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Weak Winded and Woozy Weak, winded & woozy - Connie J. Mattera MS, RN, PM Upon completion, participants will do Weak, winded & woozy – the following without critical error: what’s wrong? Integrate assessment findings in pts who present w/ respiratory distress to form an accurate field impression. This includes developing a list of differential diagnoses using higher order thinking and Connie J. Mattera, MS, RN, EMT-P critical reasoning. NWC EMSS Administrative Director Upon completion, participants will do What audible sounds indicating airway or the following without critical error: ventilatory impairment can be heard w/o Compare and contrast pts a stethoscope when inspecting the who present w/ dyspnea, airway? weakness, & possible AMS Snoring, gurgling Weigh the indications and Hoarseness contraindications of Stridor, choking sounds possible interventions Wheezes from larger bronchi and sequence evidence- Crackles heard through mouth based EMS care Expiratory grunting Pulmonary S&S airway impairment pathophysiology Secretions/debris in airway Stridor, snoring, gurgling, grunting All respiratory Restlessness, anxiety, dyspnea problems Apnea, agonal ventilations can be Use of accessory muscles; categorized rocking chest motion as impacting Retractions, tracheal tugging . Ventilation Hypoxia, hypercarbia . Diffusion Unable to speak/make age-appropriate snds . Perfusion Faint/absent breath sounds 1 Weak, winded & woozy - Connie J. Mattera MS, RN, PM What should be assessed Work of breathing about breathing? Muscles used to ventilate A patent airway does not ensure adequate ventilations or gas exchange General respiratory rate, depth Inspection cont. Breathing Diaphragmatic, w/ pursed See Saw, Apical lips breathing? Splinting? Own PEEP Origins of ventilation dysfunction Speech: talk test Sentences or syllables? Pacing of speech and breathing Quality of voice; hoarse or raspy? Airway impairment Stuttering Chest wall impairment 2 Weak, winded & woozy - Connie J. Mattera MS, RN, PM Origins of ventilation dysfunction High SCI Ventilatory depression or arrest CNS: Trauma, stroke, medical neuro condition Muscles: Ventilatory depression or arrest Myasthenia Nerves: Polio, Guillain-Barrè syndrome, MS Gravis, muscular dystrophy Breathing considerations in obese pts Factors that impair diffusion Lungs 35% less compliant Thickening of alveolar walls Weight of chest makes Destruction or collapse of alveoli breathing difficult – ↓ permeability ventilate at 8-10 mL/kg Widened SpO2 unreliable on finger – interspace use central sensor ↓ in blood flow Will desaturate if supine CO2 retention probable CPAP useful 3 Weak, winded & woozy - Connie J. Mattera MS, RN, PM Atmospheric deficiency Conditions w/ Diffusion cont. Alveolar pathology impaired . Asbestosis High permeability diffusion . COPD . ALI; non-cardiogenic . Inhalation injuries pulmonary edema . Pneumonia . Asbestosis Interstitial pathology . Near-drowning . High pressures (HF) . Post-hypoxia . Pulmonary . Inhalation injury hypertension Capillary bed pathology: atherosclerosis Assess gas exchange/ What factors influence the evidence of hypoxia detection of cyanosis? What info is obtained by assessing skin Rate of blood flow Degree of desaturation (at least 5 Gm) color, temp & moisture? Degree of desaturation (at least 5 Gm) Type of light Observer skill Adequacy of oxygenation Thickness and color of skin Adequacy of peripheral perfusion Evidence of SNS stimulation/compensation Cool, hot, pale, flushed, mottled, ashen, cyanotic, & Skin color unreliable: anemia & diaphoretic skin must be explored for cause peripheral vasoconstriction Start placing Capnography: Numeric reading + waveform monitors prn Pulse oximetry Non-invasive BP after 1 manual reading ECG rhythm + 12 lead 4 Weak, winded & woozy - Connie J. Mattera MS, RN, PM What does pulse ox measure? What’s the difference A. Mean arterial pressure between capnography B. Level of CO2 in the blood C. Amount of O dissolved in plasma & pulse oximetry? 2 D. % of hemoglobin bound with a gas Problem: Many pts have unrecognized hypoxia by physical exam alone Pulse ox is NOT the same as the pO2! If SpO2 is 90%, the pO2 is… P Values P90: SpO2 90 = pO2 60 P75: SpO 75 = pO 40 SpO2 artificially elevates when hyperventilating 2 2 For each 1 Torr pt ↓ pCO2, the pO2 ↑ by 1 Torr P50: SpO2 50 = pO2 27 Hypoxia common in HF & COPD; means severe distress in asthma Pulse oximetry range guidelines right tool the Ideal: 96%-100% right way! Mild-mod hypoxemia: 90%-95% Use the Severe hypoxia: < 90% Severely low SpO2 (< 90%) If low, validate predictor of on another site poor outcomes - use a central sensor 5 Weak, winded & woozy - Connie J. Mattera MS, RN, PM The affinity of hemoglobin for O2 is altered by conditions in the tissue the blood is flowing through… Which