NOCP 4: Specific conditions & illnesses

Neurogenic shock

Caused by severe spinal cord injury or brain injury

Results in loss of sympathetic NS functions (catecholamines not released) and severe CNS damage

S&S:

• Hypotension, bradycardia

• Warm, dry, flushed skin (vasodilation)

• Loss of bladder control, sweating, and paralysis distal to injury

Treat:

• Keep warm

• Large bore IV, maintain SBP 90mmHg

• ALS: atropine, dopamine, norepi

Septic shock

Caused by untreated infection

S&S:

• Temp over 38* or below 36*

• Tachycardia, tachypnea

Treat:

• Acetaminophen

• IV, maintain SBP 90mmHg

• ECG

• ALS: dopamine, norepi, antibiotics

Specific shock syndromes

Low volume: hypovolemic

Distributive: neurogenic, septic, anaphylaxis

Mechanical: cardiogenic, obstructive

*compensated = 15-30% blood loss

*decompensated = over 30% blood loss

*irreversible = 45% blood loss

Compartment syndrome

Swelling or bleeding inside muscle fascia due to trauma/ injury

• Pain, pallor, pulseless, paralysis, parasenthsia (numb)

Treat: reduce toxin release

• NRB 12-15 LPM

• NS bolus, ECG

• ALS sodium bicarb, Ca+

Obstructive shock

Blood flow obstructed in major heart vessel (usually superior or inferior vena cava)

*mechanical (vessel) problem, the heart is still able to pump

*caused by cardiac tamponade, tension pneumo, constrictive cardiomyopathy/ pericarditis

S&S:

• Becks Triad

• Increased RR and HR to compensate decreased CO

• Skin pale, diaphoretic, clammy

• Hyperresonant lung sounds

Treat: specific cause

Cardiogenic shock

Shock caused by the heart failing to pump blood, caused by L ventricle failure after MI, myocardial contusion, CHF, cardiac tamponade

S&S:

• Severe hypotension/ decreased CO

• Tachypnea, slow or fast HR

• Skin pale, clammy, cyanotic

• Crackles, dyspnea from L vent failure

• AMS/ confusion, syncope/orthopnea

• Pressure, radiating chest pain

• ST changes/arrhythmias/ Q waves

Treat:

• Pt supine

• NRB, ECG

• If lungs clear: 250mL bolus to increase preload

Hypovolemic shock

Shock from fluid or blood loss resulting in inadequate circulation and o2 for tissues

• Caused by hemorrhage, burns, internal bleed, dehydration

*intravascular volume (blood/plasma/electrolytes in vessels) decrease = low CO = organ failure

S&S:

• Tachypnea, tachycardia

• Hypotension

• Skin pale, cool, clammy

• Weakness, dizziness, syncope, thirst
  **high-space shock = massive fluid loss into large internal cavity (ex ABD, bowel wall, peritoneal cavity)

Treat:

• Control bleed

• Clear airway/ suction, BVM prn

• Maintain 95% sats

• ECG, 2 large bore IV

DVT

Thrombus formation in lower extremities (calf, femoral, iliac veins common), high risk for PE

• Risks factors: immobility, endothelial injury, hypercoagulability

• S&S: unilateral leg swelling, pain/tenderness, warmth, redness, cyanosis

• Homan’s sign = calf pain on dorsiflexion

Manage:

• Assess for PE symptoms

• 02 if hypoxic

• Monitor vitals and perfusion

• Needs anticoagulants and blood thinners

Peripheral vascular disease

Chronic narrowing of peripheral arteries due to atherosclerosis; reduces blood flow

Risks: diabetes, HTN, hyperlipidemia, smoking

S&S:

• cramping in legs/ thighs/ butt while walking

• Pain in feet at night, alleviated by dangling leg

• Cold, pale, cyanotic extremities

• Weak/absent dorsalis pulse

• Limb ischemia = gangrene risk

• Increased risk of MI and stroke

Cardiomyopathies

1. Dilated (DCM): enlarged ventricles, impaired systolic function

   • S&S: HF symptoms, dyspnea, fatigue, edema, arrhythmias, systolic murmur

2. Hypertrophic (HCM): thick ventricle walls cause diastolic dysfunction

   • exertional dyspnea, angina, syncope, sudden cardiac death in young athletes, systolic murmur

3. Restrictive (RCM): Stiff ventricles impair filling, impaired diastolic function

   • fatigue, edema, hepatomegaly, JVD

4. Arrhythmogenic R ventricular (ARVC): fribrofatty replacements in RV causing arrhythmias

   • Palpitations, VTach

Benign arrhythmias

Sinus arrhythmia (HR varies with respiration)

PACs

PVCs

First degree AV block

Second degree block type 1

Bradycardia/ tachycardia

Hyperventilation

Usually caused by psychological reasons (anxiety)

