Respiratory emergencies take two Flashcards
How does wheezing sound like?
high-pitched, musical, whistling sound that is best heard initially on exhalation but can also be heard during inhalation in more severe cases.
What is wheezing an indication of?
swelling and constriction/narrowing of the lower airways, typically due to bronchoconstriction, inflammation, or mucus.
If wheezing is diffuse, what does that mean and it is a primary indication of what?
diffuse (heard over all the lung fields) is a primary indication for the administration of a beta 2 agonist medication by metered-dose inhaler (MDl) or by small-volume nebulizer (SVN). (vasodilator)
In which conditions is wheezing typically heard in?
Wheezing is usually heard in asthma, emphysema, and chronic bronchitis. It can also be heard in pneumonia, congestive heart failure, and other conditions WHEN they cause bronchoconstriction
With severe obstruction of the lower airways by bronchoconstriction and inflammation, what can happen to the wheezing sound
It can significantly diminish or become absent because the velocity of the air moving is no longer adequate
How does Rhonchi (AKA coarse crackles) sound like?
snoring or rattling noises
What does Rhonchi indicate?
They indicate obstruction of the larger conducting airways of the respiratory tract by think secretions of mucus
In what conditions is Rhonchi typically heard in?
chronic bronchitis, emphysema, aspiration, and pneumonia.
What is unique about Rhonchi?
the quality of sound changes if the person coughs or sometimes even when the person changes position.
How does crackles (AKA rales) sound like?
bubbly or crackling sounds heard during inhalation
What does rales indicate?
fluid has surrounded or filled the alveoli or small bronchioles. The crackling sound is commonly associated with the alveoli and terminal bronchioles “popping” open with each inhalation.
Where do you typically hear crackles first?
The bases of the lungs posteriorly reveal crackles because of the natural tendency of fluid to be pulled downward by gravity
In which conditions is crackles heard in?
pulmonary edema or pneumonia
Patho of emphysema?
The lung tissue loses its elasticity, the alveoli become distended with trapped air, and the walls of the alveoli are destroyed. Loss of the alveolar wall reduces the surface area in contact with pulmonary capillaries. Therefore, a drastic disruption in gas exchange occurs and The patient becomes progressively hypoxemic and begins to retain carbon dioxide.
Unique S/S of emphysema?
*Pursed lips to create positive end expiratory pressure
*barrel chest
*hyperventilation
*use of accessory muscles
*Wheezing and Rhonchi sounds
Patho of chronic bronchitis?
Chronic bronchitis involves inflammation, swelling, and thickening or the lining of the bronchi and bronchioles and excessive mucus production. The inflamed and swollen bronchioles and thick mucus restrict airflow Lo the alveoli so that they do noL expand fully, causing respiratory distress and possible hypoxia.
Unique S/S of chronic bronchitis?
*a productive cough that persists for at least three consecutive months a year for at least two consecutive years (HALLMARK SIGN)
*crackles and crackles usually heard
*Wheezes and, possibly, crackles at the bases or the lungs
*Asterixis (flapping of the extended wrists)
Emergency medical care for COPD patients? (Emphysema and chronic bronchitis)
- Open airway
- Adequate breathing
- Position of comfort
- Administration of supplemental oxygen (start with NC at 2L/min and rising up to 6L/min and/or 1L above their home oxygen. reach 88%-92%)
- Use MDI or SVN
You should use CPAP for an COPD patient if….
*Moderate to severe dyspnea with the use of accessory muscles and paradoxical abdominal movement
*Respiratory rate >25 per minute
(do pressure at 5-10 cm H2O)
In an COPD patient, if CPAP is not helping the patient and their condition is deteriorating, you should….
Remove the CPAP device and begin BVM ventilation
Patho of Asthma?
Asthma is characterized by an increased sensitivity of the airways to irritants and allergens, causing bronchospasm, which is a diffuse, reversible narrowing of the bronchi and bronchioles, as well as inflammation to the lining of the lower airways.
What contributes to increased air resistance in an asthma patient?
