Respiratory EMS Protocols PDF

Respiratory Responsoft EMS Protocols Respiratory Page 47 Respiratory 10/13/2020 Adult Airway Respiratory Important skills to master for the adult airway are: ■ Best method for airway management ■ Managing the airway relevant to patients condition ■ Rapid assessment for intubation ■ Realizin...

Respiratory Responsoft EMS Protocols Respiratory Page 47 Respiratory 10/13/2020 Adult Airway Respiratory Important skills to master for the adult airway are: ■ Best method for airway management ■ Managing the airway relevant to patients condition ■ Rapid assessment for intubation ■ Realizing when planned interventions have failed and the need for an alternative technique is required Assess ABC’s, respiratory rate, effort, adequacy Respiratory Breath Sounds: Listen for absent, diminished, unequal, wheezing, Rhonchi, Crackles, Stridor. Inadequate Adequate Pulse Oximetry & Capnography Pulse Oximetry Oxygen If necessary Suction Supplemental Oxygen Oxygen Basic airway maneuvers: Manual, nasal or oral airway. Consider Spinal Injury Assessment if necessary. Ventilate with bag mask device Pulseless & Apneic Objective criteria for evaluation of the Respiratory Distress patient includes: • Accessory muscle use / retractions • O2 saturation < 94% • Respiratory rate > 24 • Unable to speak full sentences • Abdominal / paradoxic breathing • Altered mentation (GCS 11-14) Obstruction Foreign Body Airway Obstruction Intubation-Oral Apneic Direct laryngoscopy and remove using Magill forceps if possible. Intubation-Oral Establish airway and re attempt to ventilate. Cricothyrotomy-Surgical Responsoft EMS Protocols Page 48 10/13/2020 Respiratory Difficult Airway Respiratory Unsuccessful attempt at intubation by most experienced person on scene --> Spo2 >94% with BVM & 100% O2 --> YES Continue BVM, consider placement of supraglottic airway NO Able to ventilate and oxygenate with BVM ---> yes---> continue BVM NO If unable to oxygenate or ventilate with other means proceed to Cricothyrotomy-Surgical Responsoft EMS Protocols Page 49 10/13/2020 Respiratory Allergic Reaction/Anaphylactic Shock Allergic reaction: Exposure to allergen and signs and symptoms of any of the following – respiratory difficulty, wheezing/stridor, tightness in chest or throat, nausea, vomiting, flushing, hives, itching swelling of face/ lips/tongue Anaphylaxis = serious, rapid onset (minutes-hours) reaction to suspected trigger AND two or more body systems involved (eg skin/mucosa, cardiovascular, respiratory, GI) OR hemodynamic instability OR respiratory compromise Universal Patient Assessment IV/IO IV/IO Respiratory An allergic reaction may include one or several symptoms. Most allergic reactions occur within minutes of the exposure, but some reactions may occur several hours later. Cardiac Monitor Albuterol / Ipratropium (Atrovent) 2.5 mg & 0.5 mg / 5.5 ml saline Nebulized If evidence of bronchospasm, the aerosol should be discontinued if significant PVC’s appear. Diphenhydramine 50 mg IVP, IO, IM, PO Over 1 – 2 minutes, watch for hypotension Dexamethasone 10 mg IVP, IO, PO (for moderate Dexamethasone The aerosol should be discontinued if significant PVC’s appear. to severe distress) If signs of anaphylaxis (2 or more body systems OR hemodynamic instability OR significant respiratory distress) immediately give Epinephrine IM Epinephrine should be the initial treatment in patients exhibiting signs of anaphylaxis Epinephrine 1:1,000 0.3 - 0.5 mg IM May repeat every 20 minutes If wheezing Shock or Circulatory Collapse NS Fluid Bolus If none of the above are present, then treat symptomatically. In asymptomatic patients with known history of anaphylactic reaction (as opposed to local reaction), administer Epinephrine 1:1,000 1:1,000 0.3 ml IM Epinephrine ml/kg to maintain 20 ml/kg BP > 90 mmHg systolic Place patient in shock position, if tolerated. Epinephrine Epinephrine1:10,000 1:10,000 0.5 mg (5 ml) IVP, IO Epinephrine Push Dose 0.5 – 2 mL of a 10 mcg/mL solution every 2 – 5 minutes Responsoft EMS Protocols Page 50 Extrapyramidal Symptoms (EPS) is not an allergic reaction, but Benadryl can also be used for EPS. Common symptoms: Pseudoparkinsonism-tremor, masklike facies, drooling, rigidity Akathisia-motor restlessness, aniexty to inability to lie or sit quietly Dystonias- involuntary, irregular, clonic contortions of the muscles of the trunk and limbs Tardive-Having symptoms that develop slowly or that appear long after inception. Dyskinesia- impairment in the ability to control movements, characterized by spasmodic or repetitive motions or lack of coordination. 