S&S:

• Tachypnea, low ETCO2

• Numbness & tingling in fingers

• May cause syncope

Treat:

• Supportive care, talk and calm pt

Complete airway obstruction (adult)

Secondary hypoxia from foreign body/tongue/aspiration due to choking, emesis, or unconsciousness

**tachycardia, PVCs, VTach, Vfib, aystole

• Unable to talk but conscious:

  1. Continuous ABD thrusts (2 finger widths above umbilicus and below xyphoid process at 45 degree angle)

  2. Continue until object expelled or pt unconscious

• Unconscious:

  1. Check airway and mouth for visible obstruction

  2. Suction

  3. BVM 1 breath q 5 sec

  4. ALS

  5. CPR if pulseless

Pneumonia

Bacterial or viral infection of bronchioles and alveoli causing fluid build up and decreased gas exchange

S&S:

• Fever/chills/malaise

• Productive cough, green/ yellow sputum

• Pleuritic chest pain

• Inspiratory crackles

• May lead to sepsis/ shock

• Tachycardia, arrhythmias (dehydration)

Manage:

• Ventilate and o2 prn

• IV NS TKVO, ECG

• Salbutamol, ipratropium bromide

Asthma

COPD disease caused by an increased responsiveness to antigens, resulting in bronchoconstriction and airway swelling/ edema

S&S:

• Airway constriction = wheezes

• SOB, dyspnea, accessory muscle use

• More common in men but more severe in women

Treat:

• O2, salbutamol

• IV, ECG

• CPAP, Epi if severe

Pulmonary embolism

Embolism travels through R atrium and R ventricle through venous circulation, blocking a pulmonary artery

Causes: DVT, immobility, OB, post surgery

S&S:

• Pinpoint stabbing chest pain

• Cyanosis despite o2

• Sudden dyspnea/ SOB

• May lead to AMS, syncope, resp arrest, MI

Treat:

• O2, ECG

• IV TKVO (30-50mL/ hr)

• Greenfield filter (mesh clot catcher)

ARDS (Adult Respiratory Distress Syndrome)

Form of pulmonary edema caused by fluid accumulation in interstitial space

• From any injury/ infection (onset 12-72 hrs after injury) or acute

• Multiple organ failure

• Disrupts alveolar/ capillary membrane

• Affects diffusion and perfusion

Signs & Symptoms:

• Confusion/agitation

• Tachypnea,tachycardia

• Hypoxemia, unresponsive to o2

• Bilateral crackles/ wheezes/ wet lung sounds

Treatment:

• High o2 with PEEP

• IV, rapid transport

Acute Respiratory Distress Syndrome

Acute resp change

• Tachypnea/ bradypnea

• Colour changes

• Grunting/ nasal flaring/ retractions

• Sweating, body position

• Wheezing

Pulmonary edema

Fluid in lung parenchyma (alveoli, bronchioles, insterstitial space) causing swelling

Causes:

• Cardiogenic most common (MI, LHF, HTN)

• ARDS, sepsis, trauma, smoke inhalation

S&S:

• Diaphoresis/pallor

• Crackles at bases and end of inspiration

• Severe = blood streaked sputum

• Tactile fremitus

• May lead to resp/ cardiac arrest

• Tachycardia, AFib

Treat:

• 02, salbutamol, ipratropium bromide

• IV, ECG, CPAP if needed

Pleural effusion

Fluid collection in pleural space between visceral and parietal pleura (lungs & chest wall)

*fluid from infection, CHF, tumours, trauma

Signs & symptoms:

• Difficult to hear lungs on affected side (ensure no trauma)

• Pleuritic chest/ shoulder pain

• Chills/ fever if infection

• May lead to syncope, resp arrest, arrhythmias

Treat:

• High fowlers, 100% O2

• IV, ECG

Status asthmaticus

Severe, prolonged asthma attack causing full airway constriction

S&S:

• Distended chest from trapped air

• Severe acidosis, high ETC02

• Diminished/ absent lung sounds

• Pulsus paradoxus (drop of 10mmHg SBP or weak pulse during inspiration)

• Prepare for resp arrest

Treat:

• Salbutamol NEB

• IV, ECG

• CPAP, epi if needed

Chronic bronchitis

Inflammation and damage to bronchi causing hypersecretion of mucus and productive cough for:

1. At least 3 months OR

2. 2 consecutive years

Thick mucous = decreased ciliary function (alveoli unaffected)

S:S:

• “Blue bloaters”

• Barrel chest

• Crackles or wheezes

• Pursed lip breathing, lip cyanosis

• May lead to pulmonary HTN, RHF

Treat:

