First: Notes to the ECRN

First: Notes to the ECRN • Changes have/are taking place this fall • Advocate Condell became a Level I trauma center eff October 1, 2009 • Grayslake Emergency Center will begin to take BLS ambulance patients effective November 1, 2009 • This is the Lake Forest Hospital facility in Grayslake • All nurses need to be advised of these changes

Condell as Level I Trauma Center • Condell ECRN will be receiving calls from farther out departments • Region IX and Region X (Lake County’s Region) have similar criteria for Category I trauma • If a department or helicopter service is calling Condell, they have already decided we are the best destination for the patient • Take report, get an ETA, activate the Trauma Alert

Category I Trauma Patient • Any unstable patient and those meeting criteria as a Category I level trauma must be transported to the highest level Trauma Center within 25 minutes • Patients may be by-passing facilities to get to a higher level trauma center

Notes to the ECRN • Grayslake Emergency Center • Formerly referred to as the Lake Forest Acute Care Center • Just west of the intersection of Routes 45 and 120 • EMS may transport non-emergent patients being treated with BLS procedures • Will NOT transport patients with IV, cardiac monitors, in labor, and others with anticipation of the need for admission

Notes to the ECRN • Grayslake Emergency Center transport • EMS to call their respective Resource Hospital • Condell is the Resource Hospital for: • Countryside • Grayslake • Lake Forest Fire • Libertyville • Mundelein • Round Lake • Wauconda • Murphy

Note to the ECRN • EMS will alert Grayslake Emergency Center to monitor 400 • Resource Hospital will take report on 400 and give orders, if needed, including approval for the transport destination requested • Report does not need to be called to the Grayslake Emergency Center • Grayslake Emergency Center will be monitoring the call

Notes to ECRN • If EMS was unable to contact Grayslake Emergency Center, they will advise the Resource Hospital • At that point in time, can determine who will call Grayslake Emergency Center with report • The Resource Hospital will forward report OR • EMS will repeat the report • Just be clear who is forwarding report so it does get done

Note to the ECRN • Your function is as a liaison between the field personnel and the ED • Always think, “what is best for the patient?” • Obtain and record report received • Ask for clarification, if necessary • Obtain ETA

ECRN Responsibilities • EMS has an SOP to follow • EMS may still be calling Medical Control for guidance (not all inclusive list) • Minors with no parents available • Emancipated minor • The girl under 18 that is pregnant is emancipated and after delivery, if she remains a parent, she remains emancipated • The person with alcohol on board • Questionable release situations • Psychiatric calls

Radio Etiquette • Listen attentively • Fill in the radio log as completely as possible • Ask pertinent questions • Do you really need to know which leg is injured? • Respect field limitations • Limited manpower • Limited space to work in • Driver needs to be focused on driving and is not being used to communicate on the radio • This policy is now being followed by most departments

The ECRN and Medical Control • The ECRN can only give orders from the SOP’s • If orders above and beyond the SOP’s are necessary, the ED MD must order them • Before leaving the radio to ask the MD for orders, tell EMS to “stand-by” • EMS may think you are not copying their transmission if you do not acknowledge them

Clarifications for Specific Calls • Blood glucose levels • EMS is required to obtain glucose levels in the following populations: • Known diabetic with diabetic related problem • Not appropriate for the hospital to order a glucose level just because the patient is a diabetic • Unconscious unknown reasons • Any altered level of consciousness • Not all patients require a blood glucose level

Clarifications for Specific Calls • IV access • Is it really necessary in the field? • Consider the less than ideal environment in the field for invasive maneuvers • Indications IO access • Shock, arrest, or impending arrest • Unconscious/unresponsive to verbal stimuli • 2 unsuccessful IV attempts or 90 second duration

The Patient with Dyspnea ECRN CE Packet Module II 2009 Site Code: 107200-E-1209 Prepared by: Lt. William Hoover, Wauconda Fire Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P

Objectives Upon successful completion of this module, the ECRN will be able to: • Identify the anatomy and physiology of the respiratory system including • The upper airway • The lower airway • Identify clues which will assist in determining the severity of a patient’s respiratory distress. • Identify the components of the assessment of patients with dyspnea.