10/13/2020 Respiratory Esophageal Foreign Body A foreign body in the esophagus is most likely the result of a food bolus impaction. Although most foreign bodies pass readily, occasionally they are the result of some underlying medical condition. Esophageal foreign bodies can occur more frequently in mentally impaired individuals or the elderly. Signs of a esophageal foreign body may include the following: 1. Dysphagia (difficulty swallowing) 2. Pain or tenderness in the neck 3. Inability to swallow oral secretions (indication total obstruction) 4. Other symptoms such as retro-sternal fullness, regurgitation of undigested food, and painful swallowing Respiratory Universal Patient Assessment Adult AdultAirway Airway Protocol Establish patient airway. Administer Oxygen therapy as needed Intubate if necessary. IV/IO Glucagon 1 mg IVP for relaxation of esophageal smooth muscle, which may promote passage of the foreign body Ondansetron (Zofran) 4 mg IVP, IO For nausea or vomiting as warranted Patients with suspected esophageal foreign body should be transported to the closest Emergency Department. Responsoft EMS Protocols Page 51 10/13/2020 Hyperventilation Respiratory When a patient is hyperventilating, the patient is breathing rapidly, which results in excess elimination of CO2. Universal Patient Assessment This sign of increased respiratory rate and/or depth should be interpreted as possible indication of serious underlying disease and supplemental OXYGEN should be applied to the patient and transported. Therefore, EMS personnel in the field may not use a paper bag or any re-breathing device without supplemental OXYGEN. Respiratory Hyperventilation is a sign of many physiologic disorders including heart disease (M.I.), lung disease (COPD, pulmonary embolus, etc.), metabolic disorders (hyperglycemia, toxic ingestions, etc.), neurological disease, acidosis, hypoxia from any cause and others. Signs & Symptoms 1. 2. 3. 4. 5. Fatigue Nervousness Dizziness Chest pain Numbness and tingling around the mouth, hands, and feet Reassure, Exclude other medical causes Oxygen Adequate amount to maintain O2 sat > 94% Consider use of Capnography Responsoft EMS Protocols Page 52 10/13/2020 Respiratory Pulmonary Edema/CHF Pulmonary Edema Signs and Symptoms: Difficulty breathing, anxiety & restlessness, coughing that produces pink frothy sputum, pale, cool and clammy, chest pain, wheezing, course crackles, tachycardia, ankle edema, JVD, hypertension. Respiratory Universal Patient Assessment Oxygen NRB Mask 12 – 15 LPM or If patient in acute respiratory distress CPAP IV/IO Cardiac Monitor Nitroglycerin Nitroglycerin Spray/Tablet 0.4 mg SL May repeat x 2 if BP > 90 systolic and IV established(3 doses total) Nitro Paste Paste 1" 1" concurrent with 1st NTG Nitro above Hold for BP < 90 mmHg systolic BP < 90 mmHg systolic Epinephrine Push Dose 0.5 – 2 mL of a 10 mcg/mL solution See Delayed Sequence Intubation (DSI) Procedure every 2 – 5 minutes Transport with head elevated if there is no hypotension. Treat any dysrhythmia as per the protocol. Responsoft EMS Protocols Page 53 Intubate if patient shows signs of increasing respiratory distress, lethargy, unconsciousness or diminished respiratory effort. 10/13/2020 Respiratory Rapid Sequence Intubation (RSI) Respiratory Clinical Indications:  Inability to maintain adequate oxygenation utilizing less invasive means Inability to self-protect or self-maintain airway Deep coma (GSS < 8) and absent airway reflexes Contraindications See: RSI Assessment Tips Anticipated difficult airway Anticipated inability to BVM ventilate Contraindications to RSI medications Insufficient skilled personnel to assist pre and post intubation. Steps Was performed ? YES Preparation for Intubation: NO 1. Obtain a complete set of vitals including EtCO2 and RR. a. Calculate Shock Index = Heart Rate / Systolic BP, if SI > 1.0 (heart rate > SBP) resuscitate first b. Heart rate, EtCO2 shall be continuously monitored throughout procedure 2. Gather equipment needed a. King Vision – ETT, Syringe, lubricate channel b. Bougie – ETT, bougie (kiwi grip), syringe c. Traditional – ETT, Syringe, appropriate blade d. i-gel must be pre-sized and be immediately accessible before attempt 3. Position the patient “head up” at 30 degrees (or more) CPAP 4. Pre-oxygenate via cannula at 15 LPM, NRB, BVM, or CPAP. If unable to pre-oxygenate appropriately GO TO: Delayed Sequence Intubation (DSI) Sedate and Paralyze: 1. Ketamine (Ketalar) 1 mg/kg mg/kg IVP, IO 2. Rocuronium (Zemuron) mg/kg IVP, IO Maximum 100 mg 11 mg/kg Intubation Procedure 1. Maintain high-flow cannula throughout procedure 2. Perform endotracheal