medical exam

Epi-Pen

Brand name for epinephrine auto-injector

Nitroglycerin dosing

1 tablet every 5 minutes, up to a total of 3

Parenteral medication

For use outside the digestive tract

Enteral medication

Taken orally

Medication forms

Compressed powders/tablets, liquids, gels, suspensions, fine powder, gases, sublingual sprays/tablets

Standing orders (protocols)

Pre-authorized medication orders

Online medical direction

Speaking directly to a physician, listening to the order and repeating it back

Five rights of medication administration

Right patient, right time, right medication, right dose, right route

Routes of administration

Oral, sublingual, inhaled, intranasal, intravenous, intramuscular, subcutaneous, intraosseous, endotracheal

Sublingual route

Under the tongue (e.g., nitroglycerin)

Intramuscular route

Into the muscle

Subcutaneous route

Under the skin (e.g., insulin)

Endotracheal route

Sprayed directly into a tube inserted into the trachea

Pharmacodynamic considerations

What effect will it have? How will it affect this patient? Could the patient be unknowingly allergic?

After giving a medication

Reassess the patient and clearly document the medication given

Medications an EMT can administer

Aspirin, oral glucose, oxygen, activated charcoal, naloxone, albuterol/inhaled bronchodilators

Albuterol

Used in patients with asthma, emphysema, chronic bronchitis; enlarges constricted breathing tubes

Albuterol side effects

Increased HR, patient jitteriness

Albuterol delivery devices

Inhalers, spacers, nebulizers

Spacer

Allows inhalation without the patient feeling rushed

Albuterol nebulizer oxygen flow

8 L/min

Aspirin

Low dose (81 mg) for chest pain of suspected cardiac origin; reduces the blood's ability to clot

Chewing aspirin

Speeds absorption

Normal dose of baby aspirin

4 tablets

Epinephrine

Treats severe allergic reactions (anaphylaxis); relaxes smooth muscle and airway passages and raises BP through vasoconstriction

Epinephrine side effects

Increased HR and BP, pallor, dizziness, chest pain, headache, nausea, vomiting, excitability, anxiety

Nitroglycerin

Given to patients with a history of cardiac chest pain; dilates coronary vessels

Nitroglycerin contraindications

Low BP or taking medications for ED (Viagra, Levitra, Cialis, etc.) (systolic BP 100+)

Nitroglycerin side effect

Dropping BP

Oral glucose

Given to a conscious patient who can swallow, with altered mental status and a history of diabetes

Oxygen

Treats patients who are hypoxic or in danger of becoming hypoxic; also used as the propellant for nebulized bronchodilators; always given when nitrous oxide is used

Oxygen contraindication caution

COPD patients may have worsened breathing from oxygen administration

Activated charcoal

Used for poisoning by ingestion

Acetaminophen

Analgesic (pain relief) and fever reducer

Other medications to know

Diphenhydramine, force protection medications, glucagon, nitrous oxide, ondansetron

-olol suffix

Beta blockers; slow down the heart

Beta blockers and shock

Prevent tachycardia during signs of shock

Air movement and pressure

Negative pressure moves air in; positive pressure moves air out of the chest

Source of pressure changes

Contraction and relaxation of the respiratory muscles

Diaphragm innervation

C3-C5 (phrenic nerve); damage below C5 affects the intercostal muscles

Signs of respiratory failure

Rate out of normal range (too fast, or slowing and irregular), inability to speak, silent chest, shallow or labored breathing, altered mental status, diminished/unequal/absent lung sounds, abnormal HR

Upper lobe lung sound location

Mid-clavicular line, 3rd-4th intercostal space

Pediatric airway differences

Smaller airway easily obstructed, proportionately larger tongue, smaller/softer/more flexible trachea, less developed and less rigid cricoid cartilage, heavy dependence on the diaphragm

Pediatric signs of inadequate breathing

Grunting, wheezing, stridor, increased effort, flared nostrils, retractions, rapid breathing, pale or cyanotic lips/mouth

Pediatric early respiratory distress signs

Nasal flaring, retractions (above, below, and between sternum and ribs), stridor, grunting, decreased muscle tone, decreased mental status, poor peripheral perfusion, decreased HR

Stridor (location)

Heard in the upper airway, not the lungs

Falling HR in a child

If HR drops, pulse ox will drop too

EMT intervention: respiratory distress

Supplemental O2 to maintain pulse ox, assist inhaler or nebulizer, consider CPAP

EMT intervention: respiratory failure

Assisted ventilations (positive pressure ventilation) with BVM or face mask

Nonrebreather mask limitation

Requires adequate breathing to draw oxygen in; does not provide ventilation for respiratory failure patients

Ventilation rate for adults

10-12 breaths per minute

Ventilation rate for infants and children

12-20 breaths per minute

OPQRST

Onset, Provocation/palliation, Quality, Region/Radiation, Severity, Time

Onset (OPQRST)

When did the difficulty breathing begin?

Provocation (OPQRST)

What were you doing when this came on?

Quality (OPQRST)

Do you have a cough? Are you bringing anything up?

Radiation (OPQRST)

Do you have pain elsewhere? Does it spread?

Severity (OPQRST)

On a scale of 1-10, how bad is your breathing trouble?

Time (OPQRST)

How long have you had this feeling?

