EMT - Exam 4 - Ch. 19-22

what to primarily assess in patients breathing

rate/rhythm/quality + mental status, skin color, pulse ox

adequate breathing is characterized by

patients with normal mental status, no difficulty moving air, and the ability to speak in full or complete sentences without pausing

patients may have respiratory challenges, but _____

might still be breathing adequately

the rate of breathing may be normally _____ but does not indicate inadequate breathing/respiratory emergency

higher (i.e. infants crying = higher respiration, but patent/adequate airway)

adult respiratory rate

12-20 / min

children respiratory rate

18-30 / min

infant respiratory rate

30-60 / min

adeqaute breathing rhythm

regular - not dispersed, separated with pauses

adequate quality of breath sounds

present and regular

adequate chest expansion

equal and adequate

adequate effort of breathing

unlabored

adequate depth of breathing

adequate - not deep, not shallow

inadequate rate respiration

above or below normal ranges

inadequate rhythm of breathing

irregular - may be interspersed with periods of struggle, no breathing

inadequate quality of breath sounds

diminished, unequal, or absent

inadequate chest expansion

inadequate or unequal

inadequate effort of breathing

labored, increased respiratory effort

inadequate depth

shallow, may be deep (depending on accessory muscle use)

questions to ask yourself when assessing patients breathing

• is the patient breathing

• is the patient breathing adequately or inadequately

• is intervention beneficial to the patient

• will the patient benefit from ALS support

signs/symptoms of inadequate breathing

• patient has feeling of “impending doom” - anxiety

• cyanotic skin color

• altered mental status (hypoxia)

• increase in heart rate, respiration rates, or slow respiratory respirations

• diaphoretic symptoms (cool/sweaty/clammy skin)

• low oxygen saturation levels (below 95%)

• diminished lung sounds

• agonal/sporadic/gasping respirations

respiratory problems in pediatric patients can cause

the child to go into cardiac arrest

what sign is never a good sign in children with respiratory distress that points to imminent cardiac arrest

bradycardia (immediate BVM + high flow oxygen are required)

when do you administer oxygen and transport immediately

• wheezing, stridor, grunting

• increased breathing effort

• flared nostrils, muscle retractions

• rapid breathing

• cyanosis around lips/mouth

• use of abdominal muscles

• seesaw breathing

COPD (chronic obstructive pulmonary disease)

broad classification of chronic lung diseases (majority of cases caused by smoking)

what are the two major COPD conditions

chronic bronchitis and emphysema

chronic bronchitis - what is it

bronchiole lining is inflamed - leads to production of excess mucus

chronic bronchitis - signs and symptoms

• noticeable cough

• cough producing significant amounts of mucus

• dyspnea

• chest discomfort

• fatigue

• wheezing, rhonchi (due to mucus build-up)

chronic bronchitis - interventions

• administer oxygen to maintain oxygen saturation levels

• administer Albuterol or DuoNeb

• utilize CPAP to push mucus out of lower airway (increase pressure in lungs → pushes out mucus from the lower lungs)

• monitor for signs of increasing respiratory difficulty

emphysema - what is it

break down of alveolar walls → decrease surface area for proper gas exchange

• lungs lose elasticity → decreases expansion of the lungs

• air + excess carbon dioxide = increasing difficulty to breathe

emphysema - signs and symptoms

• shortness of breath (dyspnea)

• fatigue

• coughing

• wheezing

emphysema - interventions

• keep patient in tripod OR high fowlers position

• administer oxygen based on oxygen saturation needs via NRB or cannula

• administer nebulizer treatments of Albuterol or DuoNeb to improve ventilation

asthma - what is it

chronic disease of episodic flare-ups (exacerbations), leads to bronchoconstriction and restriction of airflow, mucus is also overproduced

in asthma, air flow is restricted in one direction - exhalation, why is this

inhalation = expansion of airways ; exhalation = constriction of airway, patient forces air out creating the classic wheezing sound of asthma

asthma - signs and symptoms

• shortness of breath (dyspnea)

• chest tightness or pain (due to forceful breathing)

• wheezing on exhalation (more common in children)

• increased work to breathe

• patients may present in the tripod position

asthma - interventions

• keep patient in high fowlers (sitting up) - maximum breathing comfort

• use nebulizer + DuoNeb / Albuterol (go-to-method)

• obtain oxygen saturation and capnography measurements

• assist patients with prescribed inhaler (if directed/stored properly)

• CPAP + nebulizer for severe cases

pulmonary edema - what is it

abnormal build-up of fluid (not mucus) in the alveoli, common in patients with CHF due to the heart not effectively pumping + increase in pressure → fluid backs up into the lungs, preventing adequate gas exchange

pulmonary edema - signs and symptoms

• dyspnea

• anxiety (due to difficulty in breathing)

• tachycardia

• pale and sweaty skin

• hypertension (due to pressure build-up in blood vessels)

• rapid respirations and labored breathing

• low oxygen saturation

• crackles heard upon auscultation

• gurgling sounds without auscultation (severe cases)

