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CBT425-EMT11: Respiratory Emergencies PowerPoint PPT Presentation


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CBT425-EMT11: Respiratory Emergencies. Introduction. Patients with lung & heart diseases frequently call 9-1-1 due to breathing difficulty This course reviews common disorders that can cause respiratory emergencies & prehospital management of these conditions. Objectives.

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CBT425-EMT11: Respiratory Emergencies

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CBT425-EMT11: Respiratory Emergencies


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Introduction

  • Patients with lung & heart diseases frequently call 9-1-1 due to breathing difficulty

  • This course reviews common disorders that can cause respiratory emergencies & prehospital management of these conditions


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Objectives

Identify the anatomic structures of the respiratory system

Demonstrate an understanding of the physiology of the respiratory system and its relationship to BLS treatment

Identify signs and symptoms of respiratory emergencies

Identify treatment of respiratory emergencies

Distinguish between normal and abnormal breath sounds

Identify correct technique for auscultation of breath sounds

Identify correct BVM technique and suctioning technique


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Terms

  • chronic obstructive pulmonary disease (COPD) - A category of diseases characterized by a slow process of dilation and disruption of pulmonary alveoli.

  • dyspnea - A term for shortness of breath or breathing difficulty.

  • embolus - A blood clot or other substance that has formed in a blood vessel or the heart, that breaks off and travels to another blood vessel, where it may cause blockage.

  • flailchest - A condition in which three or more ribs are fractured in two or more places such that a section of the chest wall is detached from the rest of the chest wall.


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Terms, continued

  • gagreflex - A protective contraction of the muscles of the throat caused especially by stimulation of the pharynx that prevents food and liquids from entering the airway.

  • hypoxia - A condition in which the body's cells and tissue do not have enough oxygen.

  • pleuriticchestpain - A sharp, stabbing pain in the chest that is worsened by a deep breath; often caused by inflammation or irritation of the pleura.

  • pneumothorax - Condition where air enters the pleural space and is trapped during expiration. It can occur without trauma as in a spontaneous pneumothorax.


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Terms, continued

  • pulmonaryedema - A buildup of fluid in the lungs, usually as a result of congestive heart failure.

  • rales - Crackling, rattling breath sounds signaling fluid in the air spaces of the lungs.

  • rhonchi - Coarse breath sounds heard in patients with mucus in the airways.

  • stridor - A harsh, high-pitched inspiratory sound often heard in acute laryngeal (upper airway) obstruction.


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Terms continued

tensionpneumothorax - A life-threatening condition in which air enters the pleural space and the pressure inside the lung cavity progressively increases and compresses the lung. It may displace the mediastinum and other structures toward the opposite side.

traumaticasphyxia - Condition characterized by distended neck veins, cyanosis in face and neck and bleeding in the sclera of the eye that is caused by severe compression of the chest.

wheeze - A high-pitched, whistling breath sound, characteristically heard on expiration in patients with asthma or COPD.


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New Terms

  • hypoxicdrive - A condition in which the body's stimulus for taking a breath is low oxygen. Occurs in people with COPD.

  • metabolism - The process by which food molecules are broken down to provide material and energy for cellular function.

  • pH (potential of hydrogen) - A measure of the acidity or alkalinity of a solution, numerically equal to 7 for neutral solutions, increasing with increasing alkalinity and decreasing with increasing acidity. The pH scale ranges from 0 to 14. Numbers from 7 and below represent increasing acidity.


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New Terms continued

perfusion - The movement of blood through an organ or tissue in order to supply nutrients and oxygen.

tidalvolume – The volume of gas that is moved with each breath which is normally 500 ml in an adult.

ventilation – The rate at which gas enters or leaves the lungs. Generally it is described in terms of good or poor ventilation. Bluish or dusky skin can indicate poor ventilation.


