Our Agenda Today
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Transcript of Our Agenda Today
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“Sometimes a Wheeze is Not Just a Wheeze…”
COPD and CHF
Silver Cross EMS SystemFebruary 2013 1st Trimester CME
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Our Agenda Today
• Review airway anatomy and physiology• Review the differences between COPD and CHF.• Review use of CPAP and nitroglycerin in CHF
and pulmonary edema.• Take a look at some newer airway techniques
and gadgets on the market.• (ALS) EKG strip o’ the month: AV blocks/pacing
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Quick A & P Review
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Anatomy of the Upper Airway
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Internal Anatomy of the Upper Airway
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Anatomy of the Lower Airway
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Anatomy of the Pediatric Airway
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COPD vs. CHF
•One is respiratory•One is cardiac•They may seem the same, but their treatments are very different!
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– Bronchitis– Emphysema– Asthma– Varying degrees/combination– Long-term tobacco abuse, exposure to inhaled
toxins
COPD
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COPD - Bronchitis
–Mucus overproduction– Cell enlargement in lungs, airways– Productive cough 3+ months, 2+ years– Hypoventilation of alveoli, drops O2 level in blood
– Acidosis– Increased cardiac output, RBC production
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Normal Lung Bronchitis
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COPD - Emphysema– Involves alveoli– Alveolar destruction– Alveolar coalescence– Destruction of elastin fibers surrounding alveoli– Chronic hypoxia, hypercarbia
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Emphysema
–Blebs on lung surface, possible pneumothorax–Polycythemia–Muscle wasting, malnourished appearance–Barrel chest
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Emphysema
– Chronic dyspnea– Little/no cough, little mucus production– Tripod position–Mental status changes– Heart problems, cor pulmonale, ventricular failure
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COPD-Asthma
–Bronchiole hyperstimulation, constriction–Wheezing, dyspnea–Mucus production
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COPD
• Therapeutic interventions– Transport immediately
» Do all treatment en route if possible» IV option unless patient is near respiratory failure
– Albuterol (Ventolin) 2.5 mg via nebulizer (repeat x1)» Can give in-line via ET tube if necessary
– With medical control approval:» Epinephrine 1:1000 @ 0.01 mg/kg up to 0.3 mg IM (repeat in 15
min)» CPAP
– Consider Methylprednisolone (solu-medrol) 125 mg IVP.» No longer just for longer transports
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Congestive Heart Failure - CHF
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CHF
• Congestive heart failure can involve one side of the heart, or both.
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Left Heart Failure• Left ventricle fails as an
effective forward pump• Causes backup of blood
into pulmonary circulation• Causes
– MI– Valvular disease– Chronic HTN– Dysrhythmias
• LV dysfunction– Causes LA pressure rise – Pulmonary HTN– PCP rises– Serum is forced into alveoli– Pulmonary Edema
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LHF Signs & Symptoms• Severe Respiratory Distress– Orthopnea, dyspnea, spasmodic coughing, pink frothy
sputum– Paroxysmal Nocturnal Dyspnea (night time SOB)
• Severe Apprehension, Agitation and Confusion– Smothering feeling– As hypoxia worsens agitation
• Cyanosis• Diaphoresis
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Prehospital Management of LHF
• Patients in LHF can decompensate rapidly• Goals– Decrease venous return to heart (preload)– Decrease myocardial oxygen demands– Improve ventilation and oxygenation
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Prehospital management cont.
• CPAP!– Keeps more fluid from entering the alveoli– Forces those alveoli to exchange gases– In Region VII, ALS and BLS crews both can use
CPAP!• Nitroglycerin!– Vasodilates– Forces fluid out of alveoli further
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Nitroglycerin
• One tablet or spray sublingual• Systolic blood pressure higher than 110
• May repeat x2 in 5 minutes.• If no IV, consider contacting medical control.
• Ask about ED drugs.
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Continuous Positive Airway Pressure (CPAP)
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What Is CPAP?
• CPAP is continuous positive airway pressure.• Designed to apply positive pressure to the
airways of a spontaneously breathing patient throughout the respiratory cycle.
• Airways are maintained in the open position during exhalation.
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Goal of Therapy With CPAP?
