet, if used, needs to be recessed approximately ½ inch from the distal tip. Helpful positioning in the patient with no evidence of spinal cord injury is to elevate the occiput with a small folded towel – helps put the patient into the sniffing position. Once the patient is intubated, know where the BVM mask is and the syringe in case the ET tube needs to be repositioned or the patient needs to be extubated and bagged.

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 After intubation, the patient is bagged at a rate of 1 breath every 6 – 8 seconds. If CPR is in progress, the compressor no longer pauses but provides continuous chest compressions at a rate of 100 per minute and prepares to switch at the end of 2 minutes of CPR. Manual control of the ET tube must be maintained at all times until the tube is secured in place. Document who actually placed the ET tube, the size of the tube used, the depth in cm marked on the ET tube noted after placement, steps taken to confirm placement, that capnography was confirmed, and number of unsuccessful attempts.

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 uncuffed The 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 Prior to intubation, the pediatric ventilatory rate, if not doing CPR, is 1 breath every 3 – 5 seconds. After intubation, the ventilatory rate is the same as the adult at one breath every 6 – 8 seconds.

Respiratory Rates BVM support to patient with a heart beat – rescue breathing Adults ventilate once every sec Infant & child ventilate once every 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 Coughing raises intrathoracic pressures which will increase intracranial pressures. Need Lidocaine prophylactically to blunt the cough reflex as the blade and ET tube are introduced into the airway. If the patient is in bradycardia, it is okay to administer the Lidocaine, the slow heart rate is most likely from the head insult and not from a diseased heart. Versed – amnesic and to relax the patient; does not blunt any pain perception Morphine – to relax patient and reduce anxiety Benzocaine – to reduce the gag reflex; stroke the eye lashes and if the blink reflex is present the gag reflex is still present

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 Patients in severe asthma attacks need to be bronchodilated in order to be ventilated. The drug needs to be delivered into the lungs and not just into the back of the throat. If the patient is conscious and able to ventilate with the standard nebulizer kit, someone needs to verbally coach this anxious patient through the breathing process.

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 present Known 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 Esophageal placement is the most frequent.

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 ml White 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 Warm your stethoscope by rubbing it in your palm or over your clothing. The best place to listen for lungs sounds in posteriorly – sound is best heard here. Have the patient cough to clear loose mucous. Have the patient breath gently through their open mouth. Start at the top and listen to one side, compare to the opposite side and then move the stethoscope downward and moving more laterally toward the bases.

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 Elderly do not always have a fever in the presence of an infection. The elderly and the very young may not tolerate a large amount of IV fluids from a runaway IV bag. Use 250 ml bags of IV fluid when the fluid volume needs to be carefully controlled.

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 equipment Child BVM Magill 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 Albuterol dose is 2.5 mg in 3 ml volume for all patients. Patients with respiratory complaints are extremely anxious and for good reason. They will need someone to be authoritative and act in a calm manner for them to get control of their breathing. Constantly monitor the patient’s respiratory status anticipating a deterioration and being prepared for it. Determine if the patient has ever needed to be intubated due to their asthma. If the answer is yes, there is a very high likelihood of the need for intubation during future attacks.

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 completed The chamber will be empty of liquid Some patients have improved just by bagging forcing the medication into the lungs and did not need to be intubated

Case Scenario #4 911 was called to the scene for a 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? This patient is presenting in the tripod position – sitting upright and leaning forward

Case Scenario #4 Bilateral crackles and wheezing
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 Often patients in pulmonary edema are also having an MI – hard to tell which came first and triggered the other one to occur. These are critical patients and the more hypoxic and acidotic they become, the more resistant to treatment they are.

Case Scenario #4 Stable – B/P 180/110 Nitroglycerin 0.4 mg sl
EMS interventions Is patient stable or unstable? Stable – B/P 180/110 Medications to be given: Nitroglycerin 0.4 mg sl Vasodilator 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 Carefully monitor blood pressure prior to each intervention – they all can drop the blood pressure.

Bibliography Campbell, J. Basic Trauma Life Support, 5th Edition, Brady. 2004 Dalton, Limmer, Mistovich, Werman. Advance Medical Life Support, 3rd Edition. Brady 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)

First: Notes to the ECRN

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