Region VIII EMS Systems

July 2016

Introduction

• SME video of the month

• Review of Respiratory SOPs

• Three scenarios

Announcements

• Region-None

• System- New SOP’s In Effect July 1st

Dyspnea

• Common type of emergency call in EMS

• Has various causes

• Is both a sign and a symptom

• Sensation of breathlessness or inadequate breathing

• Can be acute or chronic

Differential Diagnosis of Dyspnea

• In disease states the cause is usually a result of cardiac,

pulmonary pathology or trauma

• Severe dyspnea is a medical emergency if not treated

appropriately respiratory failure and death can occur

• When eliciting a history it is helpful to determine if the

dyspnea is acute or chronic utilizing

– Sample

– OPQRST

Dyspnea

• Acute– Asthma

– Carbon monoxide poisoning

– Cardiac tamponade

– Heart failure

– Myocardial infarction

– Hypotension

– Pulmonary embolism

– Pneumothorax

– Pneumonia

– Upper airway obstruction

• Chronic– Asthma

– COPD

– Deconditioning

– Heart dysfunction

– Interstitial lung disease

– Obesity

Differential Diagnosis Dyspnea

• Common Respiratory Causes

– Foreign body Aspiration (upper /

middle airway)

– Anaphylaxis (upper airway)

– Pulmonary Embolism (lower

airway)

– Pneumothorax (lower airway)

– Tension pneumothorax (lower

airway)

– Croup (upper airway)

– Acute epiglottitis (upper airway)

– Asthma (lower airway)

– COPD (lower airway)

– Pneumonia (lower airway)

Differential Diagnosis of Dyspnea

• Right and left heart failure

• Myocardial infarction

• Cardiomyopathy

• Valvar dysfunction

• Pericarditis

• Arrhythmias

• Hypovolemia

H’s & T’s

• Hypoxia,

• Hydrogen ion (acidosis), Hyper-

/hypokalemia

• Hypothermia

• Hypoglycemia

• Toxins/Tamponade

• Tension pneumothorax

• Thrombosis

• Trauma

Cardiac causes of dyspnea include

Dyspnea Scales

Location and lung soundsLocation Sound Phase Disease Process

Upper Airway Stridor Inspiration Viral Croup

Epiglottitis

Foreign Body Aspiration

Lower Airway Rhonchi Primarily Expiration Frank Aspiration

Bronchitis

Cystic Fibrosis

Wheeze Primarily Expiration Reactive airway disease

Asthma

Congestive heart failure

Emphysema

Endobronchial obstruction

Crackles End Inspiration Pneumonia

Exacerbation of congestive heart failure

Pulmonary edema

Diminished breath sounds Either or both Emphysema

Atelectasis

Pneumothorax (simple or tension)

Flail chest

Neuromuscular disease

Pleural effusion

Chest Wall Pleural rub Either Pleuritis

Pleurisy

Pleural effusion

Upper Airway

• Main symptoms of upper airway problem are

– Dyspnea

– Noisy breathing

• More prominent during exercise

• May be aggravated by change in body position

• Breathing is labored and increases if lying supine

Upper Airway

• Signs occur mostly during inspiration

– Change in voice: Hoarseness, barking cough

– Inspiratory stridor

– Cyanosis, drooling

– Nasal flaring

– Tachypnea

– Retractions

– Poor air entry on auscultation

– Prolonged inspiratory phase

Upper Airway

• Noisy breathing:

– Snoring: Indicates partial obstruction of the upper airway that

causes a vibration of air as it passes thru the nasopharynx and

oropharynx (tongue)