*Bronchospasm (constriction of the smooth muscle in the bronchi and bronchioles)
*Edema (swelling) of the inner lining in the airways
*Increased secretion of mucus that causes plugging of the airways
A prolonged life-threatening attack that produces inadequate breathing and severe signs and symptoms is called
acute severe asthma or status asthmaticus
acute severe asthma or status asthmaticus does not respond to…
oxygen, bronchodilators, or steroids. TRANSPORT NOWWWWW
What are the two types of asthma?
*Extrinsic asthma, or “allergic·· asthma, usually results from a reaction to dust, pollen, smoke, or other irritants in the air. It is typically seasonal, occurs most often in children, and can subside after adolescence. *Intrinsic, or “nonallergic,·· asthma is most common in adults and usually results from infection, emotional stress, or strenuous exercise.
Unique S/S of Asthma?
*Chest tightness
*Wheezing
*Use of accessory muscles
*Speaks in sentences (mild), phrases (moderate), or words/syllables (severe)
*Pulsus paradoxus (drop in systolic of greater than 10 mmHg during inhalation)
Approximately 80 percent of the cases of asthma have a slow onset (referred to as slow-onset asthma) with deterioration over a minimum of 6 hours to several days. True or false
True
80 percent of cases present with rapid deterioration within the first 6 hours after onset. True or false
False (just the percentage)
In an asthma event,
indicators of a critically ill asthma attack patient are:
*Pulsus paradoxus (a drop in systolic blood pressure of 10 mmHg or more on inhaling)
*SpO2 less than 90% while on supplemental oxygen
Treatment for asthma?
1.Established and maintained an airway,
2. applied oxygen with supplemental oxygen via NC, greater than 94%, or begun positive pressure ventilation with BVM 10-12 per min for SEVERE asthma
3. Assessed the adequacy of circulation.
4. Administracion of a short-acting beta 2 agonist (SABA) can reverse the bronchoconstriction. via a small volume nebulizer (SVN); however, a metered-dose inhaler (MDl) can be used. Unfortunately, the SABA dilates only the bronchi and bronchioles and does not reverse the infammation. Therefore, you might see lim ited improvement after the administration of the SABA.
Use CPAP for an asthma patient if…
*Patient is awake, alert, orientated, and can obey commands
*(GCS >10),
*Breathes on his own, can maintain his own airway, and has an Sp02 of <94%.
Patho of pneumonia?
Pneumonia is primarily an acute infectious disease caused by bacterium or a virus that affects the lower respiratory tract and causes Iung inflammation and fluid- or pus-filled alveoli. This leads to a ventilation disturbance
in the alveoli with poor gas exchange, hypoxemia, and eventual cellular hypoxia.
unique S/S of pneumonia
*Chest pain (sharp and localized and usually made worse when breathing deeply or coughing)
*Crackles, localized wheezing, and rhonchi heard on auscultation
Treatment of pneumonia
- Open airway
- Adequate breathing/ventilation
- Position of comfort
- Administration of supplemental oxygen (start with NC at 2L/min to 6L/min to reach 94%+)
Patho of pulmonary embolism?
Pulmonary embolism is a sudden blockage of blood flow through a pulmonary artery or one of its branches. The embolism is usually caused by a blood clot, but it can also be caused by an air bubble, a fat particle, a foreign body, or amniotic fluid. The embolism prevents blood from flowing to the lung. As a result, some areas of the lung have oxygen in the alveoli (adequate ventilation) but are not receiving any blood flow (reduced perfusion).
unique S/S of pulmonary embolism?
*Suspect pulmonary embolism in any person with a sudden onset of unexplained dyspnea and chest pain (typically sharp and localized to a specific area of the chest) and signs or hypoxia, but who has normal breath sounds and adequate volume.
* if not normal breath sounds, it’d be crackles
Treatment of pulmonary embolism?
- opened the airway
- positive pressure ventilation with supplemental oxygen or administered oxygen to maintain an SpO2 of 94% or greater.
- Continuously monitor the patient for signs of respiratory failure, respiratory arrest, hypotension, poor perfusion, or cardiac arrest.
- Immediately transpon the patient.
What are the two types of pulmonary edema?
*Cardiogenic pulmonary edema is typically related to an inadequate pumping function of the left ventricle that drastically increases the pressure in the pulmonary capillaries, which forces fluid to leak into the space between the alveoli and capillaries and, eventually, into the alveoli.
