RESPIRATORY DISTRESS – General Protocols
DESIGNATION OF CONDITION
The patient is not breathing, not breathing adequately, or experiencing agonal respirations with inadequate rate and/or depth.
EMPHASIS ON PATIENT CARE
Maintain a patent airway and assist ventilations.
FIRST RESPONDER PRE-HOSPITAL MANAGEMENT
1. Initial Management - Assess airway, breathing and circulation and manage as indicated.
2. If respirations are inadequate or absent, maintain or establish airway patency by:
BASIC and INTERMEDIATE PRE-HOSPITAL MANAGEMENT
PARAMEDIC PRE-HOSPITAL MANAGEMENT
3. Maintain or establish adequate ventilation & oxygenation for all patients by:
4. Ensure that the ventilatory device is connected to a supplemental oxygen source, if available, using an adequate oxygen flow (8-12 lpm with an oxygen concentration > 40%).
5. If the patient is non-intubated, make sure the PPVD mask is properly sealed on the patient's mouth and nose. If the patient is intubated, connect the device to the tube.
6. Ventilate the adult patient at a rate of 8-16 bpm, with inspiratory time of 1 - 2 seconds if supplemental oxygen is available. If supplemental oxygen is not available, use an inspiratory time of 2 seconds. Inspiratory/expiratory times should be at a 1:2 ratio. For infants, ventilate at 20-30 bpm, with an inspiratory time of 0.5 - 1.0 second and for children, 12 - 20 bpm at 1 - 1.5 seconds.
7. Auscultate lung sounds and watch for symmetric chest rise.
8. Avoid inspiratory pressures >20 cmH2O in non-intubated patients which can lead to gastric distention or barotraumas. Cricoid pressure should be considered.
9. Continuously monitor the ventilatory device to ensure there are no malfunctions of equipment or use.
10. Airway adjuncts should be monitored for proper placement.
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RESPIRATORY DISTRESS - Croup
DESIGNATION OF CONDITION
The most common age group affected is 1 to 3 years but this process can develop in any age patient. The onset is slow. Signs and symptoms are: hoarse voice, harsh “seal bark” cough, stridor upon inhalation, and high-pitched squeaking sounds may be present. In addition, other signs of respiratory distress may be present. Always consider the possibility of foreign body aspiration.
EMPHASIS ON PATIENT CARE
Airway management, adequate oxygenation
FIRST RESPONDER, BASIC and INTERMEDIATE PRE-HOSPITAL MANAGEMENT
1. Initial Management - Assess airway, breathing and circulation and manage as indicated.
2. Initiate transport to an appropriate medical facility. Consider ALS intercept.
3. Focused H&P - History, physical exam, vital signs.
PARAMEDIC PRE-HOSPITAL MANAGEMENT
4. Do not attempt to intubate if there is adequate air exchange.
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RESPIRATORY DISTRESS - Epiglottitis
DESIGNATION OF CONDITION
The most common age group affected is 3 to 7 years, but this process can develop in any age patient. The onset is usually rapid. Signs and symptoms are: Pain on swallowing, high fever (102 to 104) degrees Fahrenheit, drooling, mouth breathing, stridor upon inhalation, changes in voice quality, tripod positioning, chin and neck thrust forward. In addition, other signs of respiratory distress may be present. Since the development of Hemophilus B immunization, the incidence of Epiglottitis has been reduced significantly, however it should still be considered for patients presenting with the usual signs and symptoms.
EMPHASIS ON PATIENT CARE
Prevent agitation to the patient, airway management, and adequate oxygenation.
FIRST RESPONDER, BASIC and INTERMEDIATE PRE-HOSPITAL MANAGEMENT
1. Initial Management - Assess airway, breathing and circulation and manage as indicated.
2. Initiate rapid transport of the patient, in position of comfort, to the nearest medical facility. Consider ALS intercept.
3. Focused H&P including: History, physical exam, and vital signs.
PARAMEDIC PRE-HOSPITAL MANAGEMENT
4. Do not attempt to intubate if there is adequate air exchange.
5. Intubation may be very difficult due to swelling of the epiglottis and surrounding structures. Well-performed BVM ventilation can often provide adequate oxygenation until arrival at the hospital.