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Respiratory Structures

  • Airway protection & oxygen administration are perhaps the most important BLS skills you have

  • Important to know structures of respiratory system

  • Understand basic physiology affected by BLS treatment

Learning Activity for Functions of Respiratory Structures

http://www.emsonline.net/resp2011/functions.asp


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PHYSIOLOGY


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Process by which body breaks down or "burns" stored fuel to create energy

Cells use oxygen to transform stored glucose into energy

Think of glucose as "fuel" & oxygen as "match" that releases energy

Byproduct of metabolism is carbon dioxide (CO2)

Metabolism Produces Carbon Dioxide


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Metabolism

  • Carbon dioxide produced by cells & carried by circulatory system to lungs where it is expired

  • If respirations impaired

    • Carbon dioxide builds up in blood

    • Excess carbon dioxide combines with water in blood to produce acid


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pH

  • Acidity in solution such as blood measured by potentialof Hydrogen

  • Body must maintain relatively narrow pH range (neither too acidic nor too basic)

  • Respiratory system helps maintain balanced acid level or pH in blood


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The pH Balancing Act

  • Respiratory system – mirror for other changes that happen in the body

  • Blood pH becomes too low (acidic)

    • Respiratory system will attempt to fix by making lungs breathe more deeply & rapidly

    • Excreting more carbon dioxide

  • Homeostasis – body attempts to maintain balance


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Hypercarbia

  • Excessive carbon dioxide in the body

  • Results in acidosis as carbon dioxide causes chemical reaction producing carbonic acid

  • Hypercarbia can occur through:

    • Metabolic processes that form acids

    • Muscle exertion

    • Shivering

  • Occurs through decreased elimination of carbon dioxide, for example with:

    • Airway obstruction

    • Inability to exhale fully (e.g., asthma or emphysema)

    • Depressed respiratory drive (e.g., overdose of sedative drugs)


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Hypoxic Drive

  • Amount of carbon dioxide in blood is primary stimulus for breathing

  • Secondary stimulus is hypoxia

    • Decrease in oxygen

  • Occurs in small percentage of COPD patients

    • Expirations so inefficient their bodies become accustomed to higher than normal levels of carbon dioxide

    • Decrease in oxygen, rather than increase in carbon dioxide, provides primary stimulus for taking breath


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Respiratory Drive

  • Act of breathing – autonomic & involuntary function controlled by centers in brain sensitive to blood levels of oxygen & carbon dioxide

  • Body’s response to increased carbon dioxide in blood is to "blow off” carbon dioxide by increasing rate & depth of respirations


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Metabolic Problems

  • Metabolic imbalances affect chemistry of body affecting pH & other measures of body chemistry

  • Not a respiratory problem, respiratory system often tries to compensate by changing depth and/or rate of respirations


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Metabolic Problems

  • Ketoacidosis – inefficient metabolism of sugars in a diabetic causes body to turn to other fuel sources for energy (fat & muscle)

    • Byproducts – acids called ketoacids

    • Presence of ketoacids & related compounds in blood will cause lower pH

    • Respiratory system responds by increasing depth and/or rate of respirations

  • Aspirin overdose – an acid (the chemical name is acetylsalicylic acid)

    • Taken in large quantities, person becomes acidotic

    • Body compensates by increasing depth and/or rate of respirations


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Metabolic Problems

Fever increases metabolic rate, causing production of more carbon dioxide which leads to more acid in blood

  • Tissue perfusion fails (as it can in sepsis)

    • Excess metabolic acids accumulate causing metabolic acidosis with a low pH

  • Body responds by increasing depth and/or rate of respirations

    Hyperventilating breathing deeply & rapidly

  • Efficient way of ridding body of carbon dioxide which in turn may alter the body’s equilibrium

  • Causes alkalosis (meaning very "basic")

  • Symptoms of respiratory alkalosis may include faintness & tingling in the extremities


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CLINICAL SYNDROMES


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Airway Obstruction

EMS providers should intervene if choking victim has signs of severe airway obstruction

Poor air exchange or increased breathing difficulty (indicated by silent cough) cyanosis or inability to speak or breathe

Mild obstruction & victim coughing forcefully

Do not interfere with efforts to relieve obstruction

Attempt to relieve obstruction only if it becomes severe

Use a finger sweep only if you can see solid material obstructing airway of unresponsive patient


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Asthma

Chronic, inflammatory disease of airways

Asthma attacks induced by different factors:

Allergens

Infections

Exercise

Smoke

During asthma attack:

Muscles around bronchioles tighten

Lining of inside bronchioles swells

Inside of bronchioles fills with thick mucous

Severely restricts expiration of air from lungs


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Asthma

Patients often describe history of asthma

Have prescription for metered-dose inhaler

BLS treatment considerations include:

Calming the patient

Airway management

Oxygen therapy

Assisting with a prescribed inhaler

Asthma attack – muscles around airways tighten, making airway openings narrower so less air can flow through

Inflammation increases and airways become more swollen and narrow

Cells in airways also produce more mucus than normal

Extra mucus also narrows the airways.


