Scenario Sunday:
Respiratory distress patient
Part I

You are just getting settled into bed at the station, after a long day of running calls. Suddenly, your pager advises you differently, you spring from your bunk and answer your call.

911: You are called to the residence of a 68 year old female complaining of respiratory distress.

On arrival, you are met at the front door by the patients’ husband, he advises you to “please hurry, she is not doing well, she can’t breathe”! He quickly leads you down a narrow dark hallway and up a set of stairs to the patients’ bedroom. As you enter the room, you see an elderly female sitting on the edge of her bed, leaning slightly forward with her hands on her knees, while struggling to breathe. You can here audible rales as you approach.

  • What other sign could you look for effortlessly as you approach the patient?
  • Although it is apparent she in is in respiratory distress, would you ask her about her complaint?
  • What concerns do you have for this patient at this point?

Scenario Sunday:
Part II

On initial contact with the patient you quickly introduce yourself and partner while obtaining her consent for treatment.
You perform a quick assessment and find:

-        Patient is conscious, but confused to time and events with a GCS-14

-        The patient has a bounding radial pulse at 150 bpm

-        Patient is pale/cold clammy, diaphoretic; cyanosis is noted around lips and nailbeds.

-        Respirations are 28 bpm labored; BBS are =, diminished in the lower lobes with audible coarse rhonci/rales on inspiration/expiration w SpO2 90 on her 2lpm O2 at home.

-        Her B/P is 196/110

Your initial assessment takes < 2 mins, at this point in the game it is apparent the patient is in severe respiratory distress.

  • Would you decide to start interventions now, or do you need more information and/or assessment?
  • What could you do to improve oxygenation immediately?
  • Are there other signs and symptoms you would look for, in order to proceed with a proper treatment modality?

 

Scenario Sunday:
Part III

Your patient states the shortness of breath comes on at night but, is worse tonight. It wakes her from a sound sleep. The patient denies chest pain or N/V. Further assessment reveals:

-        Patient MAEWx4 with PMS intact; PEARL with = grips; No neuro deficits noted.

-        The patient is now on the monitor with a heart rate of 148-156 showing a sinus tachycardia with multifocal PVC’s noted at 4 per minute.

-        Patient has a past medical history of CHF and hypertension.

-        Patient has + 2 pitting edema noted to both feet with no distal pulses palped

-        She has NKDA and takes Lasix and Lotensin daily (unsure of dose)

Increasing the O2 has offered little relief and the patient is counting on your expertise to help her breathe better.

  • With the findings and assessment, what do you feel is happening with your patient?
  • What intervention should be initiated soon in order to improve the hypoxic state of your patient?
  • Would you intubate this patient at this point?

Scenario Sunday:
Part IV

After evaluating the patient, taking vitals and conducting an interview; it is apparent that your patient will need a better respiratory status, in order to safely move her out of a tight residence to an awaiting unit outside (3-4 minutes away if all goes well). Knowing it would almost be impossible to bag her on the long stairway and hall, you make a decision.

Follow Part V – A (Albuterol) if you decide an albuterol or bronchodilator therapy is warranted.

Follow Part V – C (CPAP) if you decide CPAP therapy is warranted.

Scenario Sunday:
Part V – A (Albuterol)

After completing a thorough assessment you decide to initiate an Albuterol treatment hoping it will improve the patients’ respiratory distress. After increasing the patient’s own O2 to 6 lpm the SpO2 remains 90. The patient advises she has had breathing treatments before and you proceed. You administer 1 nebulized Albuterol treatment and the patient reports worsening dyspnea. The albuterol treatment has had no effect, lungs sounds are actually worse, why?

Albuterol is a sympathomimetic bronchodilator that is effective for causes of bronchoconstriction (i.e., Asthma, Bronchitis) but, has little or no effect on a patient suffering from Pulmonary edema/CHF.

