Respiratory Emergencies and the Rapid Response Team

1. Respiratory Emergencies and the Rapid Response Team Lauri Stephens RRT-NPS, RPFT

2. Patient not breathing enough Sedation Central Nervous System Depression Patient increased WOB - Dyspnea Dyspnea results from 3 generalized abnormalities of respiration: Changes in ability to maintain normal respiratory “work” Neuromuscular disease-weakness Cachexia/Malnutrition Decreased respiratory muscle strength - deconditioning An increase in effort/work load COPD Pleural Effusion Restriction An increase in ventilatory requirements Anemia Metabolic acidosis Fever Hypercapnia Why Was RRT Called?

3. Pulmonary Causes Pulmonary Embolism Pneumothorax COPD/Asthma Exacerbation Pleural Effusion Pulmonary Edema Airway Obstruction Aspiration Hypoxemia Pneumonia Infection Fever Other- Sepsis Anemia (Hgb <10) Metabolic Acidosis Hyperthyroidism Chronic Liver Failure Remember ABC’s Psychogenic Causes Panic Attack Anxiety “Spiritual Distress” Hyperventilation Pain Fear Cardiac Causes Acute MI CHF Unstable Angina Pericarditis Early Mitral Stenosis Evaluation of Dyspnea

4. 46 yo male, 3 days post admission and treatment for pneumonia + acute on chronic renal failure. RRT called for tachypnea/SOB and fever. • VS - HR 128, RR 30, BP 127/82 Temp 39.3 91% on 2 lpm • Labs – RBC 1.85, WBC 9.44, HCT 21% Hgb 7.5 Creatinine 1.7 • ABG 7.38 24 85 14 • Why is this patient dyspneic? • Pt placed on 40% V-Mask • Lasix given

5. Second RRT called about 5 hours later. Patient having increased cough, sputum specimen obtained. VS about the same. • ABG – 7.40 20 86 12 • Patient just wants to go home • Denies any increase in SOB or WOB • Lungs have decent aeration, bronchial BS • Decision made to leave him on the floor • Identify PNA pathogen to guide antibiotic tx

6. Pt moved to private room Now in isolation for “whooping cough” Initial presentation of pertussis presents as typical URI, runny nose, cough & conjunctival irritation (most contagious at this point) Characteristic cough occurs after 7-10 days Many patients will not have the classic “whoop” On the rise Most deadly in infants less than 6 months Third RRT in 24 hours called ~ 4 hours later.

7. Pertussis in the Adult Patient • Up to 32% of adolescents & adults w/cough > 6 days have serologic evidence of pertussis • In adults w/confirmed pertussis, 80% had a cough for at least 3 weeks • Vomiting post cough common • We become susceptible 6-10 years post vaccination • New strains emerging • New DPT booster vaccines for adolescents and adults recently approved

8. 17 yo male, fractured tib/fib sustained in a soccer game. Family visiting re-positioned patient’s leg because he was uncomfortable. • Pale appearance, normal build • Respiratory rate 36 HR 140 • BS clear, diminished in bases • Patient c/o severe SOB “I can’t breathe” • Patient c/o chest pain “Someone sitting on chest” • Patient placed on 100% NRB Mask, SpO2 100%

9. Patient now c/o “I can’t feel my legs” “My face hurts, I can’t open my mouth” “Am I going to die?” ABG 7.77 17 352 22

10. Family asked to leave the roomPain meds and anti-anxiety Rx givenPatient relaxed, dyspnea relieved • Symtoms of hyperventilation: • Numbness or tingling in hands, feet or lips • Lightheadedness/dizziness • Cofusion • SOB • Slurred speech • Headache • Chest pain • Spasms & cramps • Muscle twitching • Trismus • Causes of hyperventilation • Stress or anxiety • Pain • Hypoxia • Sepsis • Head injury • Metabolic acidosis • Fever

11. 66 yo, restrained passenger involved in a MVC w/ multiple trauma and fractured pelvis. 11 days out. Patient became very SOB and desaturated post working with PT. • HR 136, RR 32, SpO2 90% on 100% NRB Temp 38 • BS unremarkable • Pt c/o stomach pain and it hurts to take a deep breath • Pt has occasional spontaneous dry cough • Edema noted in left leg • Pt is in isolation, wants something to drink