– Stridor: A harsh, continuous crowing sound. Mostly occur

during inspiration

Upper Airway

• Conditions include

– Foreign body obstruction

– Pharyngeal edema

– Croup

– Epiglottitis

– Anaphylaxis

Angioedema

• Rapid swelling of the dermis, subcutaneous tissue

mucosa and submucosal tissues

• Skin is swollen, tender and warm

• May last days or resolve spontaneously

Angioedema• Substances known to trigger allergic angioedema

– Certain types of food particularly nuts, shellfish, milk, eggs

– Certain medication- penicillin, aspirin, NSAIDS

– Insect bites and stings

– Latex

• Cases without an identifiable cause are known as idiopathic

angioedema. May be a problem with the immune system

causing it to misfire. Triggers include:

– Anxiety - Hot or cold temps

– Stress - Exercise

– Minor infections

Angioedema

• Hereditary angioedema is caused by a genetic mutation in

the C1 esterase inhibitor

• The body does not produce enough of this C1 protein

• C1 plays an important role in regulating the immune

system

• Triggers include : Trauma- including surgery and

infection, oral contraceptives, and pregnancy

Angioedema

• Acute episodes often involve the lip, eyes, and face.

• May also affect other parts of the body including

respiratory and gastrointestinal mucosa.

• Laryngeal swelling can be life threatening

• Often associated with local burning sensation and pain

• Pronounced itchiness and local erythema

Angioedema

• Severe attacks can indicate the onset of systemic

anaphylaxis

• Characterized initially by dyspnea

• Medications used in treating urticaria and anaphylaxis are

also used in treating angioedema

• In severe cases of laryngeal edema a surgical airway may

be needed

Angioedema

Upper Airway Condition

Anaphylaxis

• Serious life threatening allergic reaction

– Most common causes

• Food

• Latex

• Medications

• Insect stings

• Envenomation

Upper Airway Condition

Anaphylaxis• Signs and symptoms

– A swollen tongue or throat, which can cause wheezing

(wheezing is a lower condition) and dyspnea

– A weak and rapid pulse

– Nausea, vomiting or diarrhea

– Dizziness or fainting

– Abdominal pain

Upper Airway Condition

Anaphylaxis • Signs and symptoms

(continued)Skin reactions, including

hives itching, and flushed

or pale skin

– A feeling of warmth

– The sensation of a lump in the

throat

– Constriction of the airway

– Chest pain

– Headache

– Rhinitis

ADULT ALLERGIC REACTION / ANAPHYLAXIS

BLS/ALS 1. Adult Initial Medical Care SOP, p. 4-5 2. Apply ice/cold pack to site 3. BLS: at the direction of Medical Control, administer one dose EPINEPHRINE auto-

injector (EpiPen®)

ALS Allergic reaction with systemic signs, i.e. wheezing, diffuse hives, or prior history of systemic reaction, without signs of hypoperfusion 4. Administer BENADRYL (diphenhydramine) 50 mg IM or slow IV/IO. Max dose 50

mg. 5. Administer EPINEPHRINE 1:1000 0.3 mg IM. May repeat x 1 after 15 minutes if

minimal response

If age > 50 years old and/or cardiac disease history, contact Medical Control prior to administration of EPINEPHRINE

6. If wheezing, consider ALBUTEROL 2.5 mg (3 mL) via nebulizer

ALS Anaphylaxis: multisystem reaction with signs of hypoperfusion; altered mental status or severe respiratory distress/wheezing/hypoxia 1. If signs of hypoperfusion, IV/IO FLUID BOLUS in 200 mL increments

Administer EPINEPHRINE 1:10,000 0.5 mg slow IV/IO or EPINEPHRINE 1:1000 0.5 mg IM. May repeat EPINEPHRINE q 3 minutes

2. Administer BENADRYL (diphenhydramine) 50 mg slow IV/IO

If no IV, give BENADRYL (diphenhydramine) 50 mg IM

No repeat dose 3. If wheezing, consider ALBUTEROL 2.5 mg (3 mL) via nebulizer 4. Consider DOPAMINE per CARDIOGENIC SHOCK SOP, p. 23, for refractory

hypotension

Note

EPINEPHRINE may be given IM if IV/IO access delayed.