of these will influence the amount of O2 delivered to cells? A. Acid-base status B. Body temperature Capnography C.The amount of hemoglobin Indicates adequacy of ventilations, perfusion, & dead D.All of the above space by detecting how much CO2 is exhaled Gives a numeric value & graphic waveform HF should have normal, Waveform shape Capnography squared off waveform helps make a differential diagnosis Shark-fin waveform suggests a Use on intubated pulmonary and non-intubated condition pts with a NC (asthma/COPD) attachment or with delayed mask exhalation Asthma or COPD Capnography findings in HF Capnography: Incomplete inhalation/ After CPAP started, EtCO2 may briefly rise d/t improved ventilations, before it falls due to exhalation; CO2 does not get completely washed out on inhalation tachypnea Severely ↑ EtCO2 indicates ↑ pCO2 levels and ventilatory failure 6 Weak, winded & woozy - Connie J. Mattera MS, RN, PM Causes of hypercarbia Hypoventilation from any cause ■ Airway obstruction ■ Respiratory depression ■ Ventilatory muscle impairment ■ Pulmonary obstructive diseases Treatment: Correct inciting cause Breath sound auscultation S&S compromised ventilations Listen Apnea immediately S&S hypoxia for evidence of air entry if Dyspnea; accessory muscle use pt in distress Upright, tripoding; orthopnea Most ominous Ventilatory efforts weak, sound is shallow, labored, retracting silence Adult RR < 10 or 24/min EtCO2 > 45; change in waveform O is a drug and must be given to specific 2 Harmed by hyperoxia pts based indications/contraindications and in correct doses by an appropriate route - Uncomplicated Acute MI being vigilant for adverse reactions Post-cardiac arrest Acute exacerbations of COPD Which patients can be Stroke Neonatal resuscitation harmed by hyper oxia Give O2 to these pts only if evidence of hypoxia and need careful and titrate to dose that relieves hypoxemia without causing hyperoxia (SpO 94%) titration of oxygen? 2 Iscor, S. et al. (2011) Supplementary oxygen for nonhypoxemic patients: O(2) much of a good thing? Crit Care, 15(3), 305 7 Weak, winded & woozy - Connie J. Mattera MS, RN, PM Profound, prolonged hypoxia is also Who should get CPAP? Pulmonary edema COPD/asthma w/ severe distress Flail chest w/o pneumothorax So, who NEEDS O2? Near drowning SpO < 94% (Exception: COPD SpO2 < 94% (Exception: COPD Pneumonia (?) may be best managed w/ SpO 88-92%) 2 Palliative care (?) Actual or potential airway compromise (epiglottitis, airway burns) Diaphragmatic weakness Post-extubation rescue DAI (to increase O2 reserves) Globally poor tissue oxygenation & perfusion (shock) What do all these conditions have in common? Which is NOT a possible Severe dyspnea & refractory hypoxia complication of using CPAP? Poorly expanded lung fields A. Collapse of the alveoli ↑ WOB (↑ inspiratory muscle work) We’re in B. Decrease in blood pressure ↓ Minute ventilation trouble now! C. Gastric distension and vomiting Inability to remove CO2 from body Hypercarbic ventilatory failure D. Patient anxiety and claustrophobia Narcotic effect on brain ↓ RR Fatigue + ↓ RR = resp. arrest Pulmonary circulation (Q) VA/Q ratios Depends on: Adequate blood volume, intact pulmonary vessels & efficient pump Should be 1:1 Q = SV X HR VA = 5,250 mL/min Q = 70 mL X 72 BPM Q = 5,040 mL/min Q = 5,040 mL/min Patients may become hypoxic when ratio is imbalanced 8 Weak, winded & woozy - Connie J. Mattera MS, RN, PM general rate & quality of pulse: expect strong with HTN; Circulatory/Cardiac status weak if HF or dehydrated perfusion: general pulse rate, Tachycardia – hypoxia or early shock; pulse deficit quality, rhythmicity Palpitations or irregular pulse: Ask if hx of AF, PVCs common Establish that BP (SBP 90; underlying cause DBP 60) of respiratory Need MAP of 60 to difficulty is not fill CA cardiac in nature Often high in HF; if low suspect shock Perfusion impairment Inadequate blood volume Monitor ECG Inadequate hemoglobin: anemia, trauma Bradycardia is Impaired blood flow: pulmonary embolus bad! Capillary wall pathology: pulmonary contusion 12-lead IF: Why is AF common in HF? Discomfort (nose to navel, shoulder, arm, back) SOB/HF Palpitations; dysrhythmia (VT/SVT) GI complaint (nausea, indigestion) Diaphoresis; dizziness/syncope Weak/tired/fatigued With hypoxia & distress, many pts can have Why is it a concern? unrecognized ischemia 9 Weak, winded & woozy - Connie J. Mattera MS, RN, PM Ventricular hypertrophy may If HF & ACS suspected: 12-lead ASAP be evident in leads that If acute ischemia; give NTG per ACS overlie affected ventricle 12 L implications If age undetermined, use NTG dosing for R wave may be tall in V5 or pulmonary edema seen in V6, >25 mm high Typically, AMI severe Look for deep S wave enough to cause (>25 mm) in V1 or V2 pulmonary edema,
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