• Goal– to increase amount of inspired oxygen and
decrease the work load of breathing– to reduce the need for emergent intubations of
the patient in pulmonary edema– to increase the oxygenation levels of the patient– to reduce mortality and decrease hospital length
of stay
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Indications For Use of CPAP
• Patient with acute pulmonary edema/CHF• Alert, cooperative adult patient• Systolic blood pressure >90• No presence of nausea or vomiting• No major trauma• Patent airway• SaO2 <95
• Lung sounds - crackles
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CPAP And Pulmonary Edema
Severe pulmonary edema is a frequent cause of respiratory failure
CPAP increases functional residual capacity CPAP increases transpulmonary pressure CPAP improves lung compliance CPAP improves arterial blood oxygenation CPAP redistributes extravascular lung water
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When Not To Use Mask CPAP
Hypercapnia
Pneumothorax
Hypovolemia
Severe facial injuries
Patients at risk of vomiting
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Common Complications With CPAP
Pressure sores Gastric distension Pulmonary barotrauma Reduced cardiac output Hypoventilation Fluid retention
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Patient Monitoring During Use of CPAP
• Patient tolerance, mental status• Respiratory pattern – rate, depth, subjective feeling of improvement
• Lung sounds• B/P, pulse rate and quality, SaO2, EKG pattern
• Complications to monitor for:– gastric distention– nausea & vomiting
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Criteria For Discontinuing Use of CPAP
• Emergent need to intubate the patient• Inability of the patient to tolerate the tight
fitting mask– success of tolerance to the treatment increased
with proper coaching by EMS crew
• Hemodynamic instability (B/P drops below 90 systolic)
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More treatments if necessary…
• Albuterol if wheezing continues from co-morbid COPD– Make sure it’s wheezing, not crackles/rales– Albuterol can increase workload of heart
• Lasix/Morphine if medical control approves– Research showing these may not do what we
thought they always did
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Right Heart Failure
• Right Ventricle fails as an effective forward pump• Results in backpressure of blood into systemic
venous circulation• Causes– The most common cause of right heart failure is left
heart failure– Systemic HTN
• Pulmonary HTN RV / RA enlargement– Pulmonary Emboli
• Causes pulmonary HTN
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RHF Signs & Symptoms
• Tachycardia– Attempt to compensate
• Venous Congestion– Peripheral Edema
• Ankles in ambulatory pts• Presacral in bedridden
• Severe pitting edema
– JVD– Fluid accumulation in serous
cavities• Abdominal (ascites)• Pleural Space (effusion)• Pericardium (effusion)
– Liver engorgementHistory Prior MI / Chronic Pump Failure Lasix / Lanoxin
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Prehospital Management of RHF
• Not usually emergent, unless accompanied by LHF• Limit IV fluids
A good time for a saline lock, if you have them.
• IMC• Treat signs and symptoms of respiratory distress
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COPD vs. CHF
• COPD• Expiratory wheeze• Skinny w/barrel
chest• History of
asthma/emphasema/bronchitis
• Treat w/neb
•CHF•Crackles/rales•Retaining fluid•Blood-tinged sputum (pink puffers)•History of afib/heart failure/edema/•Treat w/CPAP, nitro
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Some New Airway Procedures and Gadgets
• Wave-form capnography• Quick-trach• King vision laryngoscope
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Using capnography in intubation…
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Capnography
• Phase I– Beginning of exhalation when air from anatomic dead space being
exhaled– Baseline
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Capnography
• Phase II– CO2 from larger bronchi begins to pass sensor
– Expiratory upslope– Sharp increase in CO2 concentration passing sensor, rapid departure
of waveform from baseline– Rapidly departs from Phase I, vertical line
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Capnography
• Phase III– Alveolar plateau– CO2-rich alveolar air passing sensor
– Flat, straight/slightly angled upward
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Capnography
• Phase 0– End of exhalation, beginning of inhalation– CO2 levels passing sensor quickly drop to 0
– Quick return of waveform to baseline– Straight line, rapidly returns to baseline
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Approach to PatientNormal Capnogram
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Important Points
• Capnography is a dynamic monitoring mechanism. – The therapeutic range for CO2 levels is 35-45.– It’s a positive/negative feedback system for how
resuscitation efforts are going.– Not just an initial tool for intubation
• Can hit record on monitors to chart CO2 levels.– If tube dislodged during transfer to ER bed, medics have
proof that tube was in trachea during transport.
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Inline Capnography
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Bottom Line
There are too many esophageal intubations in the field. If you have access to waveform capnography, use it!
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A short video
• http://youtu.be/p4TkeCkBeHw
• This is made by Medtronics but is applicable information no matter what capnography/monitor combo you plan to use.
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Colorimetric end-tidal COColorimetric end-tidal CO22 detector. detector.
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Quick Trach
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CricothyroidotomyIndications
• Upper airway obstruction which cannot be dislodged by back blows or direct larygoscopy and Magill forceps.
• Inability to insert an ETT past edema• Destructive facial injury precluding the use of
ALS upper airway adjuncts.
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Anatomical Landmarksfor Cricothyroidotomy
Thyroid CartilageCricothyroid
Membrane
Cricoid Cartilage
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Quicktrach
• More expensive than needle crichs, but really easy to use!
• Silver Cross EMS only allows the 4mm size, no pediatric Quicktrachs in this system.