Pulse ox assessment tip

Put it on during the initial meeting

Breathing difficulty: appearance and position

Altered mental status, barrel chest, tripod position, sitting with feet dangling, leaning forward

Breathing difficulty: work of breathing

Retractions, accessory muscle use, flared nostrils, pursed lips, interrupted words

Breathing difficulty: skin, edema, SpO2

Pale, cyanotic, or flushed skin; pedal/sacral edema; SpO2 below 95%

Breathing difficulty: noisy breathing

Audible wheezing, gurgling, snoring, stridor, coughing

Emphysema/COPD oxygen caution

High-flow oxygen may worsen the condition

Vital sign changes with breathing difficulty

Increased or decreased pulse, changes in breathing rate and rhythm, hypertension or hypotension

Inadequate ventilation care

Begin artificial ventilation

Adequate ventilation care

Nonrebreather at 15 L/min or nasal cannula at 6 L/min (do not start at 15 if COPD/emphysema suspected), position of comfort, give prescribed inhaler, consider CPAP

CPAP

Continuous positive airway pressure; noninvasive positive pressure ventilation that blows O2 continuously at low pressure to keep alveoli from collapsing

CPAP uses

Pulmonary edema (prevents fluid entering alveoli), drowning, asthma, COPD, impending respiratory failure

CPAP contraindications

Severe altered mental status or lack of normal respiratory rate, inability to sit up, hypotension/shock, nausea and vomiting, chest trauma, upper GI bleeding or recent gastric surgery, conditions preventing a good mask seal

COPD

Chronic obstructive pulmonary disease; broad classification of chronic lung diseases including emphysema and chronic bronchitis; usually due to smoking

Chronic bronchitis

Bronchiole lining is inflamed, excess mucus is produced, and cells that normally clear mucus can't do so

Emphysema

Alveoli walls break down (less surface area for exchange), lungs lose elasticity, and CO2-laden air gets trapped in the lungs

Asthma

Chronic disease with episodic exacerbations; during an attack bronchoconstriction occurs and mucus is overproduced, practically closing the small airways

Pulmonary edema

Abnormal accumulation of fluid in the alveoli; patients with congestive heart failure may have difficulty breathing because of it

Pulmonary edema signs and symptoms

Dyspnea, anxiety, pallor, diaphoresis, tachycardia, hypertension, rapid labored respirations, low O2 sat, pink frothy sputum

How pulmonary edema develops

Pressure builds in pulmonary capillaries, fluid crosses the thin barrier into the alveoli, making it hard for oxygen to reach the blood, causing dyspnea

Severe pulmonary edema signs

Gurgling heard without auscultation, wheezing, crackles, white or pink frothy sputum

Severe pulmonary edema treatment

Treat inadequate breathing, high-concentration O2, keep patient sitting up with legs in a dependent position (feet down)

Pneumonia

Infection of one or both lungs by bacteria, viruses, or fungi, causing inflammation; fever, chills, SOB, tachypnea, pleuritic pain, productive cough; febrile seizures possible in young children and infants; altered mental status in the elderly

Pneumonia signs and symptoms

SOB, cough, fever and severe chills (bacterial), pleuritic chest pain, headache, pallor, diaphoresis, fatigue, confusion

Pleuritic chest pain

Sharp chest wall pain that worsens on inhalation

Pneumonia treatment

Mostly supportive; treat inadequate breathing, give O2 if hypoxic, CPAP may be applied; may need artificial respirations

Spontaneous pneumothorax

Lung collapses without trauma or from other causes; higher risk in COPD patients, smokers, and tall, thin people

Spontaneous pneumothorax signs

Sharp pleuritic chest pain, SOB, easily tired, low O2 sat, cyanosis, tachycardia, fast breathing, decreased/absent lung sounds on the affected side; JVD and hypotension if worsening

Spontaneous pneumothorax treatment

Oxygen and transport; CPAP is contraindicated; monitor vitals, JVD, hypotension, tracheal deviation

Pulmonary embolism

Blockage in the blood supply to the lungs; commonly caused by DVT (deep vein thrombosis)

DVT risk factors

Prolonged sitting/lying in one position, active cancer, limb immobilization, surgery

Pulmonary embolism signs and symptoms

Sharp localized pleuritic chest pain, SOB, anxiety, nonproductive cough, tachycardia, tachypnea, lightheadedness, pain/swelling in one or both legs, hypotension, cardiac arrest

Pulmonary embolism treatment

Difficult to differentiate in the field; give O2, treat SOB, transport

Epiglottitis

Infection causing swelling around and above the epiglottis; can obstruct the airway

Epiglottitis signs and symptoms

Sore throat, painful swallowing, tripod position, sick appearance, muffled voice, fever, drooling, stridor

Epiglottitis treatment

Keep patient calm and comfortable, do NOT inspect the throat, high-concentration O2 without alarming the patient, transport

Croup

Viral illness causing inflammation and swelling of the larynx, trachea, and bronchi; upper airway tissues swell and restrict air; common ages 6 months-3 years; history of upper respiratory infection; characteristic seal-bark cough; worse at night

Croup signs and symptoms

Loud barking cough, hoarse voice, breathing difficulty relieved when upright

Croup treatment

If breathing inadequate: artificial respirations and transport; if adequate: call ALS and gentle transport; O2 if hypoxic; position of comfort

Bronchiolitis

Small airways inflamed by viral infection; most common cause is RSV (respiratory syncytial virus)

Bronchiolitis signs and symptoms

Cold-like symptoms and general illness that progress over a few days and can cause significant respiratory distress; often multiple children in the house are sick

Bronchiolitis treatment

Artificial ventilation if needed, blow-by oxygen if hypoxic, consider bulb syringe suction of the nose (clearing an infant's nose can significantly improve minute ventilation)