HAN 477 Midterm

Normal Vital Signs

- HR \= 60-100 bpm
- BP \= 120/80 mmHg
- SpO2 \> 94%
- RR \= 12-20 breaths/min
- ETCO2 \= 32-43 mmHg

Outward Signs of Inadequate Breathing/ Impending Respiratory Failure

- signs of fatigue
- AMS/ LOC
- RR \>30 /

30-2-can do

respirations \>30, cap refill \>2 \= red

Oropharyngeal Airway: Indications + Contraindications

common route for food & air; keep tongue out of the way/ easier to suction oropharynx

Indications
- unresponsive pt w/o gag reflex
- apneic pts being ventilated w/ bag-mask device

Contraindications
- conscious pts w/ gag reflex

Nasopharyngeal Airway: Indications + Contraindications

air passage w/ pharyngeal tonsil; used for unresponsive pts w/ altered LOC, unable to maintain their airway spontaneously

Indications
- semiconscious/ unresponsive pt w/ gag reflex
- pts who can't tolerate oropharyngeal airway

Contraindications
- suspected head injury
- history of fractured nasal bone

Oxygen Therapy Devices

- Nonrebreathing masks (NRB)
- Bag-valve-mask device (BVM)
- Nasal cannula

Nonrebreathing mask (NRB)

- preferred way to give O2 prehospital (to pts breathing adequate, suspected hypoxia)
- combo bag & reservoir mask
- moderate resp. distress
- flow rate \= 10-15 L/min
- O2 delivery 60-95%

Bag-valve mask (BVM)

- most common EMS ventilation in EMS & ER initial resp. failure
- provides less tidal volume than mouth-mouth mask
- O2 administered based on chest rise & fall: 10-15 L/min
- 65-80% delivery O2

Indications
- severe resp. distress

Contraindications
- if difficult to adequately ventilate, switch methods

Nasal Cannula (NC)

- delivers O2 through 2 small tube-like prongs fit into nostril
- flow \= 1-6 L/min
- O2 delivery 24-44%

Indications
- mild resp. distress & will calm pts w/ minimal O2
- when long-term therapy anticipated (use humidity to keep tissues moist)
- maintenance of O2 for chronic illness (eg. COPD, emphysema, bronchitis)

Allergic Reaction

- response to chemicals body releases to combat certain stimuli (allergens)
- not caused directly by outside stimulus, but body's immune system

Allergic Reaction (s&s)

- flushing
- itching
- swelling of skin
- hives
- wheezing & stridor
- persistent cough
- decrease in BP
- weak pulse
- dizziness
- abdominal cramp
- headache

mild & local (itching, tenderness, redness)
severe & systemic (shock, resp. failure)

Allergic Reaction (treatment)

- avoid allergens
- medications (diphenhydramine/ injectable epinephrine)
- allergy shots (immunotherapy)
- continue allergy education

Anaphylaxis

- life threatening allergic reaction mounted by multiple (2 or more) organ systems
- effect is more widespread/ powerful than allergic reaction


- wheezing & urticaria wheals can be signs of anaphylaxis
- hypersensitivity
- mast cell activation in response to invading substance
- histamine release (vasodilation & capillary leakage)
- leukotrienes released: more powerful than histamine

Anaphylaxis (s&s)

- swelling of conjunctiva
- runny nose
- swelling of lips, tongue, and/or throat
- fast/ slow heart rate
- low BP
- hives
- itchiness
- flushing
- pelvic pain
- lightheadedness
- loss of consciousness
- confusion
- headache
- anxiety
- shortness of breath
- wheezes or stridor
- hoarseness
- pain w/ swallowing
- cough
- crampy abdominal pain
- diarrhea
- vomiting
- loss of bladder control

Anaphylaxis (treatment)

- must be treated by epinephrine (vasoconstriction properties/ bronchodilator)
- requires O2

Medications

- epinephrine
- benadryl
- corticosteroids

Epinephrine

- mimics sympathetic (fight-or-flight) response
- causes blood vessels to constrict
- reverses vasodilation & hypotension
- increases cardiac contractility
- relieves bronchospasm
- rapidly reverses effects of anaphylaxis

