The Patient with Dyspnea

1
The Patient with Dyspnea

• April 2009 CE
• Site Code 107200-E-1209
• Prepared by Lt. William Hoover, Wauconda Fire
• Reviewed/revised by Sharon Hopkins, RN, BSN,
  EMT-P

2
Objectives

• Upon successful completion of this module, the
  EMS provider 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 patients respiratory distress.
• Discuss assessment of patients with dyspnea.

3
Objectives

• Identify history and physical exam of patients
  with dyspnea.
• Initial assessment
• SAMPLE history
• OPQRST
• Physical Assessment
• Auscultation of Lung Sounds
• 12 Lead EKG

4
Objectives

• Identify abnormal respiratory patterns and
  adventitious breath sounds.
• Cheyne-Stokes
• Kussmauls
• Agonal respirations
• Crackles
• Wheezes
• Rhonchi
• Snoring

5
Objectives

• Identify the main causes of dyspnea
• Upper airway obstruction
• Respiratory disease processes
• Cardiovascular diseases
• Neuromuscular diseases
• Other causes
• Psychogenic hyperventilation

6
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

7
Objectives

• Identify the following medications and their uses
  for patients with dyspnea
• Albuterol
• Benadryl
• Benzocaine
• Epinephrine 11000
• Lasix
• Versed
• Successfully return demonstrate intubation on the
  adult and pediatric manikins
• Successfully assemble the Albuterol kit and
  convert the kit for in-line use
• Successfully demonstrate use of the combitube if
  used by the department

8
Anatomy Physiology of Upper Airway

• Nasal cavity
• Oral cavity
• Tongue
• Uvula
• Epiglottis protects trachea during swallowing
• Vocal cords

9
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

10
Upper Airway
11
Lower Airway
12
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

13
Determining the Severity of Respiratory Distress

• Posture Sitting up, leaning on arms (Tripod)
• Unable to speak complete sentences without
  pausing to catch breath
• Breathlessness when at rest
• Imminent respiratory failure or arrest indicated
  by bradycardia, bradypnea, agonal respirations or
  apnea

14
Tripod position
15
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

16
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

17
Assessing Patients with Dyspnea

• Primary Assessment (ABCs)
• SAMPLE history
• OPQRST
• Physical Assessment
• Lung Sounds
• 12 Lead EKG
• Pulse oximetry
• Acceptable normal 95 99
• Mild hypoxia 91 94
• Severe hypoxia lt91

18
Abnormal Respiratory patterns

• Cheyne-Stokes
• Indicates brainstem injury
• Kussmauls
• Commonly found in diabetic ketoacidosis and can
  be seen in Aspirin (acetylsalicylic acid)
  overdose
• Agonal
• Indicates brain anoxia

19
Auscultating Lung Sounds

• Warm your stethoscope, have the patient cough to
  clear their airway and then youre ready to
  auscultate
• The patient should
  take deep but easy
  breaths breathing in
  and out through
  their mouth

20
Auscultating Anterior Lung Sounds
21
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

22
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

23
Main Causes of Dyspnea
24
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

25
Foreign Body Obstruction

• Esophageal foreign bodies can also present an
  airway challenge especially if the foreign body
  moves

26
Respiratory Diseases - Asthma

• Bronchoconstriction
• Stimulants cause inflammatory response
• Stimulants can include
• Allergens
• Weather changes
• Exercise
• Respiratory infections
• Foods/medications

27
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
• Irreversible airway obstruction

28
COPD vs. Healthy Lungs
29
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

30
Pneumonia
31
Aspiration A Deadly Complication
32
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

33
Pneumothorax
34
Pulmonary Embolism
35
Cardiovascular Diseases

• CHF with acute pulmonary edema
• Impaired pumping ability of the heart
• Acute Myocardial Infarction
• Death of heart muscle

36
CHF with Pulmonary Edema
37
Neuromuscular Diseases

• Muscular dystrophy
• Wasting disease of the muscles
• Amyotrophic lateral sclerosis (ALS)
• Lou Gehrigs disease
• Muscular dystrophy caused by degeneration of
  motor neurons of the spinal cord
• Guillain-Barre syndrome
• Myasthenia gravis

