adults - Edward Hospital

Report
EMS REGION VIII SOPs
2014 UPDATES
July 2014
2014 Updates

Effective August 1, 2014

SOP books will be distributed by each System
SOP Changes
SOP Page Number References


Anywhere an SOP is referenced, the SOP is
noted in BOLD type and the page number is
also included
Easier to locate SOPs that refer to another other
SOPs
Terminology: Standard Precautions

“Standard precautions” has replaced the old
wording “body substance isolation” (BSI) and
“universal blood and body secretions”
Fentanyl Dosing for Adults

Fentanyl dosing is changed and is now consistent
for adults (< 65 YO) regardless of SOP



2012 SOPs did not allow for a repeat dose of
fentanyl for the adult suspected cardiac patient with
chest pain
2014 SOPs allow for a repeat dose of fentanyl
Must have a systolic BP > 100 mmHg
Fentanyl Dosing for Adults

The initial fentanyl dose remains the same for all
adult patients < 65 year olds


1mcg/kg SLOW IV/IM, max 100 mcg
Addition of one repeat dose

0.5 mcg/kg SLOW IV/IM after 5 min, max 50 mcg
Fentanyl Dosing > 65 Years Old

New dosing for patients > 65 years old




Slower renal clearance of drugs
More likely to experience adverse effects of
opiates (even at lower doses)
Initial and repeat dosages are the same,
regardless of SOP
Must have a systolic BP > 100 mmHg


0.5 mcg/kg SLOW IV/IM, max dose 50 mcg
Repeat dose 0.25 mcg/kg SLOW IV/IM, max dose
25 mcg
Adverse Effects of Fentanyl

AMS, respiratory depression






(particularly if >65 YO)
Stupor
Delirium
Somnolence
Dysphoria
Chest wall-rigidity
Muscle rigidity (involving the respiratory
musculature including the glottis)
 Seizures
 Difficulty or inability to ventilate the patient

Adverse Effects of Fentanyl






Hypotension
Bradycardia
Nausea/vomiting
Constipation
Arrhythmias (rarely)
Hypersensitivity side effects including
anaphylaxis have been reported on rare
instances
Pediatric Fentanyl Dosing

Dosing for pediatrics has NOT changed





1 mcg/kg SLOW IV/IM, max dose 100 mcg
Remember: most pediatric dosages don’t exceed the
adult dose!
Obtain accurate weight from parents/caregivers
No repeat dose, but can call Medical Control to
request additional dosing as appropriate
NO IO route for fentanyl administration in peds

If the patient requires an IO, stabilizing the patient
takes priority to giving pain medication.
Fentanyl Administration



Administering fentanyl too quickly can cause
chest wall rigidity
IV administration should be over 1-2 minutes
If using a saline lock, push the fentanyl over 1-2
minutes, then push the saline flush over 1- 2
minutes as well
Fluid Bolus

In all SOPs, the phrase “Fluid Challenge” has
been replaced with “Fluid Bolus”


Administering a large amount of IV fluid in a
relatively short period of time is a fluid bolus.
Remember to reassess your patient after
administration of each bolus



Vital signs, including pulse characteristics
Lung sounds (crackles)
Change in condition
Pleural Decompression

“Pleural decompression” has replaced “needle
decompression” throughout the SOPs
General Patient Assessment
Page 2

Initial Assessment, Breathing


Addition of “assess lung sounds”
A reminder that auscultation of lung
sounds should occur in the primary
assessment stage of patient care
Zofran (ondansetron)
Page 4

Adult Initial Medical Care




Zofran (ondansetron) may now be administered 4
mg tab ODT or 4 mg slow IV x1 dose.
Patients must be actively vomiting and/or nauseous
prior to administration
Onset of action of IV Zofran (ondansetron) is twice
as fast as ODT
Administer over 1-2 minutes IV (no less than 30
seconds)
Zofran (ondansetron)



Not approved for prophylactic administration
(prevention) of nausea or vomiting
Can only be given IV or ODT once – NOT both.
ODT: patient should allow tablet to dissolve on
their tongue for rapid absorption into the
bloodstream

Do not have patient chew or swallow whole tablet
Initiation of ALS Care
Page 6

Abnormal vital signs respiratory rate upper limit
is changed from 28 to 30 breaths/minute

Consistent with other portions of SOPs
Adult Suspected Cardiac Patient With
Chest Pain
Page 11



Removed if “pain unrelieved by NTG”,
administer fentanyl
After administering nitroglycerin (NitroStat)
x 2 (ALS), administer fentanyl to achieve the
goal of pain relief
The goal is to alleviate all pain in the adult
suspected cardiac patient with chest pain, as
long as the patient remains stable
Adult Suspected Cardiac Patient With
Chest Pain
Page 11
Adult Pulmonary Edema
(Due to Heart Failure)
Page 21

Lasix has been removed from SOP


Dose was not adequate for the purpose of diuresis
that was needed for respiratory distress secondary
to pulmonary edema
Lasix was sometimes administered prior to
nitroglycerin (not consistent with SOP)