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COPD

Chronic obstructive pulmonary disease (COPD)

Category of diseases that includes:

Asthma

Emphysema

Chronic bronchitis

Slow process of dilation & disruption of airways & alveoli

Includes several related irreversible conditions that limit ability to exhale


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COPD

Patients present with shortness of breath, fever and increased sputum production

Medical history can include:

Upper-respiratory infection

Chronic bronchitis

Emphysema

History of smoking

Working in hazardous environment (e.g., coal smoke, asbestos)

Common medications include:

Prednisone

Proventil

Ventolin

Atrovent

Azmacort

BLS treatment for a COPD patient with respiratory distress should include high flow oxygen .


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Emphysema

Very small airways that join alveoli are damaged & walls lose elasticity

Chronic irritation of small airways causes inflammation & swelling – reducing diameter of air passages

Irritation causes bronchospasms & further decreases the lumen

On inspiration, expansion of lungs holds airways open

On exhalation, lungs relax & airways narrow, trapping air


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Chronic Bronchitis

Characterized by structural changes in airways of the lungs

Enlargement of mucous glands – cause coughing & production of sputum

Causes shortness of breath

Often accompanied by infection, mucus production & coughing


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Congestive Heart Failure

During acute exacerbation patient will present:

Sitting up

Short of breath

Diaphoretic

Pale

Cyanotic in color

Breath sounds can include rales or wheezes

Medical history can include:

Increased salt ingestion

Respiratory infection

Non-compliance with medications

Angina

Symptoms of acute coronary syndrome


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Congestive Heart Failure

Result of too much fluid in lungs making it difficult to get air in—as opposed to COPD patient who has trouble getting air out

Occurs when ventricles weakened by myocardial infarction, underlying coronary artery disease, hypertension or valve disease

Impairs heart’s ability to contract & empty during systole

Blood backs up in lungs & tissues of body

Increased pressure in left ventricle transmitted to lung capillaries

Fluid forced into alveoli

Interrupts gas exchange & results in shortness of breath

Increased pressure in right ventricle causes fluid to back up into body’s tissues

Leading primarily to swelling in lower extremities

Do not suffer from purely left- or purely right-ventricle heart failure

Rather present with combination of symptoms


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CHF Symptoms


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Congestive Heart Failure

Common medications include:

ACE inhibitors

Furosemide (Lasix)

HCTZ (hydrochlorthiazide)

Beta-blockers

Angiotensin II receptor blockers

Digoxin (Lanoxin)

Medications can help differentiate this patient's symptoms from those of someone with COPD


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Congestive Heart Failure

When treating CHF:

Seat the patient upright

Administer high flow oxygen

Consider positive pressure ventilation with a BVM if the patient is experiencing severe respiratory difficulty


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Inhalation Injuries

Breathing of chemicals, smoke or other substances

Common chief complaints include:

Shortness of breath

Coughing

Hoarseness

Chest pain due to bronchial irritation

Nausea

Individuals with decreased respiratory reserve (e.g., history of COPD or CHF) are likely to experience an exacerbation of the disease


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Inhalation Injuries

Patient in respiratory distress:

Treat immediately with high flow oxygen

Assist breathing with a BVM if the respiratory effort is insufficient

Indicated by a slow rate & poor air exchange


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Pneumonia

Symptoms include:

Fever

Chills

Cough (often with yellowish sputum)

Shortness of breath

General discomfort

Fatigue

Loss of appetite

Headache

Can be chest pain associated with breathing (usually sharp and stabbing in nature) and worsened by coughing or deep inspirations

Other signs sometimes present are rales, clammy skin, upper abdominal pain & blood-tinged sputum

Emergency care – may include oxygen therapy.


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Pneumothorax

Presence of air in pleural space

Caused when internal or external wound allows air to enter space between pleural tissues

Causes collapse of lung

Cause sharp chest pain & shortness of breath

May be able to feel subcutaneous air & breath sounds will be diminished


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Pneumothorax

Treatment of pneumothorax includes high-flow oxygen

Be judicious with use of positive-pressure ventilation

Can turn a spontaneous pneumothorax into a life-threatening tension pneumothorax.