Objectives • Identify history and physical assessment to be obtained for patients with dyspnea. • Initial assessment • SAMPLE history • OPQRST • Physical Assessment • Auscultation of Lung Sounds • 12 Lead EKG

Objectives • Identify abnormal respiratory patterns and adventitious breath sounds. • Cheyne-Stokes • Kussmaul’s • Agonal respirations • Crackles • Wheezes • Rhonchi • Snoring

Objectives • Identify the main causes of dyspnea: • Upper airway obstruction • Respiratory disease processes • Cardiovascular diseases • Neuromuscular diseases • Other causes • Psychogenic hyperventilation

Objectives • Identify treatment options for the main causes of dyspnea • Upper airway obstruction • Respiratory disease processes • Cardiovascular diseases • Neuromuscular diseases • Other causes • Psychogenic hyperventilation • Identify complications of different treatments and procedures associated with dyspnea

Objectives • Identify the following medications and their EMS field use for patients with dyspnea • Albuterol • Benadryl • Benzocaine • Epinephrine 1:1000 • Lasix • Versed • List assessment post intubation in both the adult and pediatric populations • Identify components of the regular Albuterol kit and EMS in-line procedure

Anatomy & Physiology of Upper Airway • Assists in heating, purifying, & moistening inhaled air • Nasal cavity • Oral cavity • Tongue • Uvula • Epiglottis – protects trachea during swallowing • Vocal cords

Anatomy and Physiology Lower Airway • Trachea • Right and left mainstem bronchi • Bronchial tree • Lungs • Lobes • Alveoli – the functional unit of the respiratory system where gas exchange occurs

Upper Airway Larynx joins upper and lower airways

Lower Airway Alveoli are the functional units of the respiratory system and is where gas exchange takes place

Difference With the Pediatric Airway • Fundamentally the same as an adult • Size and positioning differences • Jaw smaller, tongue relatively larger • Epiglottis floppier and rounder • Larynx more superior and anterior (higher and more forward) in children

Pediatric Considerations • Anatomical differences between adults & children dictate the following: • Oral airways slid in without turning them – tongues are larger than adults • Preferable to use straight blade due to floppy pediatric tongue • Before age 10, cricoid cartilage is the narrowest part of the airway • ETT are uncuffed

Determining the Severity of Respiratory Distress • Posture: Sitting up, leaning on arms (Tripod) • Unable to speak in complete sentences without pausing to catch breath • Breathlessness when at rest • Imminent respiratory failure or arrest indicated by bradycardia, bradypnea, agonal respirations or apnea

Tripod position – helps lungs expand

Pediatric Respiratory Distress • Patient exhibits increased work of breathing and the patient is using all resources to compensate for self • Child alert, irritable, anxious, restless • Increased respiratory effort • Use of accessory muscles • Intercostal retractions • Seesaw respirations (abdominal breathing) • Strained neck muscles

Pediatric Respiratory Failure • Energy reserves exhausted • Patient cannot maintain adequate oxygenation and ventilation (breathing) • Sleepy, less than alert • Intermittently combative or agitated • Bradycardic heart rate indicates hypoxia • Immediate attention to airway and ventilation rate to fix the bradycardia

Assessing Patients with Dyspnea • Primary Assessment (ABC’s) • SAMPLE history • OPQRST • Physical Assessment • Lung Sounds • Minimally cardiac monitor; possibly 12 Lead EKG • Pulse oximetry • Acceptable normal 95 – 99% • Mild hypoxia 91 – 94% • Severe hypoxia <91%

All Those Initials!!! • ABC’s • Airway, breathing, circulation • SAMPLE history • Signs and symptoms, allergies, meds, pertinent past history, last oral intake of fluids or solids, events leading to the incident • OPQRST of assessment • Onset – what was pt doing at the time; provocation/palliation; quality; radiation; severity on 0 – 10 scale; time of onset

Abnormal Respiratory Patterns • Cheyne-Stokes • Indicates brainstem injury • Progressively deeper, faster breathing alternating with shallow, slower breathing • Kussmaul’s • Commonly found in diabetic ketoacidosis and can be seen in Aspirin (acetylsalicylic acid) overdose • Deep, slow, or rapid & gasping

Abnormal Patterns cont’d • Agonal • Indicates brain anoxia • Shallow, slow, or infrequent breathing

Auscultating Lung Sounds • Warm your stethoscope, have the patient cough to clear their airway and then you’re ready to auscultate • The patient should take deep but easy breaths breathing in and out through their mouth

Auscultating Anterior Lung Sounds

Auscultating Posterior Lung Sounds • Start at the top and move your stethoscope from the right to the left comparing the sides as you walk your stethoscope methodically downward • Sounds are heard better when auscultated in the posterior fields directly over the skin