Nitroglycerin dilates coronary AND pulmonary
vasculature, leading to relief of respiratory
symptoms
Adult Pulmonary Edema
(Due to Heart Failure)
Page 21
Adult Pulmonary Edema
(Due to Heart Failure)
Page 21
Adult Pulmonary Edema
(Due to Heart Failure)
Page 21

CPAP is positive pressure





Increases intrathoracic pressure
Decreases venous return to the heart
Decreases cardiac output
Decreases blood pressure
Patient MUST be stable prior to administration
Adult Pulmonary Edema
(Due to Heart Failure)
Page 21

CPAP absolute contraindications
 Respiratory
arrest
 Agonal respirations
 Unconscious
 Shock with cardiac insufficiency
 Pneumothorax
 Penetrating chest trauma
 Persistent nausea and vomiting
 Facial anomalies/stroke/facial trauma
Adult Pulmonary Edema
(Due to Heart Failure)
Page 21

CPAP administration
Initial setting is 5 cmH2O
 Maximum pressure is 10 cmH2O
 Discontinue if





change in mental status
change in patient condition (e.g. ↓blood pressure)
↑anxiety/unable to tolerate mask
nausea/vomiting occur
Adult Drug Assisted Intubation Etomidate (Amidate)
Page 24

Sellick’s maneuver has been removed



Not performed consistently
Has not been proven to be effective by evidence
based medicine
After passing the tube, verify placement

Added “adequate chest expansion bilaterally and
symmetrically”
Adult Partial (Upper) Airway
Obstruction/Epiglottitis
Page 27

ALS/ Unstable


Added “severely diminished or absent breath
sounds”
If a patient doesn’t look well, consider that absence
of adventitious lung sounds means that little-to-no
air is being moved in the lungs instead of “clear”
lung sounds, indicating normal pulmonary exchange
of gases
Adult Diabetic/Glucose Emergencies
Page 29


Added dextrose 10% dosing in the event of a
severe drug shortage
System-specific procedure for details
Adult Syncope/Near Syncope
Page 30

Change in Narcan (naloxone) dose


Administration indicated if decreased
sensorium and pinpoint pupils, depressed
respirations, and possible history of
narcotic/synthetic narcotic ingestion
Don’t forget! Obtain 12-Lead ECG to rule out
cardiac origins


Narcan (naloxone) 1 mg IV/IN
Repeat dose 0.5 mg IV/IN PRN every 2 minutes up
to a max dose of 2 mg if transient response
observed
Adult Syncope/Near Syncope
Page 30
Adult Stroke
Page 32

Now includes obtaining and documenting
Last Known Well time
Requirement for hospital stroke center criteria

Time Last Known Well






Ask the family for the specific time
Relay that time to Medical Control
Give that time to the emergency nurse in report
Document the time in your run report
Section 7 criteria opening sentence reworded but the
content is the same
Adult Acute Abdominal Pain
Page 33


Fentanyl doses are now the same for adult patients < 65
YO and those > 65 YO across all SOPs
Addition of Zofran (ondansetron) IV
Adult Toxicologic Emergencies
Page 34


Narcan (naloxone) 1 mg IV/IN
Repeat 0.5 mg IV/IN PRN every 2 minutes up to a max
dose of 2 mg if transient response observed
 Focus on getting patient breathing but not causing
withdrawal
Adult Toxicologic Emergencies
Page 35

Added generic drug names to “Club Drugs”
Adult Cold Emergencies
Page 42

Fentanyl doses are now the same for adult
patients < 65 YO and those > 65 YO across all
SOPs
Adult Initial Trauma Care
Page 53


“Pelvic fracture” was changed to “pelvic
instability”
Treat any/all suspected pelvic fractures
and pelvic instability as a fracture in
prehospital setting
Adult Chest Injuries
Page 58

Sucking Chest Wound/Open Pneumothorax


“Apply occlusive chest dressing”
Removed “to create a flutter valve”


Three sided or occlusive dressing does not create a flutter
valve
If a tension pneumothorax develops with occlusive
dressing, temporarily remove the dressing to allow
air to escape
Adult Ophthalmic Emergencies
Page 60

Fentanyl doses are now the same for adult
patients < 65 YO and those > 65 YO across all
SOPs
Adult Ophthalmic Emergencies
Page 60

Tetracaine

Instill 0.5% tetracaine 1 drop in each affected eye
May repeat until pain relief achieved
 Use for Chemical/splash burn



Use for suspected corneal abrasion


Irrigate the eye first
Patch affected eye after tetracaine instilled
Do not use for penetrating injury/ruptured
globe (no tetracaine, no irrigation)
Adult Burn Injuries
Page 61

The IO route for fentanyl is approved in this
SOP. Both adults under and over 65 years old
can get fentanyl via IO
Adult Burn Injuries
Page 61

Determining TBSA burned

Rule of Nines



Include all second, third and fourth degree burns
First degree burns are not included
The Palmar method


Estimated1% TBSA
The patient’s palm, not yours!
Adult Burn Injuries
Page 61
Parkland Formula
Volume of Normal Saline:
4 mL x BSA(%) x weight (kg)
Give half of solution in
Give other half of solution in
first 8 hours
next 16 hours
Divide by 8 to determine
hourly rate (mL/hr)
Adult Burn Injuries
Page 61