• Salbutamol, ipratropium bromide

• IV, ECG

• CPAP if needed

Emphysema

Destruction of alveolar walls distal to terminal bronchioles causing…

• Decreased elastic recoil and diffusion

• Air trapped in lungs (decreased alveolar SA)

• Bronchiolar walls weaken

S&S:

• “Pink puffers” (increased RBC)

• Hyperresonance and barrel chest (hyperinflated lungs)

• Wheezes, crackles

• Dyspnea with exertion, pursed lips

• May lead to RHF, pulmonary HTN

Treat:

• Salbutamol, ipratropium bromide

• IV, ECG, CPAP if needed

STROKE S&S

• Facial droop

• Decreased/ impaired motor control of speech = dysarthria

• Impaired language processing = dysphasia

• Weak / numb one side

• Vision loss/ blurry

• Difficulty swallowing = dysphagia

• ALOC

• Ataxia (decreased/ absent coordination)

Red findings:

• Unresponsive/ to pain only

• Leg falls rapidly

• Arm drifts or falls

• No grip strength

• Incomprehensible speech/ mute

Ischemic stroke

• Most common stroke (80%)

• From embolism or thrombus

• Symptoms rage from none to paralysis

• Atherosclerosis in vessel is common

Hemorrhagic stroke

• 10-20% of strokes

• Brain bleed from stress/ exertion/ HTN

• Cerebral = often fatal

Symptoms: Bradycardia, slow/shallow resps, unequal pupils, unable to open airway

TIA

Transient ischemic attack

• Normal process, body breaks up thrombus in brain = restores blood flow

• Pt regains use of body parts

• Indicates serious condition, TIA can be stroke on the way

• When stroke symptoms go away on their own in less than 24hrs = TIA

Stroke treatment

• Titrate SpO2 92-96%

• D50W 12.5g if BGL below 3.0mmol/L

• Head of stretcher elevated 10-20 degrees

• Pt NPO

• Identify “last seen normal” time

• Stroke screen (positive = pre notification/ OLMC)

• NS IV/IO 100mL/hr

*TPA (tissue plasminogen activator) must be given within 6 hours of last seen normal time

Meningitis

HA/ ALOC, photophobia/phonophobia, nuchal rigidity, high fever, petechiae (small pinpoint spots on skin from bleeding under skin)

Werenicke’s VS Korsakoff’s

Werenicke’s: acute and reversible, due to lack of thiamine from chronic ETOH use

• Causes decreased muscle control, abnormal eye movements (ophthalmoplegia), and mental derangement

Korsakoff’s: progression of Werenicke’s, causes irreversible memory loss

Malignancy

Cells divide rapidly and stimulate blood vessel growth = tumours grow and cells migrate to other areas (metasize)

Neoplasm: new tumor growth, can be benign or malignant

• causes severe HA, seizures, blurred vision

Diabetes mellitus

Umbrella term for hyperglycemic conditions, including all types of diabetes

Type 1 diabetes

• Childhood/ adolescent diagnosis

• Pancreatic beta cells destroyed = no insulin production

• Insulin dependent (IDDM) to lower high BGLs

• Ketones build up = high risk of DKA

• Exercise/ not eating can cause hypoglycemia as these cause a drop in glucose

• Goal = rehydration 

*High BGL = over 7.0mmol/L

DKA (diabetic ketoacidosis)

Risk for diabetes type 1

Insulin deficiency = cells do not use glucose = breakdown of fat for energy

Fat breakdown produces ketones, causing acid buildup and metabolic acidosis

• BGL over 14.0mmol/L

• Polyuria, acetone odor on breath, Kussmauls resps (deep, rapid), confusion, coma

Type 2 diabetes

• Most common

• Develops in adulthood

• Genetic, lifestyle and environmental factors can lead to insulin resistance

• Insulin resistance eventually leads to impaired insulin secretion and sugar levels remain high

• Low risk for DKA = body produces enough insulin to prevent ketoacidosis

• Normal/ high insulin amounts can be produced to compensate for high BGL, but cells remain resistant

• Treated with lifestyle changes (diet, exercise) and medication (usually metformin)

• High risk for HHNK

HHNK (hyperglycemic hyperosmolar nonketotic coma)

Type 2 diabetes risk = not enough insulin for normal glucose metabolism

BGL rises to 30-40mmol/L

• Thick blood, severe dehydration, confusion, poor skin tugor, tachycardia

Cholecystitis

Inflammation of gallbladder due to gallstone blocking cystic or bile duct

S&S: fair, fat, female, forty

• RUQ pain radiating to R shoulder/ back

• Fever, N/V

• Jaundice if bile duct blocked

• Positive Murphy’s sign (pain on inspiration while palpating RUQ)

GERD/ heartburn

Damage to lower esophageal/cardiac sphincter when stomach acid enters esophagus

Indicator: bitter taste in mouth, burning sensation

*may progress to esophagitis

Esophagitis

Irritation and inflammation of esophageal lining, commonly caused by GERD and infection