  • Since the Albuterol did not help, would you initiate a second nebulized treatment?
  • Would any of the findings prompt the initiation of a second Albuterol treatment?
  • Since Albuterol is ineffective, would you consider intubation and assisted ventilations?
  • Would you consider another treatment modality for this patient after Albuterol proves ineffective?

 

Part V – C (CPAP)

If you chose CPAP as a treatment modality, you’ve chosen an APROVED TREATMENT for the pulmonary edema patient in this scenario.

-        Her prognosis just became a lot better! Great assessment!

Pulmonary edema secondary to CHF can be life-threatening if aggressive airway treatment isn’t initiated by EMS. Treatment is intended to decrease venous return to the heart, improving myocardial contractibility, decreasing myocardial oxygen demand, improving ventilation/respiration, and rapid safe transport to an appropriate facility. CPAP is an effective treatment for often rapid relief of dyspnea due to CHF/Pulmonary edema.

The medic should place the patient in a sitting position with legs dependent to increase lung volume and capacity while decreasing the work of breathing and venous return to the heart.
Administer high flow O2 using a well-fitting NRB while setting up CPAP is appropriate.

The patients BP is definitely > 100 mmHg (systolic)
Vitals prior to CPAP:

-        HR:       154 bpm; EKG showing a sinus tachycardia with 2-4 multifocal PVC’s per minute

-        BP:        194/104

-        SpO2:    92% on patients 2 lpm O2

-        ETCO2:  28

GENERAL CPAP PROCEDURE  (Always know and follow your local Pulmonary Edema/CHF Protocol)

1. Explain procedure to patient

2. Ensure adequate oxygen supply to ventilation device

3. Place the patient on continuous pulse oximetry

4. Place the patient on cardiac monitor and record rhythm strips with vital signs

5. Place the delivery device over the mouth and nose

6. Secure the mask with provided straps or other provided devices

7. Use 5 cm H2O of PEEP valve

8. Check for air leaks, CPAP works only with airtight system

9. Monitor and document the patient’s respiratory response to treatment

10. Check and document vital signs every 5 minutes.

11. Administer appropriate medication as certified

•             SL NTG 0.4 mg (up to 3 doses)
•             Lasix 40 mg IVP

12. Continue to coach patient to keep mask in place and readjust as needed 13M. Contact medical control to advise them of CPAP initiation

13.  If respiratory status deteriorates, remove device and consider intermittent positive pressure ventilation via BVM and/or placement of non-visualized airway or endotracheal intubation.

Your patients color and respiratory effort is obviously improving within 5-6 minutes and you continue treatment and assessment while transporting. It is a good idea to contact MCP/receiving facility to advise them of your ETA with a CPAP patient.

5 minutes into CPAP Vitals:

-              HR:       100 bpm; EKG showing a sinus tachycardia PVC’s are subsiding

-              BP:        160/92

-              SpO2:    98% on patients

-              ETCO2:  2

Notes to remember about CPAP:

CPAP should be continued until arrival at the ER. Evaluate vial every 5 minutes for improvement. Respiratory status and BP should improve often within minutes.

In order for CPAP to work, there must be a pressure-tight seal throughout the system. CPAP accomplishes this with a well-fitted mask that the patient wears over the mouth and nose. The circuit is attached to the mask and the patient is encouraged to breathe as normally as possible.

Many patients will begin to feel relief within seconds to minutes of application, as their lungs begin to exchange gases more easily. Many providers report that the change in their patient's condition is so dramatic that they have to convince hospital staff of the original severity level!

There are a few precautions:

The main concern is that CPAP can, and will, lower blood pressure. This makes sense: as pressure increases inside the lungs, it also increases pressure on the heart chambers and great vessels, causing cardiac output to drop. If the patient is hypotensive to begin with — i.e. the patient is experiencing cardiogenic shock with pulmonary edema — CPAP is not indicated.
The patient must also be breathing and able to follow commands in order for CPAP to work effectively.

 

 

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