38
Guillain-Barre Syndrome
39
Other Causes of Dyspnea

• Anemia
• Inadequate hemoglobin in the blood
• Unable to supply bodys oxygen demands
• Hyperthyroid disease increases rate of
  metabolism
• Metabolic acidosis
• Psychogenic hyperventilation
• Psychological causes

40
Signs and Symptoms for Patients with Dyspnea
41
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

42
Signs Symptoms of Impaired Airway

• Anaphylaxis
• Hives
• Rash that itches
• Wheezing
• Hypotension unique to anaphylaxis
• Nausea
• Abdominal cramps
• Inability to urinate
• Is quickly life-threatening

43
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

44
COPD

• 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 are not
• Inflammation of respiratory passages
• Air trapping distal to the obstruction
• Desensitization to a chronic state of hypoxia
• Patients susceptible to repeat respiratory
  infection

45
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

46
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

47
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 (lt20)
• Young individuals with tall, thin body types are
  most susceptible
• Tachypnea
• Diaphoresis
• Possible subcutaneous emphysema

48
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

49
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

50
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

51
Treatment Options
52
Treatment Airway Obstruction

• Foreign body
• Remove the object
• Patient can cough on own or rescuer needs to
  apply the Heimlich (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

53
Treatment Adult Anaphylaxis

• Anaphylaxis patient unstable
• Altered mental status B/P lt100 systolic
• Support airway intubate as necessary
• IV wide open (1000 ml normal saline)
• Epi 11000 IM 0.5 mg
• Benadryl 50 mg IVP slowly over 2 min or IM
• If wheezing, Albuterol 2.5mg/3ml
• May repeat
• If worsening, contact medical control
• Medical Control may order Epi 110,000 IV/IO

54
Treatment Pediatric Anaphylaxis

• Anaphylaxis patient unstable
• Altered mental status
• Epi 11000 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, contact medical control
• To consider Epinephrine 110,000 at 0.01 mg/kg
  IV/IO

55
Treatment of Asthma

• 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

56
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
• Provide in-line Albuterol therapy 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

57
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

58
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

59
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

60
Treatment of Stable Pulmonary Edema B/P gt100 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, contact Medical Control for
  Albuterol order

61
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

62
Treatment of Cardiac Complaints

• At minimum consider EKG monitor
• 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
• Contact ED early to decrease door to balloon time
• Transmit 12 lead EKG to hospital
• Treat abnormal rhythms

63
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

64
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

65
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)

66
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

67
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

68
Conscious Sedation Intubation

• Indications
• Failure to maintain adequate airway or for risk
  of aspiration
• Actual or impending respiratory failure
• GCS lt8 due to head injury
• Inability to ventilate/oxygenate patient after
  insertion of airway and/or BVM
• Anticipated deterioration

69
Conscious Sedation Intubation

• Contraindication
• Age less than 16
• Need permission from Medical Control
• B/P lt 100mmHg
• Known hypersensitivity or allergy to the
  medication
• Consider risk vs benefit if the patient is
  pregnant

70
Conscious Sedation Medications

• Lidocaine 1.5 mg/kg IVP only once
• If head injury/insult to decrease cough reflex
• Versed 5 mg IVP relax/sedate 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
• Morphine 2 mg IVP slow over 2 minutes relax pt
• Repeat every 3 minutes to a max of 10 mg
• Benzocaine spray eliminate gag reflex
• Limited to 1-2 short sprays to posterior pharynx

71
In-line Albuterol Kit

• Albuterol can be delivered via BVM or through ET
  tube
• Prepare kit as usual but take mouthpiece off
• Add BVM to where mouthpiece was
• Add adaptor to distal end of corrugated tube and
  prepare 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

72
In-line Albuterol Kit

• Take off mouthpiece and replace with BVM
• Add adaptor to end of blue corrugated tubing and
  attach to mask (or ET tube)
• Can begin to ventilate patient before intubation

