Section 13 Respiratory for AI.pdf

Memorial EMS Decatur Memorial EMS Springfield Memorial EMS G Respiratory Distress Protocol Correct management of the...

Memorial EMS Decatur Memorial EMS Springfield Memorial EMS G Respiratory Distress Protocol Correct management of the patient in respiratory distress is dependent on identifying the etiology of the distress and recognizing the degree of the patient’s distress. Signs and symptoms of respiratory distress will include: Shortness of breath Difficulty speaking Altered mental status Diaphoresis Use of accessory muscles Retractions Respiratory rate less than 8 or greater than 24 If the etiology is questionable or your assessment does not provide a clear etiology, Consult Medical Control for direction in patient care. Asthma/COPD/Pneumonia In addition to general signs & symptoms of respiratory distress, patients may present with inspiratory & expiratory wheezing and/or “tight” lung sounds with decreased air movement. EMR Care EMR Care should be focused on assessing the situation and initiating routine patient care to treat for shock. 1. Render initial care in accordance with the Routine Patient Care Protocol. 2. Oxygen: If respiratory distress is noted, 15 LPM via NRM or if unable to tolerate the mask, 6 LPM via nasal cannula. a. If no obvious respiratory distress is noted, apply a pulse ox. If > 94% and no signs/ symptoms of respiratory distress, no Oxygen is required. If 94%. 3. May suggest and assist patient with home prescribed inhalers. 4. Be prepared to support with BVM if necessary. EMT Care EMT Care should be directed at conducting a thorough patient assessment, initiating routine patient care to treat for shock and preparing the patient for or providing transport. 1. EMT Care includes all components of EMR Care. 2. DuoNeb: Albuterol (Proventil) 2.5mg + Ipratropium bromide (Atrovent) 0.5mg via nebulizer via nebulizer. May repeat the Duoneb x2 after completion of the first if needed for continued symptomatic relief. 3. Apply Waveform Capnography (if equipped). Table of Contents Section Table of Contents 13.G.1  Memorial EMS Decatur Memorial EMS Springfield Memorial EMS Respiratory Distress Protocol Asthma/COPD/Pneumonia {Continued} EMT Care (cont.) 4. Initiate a Paramedic Care intercept if needed and transport as soon as possible. 5. Contact receiving hospital as soon as possible or Medical Control if necessary. A-EMT/ EMT-I Care A-EMT/ EMT-I Care should be directed at continuing or establishing care, conducting a thorough patient assessment, stabilizing the patient’s perfusion, and preparing for or providing patient transport. 1. A-EMT/ EMT-I Care includes all components of EMT Care. 2. Obtain peripheral IV access. 3. In-line nebulizer may be utilized if patient is unresponsive or in respiratory arrest. 4. Epinephrine 1:1000: 0.5mg IM if the patient is suffering status asthmaticus. Epinephrine administration should be the priority in these critical patients. Special consideration should be given to administering Epinephrine if the patient is > 40 years old, has an irregular heart rate, has a heart rate > 150 bpm or has a significant history of heart disease. Consult Medical Control prior to administration if the patient meets any of these criteria. 5. For ongoing respiratory distress, the provider may initiate CPAP (see CPAP protocol) Paramedic Care Paramedic Care should be directed at continuing or establishing care, conducting a thorough patient assessment, stabilizing the patient’s perfusion, and preparing for or providing patient transport. 1. Paramedic Care includes all components of A-EMT/ EMT-I Care. 2. Methylprednisolone (Solu-Medrol): 125 mg IV. 3. In patients with persistent respiratory distress, consider Magnesium Sulfate: 2gm in 100ml D5W IV over 10-15 minutes. Pearls CPAP (Continuous Positive Airway Pressure) can be applied by A-EMT/ EMT-I/Paramedic Care to achieve PEEP (Peak End Expiratory Pressure) for patients presenting with signs & symptoms of respiratory distress. The patient must be alert and able to adequately ventilate spontaneously for CPAP to be initiated. Table of Contents Section Table of Contents 13.G.2  Memorial EMS Decatur Memorial EMS Springfield Memorial EMS Respiratory Distress Protocol Flash Pulmonary Edema In addition to general signs & symptoms of respiratory distress, patients may present with rales (or “crackles”), pedal edema, distended neck veins (JVD), orthopnea and tripod positioning. Commonly associated with CHF exacerbation. EMR Care EMR Care should be focused on assessing the situation and initiating routine patient care to treat for shock. 1. Render initial care in accordance with the Routine Patient Care Protocol. 2. Oxygen: If respiratory distress is noted, 15 LPM via NRM or if unable to tolerate the mask, 6 LPM via nasal cannula. a. If no obvious respiratory distress is noted, apply a pulse ox. If > 94% and no signs/ symptoms of respiratory distress, no Oxygen is required. If 94%. 