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Quicktrach
neck strap
syringe
stopper
hub of catheter
Picture courtesy Christ Medical Center
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Quicktrach Procedure
• Patient supine with head slightly extended if no cervical spine trauma suspected
• Locate the cricothyroid membrane• Cleanse the overlying skin
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Quicktrach Procedure cont’d• Puncture cricothyroid membrane at 90 degree angle• Aspirate air through syringe• Change the angle of insertion to 60 degrees• Slide catheter sheath forward to level of stopper• Remove stopper – may be a bit tight.• Advance plastic cannula while removing needle and
syringe
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Quicktrach Procedure cont’d
• Ventilate the patient• Secure catheter in place using the strap provided• Confirm placement– Auscultation, bilateral chest rise and fall
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King Vision Video Laryngoscope
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From the brochure…
• Durable• The King Vision is designed to be your primary tool for intubations• The display comes with a 1-year warranty• The robust, full-color, non-glare display can resist repeated cleaning and normal use wear and tear• The camera and light source are enclosed in the disposable blade, keeping the display free of fragile optics
• Portable• The King Vision is light weight, self-contained and battery operated• Assembled, the device is water resistant• Reusable display comes packaged in a protective, foam case• Blades are individually packaged so that the King Vision can be taken anywhere
• Affordable• The disposable blades allow economical use of the King Vision for all of your intubations• Low cost per use procedure• High performance visualization capabilities
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In the pyxis now…
• Silver Cross stocks unchanneled #3 King Vision video laryngoscope blades in the pyxis now.
• Not an endorsement of the product, just an accommodation for providers who use them.
• Good intubation techniques and practice still trump gadgets.
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EKG Strip O’ the Month
• AV Blocks
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Review - AV Junction
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• AV Junction = AV Node and Bundle of His• Pacemaker cells located throughout AV
Junction
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Review - Functions of AV Node
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• Backup pacemaker for SA Node• Creates delay between atrial and ventricular
depolarizations• Physiologic block for rapid supraventricular
rhythms
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Degrees of AV Blocks
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• First Degree - Delay in conduction• Second Degree - Some impulses blocked• Third Degree - All impulses blocked
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First Degree AV Block
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• An abnormal slowing of AV Junction conduction
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First Degree AV Block ECG Criteria
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• Rate - Dependent on underlying rhythm– Interpretation must include underlying rhythm
• Rhythm - Dependent on underlying rhythm• P-Waves - Normal morphology with one P-
Wave for each QRS• PRI - > .20 seconds and constant• QRS - Dependent on underlying rhythm
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First Degree AV Block Clinical Significance
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• Not usually detrimental and often resolves when ischemia corrected
• Must consider entire patient
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Second Degree AV Blocks
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• Type I– Also called “Wenckebach”– Also called Mobitz I
• Type II– Also called Mobitz II
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Second Degree AV Block, Type I
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• Intermittent block in which AV conduction gradually slows until an impulse is blocked
• “Long, longer, longer, drop! Long, longer, longer, drop!”
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Second Degree AV Block, Type I ECG Criteria
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Rate - Atrial rate unaffected but ventricular rate is less than atrial rate
Rhythm - Atrial rhythm usually regular. Ventricular rhythm is irregular with more P-Waves than QRS Complexes.
P-Waves - Unaffected with more P-Waves than QRS Complexes
PRI - Progressively increases for consecutively conducted P-Waves until QRS Complex is dropped
QRS - Unaffected
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Second Degree AV Block, Type I Etiology
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• Often caused by increased parasympathetic tone or drug effect
• Can be caused by MI
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Second Degree AV Block, Type I Clinical Significance
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• Usually transient with good prognosis• Can reduce cardiac output due to bradycardia
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Second Degree AV Block, Type II
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• Intermittent block in which not all P-Waves are conducted to ventricles but there is no progressive prolongation of PRI
• “Extra” p-waves.
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Second Degree AV Block, Type II Etiology
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• Usually due to MI or other organic heart disease
• Rarely the result of increased parasympathetic tone or drug effect
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Second Degree AV Block, Type II Clinical Significance
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• Poorer prognosis than Type I• Usually requires pacemaker• Frequently develops into Complete Block
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Second Degree AV Block, Type II ECG Criteria
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Rate - Atrial rate is unaffected but ventricular rate is less than atrial
Rhythm - Atrial rhythm regular, Ventricular irregular with more P-waves than QRS Complexes
P-Waves - Normal morphology with more P-Waves than QRS Complexes
PRI - Constant for consecutively conducted P-Waves
QRS - Usually wide but may be narrow if block is at His level or above
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Second Degree AV Block, Type II Example
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Third Degree AV Block
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• Complete blockage of impulse conduction through AV Junction
• Results in “AV dissociation” (very very bad thing)
• P’s and QRS’s “march to their own drummer”
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AV Dissociation
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• No relationship between P-waves and QRS complexes
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Third Degree AV Block Etiology
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• MI• Increased parasympathetic tone• Drug toxicity
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Third Degree AV Block ECG Criteria
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• Rate - Atrial > 60, Ventricular based on escape• Rhythm - Atrial and ventricular regular• P-Waves - Normal• PRI - No association between P-Waves and
QRS complexes (P’s and QRS’s are divorced and do their own thing)
• QRS - Narrow if intranodal, Wide if infranodal
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Questions?
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