*Noncardiogenic pulmonary edema, also known as acute respiratory distress syndrome (ARDS), results from destruction of the capillary bed that allows fluid to leak out.
Patho of acute pulmonary edema?
Acute pulmonary edema, usually caused by a cardiogenic etiology, occurs when an excessive amount of fluid collects in the spaces between the alveoli and the capillaries. This intrusion of fluid disturbs normal gas exchange which makes less oxygen available to the blood flowing through the capillaries (perfusion). This leads to hypoxemia and cellular hypoxia and hypercarbia.
unique S/S of acute pulmonary edema?
*Difficulty in breathing when lying flat (orthopnea)
*Tripod posiLion with legs dangling
*Waking up suddenly shore of breath (paroxysmal nocturnal dyspnea)
Treatment of acute pulmonary edema?
- If there is any evidence of inadequate breathing, you need co begin PPV with a bag-valve-mask and provide supplemental oxygen.
- CPAP can extremely beneficial in the acute pulmonary edema patient in respiratory distress or early respiratory failure who is awake, alert, oriented, and can obey commands ( GCS >IO), can breathe on his own, can maintain his own airway. and has an SpO, of <94%.
Patho of Sympathetic Crashing Acute Pulmonary Edema (SCAPE)
It is a sudden onset pulmonary edema caused by an increase in sympathetic nervous system output. This causes systemic vasoconstriction causing blood to be shunted to the core of the body resulting in hypertension and an increase in the pressure in the aorta and arteries. This sudden increase in afterload and high resistance in the aorta makes the heart’s ability to pump the blood out less effective. The fluid in the capillary arteries begins to leak and it begins to collect in the interstitial space and in the alveolar/capillary interface-the area between the Aeolus and capillary where gas exchange occurs. This space is no1ma ly filled with a small amount or fluid; however, as the fluid accumulates it pushes the alveolus and capillary farther apart. This doesn’t aJlow the oxygen to effectively diffuse into the capillary and carbon dioxide to diffuse from the capillary into the alveolus. The result is hypoxemia and hypercapnia.
unique S/S of SCAPE?
*HYPERTENSION greater than 160 bp systolic
Diffuse crackles (rales)
Treatment of SCAPE?
The primary focus in treating SCAPE is to improve oxygen and decrease the blood pressure. CPAP is highly recommended. Beginal 5 cm H2O pressure and tilrate up to 15 LO 18 cm. Nitroglycerin is used to reduce the vasoconstriction from
the sympathetic nervous system influence.
Patho of spontaneous pneumothorax?
a portion of the visceral pleura ruptures without any trauma having been applied Lo the chest. This allows air to enter the pleural cavity, disrupting its normally negative pressure and causing the lung lo collapse. The lung collapse causes a disturbance in gas exchange and can lead to hypoxia.
What are the two types of spontaneous pneumothorax?
*Primary spontaneous pneumothorax. Occurs in patients who have no underlying lung disease. Primary spontaneous pneumothorax occurs in patients in their teenage years to early 20s who are tall and thin. It is thought that visceral pleura is stretched within the chest cavity beyond its normal limit. Often the stretched and weakened area ruptures when the patient experiences an increase in intrathoracic pressure from an activity such as coughing, lifting a heavy object, or straining
*Secondary spontaneous pneumothorax. Occurs in patients in which there is underlying lung disease. Many also have a history of cigarette smoking or a connective tissue disorder. Also occurs in patients who have a history of lung disease such as COPD and who are more prone to spontaneous pneumothorax from areas of weakened lung tissue called blebs or bullae.
unique S/S of spontaneous pneumothorax?
A key finding in spontaneous pneumothorax is a sudden onset or shortness of breath without any evidence of trauma to the chest and with decreased breath sounds to one one side of the chest. Remember, if the patient is seated, the decreased breath sounds will beheard in the apex (top) because of gravity causing the air to rise.
Decreased breath sounds to one side or the chest (most often heard first at the apex, or top, of lung)
Treatment of spontaneous pneumothorax?
- Administer Oxygen Lo maintain an SpO2 or 94% if patient needs it.