EpiPen

Auvi-Q

• Epinephrine auto injector

• Same dosing as the EpiPens

– 0.3mg IM

– 0.15mg IM

• Talks to the patient

– Walks them through the steps for injection

Change in epinephrine ratios

Epinephrine

• Confusion has been associated with numerous

medication errors over the years

• The new epinephrine labeling will only be displayed on

mass concentrations

• 1:1000 will be labeled 1mg/ml

• 1:10,000 will be labeled 0.1mg/ml

• Effective May 1, 2016

Epinephrine

Capnography

• Measures:– Ventilation: for patient with a pulse

– Perfusion: When patient is pulseless

– Partial pressure (mmHg) or volume (% vol) of CO2 in the

airway at the end of exhalation

– Breath-to-breath measurement provides information within

seconds

– Not affected by motion, artifact, poor perfusion or dysrhythmias

Capnography

• Reflects how effective our interventions are

• Can be utilized to more objectively determine a patient’s

respiratory distress

• Provides earliest, most accurate indication of respiratory

distress

• Changes in capnography waveform provide earliest

indication of apnea, upper airway obstruction and

laryngospasm or worsening of patient’s condition

Capnography

• Utilization in upper airway conditions

• Apnea:

– No waveform, no chest wall movement, no breath sounds

• Upper airway changes or obstruction:

– chest wall moving

– decrease or no breath sounds

– May be responsive to airway maneuvers with a return of

waveform or improvement in waveform

Capnography

Lower airway

• Lung/Lower airway Causes

– Pneumonia

– Pneumothorax

– Pulmonary embolism

– Interstitial lung disease

– Adult Respiratory Distress Syndrome

– COPD

– Asthma

Lower Airway

• Signs and Symptoms

– Tachypnea

– Wheezing (expiratory most common)

– Increased respiratory effort

– Retractions

– Prolonged expiration

Lower Airway Condition

Pulmonary Embolism • A sudden blockage in the lung usually caused by a clot

that formed in the smaller vessels such as arms, legs,

pelvis

Lower Airway Condition

Pulmonary Embolism• Signs and symptoms

– Sudden onset chest pain

• Sharp, knife like or deep ache that worsens with inspiration

– Dyspnea

– Anxiety

– Cough

– Diaphoresis

– Syncope

– Tachycardia

– Tachypnea

– Decrease ETCO2 (<20 mmHg) despite normal respiratory rate and

perfusing rhythm

Lower Airway Condition

Pulmonary Embolism • A popular prehospital assessment tool for patient with

respiratory complaints is end tidal CO2 (EtCO2)

• In patients with pulmonary embolism, expect to see

normal (35-45mmHg) to slightly low EtCO2 resulting from

tachypnea and a normal waveform

• Deliver oxygen to maintain SPO2 above 94%

12 lead changes with PE

12 Lead

Pulmonary Embolism

BLS Scenario

• Medic is dispatched for a 20 y/o female complaining of

shortness of breath

• You arrive on the scene and observe the patient sitting in

a chair in the tripod position

• States watching TV when developed sudden onset of pain

between shoulder blades

• Pt is agitated, short of breath, and has faint cyanotic color

to her face

BLS Scenario

• VS BP 98/62, HR 118, RR 32 and shallow

• SPO2 89% with decreased breath sounds on right and

clear on left

• What are your priorities

• What information do you need

• What is your immediate treatment

Lower Airway Condition

Pneumothorax A pneumothorax occurs when

the potential space between the

parietal and visceral pleura of

the lung fills with air and

collapses the lung. It can occur

spontaneously or following

trauma or pathology

Lower Airway Condition

Primary Spontaneous Pneumothorax

• Risk factors Spontaneous Pneumothorax

– Age 15-30 years old

– Male have higher incidence than women

– Tall thin stature

Lower Airway Condition

Secondary Pneumothorax• Secondary pneumothorax occurs in the presence of existing lung

pathology

• Pneumonia is a possible cause of pneumothorax. Consider

Pneumocystis jiroveci pneumonia (PCP) , toxoplasmosis, and

Kaposi sarcoma in patients with human immunodeficiency virus

infection (HIV). A patient with HIV can have spontaneous

pneumothorax as the presenting symptom of their illness. HIV

carries a lifetime risk of 6% for pneumothorax, and about 85% of

that number is related to PCP pneumonia.

