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ANDI SURYA JAYA4 0 5 0 7 0 0 1 0EMERGENCY MEDICINE

BLOCK

FACULTY OF MEDICINE

TARUMANAGARA UNIVERSITY

JAKARTA

2012


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RespiratoryEmergencies


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What we know

Air is good

Pink is good

Blue is bad Air goes in

Air goes out


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Ventilation is

Movement of air in and out


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Upper Airway

In through nose

Warms

Humidifies

Filters

Past epiglottis

Into trachea Anterior to esophagus


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Sellicks Maneuver

Pressure on cartilage Pushes trachea more posterior for visualization of vocal

cords in intubation

Compresses esophagus to inhibit vomiting


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Bronchi

Branch off trachea

Bronchioles 33 divisions to alveoli No air exchange until

alveoli

Dead air space

Must ventilate with 500 cc

of inspired air to

get to alveoli


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Alveoli

Elastic muscles around bronchioles can cause spasm

Network of capillaries around alveoli for gas exchange


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Exchange of oxygen

and carbon dioxide


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Ventilation


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Mechanics of Breathing

Inspiration chest expands creates vacuum air rushes in

Expiration chest contracts creates pressure air rushes out


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Diffusionprocess of moving oxygen intoblood and carbon dioxide out

Diffusion is movement of particles (gas)from an area of high concentration to anarea of low concentration


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Hemoglobin

98% of inspired oxygen attached to the protein,hemoglobin in RBC

alveoli cells


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Hypoxialow oxygen to cells

Causes of hypoxia

Hypoxic hypoxia not enough oxygen

Anemic hypoxianot enough hemoglobin

Stagnant hypoxia not enough perfusion

shock

Histotoxic hypoxia unable to download

Cyanide poisoning


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Causes of

Respiratory Emergencies

Failure of: Ventilation: air in/ air out Diffusion: movement of gases Perfusion: movement of blood

Relieved by: epinephrine basedmedications(such as Beta 2 agonistalbuterol, terbutaline)

Compounded by: Inflammation/mucus production


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Assessment

Scene size up

Scene safety

Environment

What in and around the patient suggeststhat this is a respiratory emergency?


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General Impression of Patient

Position

Color

Mental Status Ability to Speak

Respiratory Effort


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Is this patient in distress?


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Look for pursed lip breathing or prolonged

expiration


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Tripod position suggests distress, resting weight on

knees helps with chest expansion


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Slow labored breathing is a sign of

respiratory failure


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Cyanosisblue discoloration

suggests hypoxia


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Initial Assessment

Airway open,no noises

Breathing 12-20 times per minute

Circulation warm, pink, dry, strongpulses

Disability mental status clear

Vital Signs


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Focused History

SAMPLE

OPQRST

How long has this been going on?

Start gradual or abrupt

Better or worse with position

Cough

Productive of sputum

Color of sputumwhite? Yellow? Red?green? brown?


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Additional Symptoms

Chest pain

Fever/chills

Wheezing Smoking history

Trauma


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Medications Currently Taking

Antibiotics

Oxygen

Steroids

Emphysema

Asthma

Inhalers/nebulizers

Emphysema Asthma

Cardiac drugs


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Respiratory Emergencies

For each, consider

Cause/Pathology

Signs and symptoms

Management


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Upper Airway Obstruction

Due to Foreign bodies food, toys

Tongue

Swelling

Underlying Problem VENTILATION Assessment/Associated Symptoms

Airway movement

Ability to speak

Dyspnea

Hypoxia

Sounds snoring, stridor

Oxygen saturation will be low


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Upper Airway Obstruction

Management

BLSHeimlich maneuver

ALS Foreign Body Magill Forceps

Allergic Reaction epi-pen and ALSprotocol

Epiglottitis rapid transport

Crouphumidified oxygen Sleep apneaPrescribed CPAP


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Emphysema

Destruction of alveolar walls

Underlying Problem: Diffusion

Assessment/Associated Symptoms

Dyspnea with exertion History of exposure

Barrel chest

Prolonged expiratory phase

Pursed lip breathing Thin and emaciated

Pink puffer (extra hemoglobin to make up for poor oxygenpick up)


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Management

Wont call till there is a problem

Secure airway

Correct hypoxia Respiratory drive from low oxygen not highCO2

IV access (dehydration)