3. Be prepared to support with a BVM if necessary. EMT Care EMT Care should be directed at conducting a thorough patient assessment, initiating routine patient care to treat for shock and preparing the patient for or providing transport. 1. EMT Care includes all components of EMR Care. 2. Be prepared to support the patient’ respirations with BVM if necessary. 3. Apply Waveform Capnography (if equipped) 4. Initiate Paramedic Care intercept and transport as soon as possible. 5. Obtain 12-Lead EKG and transmit to receiving hospital if capabilities exist and time permits. A-EMT/ EMT-I Care A-EMT/ EMT-I Care should be directed at continuing or establishing care, conducting a thorough patient assessment, stabilizing the patient’s perfusion, and preparing for or providing patient transport. 1. A-EMT/ EMT-I Care includes all components of EMT Care. 2. Render initial care in accordance with the Routine Patient Care Protocol. 3. For ongoing respiratory distress, the provider may initiate CPAP (see CPAP protocol) 4. Obtain peripheral IV access. Table of Contents Section Table of Contents 13.G.3  Memorial EMS Decatur Memorial EMS Springfield Memorial EMS Respiratory Distress Protocol Flash Pulmonary Edema A-EMT/ EMT-I Care {Continued} 5. Nitroglycerin (NTG): 0.4mg SL. May repeat every 3-5 minutes to a total of 3 doses (if systolic BP remains > 110mmHg). 6. Contact receiving hospital as soon as possible. Communicate early in the transmission if your patient is on CPAP so the appropriate equipment is ready upon patient arrival. Paramedic Care Paramedic Care should be directed at continuing or establishing care, conducting a thorough patient assessment, stabilizing the patient’s perfusion, and preparing for or providing patient transport. 1. Paramedic Care includes all components of A-EMT/ EMT-I Care. 2. Always monitor for and be prepared to address respiratory failure. Critical Thinking Elements Constant reassessment of the respiratory distress patient is imperative to assure that the patient has adequate ventilation and oxygenation. Closely monitor the patient’s response to treatment rendered. Patients in respiratory distress should be transported in an upright position to assist their respiratory effort. Do not delay CPAP application for administration of Nitroglycerin (i.e. you do not need to wait until all three (3) doses of NTG SL have been administered before applying CPAP). CPAP has its greatest effect when used without interruptions. CPAP should not be removed to administer NTG, a provider may coordinate those interruptions when CPAP must be transferred from portable to onboard O2 tanks. If wheezing is present and if ETCO2 waveform (if available) supports concurrent bronchospasm, refer to BRONCHOSPASM/ASTHMA/COPD Protocol. Table of Contents Section Table of Contents 13.G.4  Memorial EMS Decatur Memorial EMS Springfield Memorial EMS H Airway Confirmation Procedure (EMT, A-EMT/ EMT-I, Paramedic Care) Consistency in airway placement confirmation methods and the documentation of such is a priority in our EMS System. The following are provider-level specific requirements to confirm Supraglottic Airway and Endotracheal Tube placement. All SGA’s and ETT’s placed or attempted will be reviewed via the MEMS CQI Process. Failure to document in this manner will be actionable by the EMS System. EMT Care A “confirmed airway” at the EMT Care level is defined as established bilateral breath sounds/ absent epigastric noises when BVM ventilations are performed and one of the following: Continuous waveform capnography (if equipped). + Colormetric device color change purple to gold (eg “Easycap”). Chest rise and fall. Condensation/fogging in the tube. Clinical improvement (e.g. skin color, VS, level of responsiveness). These findings should be reassessed and documented following any major move of the patient, including but not limited to: Placing patient on a backboard or CPR device. Loading patient in an ambulance/ transferring care to higher level. Unloading the patient at the hospital/ transferring care to E.D. staff. A-EMT/ EMT-I and Paramedic Care A “confirmed airway” at the A-EMT/ EMT-I and Paramedic Care level is defined as established bilateral breath sounds/ absent epigastric noises when BVM ventilations are performed and continuous waveform capnography. These must be performed and documented at the A-EMT/ EMT-I and Paramedic Care level. Further supporting documentation may include any of the following: Visualization of tube passing chords (ETT only). + Colormetric device color change purple to gold (eg “Easycap”). Chest rise and fall. Condensation/fogging in the tube. Clinical improvement (eg skin color, level of responsiveness). These findings should be reassessed and documented following any major move of the patient, including but not limited to: Placing patient on a backboard or CPR device. Loading patient in an ambulance/ transferring care to higher level. Unloading the patient at the hospital/ transferring care to E.D. staff. Table of Contents Section Table of Contents 13.H.1