A pneumothorax can cause collapse of the entire lung. The only symptom may be sudden chest pain.


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Pneumothorax

Under normal conditions no air between these layers of pleura because sealed together

Air or blood can enter space

Example when hole is punctured in chest wall by gunshot or stab wound

Can occur spontaneously

Rupture due to disease or localized weakness of the lung lining

Result of trauma

Forceful coughing

Chest injury and prior history of pneumothorax possible medical histories

COPD – risk factor


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Tension Pneumothorax

Progressively worsening pneumothorax – begins to impinge on function of lungs & circulatory system

Caused when lung injury acts like one-way valve that allows free air to move into pleural space

Prevents free exit of that air

Pressure builds inside pleural space & compresses lungs & other organs

Early signs of a tension pneumothorax include:

Increased dyspnea

Cyanosis

Signs of shock

Distended neck veins

Shift in PMI (Point of maximum intensity, where heart is loudest through auscultation)

Tracheal displacement

Tracheal deviation


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Pulmonary Embolism

Particle such as blood clot, fat embolus, amniotic fluid embolus or air bubble gets loose in blood stream

Travels to the lungs

Embolus lodges in major branch of pulmonary artery

Circulation through large portion of lung is interrupted

Blood not able to reach alveoli & it cannot be oxygenated


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Pulmonary Embolism

Causes include:

Immobility of the lower extremities

Prolonged bed rest

Recent surgery

Signs of PE:

Sudden-onset of:

Shortness of breath

Tachypnea

Chest painworsened by breathing

Coughing up blood

Pulmonary embolism – life-threatening condition

Treated with high flow oxygen

Rapid transport

Move patient gently to avoid dislodging additional emboli


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PATIENT CARE


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Assessment of Respiratory Status

  • Assess rate & depth of respirations

  • Normal rate is between 12 & 20 respirations per minute for adult

  • Depth of respirations more subjective & varies from shallow, normal, labored or gasping

  • Together rate & depth will tell whether tidal volume is adequate.


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Assessment of Respiratory Status

  • Other signs that indicate adequate oxygen supply to body’s tissues:

  • Level of consciousness

  • Breathing effort

  • Ability to speak in complete sentences

  • Use of accessory muscles

  • Skin color

  • Breath sounds

  • Body position


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Irregular Breathing Patterns

  • Caused by specific conditions:

    • Example: Cheyne-Stokes respirations

      • May be seen in head injuries & stroke

      • Characterized by periods of breathing with gradually increasing & decreasing of tidal volume interspersed with periods of no breathing

  • Ataxic respirations – irregular, ineffective respirations with no clear pattern

  • Agonal respirations – abnormal pattern of breathing characterized by ineffective, slow inspirations followed by long pauses

    • Often sound like gasps

    • Associated with cardiac arrest or severe end-stage shock


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Auscultation of Breath Sounds

  • Proper technique for auscultating chest using a stethoscope includes:

  • Listen at six locations on the back

  • Listen at four locations on the front

  • Instruct the patient to take a deep breath through the mouth then exhale

  • Listen to one or two inspiration/expiration cycles per location

  • Avoid listening through clothing

Video demonstration available at EMS Online: http://www.emsonline.net/resp2011/auscultation.asp


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Auscultation of Breath Sounds

  • Changing airflow patterns inside lungs produce normal breath sounds

  • Make a "swishing" sound as one breathes in or out

  • Absent breath sounds can indicate apnea, pneumothorax, hemothorax or lung removal

EMTs must be able to distinguish normal breath sounds from abnormal breath sounds.


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Airway Management

  • Very important skills for EMS provider

  • Well versed in the following airway management techniques:

    • Head tilt/chin lift

    • Jaw thrust

    • Patient positioning

    • Airway adjuncts

    • Suction

    • Oxygen therapy

    • Assisted ventilation

    • Relief of foreign body airway obstruction


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Suction

  • Purpose of suction –remove vomit, blood, excretions & other matter from airway

  • Guidelines to use for suctioning:

    • Measure tip from corner of mouth to earlobe

    • Oxygenate patient well (if situation permits)

    • Insert tip into oral cavity without applying suction

    • Move suction tip side–to-side

    • Oxygenate well after suctioning


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Measure tip same as for an oropharyngeal airway—from corner of mouth to ear lobe or from center of mouth to angle of jaw

Insert tip only to base of tongue

If situation permits (e.g., there is no significant airway threat), give at least 30 seconds of oxygen before suctioning

Administer oxygen after suctioning & consider assisting ventilations with a bag-valve mask to help provide extra oxygen

Do not apply suction while inserting tip – can rob airway of oxygen.

