1. How will you manage this patient initially?

After approximately 2 minutes of initial airway management, you re-assess the patient and find that he is now unconscious and apneic. You also note that he has widespread cyanosis to his entire facial and neck areas.

2. What additional management is needed for this patient, based upon your re-assessment findings?

3. How do you determine which patients require assisted ventilation as opposed to supplemental oxygen? 4. How should this patient be managed, should he begin to vomit?

In this case study, you were managing a patient with inadequate breathing from the very beginning. In addition to not being able to speak because of such labored breathing, he was displaying the following signs of inadequate perfusion:

Diaphoresis (cool, clammy skin) is a sign that blood is being shunted from the periphery of the body (the skin) to more critical organs in the body such as the heart, lungs, kidneys, and brain. The sympathetic nervous system (fight or flight response) results in peripheral vasoconstriction that is responsible for this shunting of blood. Diaphoresis is an early indicator of inadequate perfusion, since the skin is one of the first organs from which blood is redistributed. As a result of separation of hemoglobin and red blood cells (the components of the blood that carry oxygen), the arterial blood becomes deoxygenated. Recall that deoxygenated blood is darker red in color. Internally, deoxygenated blood is actually more blue than red. This explains the color of the patient's skin. It takes approximately 40-50% of hemoglobin-red blood cell separation before cyanosis manifests therefore; it is a late sign of inadequate perfusion. Patients who are gasping for air and showing signs of inadequate perfusion should be managed with assisted ventilation immediately. The patient in this case study, due to congestive heart failure, had a back up of blood in the lungs. This directly inhibits the exchange of oxygen and carbon dioxide. Positive pressure ventilation will force excessive amounts of blood from the lungs, thereby improving oxygen-carbon dioxide exchange in the alveoli. As with many patients in respiratory failure, this patient became unconscious and apneic, which further required you to insert an oropharyngeal airway and monitor for vomiting. In cases like this, immediate transport is critical to the patient's survival. Additionally, the Intermediate should consider requesting an ALS unit, as this patient will require more invasive airway support, such as endotracheal intubation. Since the definition of shock (hypoperfusion) is inadequate tissue perfusion and this patient's problem is secondary to a respiratory problem, he is in respiratory shock.

Airway Management Scenario 2

You respond to a call, where a 45-year-old woman complains of a sudden onset of shortness of breath. Your assessment reveals that she is conscious and alert. Her skin is warm and moist. She is able to speak in full sentences and tells you that this has happened to her in the past. You can tell that she is in moderate distress with a labored respiratory rate of 28.

1. Is this patient breathing adequately or inadequately? Why?

2. How will you manage this patient's airway initially? Upon further assessment, the patient tells you that she suffers from asthma and has a prescribed inhaler, from which she has taken no puffs from today. The remainder of her past medical history is unremarkable.

3. With the history of asthma, what will change, if anything, in terms of your management?

You place the patient on a pulse oximeter and it reads 89%. The patient is still having moderate difficulty breathing. During your focused exam, you note that she has wheezing to all four lung fields upon auscultation.

4. Explain why the pulse oximeter is reading 89%.

5. Explain the physiologic process of wheezing and why it is impairing the patient's respirations.

Scenario 2 Answers

Answer 1: Recall that the most reliable indicator of overall perfusion is the patient's level of consciousness. Not only is this patient conscious and alert, but she is able to speak in full sentences, which indicates that she is moving adequate volumes of air. She is not displaying any signs of inadequate perfusion at this point; therefore, the patient is breathing adequately.

Answer 2: Initial management for a patient with difficulty breathing who is moving adequate volumes of air includes the placement of 100% oxygen with a non-rebreather (15 liters/min). If the patient does not tolerate the non-rebreather, a nasal cannula at 4-6 liters/min. can be applied. Note that this is initial management. The patient must be continuously monitored for signs of impending respiratory failure, such as altered mental status and cyanosis, as she may require assisted ventilation.

Answer 3: With a history of asthma, as well as the sudden onset of difficulty breathing (typical of an asthma attack), Intermediates must consider contacting medical control and requesting permission to assist the patient in taking her prescribed inhaler. Note that the medication must be prescribed to the patient.