- lf inadequate breathing is present, provide positive pressure ventilation. Posilive pressure ventilation in a patient suffering from a pneumothorax must be performed with great care because the pneumothorax could easily be converted inLo a tension pneumothorax (air entering the pleural cavity that cannot escape, eventually causing lung collapse). use the most minimal tidal volume necessary to ventilate the patient effectively.
*****CPAP is contraindicated in a patient with a suspected
pneumothorax regardless of the complaint or dyspnea and evidence of respiraLory distress. The positive pressure can increase the size of the pneumothorax and worsen the hypoxia.
Patho of hyperventilation syndrome?
The hyperventilation syndrome patient is often anxious and experiences the feeling of not being able to catch his breath. The patient then begins to breathe faster and deeper.The true hyperventilation syndrome patient begins to “blow off” excessive amounts of carbon dioxide. When too much carbon dioxide has been eliminated Through rapid breathing, the patient begins to experience worsened signs and symptoms of hyperventilation syndrome. One result is that the amount of calcium in the body decreases, causing the muscles of the feet and hands to cramp
unique S/S of hyperventilation?
*Numbness and tingling around the mouth, hands, and feet
*Spasms of the fingers and feet causing them to cramp (carpopedal spasm)
*Seizures that may be precipitated in a patient with a seizure disorder
*The light-headedness, dizziness, or fainting experienced by the hype ventilating patient is caused by a drastic reduction of carbon dioxide.
Treatment of hyperventilation?
The primary management is to get the patient to calm clown and slow his breathing. One technique is to have the patient close his mouth and breathe through his nose. You might need to coach the patient.
**Do not have the patient breathe into a paper bag
***Keep in mind that conditions such as **pulmonary embolism can present similarly to hyperventilation
NC at 2L/min rising up to 6L/min reaching 94% SpO2
Patho of Epiglottitis?
the epiglottis, area around the epiglollis, and base of the tongue become infected. As the condition progresses, the epiglottis and the structures connected to or immediately surrounding it and the base of the tongue become inflamed and swollen, leading
to a compromised airway and resultant respiratory compromise. this partial-to-complete airway obstruction leads to ineffective gas exchange in the lungs, hypoxia, acidosis, and eventually death.
Unique S/S of Epiglottitis?
*upper respiratory tract infection, usually for 1 to 2 days prior to onset
**Inability to swallow with drooling (late sign of impending failure)
*Tripod position, usually with jaw jutted forward (late sign of impending failure)
*Trouble speaking or pain during speaking
*High-pitched inspiratory stridor (sign of an completely closed airway obstruction)
Treatmeant of Epiglottitis?
Treatment of epiglottitis is focused on ensuring oxygenation and preventing airway obstruction. If the patient’s breathing is still adequate, the first step is administration or high-concentration oxygen at 15 LPM to maximize oxygenation of the alveoli receiving airflow. calm the patient and keep the patient in a position of comfort and transport ASAP.
If the patient continues to deteriorate and requires assisted ventilations with a bag-valve-mask device, squeeze the bag slowly. This helps direct the air past the obstruction.
Patho of pertussis?
Pertussis typically starts out
seeming similar to a cold or a mild upper respiratory infection. Within 2 weeks or so or onset, the patient develops episodes of rapid coughing (15 to 24 episodes in close sequence) as the body attempts to expel thick mucus from the airway, followed by a “crowing” or “whooping” sound made during inhalation as the patient breathes in deeply.
Unique S/S of pertussis?
*Sneezing, runny nose, low-grade fever
General malaise (weakness, fatigue, not feeling well)
**Increase in frequency and severity of coughing
Treatmeant of pertussis?
*Ensuring oxygenation
*reversing hypoxemia and perverting airway obstruction *Allow the patient to assume a position of comfort
*Administer oxygen via a nasal cannula to get an SpO2 of 94% or greater
*The EMT should also encourage the patient to expel any mucus
* calm the pateint
*transport
* Finally remember that pertussis is a contagious disease and the EMT should Lake all precautions necessary Lo prevenL becoming cross contaminated
All stages of pertussis
Pertussis has three stages. Stage 1 is characterized by findings consistent with a common cold or upper respiratory infection. In stage 2, coughing continues to worsen to the point that medical care is sought, and thus the suspicion for pertussis (whooping cough) is formed. Stage 3 is the recovery stage, and recovery is usually gradual, taking several weeks until a resolution is reached.