Note: Assisted ventilation of any type can agitate the child causing complete airway obstruction. Judicious observation and intervention are best, reserving aggressive airway interventions for children who proceed to respiratory arrest.
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RESPIRATORY DISTRESS - ASTHMA, COPD (EMPHYSEMA, CHRONIC BRONCHITIS)
DESIGNATION OF CONDITION
Constriction of the small airways of the lungs resulting in broncho-constriction, increased secretions and wheezing. The patient will almost always have a pertinent history and will be suffering from some degree of dyspnea. Wheezing may not be present and lack of wheezing with decreasing breath sounds is often a sign of impending respiratory arrest. Signs and symptoms may include any or all of the following: inspiratory wheezing, rapid and/or shallow respiratory rate, nasal flaring, and use of accessory muscles. Patient may complain of difficulty in breathing and cyanosis may be present. LOC may be decreased and there may be diminishing or silent bilateral lung sounds, wheezing, stridor, and/or sternal retractions. The patient may be tachycardic, diaphoretic, with tripod positioning. “See Saw” breathing may be present in children.
EMPHASIS ON PATIENT CARE
Airway maintenance, adequate oxygenation.
FIRST RESPONDER PRE-HOSPITAL MANAGEMENT
1. Initial Management - Assess airway, breathing and circulation and manage as indicated.
2. Initiate transport to an appropriate medical facility. Consider ILS or ALS intercept.
3. Focused H&P - History, physical exam, vital signs
4. If patient is in moderate to severe respiratory distress and acute asthma or emphysema is suspected:
BASIC AND INTERMEDIATE PRE-HOSPITAL MANAGEMENT
INTERMEDIATE PRE-HOSPITAL MANAGEMENT
5. Consider administering PREDNISONE [1 mg/kg to a max dose of 60mg for adults)] PO for acute exacerbated asthma.
6. Epinephrine 1:1,000 (0.3 mg) subcutaneous with no dose greater than 0.3 mg.
7. En-route, initiate an IV of isotonic solution at a TKO rate.
PARAMEDIC PRE-HOSPITAL MANAGEMENT
8. Consider IPRATROPRIUM [250-500mcg (.25 - .5mg)] in conjunction with Albuterol.
9. If no relief is noted and the patient is unable to exchange oxygen due to bronchoconstriction:
10. Consider IV CORTICOSTEROIDS.
11. Consider MAGNESIUM SULFATE.
Note: Do not delay transport while administering Albuterol. You may continue treatment enroute to hospital. Monitor respiratory rate and depth closely. Avoid hyper-inflation of the chest and lungs during positive pressure ventilation.
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RESPIRATORY DISTRESS - PULMONARY EDEMA
DESIGNATION OF CONDITION
Patient presenting with signs, symptoms and history of moderate to severe dyspnea and/or poor perfusion secondary to pulmonary edema. Emphasis will be placed on complete assessment of patient and history with treatment of the underlying cause if possible. Caution should be taken in getting a complete history since many of these patients are taking numerous medications for chronic conditions.
EMPHASIS ON PATIENT CARE
Airway maintenance, adequate oxygenation.
FIRST RESPONDER AND BASIC PRE-HOSPITAL MANAGEMENT
1. Initial Management - Assess airway, breathing and circulation and manage as indicated.
2. Initiate transport to an appropriate medical facility. Consider ILS or ALS intercept.
3. Focused H&P - History, physical exam, vital signs.
4. Consider CPAP.
INTERMEDIATE PRE-HOSPITAL MANAGEMENT
5. En-route, initiate an IV of an isotonic solution and infuse at a flow rate to maintain adequate vital signs.
6. Closely monitor IV drip rate. DO NOT OVERHYDRATE the patient.
PARAMEDIC PRE-HOSPITAL MANAGEMENT
7. Evaluate dysrhythmias and treat per appropriate protocols.
8. Consider NITROGLYCERIN [0.4mg] SL every 5 minutes, if patient is in severe distress, and BP > 100 systolic, HR > 60.
9. Consider the administration of the following medications:
10. Consider intubation, positive pressure ventilation, and ET suctioning as needed.