PART 9 Medicine CHAPTER Respiratory Emergencies 16 The following items provide an overview to the purpose and content of this chapter. The Standard and Competency are from the National EMS Education Standards. STANDARD • Medicine (Content Area: Respiratory) COMPETENCY • Applies fundamental knowledge to provide basic emergency care and transporta- tion based on assessment findings for an acutely ill patient. OBJECTIVES • After reading this chapter, you should be able to: 16-1. Define key terms introduced in this chapter. i. Cystic fibrosis 16-2. Explain the importance of being able to quickly rec- j. Poisonous exposures ognize and treat patients with respiratory emergencies. k. Viral respiratory infections 16-3. Describe the structure and function of the respiratory 16-9. As allowed by your scope of practice, demonstrate system, including: administering or assisting a patient with self- a. Upper airway administration of bronchodilators by metered-dose b. Lower airway inhaler and/or small-volume nebulizer. c. Gas exchange 16-10. Differentiate between short-acting beta2 agonists d. Inspiratory and expiratory centers in the medulla appropriate for prehospital use and respiratory medi- and pons cations that are not intended for emergency use. 16-4. Demonstrate the assessment of breath sounds. 16-11. Describe special considerations in the assessment and 16-5. Describe the characteristics of abnormal breath management of pediatric and geriatric patients with sounds, including: respiratory emergencies, including: a. Wheezing a. Differences in anatomy and physiology b. Rhonchi b. Causes of respiratory emergencies c. Crackles (rales) c. Differences in management 16-6. Explain the relationship between dyspnea and 16-12. Employ an assessment-based approach in order to hypoxia. recognize indications for the following interventions in 16-7. Differentiate respiratory distress, respiratory failure, patients with respiratory complaints/emergencies: and respiratory arrest. a. Establishing an airway 16-8. Describe the pathophysiology by which each of the b. Administration of oxygen following conditions leads to inadequate oxygenation: c. Positive pressure ventilation a. Obstructive pulmonary diseases: emphysema, d. Administration/assistance with self-administration of chronic bronchitis, and asthma an inhaled beta2 agonist b. Pneumonia e. Expedited transport c. Pulmonary embolism f. ALS backup d. Pulmonary edema 16-13. Given a list of patient medications, recognize medica- e. Spontaneous pneumothorax tions that are associated with respiratory disease. f. Hyperventilation syndrome 16-14. Use reassessment to identify responses to treatment g. Epiglottitis and changes in the conditions of patients presenting h. Pertussis with respiratory complaints and emergencies. 445 # 109912 Cust: Pearson Education / NJ / CHET Au: Mistovich Pg. No. 445 C / M / Y / K DESIGN SERVICES OF M16_MIST9137_10_SE_CH16.indd 445 S4CARLISLE 2/28/13 5:27 PM Title: Prehospital Emergency Care 10e Server: Short / Normal Publishing Services KEY TERMS • Page references indicate first major use in this chapter. For complete definitions, see the Glossary at the back of this book. apnea p. 448 hypoxemia p. 448 respiratory distress p. 449 bronchoconstriction p. 449 hypoxia p. 448 respiratory failure p. 449 bronchodilator p. 449 metered-dose inhaler (MDI) p. 464 small-volume nebulizer p. 464 dyspnea p. 448 pulsus paradoxus p. 476 spacer p. 464 hypercarbia p. 449 respiratory arrest p. 450 tripod position p. 472 Case Study The Dispatch As he leads you up narrow stairs to the third floor EMS Unit 106—respond to 1449 Porter Avenue, Apart- of the apartment complex, you scan the scene for ment 322. You have a 31-year-old female patient com- safety hazards and note any obstacles that will make it plaining of respiratory distress. Time out is 1942 hours. difficult to extricate the patient from the building. Upon walking into the apartment, you note a young Upon Arrival woman sitting upright on a kitchen chair, looking very You and your partner arrive at the scene and are greeted scared, and leaning slightly forward with her arms at the curb by the husband of the patient. As you step locked in front of her to hold her up. Before you can out of the ambulance and begin to gather your equip- even introduce yourself, she begins to speak one ment, you ask, “Did you place the call for EMS, sir?” He word at a time with a gasp for breath in between: states very nervously, “Yes. It’s my wife, Anna. She can’t “I—can’t—breathe.” breathe. She really doesn’t look good.” As you and your partner begin walking toward the apartment complex, How would you proceed to assess and care you ask, “What’s your name?” His voice breaks as he for this patient? tells you, “My name is John Sanders. We’ve only been During this chapter you will learn about assessment and married 2 months. Please—you’ve got to help my wife.” emergency care for a patient suffering from respiratory You reply, “John, we’ll take good care of your wife. But, distress. Later, we will return to the case and apply the you’ll