Answer 4: The pulse oximeter is a device that measure arterial oxygen saturation. Normally, it should read >95%. Since this patient is having a problem that is impairing oxygen-carbon dioxide exchange in the lungs, the blood returning to the left atrium that will ultimately perfuse the body will be relatively lower in oxygen. Remember that the pulse oximeter is an adjunct and, if possible, should be applied prior to the administration supplemental oxygen. This will allow the EMT to determine how the patient is oxygenating on his/her own. Additionally, a pulse oximeter reading >95% does not in itself rule out hypoxia. Any patient with difficulty breathing should receive supplemental oxygen, regardless of what the pulse oximeter reads.

Answer 5: The wheezing that you are auscultating in the lungs indicates constriction of bronchioles in the lungs. Wheezing is a hallmark finding of asthma. As air attempts to pass through the constricted bronchioles, a whistling sound is made. Impairment of respirations is due to decreased amount of inspired oxygen reaching the alveoli. Case Study 2 Synopsis This case study presented you with a patient, who although was having difficulty breathing, was breathing adequately. Remember, in determining the adequacy of a patient's respirations, you must note the rate, regularity, and quality. Additionally, you must note the patient's level of consciousness. This patient is breathing at a labored rate of 28 and although this parameter is abnormal, the overall effectiveness of her breathing is adequate. Remember to look at the "big picture" when assessing effectiveness of breathing, not any one single parameter.

Signs of adequate breathing include the following:

The patient is conscious and alert

The patient is able to speak in full sentences

The rate is not too fast or too slow

There is adequate chest wall movement

Absence of signs of hypoperfusion (shock) · Diaphoresis · Cyanosis (late sign) · Weak, rapid pulse Remember, continuous monitoring of this patient's airway is critical. Just because she is breathing adequately at present does not indicate how she will be breathing in 10 minutes, or even in 30 seconds for that matter.

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Airway Management Scenario 3

A patient was involved in a motorcycle accident. He is lying approximately 25 feet from his bike with his full-face helmet still on. Upon initial assessment, you hear gurgling from his airway. His respiratory rate is 6 and irregular with a weak, rapid heart rate of 140. The patient is unconscious. As you glance at his body for obvious bleeding, you note the presence of a pinkish fluid draining from his nose.

1. How will you ensure the patency of this patient's airway? You insert an oropharyngeal airway and begin assisted ventilation with a bag-valve mask and 100% oxygen due to his unconsciousness and irregular respiratory rate of 6. You notice minimal chest wall movement with each ventilation.

2. What is the most likely cause for the minimal chest wall movement with assisted ventilation? How will you remedy this?

3. Why would a nasopharyngeal airway be contraindicated in this patient? With good chest wall movement with each ventilation, you package the patient and begin to transport him to a trauma center. En route to the hospital, the patient becomes cyanotic, despite the fact that you are assisting ventilations.

4. Why would the patient suddenly become cyanotic? How will you troubleshoot this problem?

Scenario 3 Answers

Answer 1: There are several things that you will have to do in order to ensure a patent airway in this patient. First, the full-face helmet is hindering your ability to effectively manage the patient's airway, so it must be removed. This must be accomplished with simultaneous c-spine control. Once the helmet has been removed, the airway must be maintained with a jaw thrust. Gurgling respirations indicate the presence of fluid, probably blood and/or vomitus in the patient's mouth therefore; immediate suction is needed.

Answer 2: The most common problem encountered when using a bag-valve mask device is difficulty in maintaining an airtight seal. To remedy this, you must re-evaluate the mask to ensure that it is the correct size. The best method for placing the mask on the patient's face is to lock the mask under the patient's chin, and secure the bridge of the mask over the bridge of the patient's nose. If you are still unable to effectively ventilate the patient with the BVM, you will have to switch to a pocket mask with supplemental oxygen.

Answer 3: Nasopharyngeal airways are contraindicated when the patient has obvious nasal trauma or if there is drainage from the nose. In this particular patient, the pinkish fluid is most likely cerebrospinal fluid, which indicates skull fracture. If you place a nasal airway, inadvertent placement of the airway directly into the cranium may occur. Since the patient is unconscious, the oropharyngeal airway is the adjunct of choice, followed by endotracheal intubation.

Answer 4: If a patient suddenly becomes cyanotic during assisted ventilation, you must determine why. The oxygen tubing may have become disconnected from the oxygen source or the oxygen tank has depleted. These problems must be corrected immediately. Critical patients will not fare well with 21% oxygen. They need 100% oxygen in order to survive. Another cause for this sudden onset of cyanosis include airway obstruction by blood and/or vomitus or the patient's airway needs to be re-evaluated to make sure that it is still in the correct position, which in this case, should be the neutral in-line position.