Keep patient NPO
Keep accurate intake and output records


Report accurate I&O volumes to receiving nurse
Intraosseous route is approved for this SOP to
administer fluids and medication

IO can be placed through burned tissue if there are
no other options for IV/IO placement
Adult Musculoskeletal Injuries
Pages 64-65

Fentanyl doses are now the same for adult patients < 65
YO and those > 65 YO across all SOPs
Suspected Abuse or Neglect
Domestic, Sexual, Elder
Page 67


The reporting phone numbers have been
changed by the State and updated in SOPs
EMS providers are mandated to report
suspected abuse



Giving report to ED staff does not meet as the
mandated reporting legal requirements for EMS
providers
Individual providers must make reports to the
appropriate agency
Document case number, worker name, and include in
narrative if able to obtain
Suspected Abuse or Neglect
Domestic, Sexual, Elder
Page 67

Documenting suspected neglect/abuse






No accusations
Objective facts only
History as given by patient (if able) and
family/caregiver
Document physical environment if pertinent
Exact (pertinent) statements in quotes
Relevant physical findings
Emergency Childbirth
Phase III: Care of the Newborn
Page 72

Updated to reflect current neonatal
resuscitation national standards

Epinephrine (adrenaline) 1:10,000
0.1 mL/kg IV/IO q 3-5 minutes
 If unsuccessful, 0.5 ml/kg ET
 Repeat every 3-5 minutes as long as heart rate
< 60 beats per minute with CPR


DO NOT follow ET dose with flush


Ventilate the patient to assist dose distribution
Beware of mL/kg versus mg/kg….
these doses are mL/kg
Emergency Childbirth
Phase III: Care of the Newborn
Page 72
Pediatric Initial Medical Care
Page 75

Zofran (ondansetron) doses are written
by weight AND age

> 1 YO AND > 40 kg


> 1 YO AND < 40 kg



4 mg ODT or 4 mg slow IV x1 dose only
0.1 mg/kg slow IV x1 dose only
No oral dose for < 40 kg
IV administration over 1-2 minutes
Pediatric Initial Medical Care
Page 75
Pediatric Drug Assisted Intubation Versed (Midazolam)
Page 81

Sellick’s maneuver has been removed



After passing the tube, verify placement


Not performed consistently
Has not been proven to be effective by evidence
based medicine
Added “adequate chest expansion bilaterally and
symmetrically”
Focus for peds patients is on BLS maneuvers as
appropriate
Pediatric Altered Mental Status
Page 88


Added definition of Newborn (< 24 hours old)
versus Neonate (1-28 days old) under glucose
doses
Narcan (naloxone) can now be given IM (in
addition to IV/IO/IN)

Narcan (naloxone) IM route approved for peds only
Pediatric Altered Mental Status
Page 88


Narcan (naloxone) doses changed, now dosed
by weight or age
Respiratory compromise in pediatric patients is
more likely to be due to OD or accidental
ingestion, therefore different dose than adults
Pediatric Altered Mental Status
Page 88

Special Considerations


Added dextrose 10% dosing in the event of a
severe drug shortage (> 8 YO)
System-specific procedure for details
Pediatric Altered Mental Status
Page 88


To administer dextrose 12.5%, providers need
to mix their own 12.5% concentration
How do you mix D12.5?
Pediatric Toxicologic Emergencies
Page 92

Added generic drug names to “Club Drugs”
Pediatric Burns
Page 102

Pediatric fentanyl dosing for has NOT changed

Fentanyl 1 mcg/kg SLOW IV/IM, max dose 100
mcg




Peds doses rarely exceed adult doses
No repeat dose but can call Medical Control to
request additional dosing
The IO route for fentanyl is not approved in the
pediatric SOPs
If the patient requires an IO, stabilizing the
patient takes priority to giving pain
medication
Drug Appendix
Adenocard (adenosine)
Page 112

Administer Adenocard (adenosine) immediately
followed by rapid IV flush, then elevate the
extremity





Half life is 6 seconds
Proximal vein (AC or upper arm)
10-20 mL NS flush
Obtain 12-lead ECG during attempted
cardioversion if possible
Additional adverse reaction added

Drug is a respiratory stimulant and can exacerbate
asthma
Adenocard (adenosine)
Page 112

Additional contraindications for Adenocard
(adenosine)


Atrial fib/flutter with underlying Wolff Parkinson
White (WPW) syndrome
Symptomatic bradycardia except those with
functioning pacemakers
Wolff Parkinson White (WPW)
Syndrome
Page 112

Classic ECG features




Shortened PR interval
Slurring and slow rise of the initial upstroke of the QRS
complex (delta wave)
Widened QRS complex (total duration >0.12 seconds)
ST segment–T wave changes, generally directed
opposite the major delta wave and QRS complex
Wolff Parkinson White (WPW)
Syndrome
Page 112

During tachycardic episodes, may be


Cool, diaphoretic, and hypotensive
Crackles in the lungs from pulmonary vascular
congestion
Amiodarone (Cordarone)
Page 112