Abnormal Lung Sounds • Crackles (rales) • Fine, bubbling sound heard on inspiration; indicates fluid in smaller airways • Wheezes • Musical, squeaking, whistling sound heard usually on inspiration & expiration; indicates bronchial constriction • Rhonchi • Coarse, rattling noise on inspiration, indicates inflammation, mucous, or fluid in bronchioles • Snoring • Indicates partial upper airway obstruction

The patient with dyspnea:Causes Signs and SymptomsEMS Field Treatment Options

Upper Airway Obstruction • Foreign body • Airway blocked; food most common culprit • Infections – causes airway swelling • Croup – viral infection • Epiglottitis – bacterial infection • Anaphylaxis – severe reaction to allergen • Sudden onset after exposure (eating or injection common) • Laryngospasm – closure of glottic opening • May be triggered by infection or irritants • Blood thinners (Coumadin, Plavix) • Spontaneous hematomas in soft tissue of neck

Foreign Body Obstruction Toe ring • Esophageal foreign bodies can also present an airway challenge especially if the foreign body moves

Signs & Symptoms of Impaired Airway • Foreign body (FB) • Sensation of a FB after eating (food is the #1 cause of airway obstruction) • Stridor or wheezing respirations • Infection (epiglottitis, croup) • Gradual onset • Pain on swallowing, drooling • Difficulty opening mouth • Fever, cough, seal bark cough

Treatment Airway Obstruction • Foreign body • Remove the object • If patient can cough on own or rescuer needs to apply the Heimlich or abdominal thrusts (back slaps and chest thrusts for infants) • May need to use blade and handle and retrieve object while using the magill forceps • Secure the airway if unable to relieve the blockage (Quick Trach) • Infections – Croup or epiglottits • Prehospital supportive care • Supplemental oxygen • 6 ml normal saline in nebulizer kit • Albuterol if patient is wheezing with croup

Signs & Symptoms of Impaired AirwayRelated to Anaphylaxis • Anaphylaxis • Hives • Rash that itches • Wheezing • Hypotension – unique to anaphylaxis • Nausea • Abdominal cramps • Inability to urinate • Is quickly life-threatening

EMS Adult Anaphylaxis SOP • Anaphylaxis – patient unstable • Altered mental status & B/P <100 systolic • Support airway; intubate as necessary • IV wide open (1000 ml normal saline) • Epi: 1:1000 IM 0.5 mg • Benadryl 50 mg IVP slowly over 2 min or IM • If wheezing, Albuterol 2.5mg/3ml • May repeat • If worsening, medical control contacted • Medical Control may order Epi 1:10,000IV/IO

EMS Pediatric Anaphylaxis SOP • Anaphylaxis – patient unstable • Altered mental status • Epi 1:1000 IM 0.01 mg/kg (max 0.3 mg or 0.3 ml per dose) • May repeat every 15 minutes • Benadryl 1mg/kg slow IVP; max 50 mg • IV fluid challenge 20ml/kg • May repeat as needed to max of 60 ml/kg • Albuterol 2.5mg/3ml • May repeat Albuterol treatment • If worsening, medical control contacted • To consider Epinephrine 1:10,000 at 0.01 mg/kg IV/IO

Respiratory Diseases - Asthma • Bronchoconstriction • Stimulants cause inflammatory response • Stimulants can include: • Allergens • Weather changes • Exercise • Respiratory infections • Foods/medications

Signs & Symptoms of Asthma • Cough • Wheezes • Heard first at the end of exhalation • Absent breath sounds = deadly implications • Shortness of breath • Chest tightness (not to be confused with chest pain) • Use of accessory muscles in severe cases • Ask if the patient has ever needed intubation • These patients tend to deteriorate faster and need careful and close monitoring

EMS Asthma SOP • Attempt pulse oximetry reading before administration of oxygen • Assess & record VS, breath sounds, pulse oximetry before/during/after treatment • Oxygen by most appropriate route • Albuterol 2.5 mg/3ml (O2 flow at 6 L) • Severe cases, treat while transporting

EMS Treatment of Severe Asthma • Patients with inadequate ventilations or oxygenation are at risk of not being able to continue to ventilate themselves and will need intubation • In-line Albuterol therapy provided to deliver medications to the lungs • Albuterol can be delivered via BVM in-line while preparing to intubate the patient • Once intubation is accomplished, continue to deliver Albuterol via the in-line method

First: Notes to the ECRN