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First: Notes to the ECRN

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Title: First: Notes to the ECRN


1
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

2
Condell as Level I Trauma Center
  • Condell ECRN will be receiving calls from farther
    out departments
  • Region IX and Region X (Lake Countys 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

3
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

4
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

5
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

6
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

7
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

8
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

9
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

10
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

11
The ECRN and Medical Control
  • The ECRN can only give orders from the SOPs
  • If orders above and beyond the SOPs 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

12
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

13
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

14
The Patient with Dyspnea
  • ECRN CE Packet Module II 2009
  • Site Code 107200-E-1209
  • Prepared by Lt. William Hoover, Wauconda Fire
  • Reviewed/revised by Sharon Hopkins, RN, BSN,
    EMT-P

15
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 patients respiratory distress.
  • Identify the components of the assessment of
    patients with dyspnea.

16
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

17
Objectives
  • Identify abnormal respiratory patterns and
    adventitious breath sounds.
  • Cheyne-Stokes
  • Kussmauls
  • Agonal respirations
  • Crackles
  • Wheezes
  • Rhonchi
  • Snoring

18
Objectives
  • Identify the main causes of dyspnea
  • Upper airway obstruction
  • Respiratory disease processes
  • Cardiovascular diseases
  • Neuromuscular diseases
  • Other causes
  • Psychogenic hyperventilation

19
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

20
Objectives
  • Identify the following medications and their EMS
    field use for patients with dyspnea
  • Albuterol
  • Benadryl
  • Benzocaine
  • Epinephrine 11000
  • 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

21
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

22
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

23
Upper Airway
Larynx joins upper and lower airways
24
Lower Airway
Alveoli are the functional units of
the respiratory system and is where gas exchange
takes place
25
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

26
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

27
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

28
Tripod position helps lungs expand
29
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

30
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

31
Assessing Patients with Dyspnea
  • Primary Assessment (ABCs)
  • SAMPLE history
  • OPQRST
  • Physical Assessment
  • Lung Sounds
  • Minimally cardiac monitor possibly 12 Lead
    EKG
  • Pulse oximetry
  • Acceptable normal 95 99
  • Mild hypoxia 91 94
  • Severe hypoxia lt91

32
All Those Initials!!!
  • ABCs
  • 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

33
Abnormal Respiratory Patterns
  • Cheyne-Stokes
  • Indicates brainstem injury
  • Progressively deeper, faster breathing
    alternating with shallow, slower breathing
  • Kussmauls
  • Commonly found in diabetic ketoacidosis and can
    be seen in Aspirin (acetylsalicylic acid)
    overdose
  • Deep, slow, or rapid gasping

34
Abnormal Patterns contd
  • Agonal
  • Indicates brain anoxia
  • Shallow, slow, or infrequent breathing

35
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

36
Auscultating Anterior Lung Sounds
37
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

38
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

39
The patient with dyspnea ?Causes ?Signs and
Symptoms ?EMS Field Treatment Options
40
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

41
Foreign Body Obstruction
Toe ring
  • Esophageal foreign bodies can also present an
    airway challenge especially if the foreign body
    moves

42
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

43
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

44
Signs Symptoms of Impaired Airway Related to
Anaphylaxis
  • Anaphylaxis
  • Hives
  • Rash that itches
  • Wheezing
  • Hypotension unique to anaphylaxis
  • Nausea
  • Abdominal cramps
  • Inability to urinate
  • Is quickly life-threatening

45
EMS Adult Anaphylaxis SOP
  • 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, medical control contacted
  • Medical Control may order Epi 110,000 IV/IO

46
EMS Pediatric Anaphylaxis SOP
  • 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, medical control contacted
  • To consider Epinephrine 110,000 at 0.01 mg/kg
    IV/IO

47
Respiratory Diseases - Asthma
  • Bronchoconstriction
  • Stimulants cause inflammatory response
  • Stimulants can include
  • Allergens
  • Weather changes
  • Exercise
  • Respiratory infections
  • Foods/medications

48
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

49
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

50
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

51
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

52
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 not
  • Inflammation of respiratory passages
  • Air trapping distal to the obstruction
  • Desensitization to a chronic state of hypoxia
  • Patients susceptible to repeat respiratory
    infection

53
COPD vs. Healthy Lungs
54
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

55
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

56
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

57
Pneumonia
58
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

59
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

60
Aspiration A Deadly Complication
61
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

62
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

63
Pneumothorax
64
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

65
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

66
Pulmonary Embolism Blood Flow Blocked
67
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

68
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

69
Cardiovascular Diseases
  • CHF with acute pulmonary edema
  • Impaired pumping ability of the heart
  • Acute Myocardial Infarction
  • Death of heart muscle

70
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

71
CHF with Pulmonary Edema
72
EMS SOP 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, Medical Control contacted for
    Albuterol order

73
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

74
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

75
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

76
Guillain-Barre Syndrome
77
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

78
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

79
Other Causes of Dyspnea
  • Anemia
  • Inadequate hemoglobin in the blood
  • Unable to supply bodys oxygen demands
  • Hyperthyroid disease increased rate of
    metabolism
  • Metabolic acidosis
  • Psychogenic hyperventilation
  • Psychological causes

80
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

81
Additional EMS Field Treatment Options
82
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)

83
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

84
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

85
Respiratory Rates
  • BVM support to patient with a heart beat rescue
    breathing
  • Adults ventilate once every 5 - 6 sec
  • Infant child ventilate once every 3 - 5 seconds
  • Once patient intubated, all patients are
    ventilated once every 6 8 seconds

86
EMS SOP 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

87
EMS SOP 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

88
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

89
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

90
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

91
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

92
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

93
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

94
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

95
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

96
Combitube
  • Placement shown is in the esophagus
  • Proximal and distal balloons both get inflated

97
Combitube contd
  • 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

98
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

99
Case Scenario Review
  • Read the cases
  • Treatment is based on the EMS SOPs
  • Determine what your response would be on the
    radio call
  • Check your own answers with the power point slides

100
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 Patients color is dusky, slightly
    diaphoretic, cannot talk in complete sentences,
    productive cough

101
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

102
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

103
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?

104
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

105
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

106
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?

107
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

108
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

109
Case Scenario 4
  • 911 was 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
    (tripod position)
  • Appearance
  • Rapid respirations with noisy ventilations
  • Cyanotic finger tips and pale, diaphoretic face
  • Using accessory muscles
  • Your impression? Further assessment? EMS
    intervention?

110
Case Scenario 4
  • 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

111
Case Scenario 4
  • 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

112
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
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