Apply suction for no more than 15 seconds at a time

In rare cases, copious vomiting that threatens airway may require more suctioning

In infants & children, suction for shorter periods of time (e.g., no more than 5 seconds)

If there are secretions or emesis that you cannot easily remove with suction, position patient, (e.g., by using log roll) so gravity & a finger sweep can quickly clear the airway

Tips for Effective Suctioning


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Assisted Ventilation

  • Patients who lack oxygen – must take quick action to improve depth & rate of respirations

  • Bag-valve mask (BVM) – useful tool for improving ventilation & acid-base (pH) balance

  • Proper technique for assisting ventilation with a BVM is as follows:


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Unconscious breathing patient:

Consider need for an oropharyngeal airway*

Do not over-ventilate

Keep the airway open

Maintain a good seal

Apply the Sellick maneuver which can help reduce airflow into the stomach

*Follow local protocols

Non-breathing patient:

Deliver a ventilation of 1-second duration

Deliver enough volume to make the chest rise

12 ventilations/min

8-10 ventilations/min if an advanced airway is in place

Assisted Ventilation

Video demonstration available at EMS Online: http://www.emsonline.net/resp2011/ventilation.asp


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Oxygen Delivery

  • Amount of oxygen administered patient & method of administration depend on many factors including medical history & cause of respiratory problem

Video demonstration available at EMS Online: http://www.emsonline.net/resp2011/therapy.asp


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Case Studies

  • Video Care Study #1

  • http://www.emsonline.net/resp2011/vcase1.asp

  • Video Care Study #2

  • http://www.emsonline.net/resp2011/vcase2.asp


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Summary

  • Main structures of the respiratory system are:

  • Pharynx

  • Trachea

  • Epiglottis

  • Alveoli

  • Bronchi

  • Bronchioles

  • Larynx

  • Pleura

  • Diaphragm


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Summary

  • Respiratory system – important mechanism for regulating pH in body

    • Respiration impaired, carbon dioxide builds up in blood (hypercarbia) and produces an acid

    • BLS providers can help treat this condition by improving ventilation

  • Signs of severe airway obstruction include poor air exchange and increased breathing difficulty

  • Persons with COPD-related emergency may present with shortness of breath, fever & increased sputum production

  • Signs of congestive heart failure may include an acute onset of breathing difficulty, diaphoresis & cyanosis


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Summary

  • Pneumothorax can cause sharp chest pain & shortness of breath

  • Signs of pulmonary embolism include a sudden onset of shortness of breath, tachypnea, chest pain worsened by breathing & coughing up blood

  • Treatment for respiratory emergency can include high flow oxygen and, in case of decreased respiratory drive, assisted ventilations

  • CHF patients may require positive-pressure ventilations


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Summary

  • Proper technique for auscultating the chest includes:

  • Listen at six locations on the back

  • Listen at four locations on the front

  • Move from bottom to top in a medical patient

  • Instruct the patient to take a deep breath through the mouth then exhale

  • Listen to one or two inspiration/expiration cycles per location

  • Avoid listening through clothing


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Summary

  • Guidelines for use of suction include:

  • Measure the tip from corner of mouth to earlobe

  • Oxygenate the patient well (if the situation permits)

  • Insert the tip into the oral cavity without applying suction

  • Move the suction tip side to side

  • Oxygenate well after suctioning


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Summary

  • Key points for ventilating an unconscious breathing patient are:

  • Consider oropharyngeal airway

  • Do not over-ventilate

  • Keep the airway open

  • Maintain a good seal

  • Apply the Sellick maneuver which can help reduce airflow into the stomach


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Questions

EMS OnlineGuidelines and Standing Orders

http://www.emsonline.net/downloads.asp

Susan Kolwitz

Program Manager

Email support:[email protected]

Dr. Mickey EisenbergMedical Director

Ask the Doc: http://www.emsonline.net/doc.asp


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