Lower Airway Condition

Secondary Pneumothorax

– Risk Factors

• History of Asthma, COPD, Cystic Fibrosis, TB, Whooping

cough

• Previous history of pneumothorax

• Smoking

• Lung Cancer

• HIV

Lower Airway Condition

Primary and Secondary Pneumothorax• Signs and symptoms vary greatly depending on how

much air enters the pleural space

– Sudden onset chest pain may describe as sudden, sharp, or

stabbing increases when taking deep breath

– Dyspnea

– Tachycardia

– Tachypnea

– Pulses paradoxes

– Hypoxia and altered mental status

– Absent or diminished lung sounds on affected side

Pneumothorax

Lower Airway Condition

Asthma• Obstructive lower airway

diseases are characterized

by diffuse obstruction to

airflow within the lungs.

• The most common

obstructive airway diseases

are emphysema, chronic

bronchitis and asthma.

Lower Airway Condition

Asthma

• Asthma prevalence is higher in children than adults

• Children who have wheezing that begins prior to 5 years

old and persists into adulthood have increased risk of

developing asthma

• Children who have a lower incidence of pulmonary

disease even after age 5 have a lower incidence of

pulmonary disease even if the wheezing persists into

adulthood

Lower Airway Condition

Asthma

Signs and symptoms

– Wheezing

– Dyspnea

– Chest tightness

– Cough

• Signs of recent upper respiratory

infection

– Rhinorrhea, congestion,

headache , pharyngitis, and

myalgia

• Signs of exposure to allergens

– Rhinorrhea

– Pharyngitis

– Hoarseness

– Cough

– Chest tightness, discomfort, or

pain

Capnography

Lower Airway Condition

COPD• COPD is an airflow obstruction caused by chronic

bronchitis or loss of alveolar surface area associated with

emphysema

• Characterized by some degree of wheezing and airway

edema even though the mechanism is slightly different

from asthma

Lower Airway Condition

COPD• Factors indicating severe exacerbation of COPD

– Oxygen saturation <90%

– Tachypnea

– Peripheral or central cyanosis

– Mental status changes caused by hypercapnia

– ETCO2 waveform

– ETCO2 readings

Lower Airway Condition

COPD• Signs and symptoms

– Dyspnea

– Exertion intolerance

– Wheezing

– Productive cough

– Chest pain or discomfort

– Diaphoresis

– Orthopnea

– Increased respiratory rate

– Decreased oxygen saturation

Capnography

Treatment COPD

• Emergency management

– Oxygen to maintain saturation of 92%*

• An oxygen saturation that falls into the 80’s and pale or cyanotic

extremities requires aggressive airway and ventilation management

• CPAP has been shown to decrease work of breathing, increase

oxygenation and decreasing the need for intubation

• NEVER WITHOLD OXYGEN FROM A HYPOXIC PATIENT

CPAP

• Improves respiratory function in asthma/COPD

• Improvement seen due to:

– Decrease work of breathing/ reduction in fatigue

– Improved oxygenation

– Splinting of larger airways and bronchioles to reduce airway

collapse and mucous plugging

ADULT ACUTE ASTHMA COPD WITH WHEEZING

REACTIVE (LOWER) AIRWAY DISEASE

BLS 1. Adult Initial Medical Care SOP, p. 4-5

2. If patient has prescribed inhaler, obtain time of last usage. If appropriate, assist

patient with prescribed inhaler.