Indicator: dysphagia, odynophagia (painful swallowing)

*may progress to aspiration (swelling/ narrowing) or perforation (thin wall may burst)

Pancreatitis

Inflammation and blocked pancreas duct, causing pancreatic enzymes to eat the pancreas

*blockage caused by gallstones, infections, toxic drugs

*may progress to endocrine disorders/ surgery

S&S:

• Sharp localized upper epigastric pain, may radiate to lower back

• Pain worse after eating or laying down

• Jaundice if bile duct is blocked

• N/V, fever, tachycardia, muscle spasms

• Cullen’s sign/ Grey-Turner’s if pancreas has hemorrhaged

Gastritis

Inflammation of the gastric mucosa lining in the stomach

*caused by NSAIDS, ETOH, stress, smoking

*may progress to GERD, esophagitis, ulcers

S&S:

• Epigastric burning, heartburn

• Belching (eructation)

• Bloating, indigestion

• Melena or hematemesis if erosive

Encephalitis

Brain inflammation and swelling

Simple partial seizure (focal)

• Seizure with no LOC change

• Causes numbness/weakness/ dizziness/visual changes

• Twitching or brief paralysis

Complex partial seizure (focal)

AMS, lip smacking, abnormal blinking, isolated jerking

Due to abnormal discharges from temporal lobe

Absence seizure

• Sudden staring spells, blank look, unresponsive for a few seconds

• Common in children (“daydreaming” appearance)

• No postictal state (pt recovers with brief memory lapse)

Subtypes: typical vs atypical

Tonic-clonic seizure

Seizure with loss of consciousness, chaotic muscle movement, apnea/hyperventilation, diaphoresis

• Preceded by aura

• Lasts 3-5 mins

*tonic = muscle rigidity (tone)

*clonic = muscle contraction and relaxation

Status epilepticus

Seizures that continue every few minutes and pt does not regain consciousness between seizures

Can last longer than 5 mins

Myoclonic VS atonic seizure

MYOCLONIC SEIZURE

• Sudden, brief muscle jerks (like being “shocked”)

• Often occur in clusters

• Patient may stay aware
  
  

ATONIC SEIZURE

• Sudden loss of muscle tone → collapse or head nod

• High risk of injury

Patient may wear a helmet if frequent

Gastroenteritis

Inflammation of stomach and intestine mucosa lining due to viral or bacterial (cholera) infection

• Viral most common:

  • Norwalk (norovirus): adults

  • Rotavirus: children

• Bacteria enters body via food/ water or fecal-oral contact

S&S:

• Diarrhea, hematochezia/ pus stool

• Fever, N/V, ABD cramps, dehydration

Diverticulitis

Pouches in descending colon become infected when feces and bacteria becomes trapped in pouches

*pouches caused by decreased fibre (solid stools, pressure/ strain increase)

*can progress to sepsis, bowel obstruction

S&S:

• LLQ pain

• N/V, constipation, fever

Bowel obstruction

Blockage of small or large intestine from bowel twisting, adhesions (scar tissue after surgery), tumor, or physical blockage (impacted feces, foreign body)

Indications: feculant (poop) breath, small amounts of diarrhea

*may progress to bowel perforation = shock

Esophageal varicies

Widening of distal esophageal blood vessels due to liver failure/ cirrhosis, portal vein obstruction

*if blood cannot flow through liver, pressure builds in portal venous system and blood is forced through esophagus veins = widen and burst = massive bleed

S&S:

• Jaundice

• Hematemesis, melena

• Bleed = shock

Appendicitis

Accumulation of feces in appendix causing increased pressure, leading to ischemia, bacterial growth/ inflammation

*may progress to proliferation, rupture, sepsis, peritonitis

S&S:

• Visceral periumbilical pain

• Localized RLQ pain (McBurney’s point)

• N/V, low fever

• RLQ rebound tenderness/ guarding

• Rovsing, Psoas, Obturator, and McBurney’s

**Visceral pain = sensitive to stretch, ischemia, and inflammation

Cirrhosis

Final stage of liver failure: irreversible scarring and decreased liver function, likely leading to death

*caused by chronic alcoholism, hepatitis B/ C, fatty liver disease (obesity, high cholesterol)

S&S:

• Jaundice

• Edema

• Ascites

• Itchiness from bile salts/ bilirubin

Peptic ulcer disease

Ulcers in stomach lining and duodenum, acid eats away at mucosa lining = protective lining erosion, acid begins to eat organs

*caused by NSAIDS, infection, stress, smoking, ETOH

*Nexium decreases stomach acid production

S&S:

• Epigastric pain worsened after eating (subsides 3-4 hours after meal)