• patients may cough up pink-frothy sputum (severe cases)

pulmonary edema - interventions

• assess and treat for inadequate breathing

• initiate high-concentration oxygen - via NRB

• keep patients legs dangled - if possible

• CPAP - pushes fluid back into the capillaries

pneumonia - what is it

microbial/viral/fungal infection of one or both of the lungs (often just one-sided), causes inflammation of the lungs

pneumonia - signs and symptoms

• coughing up mucus (green/yellow in color)

• fever, chills, headache

• shortness of breath with/without exertion

• sharp chest pain

• pale and sweaty skin

• fatigue

• confusion

pneumonia - interventions

• supportive care

• if patient is hypoxic, administer supplemental oxygen

• assess and treat inadequate breathing (rare, but still important)

• might use CPAP

spontaneous pneumothorax - what is it

lung collapse without injury or trauma, caused by a weak spot → causes air to leak into the thoracic cavity

spontaneous pneumothorax - signs and symptoms

• sharp plueritic chest pain (usually laterally)

• shortness of breath / easily tired

• cyanosis / low oxygen saturation

• tachycardia / rapid respirations

• decreased or absent lung sounds (on side of collapsed lung)

• worsening JVD and hypotension (due to increased thoracic pressure)

spontaneous pneumothorax - interventions

• contact ALS immediately (needle decompression may be needed)

• administer supplemental oxygen

• DO NOT USE CPAP

• transport immediately for definitive care

epiglottitis - what is it

inflammation of the epiglottis causing swelling and eventual airway obstruction (in severe cases), common in children and adults (more severe in peds due to smaller airway)

epiglottitis - signs and symptoms

• sore throat, painful / difficulty swallowing

• patient may present in tripod position

• sick / feverish appearance

• muffled voice / stridor

• uncontrolled drooling (due to painful swallowing)

epiglottitis - interventions

• keep children calm and comfortable (panic = increase in swelling)

• DO NOT INSPECT THE THROAT

• administer high-flow oxygen if possible without alarming patient

• transport without lights and sirens

croup - what is it

caused by several viral infections, resulting in inflammation of the larynx, trachea, and bronchi - seen in children - restricts airways

croup - signs and symptoms

• loud barking cough (seal bark-like cough)

• hoarse voice

• difficulty breathing

• signs of hypoxia / inadequate breathing

• sounds of breathing difficulty

croup - interventions

• inadequate breathing = artificial ventilations - transport immediately

• contact ALS if breathing increasingly becomes difficult

• supplemental oxygen if patient is showing signs of hypoxia

• allow patient to remain in position of comfort

bronchioloitis - what is it

caused by the RSV virus - causing inflammation of the bronchioles - seen in children 5 yoa and younger (typically)

bronchiolitis - signs and symptoms

• gradual progression of cold/flu-like symptoms

• can worsen to respiratory distress / inadequate breathing

bronchiolittis - interventions

• artificial ventilations may be necessary

• hypoxic patients may need supplemental oxygen

• suciton nose via bulb syringe of obstructed mucus (especially in children)

cystic fibrosis - what is it

purely genetic disease appearing in childhood, causes thick mucus buildup in the lungs and digestive system

cystic fibrosis - signs/symptoms/interventions

ultimately the patient or the patients family will tell you everything you need to know: treatments, medications, signs/symptoms, an emergency or not, etc.

viral respiratory infection - what is it

any infection of the respiratory tract - most common cases of mild respiratory issues

viral respiratory infection - signs and symptoms

• cold-like symptoms (scratchy throat, fever chills, fatigue, shortness of breath, etc.)

• persistent cough (production of yellow/greenish sputum)

viral respiratory infection - interventions

• supplemental oxygen if indicated

• administration of bronchodilators for wheezing and relief if indicated

• hand washing, face mask can help prevent spread to others

acute coronary syndrome (ACS) - what is it

refers to anytime the blood supply to cells of the heart are blocked or disrupted - either suddenly or over a period of time

acute coronary syndrome - causes what

blockage causes lack of blood supply → lack of oxygen being transported to cells

ischemia refers to

the inadequate blood supply to parts of the body

acute coronary syndrome - signs and symptoms

• dyspnea

• nausea/vomiting

• syncope / near syncope

• primary complaint of vague symptoms

• patient may be grabbing or clutching the center of their chest

• tachycardia/bradycardia

• rapid onset of intense sweating

• palpitations (fluttery feeling)

• hypotension

• anxiety / feeling of impending doom

• pale/gray skin

• patient complaint of pain in epigastric region (or “heartburn”)

always assume the _____ _____ _____ when a patient presents with signs and symptoms of ACS, even if mild/non-existent

worst possible scenario - always treat as if they are having a potential heart problem / MI / ischemia attack

only administer oxygen to patients complaining of potential ACS if they

are hypoxic, or oxygen saturation is below 94%, inadequately breathing, or in respiratory distress

STEMI on an ECG

ST segment elevation myocardial infarction - occurs when one of the coronary arteries is completely blocked