Adverse effects

May also prolong the QT interval, leading to
ventricular dysrhythmias
Dextrose
Page 115


In the event of drug shortages of D50%,
use D10% per System-specific procedure
Dextrose can be administered IV or IO
Etomidate (Amidate)
Page 115

Etomidate (amidate) can be administered IV or
IO
Epinephrine (adrenaline)
Page 116

Epinephrine (adrenaline) can be administered IV
or IO for anaphylaxis


Differentiate between anaphylaxis and systemic
allergic reaction
Neonatal doses changed
Systemic Allergic Reaction





Onset: gradual
Skin: mild-to-moderate flushing, rash, hives
Respiration: mild-to-moderate
bronchoconstriction
GI System: mild cramps, diarrhea
Vital Signs: normal-to-slightly abnormal


(↑pulse, ↑RR)
Mental Status: normal
Anaphylaxis
Signs/Symptoms






Onset: sudden, typically 30-60
seconds
Skin: severe flushing, rash, hives,
angioedema (swelling) of face or
neck
Respiration: severe
bronchoconstriction (wheezing),
laryngospasm (stridor),
difficulty breathing
GI System: severe cramps, diarrhea,
vomiting
Vital Signs: early↑pulse/late↓,
early↑RR/late↓RR, falling BP
Mental Status: anxiety,
confusion/unconsciousness
Ominous Signs



Sense of impending
doom
Respiratory distress
Signs of shock
Epinephrine (adrenaline)
Page 116

Updated to reflect current neonatal
resuscitation national standards

Epinephrine (adrenaline) 1: 10,000
0.1 mL/kg IV/IO q 3-5 minutes
 If unsuccessful, 0.5 ml/kg ET
 Repeat every 3-5 minutes as long as heart rate
< 60 beats per minute with CPR


DO NOT follow ET dose with flush


Ventilate the patient to assist dose distribution
Beware of mL/kg versus mg/kg….
these doses are mL/kg
Fentanyl
Page 117

The IO route for fentanyl is not approved in most
SOPs, except the Adult Burn SOP


If the patient requires an IO, stabilizing the patient
takes priority to giving pain medication.
Pushing IV fentanyl too quickly can cause chest wall
rigidity
 Administration should be over 1-2 minutes
 If using a saline lock, push the fentanyl over 1-2
minutes and then push the saline flush over 1-2
minutes
Fentanyl
Page 117




The dosing of fentanyl is changed and is now
consistent for adults regardless of SOP
Adult patients receiving fentanyl must have a
systolic BP > 100 mmHg
The initial fentanyl dose remains the same for all
adult patients < 65 years old
Now all adult patients < 65 years old,
regardless of SOP, can have one repeat dose
up to a maximum of 50 mcg
Fentanyl

New doses added for patients > 65 years old




These patients tend to have slower renal clearance
of drugs and are more sensitive to the effects of
opiates even at lower doses.
Adult patients receiving fentanyl must have a
systolic BP > 100 mmHg
Initial dose of 0.5 mcg/kg (max 50 mcg) SLOW
IV/IM
Repeat dose of 0.25 mcg/kg (max 25 mcg)
SLOW IV/IM
Fentanyl
Page 117

Pediatric fentanyl dosing for has NOT changed

Fentanyl 1 mcg/kg SLOW IV/IM, max dose 100
mcg




Peds doses rarely exceed adult doses
No repeat dose but can call Medical Control to
request additional dosing
The IO route for fentanyl is not approved in the
pediatric SOPs
If the patient requires an IO, stabilizing the
patient takes priority to giving pain medication
Glucagon (GlucaGen)
Page 117


For Beta Blocker or Calcium Channel Blocker
overdose, may be administered IV or IO
Adult dose1 mg slow IV/IO


Pediatric dose 0.5 mg slow IV/IO


May repeat x1
May repeat x1
Administer in cases where suspected BB or CCB
overdose is suspected and the patient has
hypoperfusion with associated bradycardia
Glucose, oral
Page 117


New to drug appendix
Dose


Onset


Hypoglycemia in patients with normal mental status and
intact gag reflex
Contraindications


~10 minutes
Indication


Pediatrics and adults = one tube/15 grams
Altered mental status and no gag reflex
Adverse reactions

Nausea, and potential for aspiration in patients with
impaired airway reflexes
Narcan (naloxone)
Page 118

New dosing for adults




Initial dose of 1 mg IV/IN
May repeat 0.5 mg IV/IN prn q 2 minutes up to a
max dose of 2 mg if transient response observed
Old wording was “as needed”
Focus now is on getting patient breathing but not
causing withdrawal
Narcan (naloxone)
Page 118

Narcan (naloxone) doses changed for pediatrics,
now dosed by weight or age

≤20 kg or < 5 YO


≥20 kg or ≥ 5 YO


0.1 mg/kg IV/IO/IM/IN
2 mg IV/IO/IM/IN
Can now be given IM (as well as IV/IO/IN)
Versed (midazolam)
Page 119