• Pain flare up at night

• May progress to stomach perforation

• Hematemesis, melena

Chronic renal failure

Inadequate kidney filtration due to loss of nephrons (70% or higher)

• End-stage = 80% lost

• Causes metabolic instability

• Pt requires dialysis or transplant

Assessment: 

• Positive Lloyd’s (pain on percussion of costovertebral angle)

• AMS, malaise, lethargy, HA, cramps

• Uremic frost: urea excreted through sweat glands = white, powdery crystals on skin

• Prolonged PR or QT intervals

*high potassium retention causes peaked T waves

Acute renal failure

Sudden decrease in glomeruli filtration and urinary output over a period of days

Types:

1. Prerenal: hypotension, tachy, dizzy, oliguria (below 500mL/ day), anuria (0-50mL) *nomal = 1200mL

2. Intrarenal: rash, inflammation

3. Postrenal: distended bladder, hematuria, flank/ suprapubic pain

*May progress to chronic renal failure

Kidneys unable to filter waste from blood = fatal amounts can accumulate

• caused by HTN, CHF, diabetes

GI/GU general management

Treat symptoms as they present (pain, N/V)

Goals:

• Maintain 96% sats (prevent hypoxic organs)

• Normal BP: IV TKVO 125 mL/ hr

• Hypotension: 10-20mL/kg (maintain SBP 80-90mmHg

• Gravol, ECG

*ALS: Morphine, Toradol, Fentanyl

Renal calculi/ colic

RENAL CALCULI

Kidney stones created from crystal formations in collecting system

= 11/10 pain, hemorrhage and obstruction complications

• Dehydration causes salts and calcium to crystalize

• Caused by heredity, bowel disease, immobility, surgery, medications, poor diet

RENAL COLIC

Pain caused by renal calculi

• Pain starts in flanks/back and migrates to groin

• Abnormal urine colour/ hematuria, dysuria

*pain occurs when calculi passes through ureter

Lower vs upper UTI

LOWER UTI

More common UTI

• Includes urethritis, cystitis (bladder), and prostatitis (prostate)

UPPER UTI

Less common UTI that occurs when infection travels upwards

• Pylonephritis and risk of abscess (intrarenal and perinephric)

Causes of upper GI bleed

Peptic ulcer disease, esophageal varices, Mallory-Weiss, gastritis, esophagitis

**hematemesis, melena

Causes of lower GI bleed

Diverticulitis, hemorrhoids, Chron’s/ colitis

**hematochezia

Renal and bladder obstructions

Renal:

• Kidney stones, blood clots, tumours

  • Severe flank pain, radiates to groin (renal colic)

Bladder:

• Benign prostatic hyperplasia (BPH), bladder stones, tumours

  • Hematuria, weak stream, hesitancy, urinary retention

  • recurrent UTI (chronic)

  • N/V (acute)

Syphillis

Highly infectious STI that usually resolves in 1-3 weeks and goes unnoticed in half of pts

Incubation for approx three weeks before symptoms develop

• Chancre = open sore/ ulcer

Chlamydia

STI that often accompanies other infections such as gonorrhoea

Can transmit to fetus during delivery

• Women = abnormal vaginal discharge, dysuria, pelvic/low ABD pain

• Men = dysuria, discharge, penile or rectal swelling (often asymptomatic)

• Can cause pneumonia and conjunctivitis

Gonorrhea

STI from bacteria that commonly affects cervix, urethra, rectum, throat and eyes

• Causes urethritis in men (dysuria and discharge)

• Women may have generalized lower ABD pain (can progress to IBD) + dysuria/discharge/labial swelling/lesions

*80% asymptomatic

Brain abcess

Collection of localized pus in brain tissue as a result of an infection

S&S: lethargy, hemiparesis (weak on one side), nuchal rigidity, N/V, HA, seizure

Moderate & severe hypothermia management

*HT-2: AMS and not shivering (moderate)

*HT-3: Unconscious with signs of life (severe)

• active rewarming (warm IV fluids, heat pads) to trunk only

• prevent movement and contact OLMC

• possible transport to facility with ECMO or CPB (coronary pulmonary bypass) if one of the following present:

  • SBP under 90mmHg, ventricular arrhythmia, or core temp less than 28 degrees

Mild hypothermia management

HT-1: Pt conscious and shivering (mild)

• passive rewarming (blankets, warm enviro, warm fluids, etc)

• encourage movements

• oral glucose or sweet drink

Profound hypothermia management

HT-4: unconscious with no signs of life (profound)

• Treat for hypothermia cardiac arrest

• If V-fib/ V-tach/ shock advised: shock ONCE until temperature 30 degrees or higher

HT-5: death due to irreversible hypothermia (dead)