Albuterol for Bronchodilation ifwheezing


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Chronic Bronchitis

Increased mucus production

Decreased alveolar ventilation

Underlying Problem: VENTILATION

AND INFLAMMATION Assessment/Associated Symptoms

History of long term exposure to toxins

Frequent respiratory infections Heavy sputum production

Obese and cyanotic (blue bloater)


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Management

Secure airway

Correct hypoxia

IV access (dehydration) Albuterol Bronchodilation if wheezing


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Asthma

Lower airway obstruction

Bronchospasm

Edema

Mucus

Caused by

Irritants

Respiratory infection

Emotional distress


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Asthma

Underlying Problem: VENTILATIONAND INFLAMMATION


Non productive cough Wheezing

Speech dyspnea one word sentences

Use of accessory musclesStatus Asthmaticusnot responding to

treatment


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Breath sounds?

IF BRONCHOLES TOTALLYOCCLUDED NO BREATH SOUNDS ATALL ---SILENCE IS BAD, BAD, BAD


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Management

Secure airway

Correct hypoxia

IV access (dehydration) Bronchodilation Beta 2 agonist

Inhaled, nebulized and/or subcutaneous

Albuterol, terbutaline


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Pneumonia

Infection of the lungs

Alveoli and interstitial spaces fill withfluid

Includes Severe Acute RespiratorySyndrome (SARS) and tuberculosis

Underlying Problem: DIFFUSION


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Looks ill

Fever and chills

Productive cough

Chest pain with respiration


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Management

BSI wear a mask

Secure airway

Correct hypoxia IV access (dehydration)

If wheezing -- Bronchodilation Beta 2

Agonist -- albuterol


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Costochondritis

Viral chest wall pain

Inflammation of muscle walls andcartilage of chest

Underlying problem: VENTILATIONAND INFLAMMATION


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Sudden onset

No trauma

Pain on deep inhalation

Pain on palpation

May have fever or history of cold


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Management

Correct hypoxia

Symptom relief

Anti-inflammatory medications Ibuprofen


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Toxic Inhalation

Inhalation of Super heated air

Chemicals

Combustion products

Steam

Lower airway edema

Bronchospasm

Underlying Problem: VENTILATION,INFLAMMATION, DIFFUSION


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Nature of inhalant

Burns to face, nose, mouth

Strider


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Management

Rescuer safety

Remove from further exposure

Secure airway may need intubation

Correct hypoxia

IV access

Rapid transport

Correct wheezing with beta 2agonist-- albuterol


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Carbon Monoxide Poisoning

Inhalation of gas that binds withhemoglobin

Underlying Problem: CELLULAR HYPOXIA Assessment/Associated Symptoms

Headache Irritability Errors in judgment Confusion

Vomiting Flu symptoms Pink color


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Management

Rescuer safety

Remove from source

Secure airway High flow oxygen

Hyperbaric chamber


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Pulmonary Emboli

Blood clot (or other emboli) inpulmonary circulation blocking bloodflow

Ventilation perfusion mis-match

Underlying problem: PERFUSION,DIFFUSION


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Assessment/Associated Symptoms:

Sudden onset acute chest pain

Sudden onset acute dyspnea

Tachypnea fast breathing

Tachycardia fast heart rate

Recent history of being inactive


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Management

Secure Airway

Correct hypoxia

IV Access


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Spontaneous Pneumothorax

Sudden loss of pleural seal

Underlying Problem: DIFFUSION,


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Non traumatic

Sudden onset dyspnea

No pain on palpation

May develop tension and JVD

Breath sounds absent on 1 side


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Management

Secure airway

Correct hypoxia

Watch for tension pneumothorax

IV access


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Hyperventilation

Increased minute volume

Underlying problem: too much oxygen and not

enough carbon dioxide (ACID/BASE DISRUPTION) Assessment/Associated Symptoms

Tachypnea

Numbness and tingling of fingers, toes, mouth

(Carpopedal spasms)


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Breath sounds are present on bothsides