intubation (if unable to intubate after 2 attempts, proceed to supraglottic airway) 3. Confirm tube placement (waveform capnography is priority, confirm with equal breath sounds and absent epigastric sounds 4. Inflate ETT cuff with 10 mL air 5. Note/document ETT depth at lip line, secure tube 6. Reassess the need for additional sedation Sedation for Transportation: 1. Fentanyl (Sublimaze) 2 mcg/kg mcg/kg IVP, IO No dose limit/no Maximum dose 0.1 mg/kg 2. Midazolam (Versed) Adults 2 mg IVP, IO, Pediatrics 0.1 mg/kg IVP, IO to Maximum dose of 2 mg 3. Fentanyl and Midazolam may be given up to two additional doses every 20 minutes to maintain adequate sedation. Responsoft EMS Protocols Page 54 10/13/2020 Respiratory Delayed Sequence Intubation (DSI) Respiratory If unable to pre‐oxygenate appropriately Clinical Indications:  Requires intubation per RSI protocol AND is agitated or is otherwise intolerant of preoxygenation via nasal prongs, non-rebreather mask, bag-valve-mask, and/or non-invasive ventilation Steps Was performed ? YES NO Preparation for Intubation: 1. Obtain a complete set of vitals including EtCO2 and RR. a. Calculate Shock Index = Heart Rate / Systolic BP, if SI > 1.0 (heart rate > SBP) resuscitate first 2. Gather equipment needed a. King Vision – ETT, Syringe, lubricate channel b. Bougie – ETT, bougie (kiwi grip), syringe c. Traditional – ETT, Syringe, appropriate blade d. i-gel must be pre-sized and be immediately accessible before attempt 3. Position the patient “head up” at 30 degrees (or more) Sedate and Paralyze: 1. Ketamine (Ketalar) mg/kg SLOW IVP, IO over 15 – 30 seconds to prevent apnea 1 mg/kg Preoxygenate 1. Place standard nasal cannula at 15 LPM 2. Choose pre-oxygenation device based on the patient’s SpO2 a. SpO2 > 95% use: ai. bag-valve-mask (BMV) with PEEP valve and a good seal at 15 LPM O2, or aii. Non-rebreather (NRB) mask and a good seal at 15 LPM O2 (or more) b. If SpO2 < 95%: bi. BVM with PEEP valve and a good seal 3. Pre-oxygenate for at least 3 minutes Paralyze: 1. Rocuronium (Zemuron) mg/kg IVP, IO Maximum 100 mg 11mg/kg Intubation Procedure 1. Maintain high-flow cannula throughout procedure 2. Perform endotracheal intubation (if unable to intubate after 2 attempts, proceed to supraglottic airway) 3. Confirm tube placement (waveform capnography is priority, confirm with equal breath sounds and absent epigastric sounds 4. Inflate ETT cuff with 10 mL air 5. Note/document ETT depth at lip line, secure tube 6. Reassess the need for additional sedation Sedation for Transportation: 1. Fentanyl (Sublimaze) 22 mcg/kg mcg/kg IVP, IO No dose limit/no Maximum dose 2. Midazolam (Versed) Adults 2 mg IVP, IO, Pediatrics 0.1 mg/kg mg/kg IVP, IO to Maximum dose of 2 mg 3. Fentanyl and Midazolam may be given up to two additional doses every 20 minutes to maintain adequate sedation. Responsoft EMS Protocols Page 55 10/13/2020 Respiratory Respiratory Distress Some causes of respiratory distress include: Pulmonary Edema, COPD, Asthma, Emphysema, Anaphylaxis, Pulmonary Embolism, Pneumothorax, Pneumonia, Bronchitis, or Cardiac related problem. Patients may present with complaint of shortness of breath, pursed lip breathing, Tripod position, accessory muscle use and inability to complete sentences. Respiratory Universal Patient Assessment Oxygen Cardiac Monitor IV/IO Wheezing / Rhonchi Crackles / Signs of CHF Pulmonary PulmonaryEdema Edema Protocol Many specific disorders are responsible for respiratory distress. Included area; Chronic bronchitis & emphysema-COPD, asthma, pneumonia, and lung cancer. Albuterol 2.5 mg/ 3 ml saline and Ipratropium 0.5 mg/ 2.5 ml saline Mixed together (May repeat x 2) Dexamethasone 10 mg IVP, IO, IM, PO For moderate to severe distress Continued Distress Refractory to above treatments Magnesium Sulfate 2 grams / 100 ml NS Infuse over 20 minutes. IV Infusion NOTE: Use EPINEPHRINE with caution in any patient who has used an aerosol bronchodilator within the past 4 hours. NOTE: Consider other causes of wheezing in the patient with presumed asthma Discontinue treatment if significant PVC's appear. Epinephrine 1:1,000 0.3 – 0.5 ml IM May be given concurrent with above in severe cases or anaphylaxis. May repeat in 20 minutes if needed Transport in a position of comfort Patients over 50 years of age who receive EPINEPHRINE or ALBUTEROL/IPRATROPIUM should be placed on a monitor and transported. If patient continues to deteriorate and Intubation Pulse oximetry < 94% consider CPAP, CPAP or Intubation. See Rapid Rapid Sequence Sequence Intubation Intubation (RSI) (RSI) Procedure Responsoft EMS Protocols Page 56 10/13/2020