• Discontinue/ withhold resuscitation

Multiple sclerosis

Inflammation disease where the insulating nerve cell coverings in the brain + spinal cord are damaged

• Fatigue, cognitive impairment, mood changes

• Nystagmus, optic neuritis, diplopia (double vision)

• Dysphagia, dysarthria

• Pain, hypoesthesias (decreased sensation), paraesthesias (abnormal sensation)

• Incontinence, diarrhea, constipation

Parkinson’s

Progressive neurodegenerative disorder caused by the loss of dopamine producing neurons

• Tremors, bradykinesia, rigidity, postural imbalance, freezing movements

• Cognitive impairments, mood disorders

• GI issues, sweat/olfactory disturbances

ALS (amyotrophic lateral sclerosis)

AKA Lou Gehrig’s disease/ Charcot disease

Progressive neurodegenerative disease causing death of motor neurons, which control voluntary muscle movement

• Leads to eventual paralysis; death likely in 3 years

• Muscle weakness, cramps, and twitching

• Decreased fine motor skills

• Dysarthria (speak) and dysphagia (swallow)

• Diaphragm weakens = resp issues

Cerebral palsy

Neurological disorder resulting from damage to the developing brain

• Usually from birth

• Brain injury often from asphyxia, hypoxia, infections, trauma

• Non-progressive, but symptoms can change

• Impairs motor function = ataxia, difficulties controlling voluntary muscles

• Can also affect speech, hearing, learning, and vision

Flail chest

2 or more adjacent borken ribs causing an unattached segment from chest wall

Flail segment = paradoxical movement (inwards during inspiration and outwards on expiration)

• Result of blunt chest trauma

• S&S: severe chest pain, dyspnea, shallow resps, tachypnea, crepitus over fractures

  • may progress to pulmonary contusion, hemothorax, pneumo/ tension pneumo

• Manage:

  • Ensure open airway, NRB/ BVM

  • IV (maintain SBP 90mmHg)

  • ECG (tachy, PVCs)

  • Early intubation prep

  • Pain relief from ALS (no entonox)

Open pneumothorax

sucking chest wound

Air enters pleural space (b/w lungs & chest wall) through penetrating chest wound, sucked in air disrupts negative intrapleural pressure = collapsed lung

S&S:

• Hypoxia, tachypnea, dyspnea

• Visible hole in chest (bubbling)

• Decreased or absent breath sounds on affected side

• Subcutaneous emphysema (palpable air under skin)

  Treat:

  • Seal wound with gloved hand immediately once discovered

  • NRB 15LPM

  • 3 sided occlusive dressing with flutter valve (or SAM seal)

  • Monitor closely for signs of tension pneumothorax and hemothorax

Tension pneumothorax

Air enters thorax but cannot escape, increasing thoracic pressure causes compression to lungs, heart, and major blood vessels

*caused by blunt force trauma

Obstructive shock: intrapleural pressure rises = lung collapse = mediastinum shift = compressed vena cava and decreased venous return = low CO

S&S:

• JVD, tracheal deviation away from affected side

• Severe dyspnea, tachypnea/cardia

• Absent lung sounds, hyperresonance

• Subcutaneous emphysema

  Manage:

  • 45* semi fowlers

  • NRB 12-15LPM/ BVM

  • Needle decompression ALS

  • Load and go + OLMC

Hemothorax

Blood accumulation in thorax and lungs causing lung compression, decreased ventilation and reduced venous return

*from blunt/ penetrating trauma, AAA

S&S:

• Flat neck veins (hypovolemia)

• Dull or absent breath sounds on affected side, dull percussion

• Hypoxia, tachy/bradycaria, hypotension

• Hemoptysis

• Pallor, diaphoresis, cool

*over 1000mL of blood: massive hemothorax

• Manage:

  • Open airway, NRB

  • 500mL NS bolus (max 2L) if hypovolemic

  • Monitor for tension hemo-pneumothorax (JVD, tracheal deviation)

  • Rapid transport and OLMC

Cardiac tamponade

Blood/ pus fills the pericardial sac and compresses the heart, impairing ventricle filling

Decreased ventricle filling = decreased SV = low CO = hypotension = obstructive shock

Caused by penetrating/ blunt trauma, pericarditis, cancer, infections, aortic aneurysm

S&S:

• Beck’s Triad (hypotension, muffled heart tones from fluid, JVD from increased R heart pressure)

• Pulsus paradoxus (10mmHg SBP drop or weak pulse on inspiration)

• Tachycardia, tachypnea

  Manage:

  • O2 to maintain 94%

  • Load and go + OLMC

  • Treat shock = 500mL IV/IO NS bolus until SBP over 90mmHg (max 2L) on route

  • ECG (usually tachy)

  • Treat dysrhythmias (tachy/ low voltage QRS/ bradycardia/ PEA)