Scenario 3 Synopsis

This patient was in critical condition and required immediate assisted ventilation however, in order to effectively accomplish this, patency of the airway must be assured first. His full-face helmet was hampering your ability to do this, so you removed it. Assisting ventilations in a patient with blood and/or vomitus in the mouth will force the fluid into the lungs and will be of no benefit to the patient; therefore, immediate suction to clear the airway must be performed. You must ensure a patent airway before you can effectively manage it. The minimal chest movement with assisted ventilation as well as the development of cyanosis are perfect examples of why you must continually re-assess the airway while management is in progress. Even though the fixes for these problems are relatively simplistic, failure to troubleshoot and correct them will result in worsened hypoxia in the patient therefore; you cannot expect the patient to improve, let alone survive. When providing assisted ventilation to a patient, signs that the patient may be improving include the following: Improvement in heart rate · Remember that children respond to hypoxia with bradycardia Improvement in color (if previously cyanotic) Improvement in level of consciousness (not likely with this patient, due to his injuries)

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Airway Management Scenario 4

You receive a call from an elderly man, who experienced a sudden onset of sharp chest pain and shortness of breath. When you arrive, you find the man nervously pacing in his front yard. As you get out of the ambulance and approach him, you can see that he is grossly cyanotic in the facial area. You ask him what happened, and in minimal word sentences, he responds, "I can't breathe!" When you attempt to place a non-rebreather mask on the patient, he rips it from his face.

1. What is your alternative to the non-rebreather mask when he will not tolerate it? The only vital signs that you are able to obtain due to the man's restlessness are his respirations, which are 38 and labored, and his heart rate, which is weakly present at the radial artery at a weak and thready rate of 150.

2. What is the adequacy of this patient's respirations?

3. How will you manage his obvious hypoxia? You place the man in the ambulance and quickly prepare him for transport. He remains extremely restless and you notice that his cyanosis is worsening. You place a pulse oximeter on him and it reads 77% and a heart rate of 150, which corresponds with his radial pulse. You proceed to the hospital code 3. En route to the hospital, the man gives you a piece of paper that lists his past medical history. It includes: Hypertension Acute myocardial infarction Pulmonary embolism

4. Based upon his past medical history, which of the following do you suspect to be the cause of his problem? You are approximately 15 minutes from the nearest hospital, when you notice that the man appears to be "sleepy." He is not near as restless as before. You reassess him and find his breathing to be extremely shallow at a rate of 32.

5. What is your best approach to management of this patient at this point?

Scenario 4 Answers

Answer 1: Being that the man will not tolerate a non-rebreather, he will most likely not allow you to place him supine in order to assist his breathing, your only choice is to place him on a nasal cannula. Patient's who are this restless and uncomfortable will not allow the oppressive feeling of a mask over their face.

Answer 2: At the rate at which he is breathing, as well as his profound restlessness, he is not breathing effectively. The signs of hypoxia that he is exhibiting, such as restlessness, and a weak, thready radial pulse confirms his severe hypoxia.

Answer 3: At this point, the patient is still too restless and combative to allow you to provide him the volume and percentage of oxygen that he requires (assisted ventilation with a bag-valve mask), nor will he allow you to place a non-rebreather; therefore, your only choice is to continue oxygen therapy with the nasal cannula and notify the hospital early as you are transporting code 3. This man will require endotracheal intubation in order to provide him the oxygen content that he obviously needs.

Answer 4: An acute onset of sharp chest pain and difficulty breathing as well as the worsening cyanosis are classic signs of an acute pulmonary embolism. There is a blockage of a major pulmonary artery that is not allowing his blood to be oxygenated in the lungs. Because the pulse oximeter is corresponding with his heart rate, 77% is probably a true reading.

Answer 5: Unfortunately, this patient has become so hypoxic that his level of consciousness is diminished. This sudden deterioration is most likely due to both the low levels of oxygen in his blood and increased levels of carbon dioxide. You must be very aggressive at this point as you place a nasopharyngeal airway (he still has a gag reflex) and assist ventilations with a bag-valve mask with a reservoir and 100% oxygen attached. This man is dangerously close to cardiac arrest.

