Respiratory Emergencies

1. Respiratory Emergencies Trinity EMS

2. Focused History for Responsive Medical Patient History of the present illness SAMPLE history Focused physical exam Baseline vital signs

3. History of Present Illness O – Onset (what were you doing when it started?) P – Provokes (does anything make it better or worse?) Q – Quality (can you describe what it feels like?) R – Radiation (does the pain travel to other body parts?) S – Severity (0-10 scale with 10 being the worst) T – Time (When did this start)

4. SAMPLE History S – Signs and symptoms A – Allergies M – Medications P – Previous medical history L – Last oral intake E – Events leading to the illness

5. Focused Physical Exam Quick assessment of the following areas: Head Neck Chest Abdomen Pelvis (not necessary if CC is respiratory) Extremities Posterior

6. Vital Signs Respirations (rate, quality, depth) Pulse Skin color, temperature, condition (capillary refill in infants and children) Pupils Blood pressure O2 saturation (pulse oximeter) Never rely on pulse oximeter as your only verification of a respiratory problem. Poor pulses, cold extremities and other factors can skew the reading.

7. Interventions and Transport Perform interventions as needed and transport the patient. Consider ALS intercept if patient condition warrants it.

8. Focused History for Unresponsive Medical Patient Perform rapid physical exam Obtain baseline vital signs Consider request for advanced life support Take a history of the present illness and a SAMPLE history from family or bystanders

9. Adequate Breathing Rates Adult 12-20 breaths per minute Child 15-30 breathes per minute Infant 25-50 breaths per minute Be sure to check the depth of breathing also. Rate alone is not an indicator of sufficient respirations.

11. Assessing Lung Sounds Wheezes – high-pitched sounds which indicate narrowing of lower airways. Common in asthmatics and COPD patients. Crackles – fine bubbling sounds causes by fluid in the alveoli usually heard on inspiration. Rhonchi – lower pitched sounds that resemble rattling caused my mucous in the larger airways. (should be able to clear with a cough) Stridor – high pitched sound heard on inspiration that indicates a partial obstruction of the trachea or larynx.

14. Medication Administration Assure the four “rights” for administration of a medication: Right patient Right medication Right dose Right route

15. Prescribed Inhalers Generic: albuterol, isoetharine, metaproterenol Trade Name: Proventil, Ventolin, Bronkosol, Bronkometer, Alupent, Metaprel

16. Prescribed Inhalers Indications: Patient exhibits signs and symptoms of respiratory emergency. Patient has physician prescribed hand-held inhaler. Medical direction gives specific authorization to use.

17. Prescribed Inhalers Contraindications: Patient is unable to use device (not alert). Inhaler is not prescribed for patient. No permission has been given by medical direction. Patient has already taken maximum prescribed dose prior to EMT-B’s arrival.

18. Prescribed Inhalers Dosage: Number of inhalations is based on medical direction or physician’s order. Actions: Beta agonist bronchodilator dilates bronchioles, reducing airway resistance. Side Effects: Increased pulse rate Tremors Nervousness

19. Prescribed Inhalers Reassessment Strategies: Gather vital signs Perform focused reassessment of chest and respiratory function Observe for deterioration of patient, if breathing becomes inadequate, provide artificial respirations

20. Respiratory Distress (SMO) FR Routine Medical Care Position of comfort

21. Respiratory Distress (SMO) BLS FR care Oxygen 2-6 LPM via nasal cannula (if on home O2, increase by 1 LPM). History of bronchodilator therapy within past four hours. Prescribed inhaler – assist patient with medication

22. Respiratory Distress (SMO) Contact Medical Control for nebulizer therapy. Medications utilized The first held nebulizer treatment > 12 years old Proventil 0.083% solution, 3 ml, unit dose Atrovent 0.02% solution, 0.5 mg/2.5 ml, unit dose Empty both medications into nebulizer reservoir The second and subsequent nebulizer treatments for adults and children > 12 years will be: Proventil 0.083% solution, 3 ml, unit dose Empty the full unit dose Proventil Solution into nebulizer reservoir For Children < 12 years of age all nebulizer treatments will be: Proventil 0.083% solution, 3 ml unit dose Empty unit dose Proventil Solution (0.083% / 3ml) into nebulizer reservoir

23. Respiratory Distress (SMO) Instruct patient to breathe calmly and deeply Vitals – monitor Treatment Connect to oxygen and flow at 6 LPM Lasts 5-15 minutes Epipen Auto-injector 0.3 mg IM Transport ASAP

24. Contraindications to nebulizer therapy > 6 treatments within the past 2 hours Allergy to Albuterol (Ventolin, Proventil), or Atrovent (Ipratroprium Bromide) HR >170 minute BP > 160/100 Contraindication to Atrovent = allergy to soy lecithin or related food products such as soybean or peanuts.

25. Acute Pulmonary Edema FR Routine Medical Care BLS Routine Medical Care Sit patient up (High Fowlers), feet dangling Loosen clothing Oxygen 10-15 LPM nonrebreather mask if tolerated (if not tolerated, 4-6 LPM per nasal cannula). If breathless/see cardiac arrest protocol NTG – if systolic BP >100, may repeat every 5 minutes to a maximum of 3 doses. Consider ALS assist, Transport ASAP

26. Anaphylactic Shock

27. Anaphylactic Shock FR Routine Medical Care BLS Routine Medical Care O2 10-15 LPM by NRB mask (if NRB mask not tolerated, give O2 at 4-6 LPM) Epipen 0.3 mg IM (1:1000) Transport ASAP Epipen 0.3 mg IM may repeat in 5 minutes

28. Signs / Symptoms of Anaphylaxis Cardiovascular: hypoperfusion Respiratory: Acute respiratory distress, stridor, wheezing CNS: Headache, dizziness, and seizure GI: Abdominal pain, nausea, vomiting, and diarrhea Skin: Hives, flushing, itching