12. ABG 7.48 30 68 21 CXR unchanged from previous CT ordered – Will patient fit in scanner? Can she lay flat? ???? Isolation Patient just wants apple juice Risk Factors for PE Prior History DVT or PE Recent Surgery, Pregnancy, Trauma, Fractures or Immobilzation Malignancy, Chemotherapy CHF or MI Burns Old Age, Obesity, Oral Contraceptives or Estrogen Replacement Varicose Veins IV Drug Abuse Polycythemia, Hemolytic Anemia, Fibrinogen Abnormality, Early Coumadin Therapy and Heparin Associated Thrombocytopenia Type A blood What would you recommend at this point?

14. First or second most common cause of unexpected death in most age groups Most commonly (80%) diagnosed on autopsy (~60% of pt’s dying in the hospital + for PE) 10% of patients diagnosed w/PE will die within 1 hour Only 1/3 of the rest will be diagnosed & treated Incidence & findings of massive PE 96% Tachypnea 58% Rales/Crackles 53% Accentuated 2nd Heart Sound 44% Tachycardia 43% Fever (>37.8C) 36% Diaphoretic 24% LE Edema 23% Cardiac Murmur 19% Cyanosis Pulmonary Emboli Facts

15. 640# Paraplegic in for treatment of decubitus ulcers, history of ostructive sleep apnea. • RRT called for acute desaturation and patient decreased LOC • Patient supine in FluidAir/Clinitron bed • Patient recently had “wound care”

16. Patient lethargic, with shallow respirations. Will take deep breaths when stimulated and then falls asleep and RR decreases to 4. On 100% NRB Mask SpO2 =82% • Do we need a gas? • 7.26 82 54 26 • What do you want to do now? • Stay on floor or transfer to unit?

17. Patient Outcome • Transferred to unit • Placed in Bariatric air bed • BiPAP 25/8 • Patient woke up ~6hours later • Patient recognized RCP from previous episode • Patient reported that he had lost ~150 since last hospitalization

18. 68yo male, chronic renal failure, Hx IVDA & ETOH, Hep C+, admitted via the ED overnight with a nosebleed. • RRT called for inability to awaken patient • Respirations very irregular, with frequent apnea and no respiratory effort observed (was not obstructing) Cheyne-Stokes respirations • BS essentially clear • SpO2 93% on 3 Lpm • HR 130. BP 90/52

19. What do you want to know? Any labs? CXR? • Received Xanax ~ 8 hours ago for agitation • ABG 7.30 61 70 22 • Pinpoint pupils • Arouses with stimulation and becomes very agitated • Mumbling about his friend who visited ‘this morning” • RN wants nasal airway placed

20. Decision made to try Narcan/Naloxone (opioid antagonist). Patient responded, becoming combative and agitated, but breathing. • Should he stay on floor or transfer to unit? • Narcan takes effect in about 2 minutes and lasts ~45 minutes • Duration of action of narcotics may exceed that of Narcan • Dose to response- .4mg-2mgQ2-3 minutes up to 10mg

21. 88 yo edentulous male, status post CVA. RRT called for SpO2 of 77% on 3 LPM and increased WOB. • Rhonchorus BS heard from bedside • Loose, wet cough • Intercostal retractions and use of accesory muscles present • Patient lethargic, breathing with mouth “open” • RR 28, HR 112 BP 102/70

22. What is your first “move”? • “A” for airway! • Secretions pooling back of throat • Oral mucosa noted to be very dry • Huge oral cast cleared from pharynx • Patient needs hydration & frequent oral care

23. 44yo 5 days post motorcycle vs car. C-2 fracture, pelvic fracture and left clavicle fracture. Some concern over possible vertebral artery injury. • RRT called for Mental status changes • Doesn’t recognize wife • Speaking gibberish • Vital signs all WNL • Difficult to assess BS/Chest due to Halo • Wife reports difficult night and patient being very anxious

24. What are your concerns? • ABG 7.53 28 112 22 on room air • Now what? • Head CT normal • Can he stay on floor or does he need to transfer?

25. The End