Learning Station 3 Environmental Emergency 2 A Life-Threatening Respiratory Emergency

1999 American Heart Association

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Acknowledgments
Paul Berlin, MS, EMT-P, designed and developed many drafts of these instructional materials for respiratory emergencies. He has generously donated his work to the AHA, and we gratefully acknowledge his contribution. In addition, B. Keith Chapman, EMT-P, contributed to the content and organization of these materials.
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Case 1

911 call: severe shortness of breath 52-year-old distressed man Sitting upright on restaurant floor Unfinished beef burrito Gasping for breath Too short of breath to respond verbally Empty albuterol inhaler
You may begin managing this patient now. What are your first thoughts and actions?
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Case 1
Primary ABCD Survey A: Mouth open, gasping B: Almost no air moving, barely audible wheezing C: Panic in eyes, cyanotic, follows commands D: VF not possible
Assess Manage: What are you going to do NOW?

Secondary ABCD Survey

A: Intubation indications: present GO! Patient sees ET tube, shakes head NO B: Ventilation and oxygenation (before intubation) Severe distress obvious Respirations = 50/min, shallow; room air pulse O2=82% Listen to back = no inspiratory breath sounds C: Monitor and BP Heart rate = 132 bpm Rhythm = sinus tachycardia; BP = 180/60 mm Hg
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Secondary ABCD Survey

D: Differential Diagnosis First thoughts:airway obstruction Mechanical/object Anaphylaxis Reversible small airways/asthma Fixed airways COPD

A Key ACLS Principle

If assessment reveals a critical problem: Go no further until the problem is corrected!

Example: Object obstructs airway

Mechanical Obstruction
Go no further until corrected!

Basic FBAO techniques Direct laryngoscopy Cricothyroidotomy

Secondary ABCD Survey

Keep Thinking!
D: Differential Diagnosis What has happened to this person?

An anaphylactic reaction?
An asthmatic episode? An intrathoracic event? Large pneumothorax? Massive pulmonary embolus? Major artery AMI? Others?
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Most Likely: Status Asthmaticus

Assess Severity
History and PE
Previous episodes = asthma and intubation Skin color: cyanosis Initial peak flow (PEFR) Repeat PEFRs Duration of symptoms

Ominous Signs
Drop in respiration rate Drop in HR Decrease in LOC Bagging more difficult Neck veins distending Wide pulsus paradoxicus

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Emergency Treatment: Life-Threatening Asthma

Treatment falls into 4 categories: Airway Breathing Circulation Drugs
What to do if patient keeps getting worse? List interventions to use most important first
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Background: Therapy for Life-Threatening Asthma

Patients are desperately ill Patients are unresponsive to standard therapy Patients deteriorate rapidly right before your eyes You cannot try a drug or therapy if you have never heard it used for asthma Memorize a list of agents to use May not be usual care for asthma Do not let a patient die without trying these approaches
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Maximum Treatment Sequence for Life-Threatening Asthma 1

1. Oxygen 2. Nebulized 2-agonists Metaproterenol (albuterol) = mainstay Isoetharine 3. IV corticosteroids 4. Nebulized anticholinergics ipratropium (Atrovent)
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Maximum Treatment of Life-Threatening Asthma 2

The role of the following medications is controversial:

Terbutaline Given subcutaneously, IV, or IM Aminophylline Third line after 2-agonists, steroids Better in children Magnesium sulfate Add if refractory to above treatments Isoproterenol Desperate measure; for patients intolerant of inhalation treatment
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Maximum Treatment of Life-Threatening Asthma 3

IV epinephrine Aggressive approach May prevent need to intubate IV sodium bicarbonate Acidosis opposes sympathetic amines Use to normalize pH in known acidosis Tracheal intubation Ketamine anesthetic of choice for severe asthma Rapid sequence intubation

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Life-Threatening Asthma
Summary of Interventions to Consider
Oxygen 2-Agonist IV corticosteroids Epinephrine Terbutaline Theophylline Nebulized anticholinergics Magnesium Ketamine Paralysis Intubation and mechanical ventilation Assisted exhalation Empiric needle thoracentesis

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Case Progression

Patient: unresponsive and intubated Ventilations with BVM: difficult O2 saturation: continues to fall BP and rhythm: hypotensive, bradycardic; progressively worse

What approach is best at this time?

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What Approach Is Best at This Time?

ALWAYS BEST: return to the basics Repeat: Primary and Secondary ABCD Surveys Discover: Inaudible breath sounds, bilaterally Distended neck veins Tympanitic chest to percussion
What is your diagnosis and treatment now?
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Case Progression

Diagnosis: presumed bilateral pneumothorax Treatment: bilateral chest needle decompression Response: immediate air-venting; relief of left and right tension pneumothorax Response: BVM ventilation: improves O2 saturation increasing HR increasing
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Summary: Keys to Care of Life-Threatening Asthma

Assessment and history Peak flow (PEFR) 2-Agonists Steroids Differential diagnosis Obstruction Pneumothorax
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Questions? Comments?

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