Oxygen Saturation is greater than

94% on room air


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Management

Secure airway

Correct respiratory rate slow down

Oxygen by mask as 6 liters

IV access

Central Nervous System


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Dysfunction -- Brain Head trauma, stroke, brain tumor, insulin

shock, drug toxicity Underlying Problem: VENTILATION

Assessment/Associated Symptomsslow shallow breathingdecreased tidal volume and minutevolume

cyanosis


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Management

Secure airway

Correct hypoxia

May need to assist ventilations

IV access

Treat underlying cause if able



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DysfunctionSpinal Cord

Trauma, polio, multiple sclerosis,myasthenia gravis, ALS

Underlying problem: Ventilation

Assessment/Associated Symptoms: Slow shallow respirations

Poor use of chest muscles Decreased tidal volume and minute

volume


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Management

Secure airway

Correct hypoxia

May need to assist ventilations

IV access


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Respiratory Failure

Inability of the to meet the basicdemands for tissue oxygenation

Underlying Problem: VENTILATION,PERFUSION, DIFFUSION


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Assessment/Associated Symptoms: Gradual onset of

Inadequate oxygen productionInadequate CO2 removal

Tachycardia and Tachypnea

Followed in end stages byBrady cardia and Bradypnea

CyanosisPoor chest wall movementProfound acidosis


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Management

Open airway and mechanicallyventilate

IV access and correct hypovolemia

Work to correct underlying problem


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Respiratory

Emergenciesor all that wheezes is NOT

asthma


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Definitions

Apnea

Dypsnea

OrthopneaTachypnea

BradypneaHypercarbia

Acidosis

Alkalosis

VentilationDiffusion

PerfusionRespiration


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Anatomy

Anatomy


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Anatomy

Ph i l


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Physiology

Takes in oxygen

Disposes of wastes

Carbon dioxide

Excess water

O2+Glucose

CO2+ H2O

The Cell

Ph i l


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Physiology


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Ph i l


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Physiology

Autonomic Function

Primary drive: increase in

arterial CO2

Secondary (hypoxic) drive:decrease in arterial O2


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I d t B thi


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Inadequate Breathing

Breathing rate < 12 or > 20*Shallow or irregular respirations

Unequal chest expansion

Decreased or absent lung sounds

Accessory muscle usage

Pale or cyanotic skin colorCool, clammy skin appearance

O


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Obstructive Pathophysiology

Tongue Foreign body obstruction

Anaphylaxis and angiodema Facial trauma and inhalation

injuries (burns)

Epiglottitis and Croup Aspiration

R i i P h h i l


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Restrictive Pathophysiology

Asthma

COPD

Emphysema

Chronic Bronchitis

Diff i P th h i l


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Diffusion Pathophysiology

Pulmonary Edema:Left-sided heart failure

Toxic inhalations

Near drowning Pneumonia

Pulmonary Embolism:

Blood clotsAmniotic fluid

Fat embolism

V til ti P th h i l


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Ventilation Pathophysiology

Trauma: rib fractures, flail chest,spinal cord injuries

Pneumothorax, hemothorax, SCW

Diaphragmatic hernia

Pleural effusion

Morbid obesity

Neurological/muscular diseases:polio, MD, myasthenia gravis


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Control System Pathophysiology

Head trauma

CVA

Depressant drug toxicity

Narcotics

Sedative-hypnoticsEthyl alcohol

FBAO


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FBAO

Obstruction mayresult from headposition, tongue,aspiration, or

foreign body. Be prepared to

treat quickly andaggressively.

Head-tilt/chin-liftto open airway

U Ai I f ti


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Upper Airway Infections

Bronchitis Common cold

Diphtheria

Pneumonia

Croup

Epiglottitis Severe Acute Respiratory

Syndrome

U Ai I f ti


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Upper Airway Infections

Si & S t


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Signs & Symptoms

Dyspnea or respiratorydistress

Seal-bark cough Acute angiodema

Excessive salivation Stridor

Sniff positioning

A t P l Ed


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Acute Pulmonary Edema

Fluid buildup inlungs

History of CHF

High recurrence Signs & symptoms:

Dypsnea

Frothy, pinksputum

Pedal edema,ascities

Rales, wheezes

.

P d l Ed


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Pedal Edema

A it


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Ascites


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COPD


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COPD

Damaged lungsfrom repeatedinfections orinhalation of toxicagents.

