Respiratory Emergencies

1. Respiratory Emergencies Erin Moorcones, RN, MSN, C-PNP

2. Anatomy and Physiology

4. Anatomy

5. Cellular oxygenation Adequate amount of O2 delivered to cell The affinity of hemoglobin for oxygen The ease in which hemoglobin release oxygen to cell

6. Affinity of Hgb for oxygen is described in the oxygen-hemoglobin dissociation curve. If it shifts to left- hgb picks up o2 easier in the lungs, but does not release to the tissues as easy. When it shifts to right, oxygen uptake by hgb is slower, but it is transported to cells easier. This is affected by temp, acid-base balance, and co2.

7. Normal gas exchange

8. Patient Assessment

9. Assessment Airway First! Work of breathing, nasal flaring, retractions, accessory muscle use Occupational exposure Smoking history

10. Acute bronchitis Usually caused by a virus- Influenza A &B, parainfluenza, RSV, rhinovirus, coxsackie virus, and adenovirus. Secondary infections possible from mycoplasma pneumoniae, haemophilusinfluenzae. Most common in smokers, young children, and during winter months.

11. Acute bronchitis S/S- sore throat, stuffy nose and dry non productive cough (may be worse at night). Sometimes with low grade fever, chest discomfort and fatigue. Aggravating factors- cold, talking, deep breathing, laughing Diagnosis- clinical exam. Would you get an xray? Why? Treatment- Fluids, avoid irritants and smoking. ABX?

12. Pneumonia Causes- bacterial, viral, or fungal Primarily effects young children, debilitated adults, those with underlying chronic conditions. 6th leading cause of death in US, and leading cause of death in the elderly. What would be RF for pneumonia?

13. Pneumonia S/S- fever, malaise, cough, hemoptysis, dyspnea, pleuritic chest symptoms. Physical exam- crackles on auscultation that don’t clear with coughing, diminished breath sounds/cough, fever. Alternate s/s- vomiting, abdominal pain, mental status changes, headaches. Diagnosis- xray, CBC, pulse ox, abg Core Measures…antibiotics within 4 hours!

17. Core Measures-Community Acquired Pneumonia One of joint Commissions recommendations Those pts presenting to ED must have O2 assessment or ABG During triage patient’s pneumococcal vaccination status and smoking hx must be documented (cessation material must be provided to ay admitted smokers). BC must be done prior to any abx administration. ABX should be administered w/I 4 hours of arrival to ER

18. Asthma Obstructive disease caused by airway inflammation and hyperreactivity. Males more affected than females. 30% of those diagnosed with asthma as children will have it as adults. + family hx in more than 1/3

21. Asthma Diagnosis History- patterns, triggers, allergies Physical exam- rhinitis, sinusitis, or nasal polyps, wheezes, and prolonged expiratory phase. Labs- CBC with diff, nasal smears, and sputum specimen. In those older then 5- spirometry, peak expiratory flow rate

22. Asthma Treatment Goal is to relieve hypoxemia and airflow obstruction and decreasing airway inflammation O2, SABA’s, systemic steroids

23. Emphysema & Bronchitis

24. Pulmonary Embolus 650, 000 patients diagnosed annually 10% of patient with fatal PE die within 1 hour of onset of symptoms. 90% of thrombi originate in deep vessels of the leg. Stasis of blood damage to epithelium of vessel wall, and alterations in coagulation ( Virchow’s triad)- lead to thrombi formation. Thrombi becomes dislodged and travels and lodges in pulmonary vessel, obstructing blood flow.

25. Pulmonary Embolus s/s- dyspnea, tachycardia, tachypnea, restlessness, anxious, severe chest pain, cough, fever If large vessel occluded can cause hypotension and right sided heart failure.

27. Pulmonary Embolus Diagnosis and treatment DX- identify VQ mismatch, ABG, 12 lead EKG, CXR, labs, CT TX- ABC’s, pain meds, heparin protocols, possible surgical intervention

28. Pulmonary Edema Cardiogenic vs Non cardiogenic

30. S/S of pulmonary edema Severe dyspnea, diaphoresis, hypertension, tachycardia, anxiety, tachypnea. Pitting edema, weight gain, bounding pulse, skin cool/pale, cough with frothy white sputum, cyanosis

31. Treatment of pulmonary edema Goal- increase oxygenation, decrease cardiac workload, increase cardiac function Bronchodilators- decreased bronchospasm Digoxin- increase contractility, decrease HR Dobutamine- inc contractility, decrease PVR Diuretic therapy Positioning

32. What is this?

33. Pneumothorax Usually occur in males 20-40y/o, tall and thin Spontaneous- usually caused by ruptured emphysematous bleb. Smokers increased risk Iatrogenic causes- trauma, insertion SVC, mechanical ventilation

34. Pneumothorax S/S- chest pain on affected side, sob Larger pneumo- subQ emphysema, cyanosis, severe sob, cyanosis Treatment- needle aspiration or chest tube for larger pneumo, if <15% you can observe

35. Carbon Monoxide Poisoning Hemoglobin has greater affinity for CO than for oxygen, resulting in O2 being displaced by CO. Carboxyhemoglobin (COHb) levels >10% indicate CO exposure Smokers of individual exposed to automobile exhaust can have baseline 10-15% 5-10% experience HA or vertigo 10-20% experience HA, nausea, vomiting, loss of coordination, dyspnea, pt may be flushed 20-30%- confused, lethargic, visual disturbance

36. CO poisoning ST depression due to myocardial hypoxia COHb levels 40-60%- comatose, seizures, ectopy COHB >60% incompatible with life Pulse ox not reliable indicator of oxygenation status Treatment- if cyanide suspected, treat with antidote

37. Foreign Body Aspiration Most common in children and older adults Upper airway presentation- severe distress-no distress, can present like choking patient. Lower airway- can be asymptomatic Treatment- BLS, visualization with laryngoscope, lower airway requires bronchoscopy

39. Submersion Injuries 5th leading cause of accidental death in US Approx 8000 deaths/yr Hypoxia is cause of death in all drowning patients Wet drowning- asphyxiation results in relaxation of airways, allowing H2O to enter airway Dry drowning- 10-20%, aspiration of H2O does not occur because airway doesn’t relax until cardiac arrest What is significant info to obtain is submersion injuries?

40. Treating submersion injuries Assessing ventilation status Address hypothermia Fluid resuscitation CXR Gastric tube insertion