3. Reassess patient's respiratory status and begin transport

4. At discretion of Medical Control, additional doses of inhaler may be given

5. ALBUTEROL 2.5 mg (3 mL) via nebulizer per System-specific procedure

6. Consider possibility of congestive heart failure (CHF) / pulmonary edema in

wheezing patient, if patient has a history of CHF, and/or pulmonary edema. If so,

treat per PULMONARY EDEMA SOP, p. 22.

ALS 1. Adult Initial Medical Care SOP, p. 4-5 2. ALBUTEROL 2.5 mg (3 mL) via nebulizer 3. Partial response: repeat ALBUTEROL immediately 4. If no response to ALBUTEROL or patient in severe respiratory distress:

consider NIPPV / CPAP per System-specific procedure

If age ≤ 50 and patient has no history of cardiac disease, consider EPINEPHRINE 1:1000 0.3 mg IM

If age > 50 and/or cardiac disease history, contact Medical Control

5. If imminent respiratory arrest, INTUBATE and use in-line ALBUTEROL 2.5 mg (3 mL)

Hyperventilation syndrome

• Respiratory disorder, psychologically or physiologically

based, involving breathing to deeply or too rapidly

• Causes are unknown

• Sudden and everyday are two forms

• Causes carbon dioxide levels to decrease

Hyperventilation syndrome

• Lower levels of carbon dioxide reduce blood flow to the

brain resulting in nervous system and emotional

symptoms– Weakness

– Fainting

– Dizziness

– Confusion

– Agitation

– Feeling as if you can’t breathe

Hyperventilation

• Over breathing can also cause Calcium levels to drop in your blood which

results in these CNS symptoms

– Numbness and tingling (in arms and around mouth)

– Spasms or cramps in hands and feet

– Muscle twitching

• May also cause cardiac symptoms– Chest pain or tenderness

– Shortness of breath

– Wheezing

Hyperventilation Syndrome

• Symptoms usually last longer (hours as apposed to

minutes)

• Usually happens in younger people

• Improves with exercise

• Pain does not improve with medication

Hyperventilation Syndrome

• Medical conditions can cause hyperventilation

• In children a medical cause is more likely than stress

• Administer oxygen

• Paper bag treatment is no longer considered appropriate

• Tetany, paresthesia and carpopedal spasm may occur

Hyperventilation syndrome

Hyperventilation Syndrome

ALS Scenario

• Medic is dispatched for the 60 year old female with

shortness of breath

• Pt is in tripod position with increased work of breathing

and accessory muscle use, breathing at a rate of 40 and

unable to speak more than one word/sentence

• She tells to you I…..can……’t……….breathe

ALS Scenario

• HPI= per patient’s husband, patient awoke this morning

with shortness of breath and has experienced increased

work of breathing with exertion

• Patient has recent history of a cold, but husband

concerned she may now have pneumonia

• PMHX- diabetes, heart failure, hypertension

• Medications: Lasix 80 mg bid, digoxin 0.125mg daily,

Regular insulin 30u twice daily , Levaquin and an

albuterol inhaler

ALS Scenario

• VS 170/104 HR 118 RR 28 SPO2 87% RA

• ECG

• What are your treatment priorities

Case Scenario

• You are dispatched for the patient complaining of

shortness of breath at the local rehab facility You find a

40 year old, obese female, lying supine on her bed with

very labored respirations audible from outside the room

• The patient is staring at the ceiling and does not respond

to your presence Patient is pale with cyanosis around the

lips. Staff disappears when you get there

Scenario

• Assessment reveals

– Airway- Patent, no vomitus or obstruction

– Breathing- Shallow, very labored and rapid at 36 bpm with lung sounds

diminished and audible rales in all fields Perioral and peripheral cyanosis

present

– Circulation- Skin is pale, cool, diaphoretic No trauma or bleeding Pulse

difficult to palpate

– GCS = 3

– History CHF, COPD, recent hip replacement surgery

Case Scenario• Initial Capnography waveform

• Placed on Hi flow oxygen at 15

L/m via BVM

Scenario

• Potential causes

• Treatment

• Rapid transport

Questions?