Atherosclerosis

Plaque (lipids, cholesterol) build up in arterial walls (lumen)

• Indicated by hx/ HTN

• Treat symptoms as needed

• Progresses to arteriosclerosis

• Normal ECG/ ETCo2

Arteriosclerosis

Hardening/ stiffening/ thickening of lumen causing decreased elasticity and narrowing vessels

• Indicated by HTN

• Treat symptoms as needed

• Normal ECG/ ETCo2

HTN emergency

*pt usually on Ramipril

• Caused by lifestyle, MI, CHF, stroke

• Indicators:

  • 140/90 +

  • HA, flushed skin

  • Diastolic continues to rise, watch for MAP of 150

• Treat:

  • 02 to maintain 94%

  • IV TKVO

  • 12 lead

  • Prepare for seizures, MI, stroke

• ECG: tachy, PVCs, PACs

Aortic aneurysm

Thinning and widening of artery in the aortic arch or descending aorta

• S&S:

  • Substernal/ throat/ neck/ jaw/ face pain (if ascending)

  • Flank/ shoulder blade/ back/ ABD/ lower extremity pain (descending)

• Treat:

  • IV, ECG, maintain 94% sats

  • ALS morphine

  • May progress to aortic dissection

• ECG: normal, tachy, ST depression

Acute aortic dissection

Intima layer torn in aortic arch or descending aorta

S&S:

• Max pain from onset

• Pain b/w shoulder blades *tearing, ripping

• May have stroke-like symptoms

• Different BPs in each arm

• May progress to AAA, hypovolemic/ cardiogenic shock, cardiac arrest

Treat:

• 02, IV, ECG

• ALS morphine

• No ASA or nitro

• SBP goal = 90mmHg

ECG:

• tachy, dysrhythmias, VTach, VFib

Ruptured AAA

Fluid rupture at dissection site, usually in descending aorta

S&S:

• Pulsating mass in ABD, pain “pulled muscle”

Treat:

• Load and go

• O2, IV TKVO (large gauge, small fluid amounts)

• Allow permissive hypotension (70-90 mmHg SBP)

• May progress to hypovolemic/cardiogenic shock, cardiac arrest

ECG:

• Tachy, dysrhythmias, VTach, VFib

Stable angina

Spasms in coronary arteries and insufficient o2 supply to myocardium causing pain

S&S:

• Usually triggered by exertion/ stress

• Nitro effective?

• Heavy chest pain, radiating down arm

• Pain for 10-20 min

Treat:

• Rest, O2 to maintain 94% sats

• ASA, 12 lead within 10 mins

• IV, nitro 0.4mg SL q 3-5 mins

• ALS morphine

• May progress to hypoperfusion, hypoxia, unstable angina, MI, heart blocks

ECG:

• ST depression

Unstable angina

Angina that is not alleviated with rest or medication

*same treatment and risks as stable angina

Myocardial infarction

Sudden or complete occlusion in coronary artery in the myocardium resulting in ischemia and necrosis

S&S:

• Male: retrosternal pressure, pain/ squeezing/ weight on chest, pallor, diaphoresis, cool skin

• Female: lightheadedness, N/V, epigastric burning, pain b/w shoulder blades, low back pain (especially diabetic women)

Treat: *goal = reperfusion

MONA: morphine, oxygen, nitro, ASA

• NC to maintain 90-94% sats

• ASA, 12 lead within 10 mins, vitals

• IV, ALS morphine

• No nitro for right sided ventricular infarction / SBP under 100/ phosphodiesterase inhibitors

• Semi-fowlers

• Prepare for cardiac arrest

ECG:

• STEMI:

  • ST elevation in 2 or more leads

  • complete blockage

  • + troponin

• NSTEMI

  • ST depression, T wave inversion

  • partial blockage

  • + troponin

STEMI locations vs ECG

Septal: v1, v2

Anterior: v3, v4

• Left anterior descending artery

Lateral: v5, v6, I, aVL

• Left circumflex artery

Inferior: II, III, limb leads, aVF

• Right coronary artery

Ischemia = depression, reversible with o2

Injury = depression/ elevation, need o2

Infarct = elevation

***Right ventricular MI:

• hypotension, JVD, clear lung sounds

• Only identified with R sided leads

• NO nitro

**Anterior STEMI: lead II

Left sided heart failure (LHF)

Left ventricle failure usually caused by MI or HTN, results in back up of blood in lungs

Blood back up in L atrium = pul veins = pul capillaries

S&S:

• Pulmonary edema

• Crackles/ rales

• Chronic dyspnea

• Hemoptysis, tachypnea

• Reduced CO = weak pulses, hypoperfused extremities

Treat:

• Goal = preoxygenation

• If adequate BP: sit pt up with legs dangling for symptom relief (reduces venous preload, less pul congestion, increases lung expansion)