- Adult EpiPen dosage \= 0.3 mg
- Pediatric EpiPen dosage \= 0.15 mg
- Twinject auto-injector contains 2 doses of epinephrine

Benadryl

- antihistamine
- blocks effects of naturally occuring chemical histamine causing vasodilation in body
- helps w/ urticaria & itching associated w/ reaction

Emergency Dosage \= 50 mg IV

Corticosteroids

- anti-inflammatory
- helps to long-term reduce inflammation (vs. epinephrine working immediately)
- modifies body's immune response to various conditions & decreasing inflammation

Emergency Dosage \= 125 mg IV

OPQRST (history of present illness)

- ONSET (when did it start)
- PROVOCATION (does anything make injury better or worse)
- QUALITY
- REGION/ RADIATION/ REFERRAL (does the pain radiate to anywhere)
- SEVERITY
- TIME

SAMPLER (patient assessment)

- Signs & symptoms
- Allergies
- Medications
- Past medical history
- Last oral intake
- Events that led to injury/ illness
- Risk factors

ABCDE

- Airway
- Breathing
- Circulation
- Disability (AMS/ LOC)
- Exposure

AVPU

- Alert
- Verbal response
- Painful response
- Unresponsive

ACID (hypersensitivity types)

- Allergic
- Cytotoxic
- Immune complex deposition
- Delayed

DOPE (causes of acute deterioration in intubated pt)

- Displaced tube
- Obstructed tube (pt secretions, biting)
- Pneumothorax (can occur during positive pressure ventilation)
- Equipment failure (ventilator out of O2?)

AEIOU-TIPS (causes of AMS/ decreased LOC)

- Alcohol, anaphylaxis, acute MI
- Epilepsy
- Insulin (glucose)
- Opiates
- Uremia

- Trauma
- Intracranial (tumor, hemorrhage, hypertension)
- Poisoning
- Seizure, stroke, syncope

Respiratory Patterns (diseased)

- agonal respirations
- cheyne-stokes respirations
- ataxic respirations
- kussmaul's respirations

Agonal Respirations

- slow, shallow, irregular breaths/ occasional gasping
- pt may appear to be breathing after heart stopped
- associated w/ death

Cheyne-Stokes Respirations

- rhythmic increase (hyperventilation) + decrease (apnea) in rate & depth of respirations
- commonly seen in unconscious, comatose or death-bound pts
- associated w/ stroke + head injury patients, CHF, increased ICP

Ataxic Respirations

- irregular/ unidentifiable pattern
- associated w/ serious head injuries

Kussmaul's Respirations

- deep gasping respirations
- associated w/ metabolic & toxic disorders (diabetes)

Lung sounds (diseased)

- stridor (upper airway)
- crackles, rales, rhonchi, wheezing \= lower airway
- pleural friction rub

Stridor

strained, high-pitched sound heard on inspiration
- obstruction in the pharynx or larynx
- foreign body obstruction, epiglottitis

Crackles/ rales

bubbling/ noisy crackling sounds
- caused by fluid/ mucus in air passages
- pneumonia

Rhonchi

loud rumbling sounds in bronchi obstructed by sputum
- chronic mucus in upper airways
- COPD, pneumonia

Wheezing

whistling sounds during expiration
- occurs in asthma, bronchiolitis, COPD, pneumonia, foreign body obstruction (kids)

Pleural friction rub

creaking/ grating sound from rough, inflamed surfaces of pleura rubbing together
- pleurisy/ chest cavity conditions

Pneumothorax (s&s)

air in pleural cavity caused by puncture of lung/ chest wall
- air hunger
- resp. distress
- tachycardia
- hypotension
- tracheal deviation (opposite side of injury)
- unilateral absence of breath sounds
- JVD
- cyanosis (late)

Pneumothorax (treatment)

- needle decompression
- chest tube
- supplemental O2

Capnography (ETCO2)

measures CO2 output in expired air (ETCO2) & provides waveform
- gives better understanding of ventilatory status (during resp. distress and cardiac arrest interventions)
- normal \= 32-43 mmHg

eg. hypoventilation --\> retained CO2 --\> resp. acidosis

Hypersensitivity

excessive, harmful immune reaction to antigens
- require pre-sensitized (immune) state of host
- 4 types based on mechanisms + time for reaction