help us more if you can calm down.” procedures learned. INTRODUCTION RESPIRATORY ANATOMY, Few things are more frightening to the patient than the PHYSIOLOGY, AND inability to breathe easily, and one of the most common symptoms of a respiratory emergency is shortness of PATHOPHYSIOLOGY breath. A number of other signs and symptoms may ac- The respiratory system can be divided into three por- company difficulty in breathing, which is also known as tions. The first two are the upper and lower airways, respiratory distress. Respiratory conditions may present with the vocal cords (or glottic opening) being the very similarly; this is because many of these findings are transition between the two. The primary purpose of from the body’s attempt to improve breathing adequacy, the upper and lower airways is the conduction of air not necessarily from the specific respiratory condition. into and out of the lungs. The third portion of the As such, many of your treatment modalities are similar respiratory system consists of the lungs and acces- for these conditions. It is important for you to recognize sory structures, which work in concert with the upper the signs and symptoms of respiratory emergencies, and lower airways to allow the oxygenation of body complete a thorough patient interview and physical as- cells and the elimination of carbon dioxide from the sessment to determine the cause, and provide immedi- bloodstream. ate intervention. 446 www.bradybooks.com DESIGN SERVICES OF # 109912 Cust: Pearson Education / NJ / CHET Au: Mistovich Pg. No. 446 C / M / Y / K S4CARLISLE M16_MIST9137_10_SE_CH16.inddTitle: Prehospital 446 Emergency Care 10e Server: Short / Normal Publishing Services 2/28/13 5:27 PM Normal Breathing information to the brainstem to prevent accidental over- expansion injuries, and irritant receptors in the walls Most patients you encounter as an EMT will be breath- of the bronchioles detect the presence of abnormalities ing normally. When referring to normal respiratory such as excessive fluid, toxic fumes or smoke, or signifi- rates, you must remember that normal is defined dif- cant air temperature changes. ferently for each individual patient group based on age Finally, receptors near the alveoli, called juxta- and preexisting disease. For example, a 19 year-old capillary receptors, detect when the alveolar-capillary sitting in a recliner breathing 24 times per minute is beds are becoming abnormally engorged with blood as a fast rate and should raise a concern. However, a re- a result of heart failure. These receptors are believed spiratory rate of 24 per minute in an elderly patient is to play a role in the feeling of shortness of breath the considered to be near the average rate. The following patient may experience, and they may also promote findings are consistent with a patient who is breathing shallow and rapid breathing. adequately: • An intact (open) airway Assessing Breath Sounds • Normal respiratory rate • Normal rise and fall of the chest During the physical exam, auscultation of breath • Normal respiratory rhythm sounds may provide additional evidence of breathing • Breath sounds that are present bilaterally difficulty. The general complaint of breathing difficulty • Chest expansion and relaxation that occurs normally can result from a variety of conditions; therefore, be- • Minimal-to-absent use of accessory muscles to aid in ing able to describe the type of breath sounds may be breathing helpful to medical direction when you ask for a medi- cation order. The following should also occur in a patient who is To achieve the most accurate interpretation of breath breathing adequately, provided that no other condition sounds, it is important to auscultate in the appropriate or injury is involved: fashion. Whenever feasible, have the patient sit upright • Normal mental status and, while using the diaphragm end of your stetho- • Normal muscle tone scope over bare skin (never auscultate over clothing), • Normal pulse oximeter reading (94%) instruct the patient to cough one or two times and then • Normal skin condition findings take deep rhythmic breaths (inhalation and exhalation) with his mouth open. You may need to instruct the pa- tient a few times to make no airway/vocal sounds while Abnormal Breathing he does this. Place the head of the stethoscope on the patient’s thorax, and listen the whole way through the Abnormal factors that are present in certain pulmonary phases of inhalation and exhalation. If necessary, listen (lung) conditions can decrease the efficiency of gas ex- to a few of the patient’s breaths (each breath includ- change across the alveolar-capillary membrane. They ing both inhalation and exhalation) at each auscultation include: location to ensure your interpretation of any abnormal • Increased width of the space between the alveoli and breath sound. Finally, listen to sounds on one location blood vessels of the body, and then listen to the exact location on • Lack of perfusion of the pulmonary capillaries from the other side (mirror location), before moving on.