Signs & symptoms:

Chronic cough

Rhonchi, wheezing SpO2 88-92%

Clubbing

Pursed lip breathing

Clubbing


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Clubbing

Asthma


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Asthma

Common butserious disease

Acute bronchioleconstriction with

increased mucusproduction

Signs & symptoms: Wheezing

Patient looks tired

Cyanosis

Pneumothorax


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Pneumothorax

Spontaneous ortrauma induced

Accumulation of air

in the pleuralspace

Signs & symptoms:

Dypsnea

One-sided chestpain

Absent ordecreased breath

sounds

Anaphylaxis


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Anaphylaxis

Characterized byrespiratory distressand hypotension

Usually resultsfrom bodyresponse toallergen.

Airway obstructiondue to angiodemais major concern


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Pleural Effusion


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Pleural Effusion

Collection of fluidoutside the lung

Caused by

irritation, infection,or cancer

Signs & symptoms:

Dypsnea

Decreased breathsounds overeffected area

Positional comfort

Pulmonary Embolism


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Pulmonary Embolism

Blood clot thatbreaks off,circulating throughvenous system.

Signs & symptoms:

Dypsnea/tachypnea

Cyanosis

Acute pleuritic pain Hemoptysis

Hypoxia

Pulmonary Embolism


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Pulmonary Embolism

Hyperventilation


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Hyperventilation

Over-breathing resulting in adecrease in the level of CO2(alkalosis)

Signs and symptoms: Anxiety

Tingling in hands & feet (carpal-pedalspasms)

A sense of dypsnea despite rapidbreathing

Dizziness

Numbness

ARDS


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ARDS

Pulmonary edema caused by fluidaccumulation in the interstitialspaces, interfering with diffusioncausing hypoxia (fluid balance)

Underlying etiology includes sepsis,pneumonia, inhalation injuries,emboli, tumors

Mortality rate >70% Supportive care at the BLS level

Patient Assessment


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Patient Assessment

BSI/Scene Safety

Initial Assessment (Sick/Not

Sick)Focused Exam

Detailed ExamAssessment

Treatment and Plan

Initial Assessment


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Initial Assessment

Initial Impression:Body positionSkin signs and color

Respiratory rate and effortMental statusPulse (rate & character)

Determine Sick/Not Sick(Oxygen?) Identify and correct immediate

life threats ABCS!

Focused Exam (S)


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Focused Exam (S)

Signs and symptoms

Allergies (med allergies)

MedicationsPast medical history

Last meal or intakeEvents leading to call

Focused Exam (S)


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Focused Exam (S)

Onset

Provocation

Quality

Radiation

Severity

Time


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Listen to the patient

they will tell exactly what iswrong!

Focused Exam (O)


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Focused Exam (O)

Vital signs:Skin (signs of adequate perfusion)

Level of consciousness

Respiratory rate and effortLung sounds (SpO2?)

Pulse rate and character

Blood pressure (bilateral?)Pupillary reaction

Focused Exam (O)


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Focused Exam (O)

Crackles (Rales) CHF

Pneumonia

Rhonchi

Pneumonia

Aspiration

COPD Sometimes Asthma

Stridor FBAO Croup Anaphylaxis Epiglottitis Airway burn

Wheezing Asthma CHF COPD

Focused Exam (O)


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Focused Exam (O)

Based upon your clinicalfindings.

Observe the patient whilethey are talking to you, noteany distress.

Watch for critical signs: JVD,tracheal deviation, paradoxialchest movement.

Detailed Exam


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Detailed Exam

Complete and thorough head,neck-to-toe exam with non

critical patients. Elicit further information andnecessary interventions.

Key in on critical signs!


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Plan


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Plan

Medics?ABCs/Monitor vitals

Patient in position of comfort.

Oxygen via ?Assist with medications.Maintain body temperature.

Calm and reassure.Minimize patient movement.

Rapid transport!

PT Management (P)


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PT Management (P)

Golden Rules:

If you are thinking about giving O2, thengive it!

If you cant tell whether a patient isbreathing adequately, then they arent!

If youre thinking about assisting apatients breathing, you probably shouldbe!

When a patient quits fighting it does notmean that the are ettin better!

Tools of the Trade


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Tools of the Trade


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Happy Thanksgiving, and thanks to you all for allyour hard work.

Date post:	02-Jun-2018
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