4 Types of Hypersensitivity Reactions

1. Type I (acute/immediate) hypersensitivity (IgE)
2. Type II (antibody-dependent cytotoxic) hypersensitivity (IgG, IgM)
3. Type III (Ag-Ab immune complex) hypersensitivity
4. Type IV (delayed) hypersensitivity (T cells, cell-mediated)

Type I Hypersensitivity (acute/ immediate - IgE)

IgE-mediated release of histamine/other mediators from mast cells & basophils

- overreaction to allergen from skin, inhaled, swallowed, injected
- bees stings, latex, medications, pollen, dust, animal dander, food (harmless substances)
- most common allergies, anaphylaxis, atopy, asthma

Type II Hypersensitivity (antibody-dependent cytotoxic - IgG, IgM)

IgG/ IgM antibodies bound to cell surface antigens

- hemolytic reactions
- goodpasture syndrome (kidney failure, lung disease)
- hyperacute graft rejection
- myasthenia gravis

Type III Hypersensitivity (Ag-Ab immune complex)

antigen-antibody immune complexes deposit in venules

- hypersensitivity pneumonitis
- systemic lupus erythematosus
- polyarteritis nodosa
- serum sickness

Type IV Hypersensitivity (delayed/ T-cells, cell-mediated)

mediated by T-cells rather than antibodies

- chronic graft rejections
- PPD tests
- latex
- nickel allergy
- poison ivy
- contact dermatitis

Asthma

chronic inflammation & constriction of bronchi

- airway overly sensitive to allergens, viruses, environmental irritants
- inflammation prime cause of symptoms
- patient initially hyperventilates (decreased CO2 --\> respiratory alkalosis)
- continued airway narrowing --\> exhalation difficult (increased CO2)
- tachypnea, tachycardia, wheezing, retractions
- accessory muscle recruitment
- decreased O2 sat.

Asthma (diagnosis)

- asthma usually diagnosed by hx. of episodes
- bacterial pneumonia, viral respiratory infections, COPD, CHF, foreign object, can all present w/ wheezing
- asthma vs. COPD \= asthma airway narrowing is reversible

Asthma (s&s)

- wheezing
- dyspnea
- chest tightness, discomfort, pain
- cough
- signs of recent URI
- signs of exposure to allergens

Asthma (treatment)

depends on severity

- inhaled beta-2 agonists (albuterol, levalbuterol/ Xopenec used in early wheezing)
- terbutaline or epinephrine (IV or injection added for more severe attacks)
- IV corticosteroid (reduce inflammation in bronchi, may take hours to work - long acting)
- even w/ aggressive pharm. therapy, some pts may progress to severe resp. distress/ failure

Meningitis

inflammation of meninges & infection of CSF; contagious

- life-threatening, acute meningitis is usually bacterial infection
- bacterial presents more quick than viral
- bacteria colonize in nasopharynx, spread to CSF
- lack of antibodies & WBCs in CSF
- surrounding brain pressure reverses flow of CSF
- suspect meningitis in older + younger pts, suppressed immune system pts, live in crowded places

- infants \= group B streptococcus or E. coli
- after 1 year old \= Streptococcus pneumoniae & Neisseria meningitidis

Meningitis (s&s)

classic initial symptoms
- headaches
- nuchal rigidity
- fever/ chills
- photophobia
- seizures
- AMS
- coma
- death
- Kernig's sign (stiff hamstrings)
- Brudzinski's sign (stiff neck)

- meningismus \= triad (nuchal rigidity, photophobia, headache)

Kernig's sign (sign of meningitis)

severe stiffness of hamstrings, inability to straighten leg when hip flexed to 90 degrees

Brudzinski's sign (sign of meningitis)

stiff neck \= involuntary flex of hip & knee when neck is flexed to chest when supine

Meningitis (treatment)

- pts w/ acute bacterial meningitis may decompensate quick & require emergency care & antibiotics

- head CT to rule out stroke
- lumbar puncture to test CSF
- IV antibiotics

Stroke

aka "brain attack" - blood flow to brain obstructed/ interrupted
- ischemic or hemorrhagic