73
CPAP Device

• Place a non-rebreather O2 mask while setting up
  the equipment
• Medications are administered along with CPAP
• Medications and CPAP used can all cause a drop in
  blood pressure monitor carefully
• Connect fixed Whisperflow generator to portable
  O2 regulator
• Open packaging and attach patient corrugated
  tubing to bottom of generator
• Add filter to side of generator

74
CPAP contd

• Attach other end of patient tubing to bottom of
  mask
• Attach 10 cm isobaric peep valve to front of mask
• Connect head strap to top one side of mask
• Turn on O2 tank
• Place mask over patients face and make final
  strap connections
• Quick connect generator to on-board O2 source
  during transport

75
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

76
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

77
Combitube

• Hyperventilate patient prior to insertion
• Check and prepare equipment lubricating distal
  tip
• Perform a tongue-jaw lift
• Insert device in mid-line and to depth until
  printed ring is at level of teeth
• Inflate pharyngeal cuff with 100 ml of air
• Inflate distal cuff with 15 ml of air

78
Combitube

• Placement shown is in the esophagus
• Proximal and distal balloons both get inflated

79
Combitube contd

• Begin ventilations via tube 1
• Confirm placement
• 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

80
Case Scenario 1

• 911 is 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 Patients color is dusky, slightly
  diaphoretic, cannot talk in complete sentences,
  productive cough

81
Case Scenario 1

• What else needs to be done during the assessment
  phase?
• History is this problem old or new
• Lung sounds
• EKG monitor possibly 12 lead based on
  assessment findings
• Sputum is dark brown

82
Case Scenario 1

• Patient found to have exacerbation of signs and
  symptoms of COPD with wheezing possibly a
  secondary lung infection
• 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

83
Case Scenario 2

• You have arrived at the scene of a local fast
  food chain for a 3 year-old choking victim
• Upon your arrival you note the patient is
  conscious and appears exhausted while clutching
  at their throat, color is pale, and they have a
  weak cough
• As you approach, the child looks at you with wide
  eyes and is trying to cough but is now no longer
  making any sound
• What is your assessment your action plan?

84
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

85
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?
• Dont 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

86
Case Scenario 3

• You are 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 do you need to
  assess? What is your treatment?

87
Case Scenario 3

• Initial impression acute asthma attack
• Assessment
• 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

88
Case Scenario 3

• The patient is so exhausted, their level of
  consciousness is deteriorating and SpO2 is
  falling
• Prepare for in-line Albuterol administration and
  intubation
• With kit already set up, remove mouthpiece and
  attach BVM
• Attach connector to blue corrugated tubing and
  then to mask to bag patient to deliver medication
  to the lungs
• Prepare to intubate patient if situation does not
  improve
• Intubate patient and confirm placement
• Connect adaptor to ET tube in place of mask
• Confirm ET tube placement

89
Case Scenario 4

• 911 is called to the scene for a 68 year-old male
  with sudden onset of difficulty breathing
• Patient is sitting upright on a chair, leaning
  forward resting their arms on their thighs
• Appearance
• Rapid respirations with noisy ventilations
• Cyanotic finger tips and pale, diaphoretic face
• Using accessory muscles
• Your impression? Further assessment? Intervention?

90
Case Scenario 4

• Further assessment
• 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

91
Case Scenario 4

• Interventions
• Is patient stable or unstable?
• Stable B/P 180/110
• Medications
• Nitroglycerin 0.4 mg sl
• Vasodilator
• Lasix 40 mg IVP (80 mg if used at home)
• Morphine 2 mg IVP
• If wheezing, request Albuterol from Medical
  Control
• Device
• CPAP keep alveoli open

92
Bibliography

• Campbell, J. Basic Trauma Life Support, 5th
  Edition, Brady. 2004
• Dalton, Limmer, Mistovich, Werman. Advance
  Medical Life Support, 3rd Edition. Brady. 2007.
• 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)
• www.WebMD.com

93
Thanks and Be Safe!

• Please provide suggestions for improving this
  presentation on your evaluation form.