Added IO route as additional route to IV
Zofran (ondansetron)
Page 119



As alternative route to ODT, adults may now
be given 4 mg Zofran (ondansetron) SLOW IV x1
dose only
Zofran can only be given IV or ODT once –
NOT both
Pediatric Zofran (ondansetron) doses are by weight AND
age

> 1 YO AND > 40 kg


> 1 YO AND < 40 kg



4 mg ODT or 4 mg slow IV x1 dose only
0.1 mg/kg slow IV x1 dose only
No oral dose for < 40 kg.
IV administration over 1-2 minutes
RESPIRATORY:
OXYGENATION VS VENTILATION
Region VIII EMS Systems
Objectives






SME video of the month
Describe the respiratory system and the process of
breathing
Recognize adequate vs inadequate oxygenation vs
ventilation in patients
Understand the tools used for monitoring both
oxygenation and ventilation
Discuss acute and chronic disease processes that effect
oxygenation and/or ventilation
Discuss considerations for selecting the best device for
delivering oxygen and ventilations
Announcements

Region

System
SME video
Review of Respiratory System
Upper Airway
• Pharynx
•
•
•
•
•
•
•
Nasopharynx
Oropharynx
Larynx
Thyroid cartilage
Glottic opening
Cricoid ring
Trachea
Review of Respiratory System
Lower Airway
 Trachea
 Bronchi and
bronchioles
 Alveoli
 Lungs
Review of Respiratory System

Breathing is only one of the activities of the
respiratory system
 The
body’s cells need continuous supply of oxygen for
the metabolic processes necessary to maintain life


The respiratory system works with the circulatory
system to provide oxygen and remove waste
products of metabolism (carbon dioxide)
Helps to regulate pH of the blood
Review of Respiratory System

Every 3-5 seconds, nerve
impulses stimulate ventilation,
which moves air through a
series of passages into and
out of the lungs

There is an exchange of gases
between the lungs and blood,
which is called external
respiration

The exchange of gases between
the blood and tissues is called
internal respiration

Cellular respiration (metabolism)
is when the cells utilize the
oxygen for their specific activities
Review of
Respiratory
•
•
•
Breathing is primarily
controlled involuntarily
by autonomic nervous
system
Regulation is largely
r/t maintaining normal
gas exchange and
blood gas levels
Receptors in the body
constantly measure the
amount of oxygen
(O2), carbon dioxide
(CO2) and hydrogen
ions (pH) to signal the
brain to adjust rate
and depth of
respirations
Review of Respiratory


98% of O2 is carried
bound to Hemoglobin
(the other 2% is
dissolved in blood
plasma)
In summary, we breathe
not only because we
need O2 to survive, but
to get rid of CO2, a byproduct of cellular
metabolism
Common Respiratory Diseases

Obstructive Airway Diseases
 Chronic Bronchitis
 Emphysema
 These
2 often coexist and are then termed chronic
obstructive pulmonary disease (COPD)
 Asthma
 Status
Asthmaticus is a severe prolonged asthma
exacerbation that cannot be broken with repeated doses of
bronchodilators

True emergency, requires early recognition and may quickly lead
to respiratory failure
Common Respiratory Diseases or
Disorders


Upper Airway Infections
Pneumonia


Adult Respiratory Distress Syndrome (ARDS)




Can be viral or bacterial
Respiratory failure with acute lung inflammation and diffuse
alveolar-capillary injury
Pulmonary Embolism (PE)
Spontaneous Pneumothorax
Lung Cancer
Let’s start with the patent Airway . . .

Head-tilt/chin lift Maneuver
 Opening

Jaw thrust without head-tilt
 Opening

the airway with repositioning
the airway if spinal injury is suspected
Suction
 Remove
secretions or debris
Airway Management
•
Nasopharyngeal (nasal) Airway
 Maintain

airway in a semiconscious patient
Oropharyngeal (oral) Airway
 Maintain
airway on an unconscious patient
(no gag reflex)
Airway Management

Endotracheal Intubation – patient can no longer
protect airway
 Advantages:
 Provides
complete airway management
 Helps prevent aspiration
 Positive pressure ventilation can be given
 Control of volumes of ventilation
 Tracheal suctioning is possible
 Prevents gastric distention
 Provides a route for some medications (not preferred,
but worst case if no IV/IO)
 High concentration of oxygen can be given
Airway Management

Alternative Airways:
 King
Airway
Advantage is ease of
use
 Can reduce time spent
off the chest if CPR is
ongoing

 Cricothyroidotomy

Surgical or Needle, per
system specific
procedure
Airway Management

Traits to look for in difficult to obtain airways
(ANOTES):
A: Awake patients (with a Glasgow Coma Scale score
greater than 3)
 N: Neck (short or “no neck”)
 O: Obese patients
 T: Trauma (facial, airway or requiring C-spine stabilization)
 E: Emesis
 S: Space: limited space about the head to manage the
airway

Definition of Ventilation
The process of air movement into and out of the
lungs
For ventilation to occur, the following must be intact:
 Patent upper airway
 Neuro control – brain stem
 Muscles of respiratory system, including diaphragm
and intercostal muscles
 Functional lower airway, including functional alveoli
Inadequate Ventilation