Ischemic Stroke

thrombus/ embolus obstructs a blood vessel

Hemorrhagic Stroke

diseased/ damaged vessel ruptures

Stroke (s&s)

- acute neuro deficit
- abrupt weakness on 1 side of face, 1 arm/ leg, entire side of body
- sudden decrease/ loss of consciousness
- lose vision
- nausea/ vomiting
- difficulty speaking (dysarthria)
- hemiplegia

Thrombotic Stroke Sites

- middle cerebral arteries (face/ arm weakness)

- anterior cerebral arteries (leg weakness, AMS, impaired judgement)

- posterior cerebral arteries (visual/ memory deficits)

- Circle of Willis

Transient Ischemic Attack (TIA)

- brief episode of blood flow loss to brain
- usually caused by partial occlusion resulting in temporary neurologic deficit (impairment)
- often precedes a CVA

Stroke vs. TIA

- TIA symptoms resolve w/in 24 hrs (most w/in 1 hr)
- 10% of TIA pts suffer stroke w/in 90 days of TIA
- other DDs \= hypoglycemic episode, migraine headaches, electrolyte abnormalities, CSF infections, MS, Guillain-Barre, psychiatric disorders

FAST (stroke)

- Facial drooping
- Arm weakness
- Slurred speech
- Time (call 911 asap/ 3-4 hrs)

Time (as a factor in strokes)

- if prior history of stroke, need to know baseline functioning & mental status
- have to give tPA 3-4.5 hrs w/in onset of symptoms

Last Known Well Time

last time pt was seen acting normally & time to symptoms is crucial

tissue plasminogen activator (tPA)

fibrinolytic agent that dissolves clots in vessels supplying blood to brain

- can restore blood flow to affected part of brain
- reduce effects of stroke/ long-term disability

Stroke (treatment)

- rapid transport to stroke center ASAP
- stroke scales indicate presence of stroke & severity (Cincinnati, NIH)
- FAST mnemonic \= quick ID of stroke victim
- evaluate ABC, intervene if necessary
- check blood & correct glucose level
- supplemental O2 if

Glascow Coma Scale (GCS)

scale used to assess consciousness of patient (E3, V4, M5)
- eye opening
- verbal response
- motor response

- highest GCS \= 15
- lowest GCS \= 3
- GCS 8 or less \= sign of neuro concern

- 13-14 \= mild dysfunction
- 9-12 \= moderate-severe dysfunction

Cranial Nerves (on occasion our trusty truck acts funny, very good vehicle any how)

12 pairs of nerves that carry messages to and from the brain

1 - Olfactory (smell)
2 - Optic (visual acuity)
3 - Oculomotor (eye movement, pupil dilation)
4 - Trochlear (vertical eye movement)
5 - Trigeminal (S: facial sensation, M: facial expression)
6 - Abducens (lateral movement of eyeballs)
7 - Facial (S: taste, M: facial expression)
8 - (Vestibulocochlear) acoustic/ auditory (hearing + balance)
9 - Glossopharyngeal (S: taste, M: swallowing)
10 - Vagus (S: sensation in throat & visceral muscles, M: vocal cords, peristalsis)
11 - Accessory (head + shoulder movement)
12 - Hypoglossal (tongue movement)

OOOTTAFVGVAH \= On Occasion Our Trusty Truck Acts Funny, Very Good Vehicle Any How

Examination Techniques

Inspect

Palpate
- pulse \= fingers
- skull \= palm
- skin \= back of hand

Auscultate

Percussion (detect changes in densities of body cavities)

history taking

CPAP (continuous positive airway pressure)

noninvasive ventilatory support for resp. distress (common for sleep apnea pts to wear at night, becoming widely used @ all levels of healthcare)

CPAP Pathophysiology

- increases lung pressure
- opens collapsed alveoli, pushes O2
- use caution for low BP pts
- forces interstitial fluid back into pulmonary circulation

CPAP Indications

- O2

CPAP Contraindications

- resp. arrest/ unconscious
- s&s of pneumothorax/ chest trauma
- active GI bleeding/ vomiting
- unable to follow verbal commands