Scenario 4 Synopsis

There are times when you will have to manage a patient who is in obvious need of 100% oxygen and assisted breathing, but their restlessness will not allow you to do this. At this point, any amount of oxygen that the patient will tolerate should be given. In this case, it is with a nasal cannula and although this will not provide him with the concentration of oxygen that he needs, it is certainly better than nothing. This was a typical case presentation of an acute pulmonary embolism, where the patient is extremely restless due to profound cerebral hypoxia. In addition, the following signs also indicate inadequate perfusion:

Weak and thready radial pulse with tachycardia

A pulse oximeter reading of 77%

Profound, rapidly worsening cyanosis

The EMT should expect this type of situation in patients with acute pulmonary embolism and must provide the highest concentration of oxygen that the patient will allow. The history of acute MI and hypertension are risk factors for a pulmonary embolism. You must monitor the patient carefully and be prepared to intervene rapidly should the patient stop breathing or lose consciousness to a point where he will tolerate assisted breathing. Due to the extent of this patient's hypoxia, he is at an extremely high risk for cardiac arrest; therefore, you must have the AED ready as well. Rapid transport with aggressive airway management is the management modality of choice.

Geriatric Prehospital Care

As we age, the number of prescription drugs we take also increases. Some studies suggest that older adults receive between 29 and 34 prescriptions per year. While that seems like a huge amount of drugs, consider that many older patients have a multitude of conditions ranging from diabetes to COPD to CHF and a myriad of other complaints. Additionally, direct-to-consumer advertising and pharmaceutical marketing to doctors may also play a role in an increasing number of medications that an older patient uses. Medication use is not without its hazards. It should be noted that the adverse effects of these drugs coupled with medication errors are responsible for nearly 20 percent of all emergency department visits annually. In the elderly, taking the wrong medication could not only lead to feeling poorly, it could be fatal. There are a number of drugs that the elderly should avoid, or, at the very least, use with extreme caution. These medications pose hazards in the older adult because of the effects of aging such as decreased body mass, reduced serum proteins (for protein-bound medications) and a reduction in hepatic and renal function that metabolizes and excretes the drug. EMS professionals are often the first to encounter the adverse effects of dangerous drugs and can play a crucial role in calling attention to a potential pharmaceutical hazard. EMTs and paramedics should be aware of some of the medications to be avoided in the elderly population. These drugs include: Antidepressants such as amitriptyline (Elavil, Endep, Etrafon, Limbitrol, Triavil) since they may cause inability to urinate, dizziness and drowsiness in the elderly. Anti-hypertensives such reserpine (Regroton, Hydropres) that can cause severe depression. Arthritis drugs including indomethacin (Indocin) that has been known to cause confusion and headaches. However, it may be appropriate in some elderly patients in certain such as the pain of gout. Phenylbutazone (Butazolidin) should also be avoided because of a risk of bone marrow toxicity in the elderly. Anti-diabetic drugs including chlorpropramide (Diabenese). This medication has a very long half-life, especially in the elderly. Chlorpropramide often leads to severe fluid retention and prolonged periods of dangerously low blood sugar in geriatric patients. Muscle relaxants and antispasmodics such as carisoprodol (Soma). In geriatric patients, Soma has the potential for central nervous system toxicity is greater than the potential benefit. Cyclobenzaprine (Flexeril) and orphenidrine (Norflex, Norgesic) can cause dizziness, drowsiness and fainting in the elderly putting the older patient at high risk for falls and fall injury. Pain relievers including propoxyphene (Darvon, Darvocet, Wygesic). In the elderly, this has been associated with seizures and arrhythmias. It is very addictive, and some experts feel that it is barely better than aspirin for pain control. Propoxyphene also has more side effects than morphine. Tranquilizers and sleeping aids such as chlordiazepoxide (Librium, Librax). This is a long-acting tranquilizer, and longer yet in the elderly. It causes sedation and can contribute to falls and fractures. Diazepam (Valium) is an addictive and long-acting tranquilizer leading to drowsiness, confusion and falls. It is estimated that the half-life of diazepam is equal to the age of the patient. Meprobamate (Miltown, Deprol, Equagesic, Equanil) is a tranquilizer that is sometimes combined with an antidepressant or pain reliever is addictive, too long-acting and can lead to falls. The above list is not all-inclusive of the medications that should be avoided by elderly patients. It does, however, represent several drug types that can spell disaster for the older adult.

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