Dosage for meter dose inhaler?
Each time an MDI is depressed, it delivers a precise dose of medication to the patient. The total number of times the medication can be administered is determined by medical direction.
Dosage for small volume nebulizer?
When using an SVN, it usually takes 5-10 minutes for the patient to inhale the medication, depending on the rate and depth of breathing. The medication should be inhaled until the SVN no longer produces a mist.
Administration for MDI?
- Ensure right patient, right medication, right dose. right route, and right date. Determine if the patient is alert enough to use the inhaler and if any doses have already been administered prior to your arrival.
- Obtain an order, either on-line or off-line, from medical direction to assist with the administration of the medication.
- Ensure that the inhaler is at room temperature or
warmer. Shake the canister vigorously for at least 30 seconds. - Instruct the patient to take the inhaler in his hand
- Have the patient exhale fully.
- Have the patient place his lips around the mouth piece (opening) of the inhaler.
- Have the patient begin to slowly and deeply inhale over about 5 seconds as he or you depress the canister. Do not depress the canister before the patient begins to inhale. This would allow a majority of the medication to be lost into the air and it will not reach the lower respiratory tract.
- Remove the inhaler and coach the patient to hold his breath for 10 seconds or as long as comfortable.
- Have the patient exhale slowly through pursed lips.
- Replace the oxygen mask on the patient. Reassess the breathing status and vital signs.
- Reassess the patient and consult with medical direction if additional doses are needed. If an additional dose is recommended, wait at least 2 minutes be tween each administration or longer based on the medication being administered or medical direction’s order.
Administration for SVN?
- Ensure right patient, right medication, right dose, right route, and right date. Determine if the patient is alert enough to use the nebulizer and if any doses have already been administered prior to your arrival.
- Obtain an order, either on-line or off-line, from medi cal direction to assist with the administration of the medication.
- Disassemble the medication chamber from the mouthpiece by unscrewing it. While holding the medication reservoir upright, pour in the medication and reassemble the device.
- Attach the tubing extending from the bottom of the drug reservoir to the nebulizer compressor and turn it on, or attach the tubing to an oxygen tank with the
- Instruct the patient to take the nebulizer in his hand
and hold it upright. If the patient is unable to hold the device, you may have to do this for the patient, being sure to continuously hold it upright for optimal nebulization of the medication. - Have the patient exhale fully.
- Instruct the patient to place his lips around the mouthpiece of the nebulizer.
- Have the patient begin to slowly and deeply breathe in the mist.
- Instruct the patient to occasionally (every 2-3 breaths) hold his breath after inhalation as long as he comfortably can, to assist with medication distri bution throughout the respiratory tree.
- Have the patient exhale normally, and occasionally (every 2-3 breaths) instruct the patient to cough during exhalation to facilitate removal of any mucus or secretions that may be present.
- You may need to occasionally shake the nebulizer to dislodge any medication that tends to collect on the sides of the drug reservoir. In about 5-10 minutes, the misting of medication should cease and the liquid medication you placed in the nebulizer will be gone.
- Reassess the patient and consult with medical direction if additional doses are needed. If an ad ditional dose is recommended, wait at least 2 min utes between each administration or longer based on the medication being administered or medical direction’s order.
Appearance of someone in respiratory distress
Normal
The circulation of someone in respiratory distress
Normal
Breathing of someone in respiratory distress
Increased Work of breathing
*Flared nostrils
*retractions
*abnormal sounds (stridor, grunting, wheezing)
*abnormal positing (Sniffing, tripod, refuse to lie)
Circulation of someone in respiratory failure
Normal or abnormal
*cyanosis
*pale
*mottled
Appearance of someone in respiratory failure
Abnormal
*decreased muscle tone
*gaze
*inconsolable
*irritable
Breathing of someone in respiratory failure
Increased Work of breathing
*Flared nostrils
*retractions
*abnormal sounds (stridor, grunting, wheezing)
*abnormal positing (Sniffing, tripod, refuse to lie)
*Head bobbing