Occurs when the body cannot:
 compensate
for increases in O2 demands
 maintain normal oxygen/carbon dioxide balance

Causes:
 Infection
 Trauma
 Brain
stem insult
 Noxious or hypoxic atmosphere
Signs and Symptoms
Respiratory Distress







Tachypnea
Use of accessory muscles
(intercostal, suprasternal or
substernal retractions)
Adventitious breath sounds
Nasal flaring
Tripod or position of comfort
Grunting
Cyanosis
Respiratory Failure






Decreased level of
consciousness
Increased work of
breathing
Poor air entry
Decreased breath sounds
Bradycardia
Apnea or respirations less
than 6 per minute
Respiratory Distress vs Failure
1.
Adventitious Breath Sounds:
 http://www.youtube.com/watch?v=5JA6D1Mguh0
2.
Respiratory Distress or Failure?
 http://www.youtube.com/watch?v=uA02h6FYSYQ
3.
Respiratory Distress or Failure?
 http://www.youtube.com/watch?v=0YJxz-Sxx90=
Causes of Respiratory Distress/Failure

Failure to Maintain Airway
 Upper
Airway obstruction
 Foreign
body
 Anaphylaxis (laryngeal edema)
 Epiglottitis
 Croup
 Tracheal trauma
 Lower
Airway Obstruction
 Bronchospasm
 Inhaled
objects (foreign body aspiration)
Causes of Respiratory Failure
Failure to Ventilate

Neuro



Opioids, sedative or
anesthetic agents
Brain or spinal injuries
Muscular



Steroids
Myasthenia Gravis (or
other neuromuscular
disorders)
Failure to Oxygenate



 COPD
 Pneumonia
Trauma


Chest wall trauma such as
flail chest
Pneumo-/hemothorax
Pulmonary Embolism
Pulmonary Fibrosis
Interstitial Lung
Disease

Pulmonary Edema
Ventilation vs Oxygenation


It is important to
remember that these terms
are NOT synonymous
Adequacy of ventilation is
evaluated using
qualitative, external cues
such as respiratory rate,
chest rise and fall,
compliance of a bagvalve mask
Ventilation

Many studies have shown that HCP’s tend to
hyperventilate patients
 Both
the rate and volume of assisted ventilations are
often too high
 Hyperventilation causes vasoconstriction which can lead
to hypoperfusion to major organs (especially the brain)
 American Heart teaches that providers should
administer ventilation at 10-12 breaths per minute and
titrate to achieve EtCO2 of 35-40mm/Hg using
continuous waveform capnography
Ventilation



Capnography is a
quantitative tool that can be
used to monitor ventilation
adequacy r/t end tidal CO2
concentration (EtCO2)
Our medulla measures CO2
levels to adjust rate and
depth of respirations
If patient is having
respiratory distress, the
provider should measure
CO2 to determine if breaths,
whether spontaneous or
artificial, are adequate
Normal CO2 level 35-45mm/hg
Hypocapnia (CO2 < 35mm/hg)
•
Hyperventilation (blowing off too
much CO2)
•
•

Metabolic condition such as
diabetic ketoacidosis or kidney
failure
•
Hypotension
Shock
Hypothermia
•
Ventilatory failure
(hypoventilation)


Hypoperfusion
•
•
Hypercapnia (CO2 > 45mm/hg)

CO2 Retention


Metabolism is slowed in
hypothermic state, so less CO2 is
produced
COPD
Respiratory Acidosis



Narcotic overdose
Stroke that affects the
brainstem
Chest wall injury
Chest muscle weakness
Fever (hypercatabolic state)
Capnography


American Heart defines capnography as the
measurement and graphic display of CO2 levels in
the airway, which can be performed by infrared
spectroscopy
Long the standard for monitoring intubated patients,
especially in the operating room and intensive care
units, capnography is now a standard tool for
assessing ventilation in both intubated and nonintubated patients
Ventilation and Capnography

Our bodies “blow off”
CO2, so during
expiration an upstroke in
the waveform is seen
This creates a plateau
until the end of expiratory
phase
 It is at this peak level that
the EtCO2 value is
measured and resulted


During inspiration, CO2 is
purged from the airway
and alveoli, so the
waveform drops down to
baseline
Normal Capnogram
Field Application for Capnography

Triage Tool
Help narrow a differential diagnosis of dyspnea
 Assist in assessing severity of asthma attack
 Trend CO2 retainers if patient has COPD


Monitor for relapses following therapies


Such as following administration of a bronchodilator
CPR

Correlate blood delivery to the lungs (adequate chest
compressions, ventilations)
Field Application for Capnography


Endotracheal or other advanced airway placement
confirmation
 Waveform should appear to be SQUARE if tracheal
intubation is successful
Ongoing assessment of ventilations following
insertion of advanced airway
 Rate AND volume of assisted ventilation
Troubleshoot Abnormal Waveforms
Oxygenation