CPAP Complications/ Considerations

- gastric distention (especially in kids)
- can feel claustrophobic- possibility of pneumothorax
- can lower pt's BP
- if pt shows signs of deterioration, remove CPAP & begin BVM

Brain (lobes & functions)

- Frontal lobe
- Temporal lobe
- Parietal lobe
- Occipital lobe

Frontal Lobe

speech, motor cortex

Temporal Lobe

smell, hearing, auditory association area

Parietal Lobe

speech, taste, reading, somatosensory association area

Occipital Lobe

vision, visual association area

Major brain regions

- cerebrum
- cerebellum
- diencephalon
- brain stem
- cerebrospinal fluid (CSF)

Cerebrum

- conscious thought
- memory storage & processing
- sensory processing
- regulation of skeletal muscle contraction

- divided in 2 hemispheres
- superficial layer of gray matter \= cerebral cortex

Cerebellum

2nd largest area of brain
- coordination
- balance
- modulation of motor commands from cerebral cortex

Diencephalon

link b/w cerebrum & CNS

Brain stem

midbrain, pons, medulla
- processes visual & auditory info
- maintains consciousness
- somatic & visceral motor control
- regulates autonomic function

Cerebrospinal fluid (CSF)

- surrounds & bathes exposed surfaces of CNS
- provides protective cushion around brain & spinal cord
- utilized by brain to monitor changes in internal environment
- found in subarachnoid space in brain & spinal cord & w/in cavities & canals

Seizure

- brief episodes of abnormal/ asynchronous neuronal activity in brain
- look for anti-seizure medication/ medical alert bracelet
- possible causes \= epilepsy, head injury, meningitis, toxins

Epilepsy

- seizure occurs when burst of electrical impulses in brain escape normal limits
- spread to neighboring areas
- create an uncontrolled storm of electrical activity
- impulses can transmit to muscles, cause twitches/ convulsions

Guillain-Barre Syndrome

group of acute immune-mediated polyneuropathies/ autoimmune response to recent infection

- deteriorates myelin sheath
- antibodies against peripheral nerves

Guillain-Barre syndrome (s&s)

- weakness
- numbness
- paralysis
- lose function in feet & moves up to lungs
- lack of deep tendon reflexes
- loss of vibratory sense, proprioception & touch
- ventilation to compensate for resp. muscle weakness (pneumonia side effect)

Upper Airway (anatomy)

main functions \= warm, moisten, filter air

- nasal cavity: conchae & meatuses increase turbulence

(3 regions)
nasopharynx--\> oropharynx--\> laryngopharynx

Lower Airway (anatomy)

function \= conduct air to gas exchange surfaces

- trachea & bronchi (supported by cartilage) + lungs
- smooth muscle in walls of bronchiole tree --\> dilation & constriction
- smallest bronchioles connect to alveoli
- O2 transported back to heart, rest of body

Larynx

- keeps food & drink out of airway
- marks where upper airway ends & lower airway begins
- extrinsic muscles \= connect larynx & elevate during swallowing
- intrinsic muscles \= vocal cords

Tidal Volume (TV)

amount of air inhaled or exhaled w/ each breath under resting conditions
- avg. \= 500 ml

Ventilatory support (adequate volume)

- monitor SpO2 & arterial blood gas (ABGs)
- observe RR, chest wall movement, use of accessory muscles

Obstructive lung disease

hard to exhale all air in lungs

- air comes out slower than normal
- high amount of air stays in lungs after full exhalation

- COPD: emphysema & chronic bronchitis

Restrictive lung disease

lungs restricted from fully expanding

- usually conditions affecting stiffness in lungs or chest wall, weak muscles, damaged nerves

- interstitial lung disease
- sarcoidosis (autoimmune)
- obesity
- scoliosis
- ALS
- MD

Carbon Dioxide (CO2)

- gas (waste) released by body cells
- transported via veins to heart to lungs for exhalation
- increased CO2 \= lower pH, more acidic blood
- decreased CO2 \= slower RR

Facilitation

using techniques that encourage patients to feel open to giving you info

Reflection

pausing to consider something significant you've just been told