NSTEMI on an ECG

non-STEMI - occurs when there is a partial blockage in the coronary artery

what medication is given first in the line of BLS medicines given for cardiac related problems

aspirin - because it is chewed (requires alert/oriented patient), unlike Nitro which dissolves

coronary artery disease (CAD) - what is it

spectrum of conditions that narrow or block arteries (often fat/plaque buildup) - not typically a medical emergency, though can become one over time

angina pectoris - what is it

simply, chest pain - caused by reduced blood supply (& oxygen) to the myocardium, pain usually appears in time of exertion (even with very little exertion)

angina pectoris - signs and symptoms

• chest pain

• shortness of breath

• nausea

• sweating

• syncope

• symptoms that tend to resolve after rest

• symptoms lasting around 5 minutes

angina pectoris - interventions

• assume patient is having a myocardial infarction

• consider supplemental oxygen

• administer aspirin and nitroglycerine

• obtain a 12-lead ECG

• initiate transport

• contact medical direction if symptoms resolve for further direction

acute myocardial infarction (heart attack) - what is it

accumulation of plaque causes the blood vessels to narrow - buildup can facilitate the formation of blood clots (thrombus or embolism) → causes decrease in oxygen to the myocardium

thrombus

occlusion of blood flow formed by buildup - clot that is stationary

embolism

occurs when a thrombus breaks loose and moves to occlude the blood flow in other, smaller arteries

acute myocardial infarction - signs and symptoms

• ischemia

• dysrhythmias

• hypotension

• shortness of breath

• chest pain - patient may be clutching at the center of the chest

acute myocardial infarction - assessment

• find out what medications patient may be taking

• ensure patient has a pulse and is breathing

• identify signs/symptoms of ischemia

acute myocardial infarction - interventions & treatments

• initiate immediate transport

• contact ALS support

• be prepared for possible cardiac arrest - inadequate breathing

• administer aspirin and nitroglycerine

• start 12-lead ECG

congestive heart failure - what is it

chronic, progressive condition that affects the hearts ability to pump blood normally and efficiently - implies that one or both ventricles can no longer efficiently pump

congestive heart failure - what does it cause

fluid back up - either in the lungs - pulmonary edema (right ventricle failure), or in the veins - JVD, pedal edema (left ventricle failure)

congestive heart failure - signs and symptoms

• signs of pulmonary edema (crackles, shortness of breath, etc.)

• pedal edema (swelling in the feet)

• patient takes beta-blockers, ACE inhibitors, and diuretics/Lasix

• unusual weight gain

• abdominal swelling

• JVD

• coughing up frothy sputum

congestive heart failure - interventions

• vital signs

• detailed cardiovascular exam

• consider CPAP application

• contact ALS if pulmonary edema is present

• administer Nitroglycerine (vasodilaiton reduces fluid load on the heart)

aneurysm - what is it

over dilation, and eventual rupture of an artery

aneurysm - signs and symptoms

• sudden nausea and vomiting

• stiff neck

• pulsating mass in abdomen (sign of a triple A)

• eye pain / sensitivity to light

• confusion or loss of consciousness

reticular activating system (RAS)

responsible for staying awake, paying attention, and sleeping functions (essentially - consciousness)

three basic requirements for the RAS to function

glucose, water, oxygen (any lack in these causes a change in mental status)

what is the #1 priority when dealing with a patient with altered mental status

safety - patients with altered mental status can be unpredictable

what must always be assumed if a patient has altered mental status

the patient is likely to have airway/breathing problems

on a patient with altered mental status what must be assessed first

AVPU (not precise, but is a gauge for current mental status)

how do you assess a patient with altered mental status

ask patients family or bystanders, or conduct a thorough body exam

question to ask family or bystanders in a patient with altered mental status

• is this a normal mental state for them

• how were they acting before they became altered

when and where does the pancreas release insulin

from islets of langerhans, when bloog glucose reaches 90 mg/dL

normal range for blood glucose (per local protocol)

70-110 mg/dL

diabetes mellitus - what is it

the underproduction of insulin or inability to produce insulin properly (can be type 1 or type 2)

people with diabetes either:

• can’t produce insulin

• don’t produce enough insulin

• have a body that is resistant to insulin (doesn’t use it)

type 1 diabetes (formerly insulin-dependent diabetes)

pancreas does not secrete enough insulin → no transfer of circulating glucose into the cells

type 2 diabetes (formerly insulin)

body’s cells fail to utilize insulin properly, although pancreas secretes enough insulin

patients with type 1 diabetes are typically given

synthetic insulin to make up for deficit

patients with type 2 diabetes can typically regulate through

diet, oral-antidiabetic, or (sometimes) synthetic insulin

hypoglycemia - what is it

low blood glucose levels (below 70 mg/dL) - resulting in rapid onset of signs/symptoms

hypoglycemia - signs and symptoms

• altered mental status - possible loss of consciousness

• pale, sweaty skin

• tachycardia

• rapid breathing

• potential seizures