Adequacy of oxygenation, such as pallor, cyanosis
or other physical findings are not as reliable as signs
of ventilation (ie: chest-rise and fall, resp. rate)
 Pulse-oximetry
is the quantitative tool that monitors
saturation of peripheral O2 (oxygenation/SpO2)
 This
tool has its limitations:
 Hypoxia follows hypoventilation, which can take
30 seconds or more for the pulse-ox to reflect
 Hypovolemia, vasoconstriction, peripheral vascular
disease and even nail polish can cause false readings
Oxygen Delivery Devices

Nasal Cannula – delivers 1-6L, approximately
24-44% concentration, of O2
 Indications
for use: treat hypoxia, dyspnea
or increased myocardial work
 Contraindications: nasal trauma or blockage
 Consider placing patient on 10L while intubating!
Oxygen Delivery Devices

Non-rebreather Mask – delivers 10-15L,
approximately 90% concentration, of O2
 Indications
for use: respiratory distress, trauma
 Contraindications: CO2 retainer such as COPD
exacerbation

Bag-valve Mask – delivers15L, 90%+ concentration,
of O2
 Indications
for use: respiratory failure, support
for bradypnea or apnea, positive pressure to
open the airway/alveoli (this is used to administer oxygen and ventilations BOTH)
Ventilation vs Oxygenation
*** REMEMBER: the provider is the best “monitor”
***
 If
available, combining pulse-ox and capnography are
ideal for monitoring oxygenation and ventilation, as
providers can detect insufficiencies early and intervene
 While they are helpful tools, Pulse-oximeters and
capnometers do not treat the patient, YOU DO
 The provider in charge of the airway and ventilating
needs be able to focus on this task only so as not to
have poor outcome that hyperventilating a patient can
cause
BREAK TIME
Scenario 1
EMD / BLS
EMD/BLS
•
Call comes in as an 8 year old shortness of breath
from the local elementary school
•
EMD: What questions would you ask the caller?
•
EMD: Which units would you dispatch? How many?
BLS Arrives on Scene:

General Appearance


Work of Breathing


Awake, alert, anxious
Dyspnea
Circulation

Hot, dry, red, patchy,
swollen areas on skin of
extremities and face
BLS Scenario




A – patent (“tightening”),
no stridor noted at this
time
B – increased effort,
audible wheezes without
auscultation, SpO2 92%
C – flushed, capillary
refill is 2 seconds, pulse is
strong and fast
Vitals: B/P 105/65, P
128, R 30, T 99.0






S - hives, itchy, throat tightening
and dyspnea
A – tree nuts, no known drug
allergies
M – EpiPen Jr (at home),
Albuterol inhaler
P – asthma, seasonal and food
allergies
L – lunch about a 20 min ago
E - ate a cookie offered to him
by another student, started to
feel throat closing feeling and
itchy, hot skin in class right after
lunch
BLS Scenario

Obtain SAMPLE history

Initial Medical Care
 You
have already assessed for signs of respiratory
distress vs failure
 Reassure
 Should
patient, place in position of comfort
this patient receive oxygen? What would you use
to deliver this? Should you assist ventilations?
BLS Scenario



Should you give this patient an auto-injection of
Epinephrine (EpiPen)?
Where is the site of injection?
What if the school nurse says she cannot find his
prescribed EpiPen and hands you an adult EpiPen
because its all she could find?
BLS SKILL REVIEW
Epinephrine Auto-injector
BLS Skill Review

Indications for use of EpiPen


EpiPen® (epinephrine) 0.3 mg and EpiPen Jr® (epinephrine)
0.15 mg Auto-Injectors are indicated in the emergency
treatment of type 1 allergic reactions, including
anaphylaxis, to allergens, idiopathic and exercise-induced
anaphylaxis, and in patients with a history or increased risk
of anaphylactic reactions. Selection of the appropriate
dosage strength is determined according to body weight.
Important Safety Information

EpiPen Auto-Injectors should only be injected into the
anterolateral aspect of the thigh. DO NOT INJECT INTO
BUTTOCK, OR INTRAVENOUSLY.
EpiPen for Anaphylaxis
http://www.epipen.com/Howto-Use-EpiPen
Scenario 2
BLS/ALS
BLS/ALS Scenario


Your medic unit is dispatched for 78 year old
female shortness of breath
You arrive on scene where a daughter directs you to
the bedroom to find the female patient sitting in
high-fowler’s position with several pillows propped
behind her
 Appearance:
awake and alert with a GCS of 15
 Increased work of breathing noted
 Skin is pale
BLS/ALS




A – patent
B – dyspnea, rales
audible from across the
room
C – pale, cool to the
touch, edema to BLE
Vitals:
B/P: 194/106
 P: 116
 R: 28
 T: 97.6







S – short of breath
A – PCN
M – Metoprolol, Plavix,
Norvasc, Crestor, Diovan HCT
P –cardiac stents, high
cholesterol, CHF, pneumonia
L – dinner about 6 hours ago
E – over the last week she has
needed to be propped up
more to sleep d/t inability to
breath lying flat
ALS
•
•
Are we thinking pulmonary edema d/t heart failure?
Goal is to reduce the preload and afterload on the
heart
•
•
•
If available, place the patient on continuous
waveform capnography
CPAP should be considered sooner rather than later
•
•
•
administration of nitroglycerin
Reduces work of breathing
Helps reduce preload on the heart
Do we use a diuretic? NO!!!
Medications of the month
Albuterol
Albuterol