• O2 to maintain 90-94% sats

• CPAP if needed

• IV TKVO, ECG

*No Lasix (induces hypokalemia and dysrhythmias)

• LHF may progress to RHF, resp arrest, cardiac arrest

ECG:

• AFib, Q wave, MI, tachycardia

Right sided heart failure (RHF)

Back pressure in lungs causes strain to right ventricle, eventually becoming unable to pump blood effectively into pulmonary circulation

Blood backs up in systemic venous circulation = fluid overload in body

**Cor pulmonale: RHF from pul HTN/ chronic lung disorders

Caused by LHF, pulmonary HTN, pulmonary edema

S&S:

• JVD

• Pedal edema/ pitting at ankles

Treat:

• Semi fowlers or sit up with legs dangling

• Maintain 94% sats

• ECG, IV TKVO

ECG:

• AFib, heart blocks, tachycardia

Endocarditis

Bacterial inflammation of endocardium and heart valves (tricuspid and pulmonary)

S&S:

• Different BP in each arm

• Fever, night sweats

Treat:

• IV, ECG, 02 (maintain 94%)

• Antibiotics

• May progress to HF, sepsis, cardiogenic shock

ECG:

• Prolonged PR interval

• 3rd degree heart block

Myocarditis

Inflammation to myocardium (heart wall) caused by bacterial/ viral infection or drugs/ ETOH/ toxins

S&S:

• Flu-like symptoms

• Tachycardia, fever, malaise

• Epigastric pain

• May be bradycardic if conduction system involved

• Can progress to acute HF, sepsis, cardiogenic shock (MI symptoms)

Treat:

• IV, 12 lead, 02 (maintain 94%)

• Antibiotics, ALS atropine

Pericarditis

Inflammation of pericardium; many different causes but usually viral or idiopathic (unknown cause)

S&S:

• Pleuritic chest pain, worsens when pt supine/ inhaling

• Dyspnea (worsens if fluid or tamponade develops)

• Dysphagia (if effusion compresses esophagus)

Treat:

• IV, 12 lead, 02 (maintain 94%)

• Antibiotics or NSAID

• May progress to AHF, sepsis, cardiogenic shock

ECG:

• ST elevation in many leads (altered repolarization of cells)

• PR segment depression

Myocardial contusion

Myocardial bruising from blunt anterior chest trauma (MVC, falls, blasts, CPR)

Blunt force to muscle = inflammation, bleeding, necrosis = valve/ electrical dysfunction

S&S:

• May mimick MI, chest pain & palpations

• Crackles (ventricular dysfunction = blood back up in pul arteries)

• Hypotension (severe)

• PVCs, PACs, AFib, flutter

• May progress to cardiogenic shock, cardiac tamponade, tension pneumo, hemothorax

  Manage:

  • 12 lead to rule out MI

  • NRB

  • IV (maintain SBP 90mmHg)

Diaphragmatic tear

Injury to diaphragm allowing ABD organs to herniate into chest cavity due to negative thoracic pressure

Herniated organs compress lungs = decreased ventilation and possible bowel obstruction/ proliferation

• Caused by severe blunt trauma or penetrating trauma

• Usually L sided as liver protects R side

• S&S: dyspnea, vague or sharp chest ABD pain, bowel sounds heard in ABD, scaphoid (sunken) ABD

Tracheal/ bronchial tree injury

80% of cases near carina

Injury from blunt force/ spinal trauma, can rapidly lead to resp failure, tension pneumo, pneumo/hemothorax

Air/ fluid leaks from trachea/bronchi into surrounding tissue (mediastinum, pleural space, subcutaneous tissue)

S&S:

• Tachypnea, dyspnea, resp distress

• Hemoptysis

• Subcutaneous emphysema around chest, face, neck

  Treat:

  • NRB/ BVM

  • NO intibation

  • IV, ALS

  • Monitor for pneumo/hemothorax and tension pneumo

Diaphragmatic tear

Herniation of organs and internal hemorrhage due to severe blow to ABD

S&S:

• Hypotension, tachypnea/cardia

• Bowel sounds auscultated in chest

• Late sign: N/V, ABD distension

Treat:

• BVM, IV

• ALS nasogastric tube

Pulmonary contusion

Blunt force chest trauma causes lung swelling and hemorrhage into parenchyma (alveoli & bronchioles)

Reduced lung compliance = impaired gas exchange, hypoxia, eventual resp failure

S&S:

• Takes hours to develop

• Dyspnea, tachypnea, hemoptysis

• Crackles/rales, wheezes

• Diminished lung sounds

• May progress to pul edema, hemothorax, tension pneumo

  Manage:

  • NRB/ BVM

  • IV, ECG

  • Avoid fluid overload (worsens pulmonary edema)