Brand Names: Proventil, Ventolin
Adult/Pediatric Dose: 2.5mg of 0.83% solution (3ml) via
nebulizer (6LPM O2 supply) until mist stops (usu 5-15 min)
Action: binds and stimulate Beta 2 receptors, resulting in
bronchial smooth muscle relaxation and bronchodilation
Indications: asthma, bronchitis with bronchospasm, COPD
with wheezing, allergic reaction or anaphylaxis with
wheezing
Albuterol

Contraindications:
 angioedema,
hypersensitivity to albuterol, caution in
lactating women, cardiovascular disease history

Adverse Reactions:
 hyperglycemia,
hypokalemia, palpitations,
tachydysrhythmias, anxiety, tremors, nausea/vomiting,
throat irritation, dry mouth, HTN, insomnia, headache,
paradoxical bronchospasm
MEDICATIONS OF THE MONTH
Etomidate
Etomidate




Brand Name: Amidate
Adult Dose: 0.6 mg/kg rapid IV, NO Repeat dose and
NO PEDS
Action: non-barbiturate hypnotic without analgesic
properties. Has minimal effects on cardiac or respiratory
systems. Onset is 10-20 seconds with duration of 3-5
minutes
Indications: sedation for endotracheal intubation
Etomidate

Contraindications:
 hypersensitivity
to Etomidate, only use in pregnancy if
potential benefits justify the potential risk to fetus

Adverse reactions:
 hypotension,
respiratory depression, injection site pain,
temporary involuntary muscle movements, frequent
nausea and vomiting, hyper-/hypoventilation, short
duration apnea, hiccups, laryngospasm, snoring,
tachypnea, HTN, dysrhythmias
Do Not Forget Your Med Checks!
Cardiac Rhythm of the Month
Torsades de Pointes



An uncommon and distinctive form of polymorphic
ventricular tachycardia (VT) characterized by a
gradual change in the amplitude and twisting of the
QRS complexes around the isoelectric line
Associated with prolonged QT intervals, which can
be congenital or acquired (such as drug therapy
induced or other body system disorders)
Tends to occur in bursts that are not sustained but
can recur and may degenerate into ventricular
fibrillation (VF)
Torsades de Pointes

Patient presentation may
include:
Palpitations
 Dizziness
 Syncope
 Nausea
 Cold sweats
 Shortness of breath
 Chest pain
 Sudden Cardiac Death

Treatment:

Determine if patient has
a pulse and then follow
the appropriate
ventricular tachycardia
SOP

Magnesium is ultimate
drug of choice


Lowers the amplitude of
early afterdepolarization
(EAD) by decreasing the
influx of calcium
Scenario 3
ALS
ALS Scenario


Your medic unit is dispatched for the 44 year old
female shortness of breath
Upon arrival, you find the patient in a tripod
position, having difficulty getting more than a word
or 2 out
 Appearance:
awake, alert, anxious
 Work of Breathing: increased effort
 Circulation: pale, diaphoretic
ALS





A – patent
B –intercostal and
substernal retractions,
diffuse wheezes
C –strong peripheral
pulses, cap refill 2
seconds
Vitals:
B/P:168/94
 P: 130
 R: 40
 T: 100.4






S – cough, dyspnea
A – environmental, no drug
allergies
M –Xopenex, Xyzal, Chantix
P – asthma with intubation in
the past, allergies, smoker
L – dinner last night
E – URI symptoms x2 days,
labored breathing is new onset
today and she tried 2 nebs
prior to your arrival
ALS
Asthma Exacerbation




Possible Status Asthmaticus
Need to correct the
hypoxemia caused by
narrowing and blocked
airways
Follow ADULT ACUTE
ASTHMA SOP
Slap the Cap  (monitor
waveform capnography for
trends with treatments –
note the “shark fin”
appearance in
bronchospasm
Airways affected by asthma
ALS

Consider CPAP early to:
 Decrease
 Recruit
 Splint
work of breathing, reducing fatigue
alveoli and improved oxygenation
larger airways, reducing airway collapse and
mucous plugging
Als skill review
Continuous Positive Airway Pressure (CPAP)
CPAP

Prehospital indications for CPAP use:
 Congestive
Heart Failure
 Asthma/COPD
 Drowning
 Carbon Monoxide Poisoning
 Pulmonary Infections
CPAP

Contraindications:
 Cardiogenic
Shock
 Patient
is hypotensive and CPAP increases intrathoracic
pressures, thereby lowering venous blood return to the right
side of the heart
 Altered
Mental Status or unconscious
 Facial Trauma, anomalies or stroke with facial droop
 Pneumothorax or penetrating chest trauma
 Persistent nausea/vomiting
 Agonal respirations/respiratory arrest
CPAP

Additional Education from Bob Spoula – Edward
Hospital Respiratory Therapy Educator (CPAP
PowerPoint)
Questions? Contact EMS Office

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