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Region X SOP Review

Understand asthma and COPD symptoms, treatments, and more with Region X's SOP review at Condell Medical Center. Learn to identify and manage acute conditions like asthma attacks and COPD effectively.

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Region X SOP Review

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  1. Region X SOP Review December 2009 CE Advocate Condell Medical Center EMS System Site Code #107200E-1209 Prepared by Sharon Hopkins, RN, BSN, EMT-P

  2. Objectives Upon successful completion of this module, the EMS provider will be able to: • 1. identify the signs and symptoms of an acute asthma attack • 2. identify the Region X SOP treatment for acute asthma. • 3. identify signs and symptoms of COPD. • 4. identify the Region X SOP treatment for COPD. • 5. identify signs and symptoms of acute pulmonary edema.

  3. Objectives cont’d • 6. identify the Region X SOP treatment for acute pulmonary edema. • 7. identify signs and symptoms of a diabetic reaction. • 8. identify the Region X SOP treatment for a diabetic reaction. • 9. identify signs and symptoms of hypertensive crisis. • 10.identify the Region X SOP treatment for hypertensive crisis. • 11.identify assessment of acute abdominal pain.

  4. Objectives cont’d • 12. identify the Region X SOP treatment for acute abdominal pain. • 13. identify assessment of acute flank pain. • 14.identify the Region X SOP treatment for acute flank pain. • 15.identify indications, contraindications, dosing, side effects, and documentation for Albuterol. • 16. identify indications, contraindications, dosing, side effects, and documentation for Lasix.

  5. Objectives cont’d • 17. identify indications, contraindications, dosing, side effects, and documentation for Nitroglycerin. • 18. identify indications, contraindications, dosing, side effects, and documentation for Morphine. • 19. identify indications, contraindications, dosing, side effects, and documentation for Dextrose. • 20. identify indications, contraindications, dosing, side effects, and documentation for Glucagon.

  6. Respiratory System • Functional unit – the alveoli • Tiny air sacs at the distal end of the respiratory system • Oxygen is removed from the air and bound with hemoglobin in the blood • Carbon dioxide is displaced from blood into the alveoli and blown out as expired air • Measureable with ETCO2 detectors

  7. Acute Asthma • Chronic inflammatory condition • Reversible widespread narrowing of the airways (bronchospasm) • Symptoms usually develop in response to a trigger • Viral infection, dust, cold, smoke • Produces: • intermittent wheezing • excess mucous production • edema of the airways

  8. Acute Asthma • YOU CAN DIE FROM ASTHMA • Overall mortality rate 5% • 1 in 100 hospitalized patients die per year • Death rates are higher in persons less than 35 years of age • Fastest growing asthma rates are in children under 5

  9. Triad of Asthma Airway edema Increased mucous production Bronchospasm

  10. Signs and Symptoms of Asthma • Bronchospasm • Constriction of smooth muscle that surrounds the larger bronchi in the lungs • Air moving thru constricted tubes vibrates the passageway creating wheezing • Wheezing is widespread • Bronchoconstriction may be so severe that no breath sounds are heard • Ominous sign

  11. Signs and Symptoms of Asthma • Increased mucous production • Thick secretions plug the distal airways • More air trapping occurs • Dehydration makes secretions even thicker which worsens air trapping • Taking antihistamines contributes to increased dryness • Secretions thicken

  12. Signs and Symptoms of Asthma • Bronchial edema • Wall of the bronchial tubes swell which narrows the lumen (opening of the tube) • Swelling of bronchioles creates turbulent airflow, wheezing, and air trapping

  13. Treatment Goals for Asthma • Reverse bronchospasms with a bronchodilator medication • Thin mucous secretions with improving hydration (ie: IV fluids) and expectorants • Reduce airway edema with corticosteroid medications • Administered/prescribed in the hospital

  14. COPD • Chronic obstructive pulmonary disease • 2 distinct entities • Emphysema • Chronic bronchitis • These populations have little to no respiratory reserve

  15. Hypoxic Drive • A rare occurrence in a small population of the most chronic form of pulmonary disease and in the end stages • Brain switches to a hypoxic drive to breathe • Decreased levels of O2 stimulate breathing • Increased levels of CO2 no longer a stimulus • For the patient that becomes apneic, bag them • Adult rate 10 - 12 breaths per minute • Allow for adequate exhalation time

  16. Signs and Symptoms Emphysema • Barrel chest – chronic over inflation of chest • Tachypnea – attempt to maintain normal CO2 levels • Wasting muscle mass - use extreme amounts of energy to breathe • Pursed lip breathing – attempt to exhale as much CO2 as possible • “Pink puffer” – usually always good color

  17. Signs and Symptoms Chronic Bronchitis • Excessive mucous production in bronchial tree • Chronic or recurrent productive cough • Usually somewhat obese • Congested • Bluish complexion • Chronically elevated levels of CO2 • Chronically lower levels of O2

  18. Region X SOPAsthma/COPD with Wheezing • Routine Medical Care • Obtain pulse oximetry before O2 application, if possible, as a baseline • Obtain VS, breath sounds, pulse oximetry • Albuterol 2.5 mg/3ml • O2 flow at 6L/minute • Transport • Contact Medical Control to consider CPAP with COPD

  19. Albuterol • Sympathomimetic, bronchodilator • Relaxes smooth muscles in bronchial tree to relieve constriction • The drug has more selectivity in the lungs than influence in the heart • Use to treat patient presenting with wheezing • Could produce tachycardia • Administer 2.5 mg in 3 ml of solution for all ages

  20. Albuterol cont’d • Watch for tachycardia, tremors, restlessness, dysrhythmias • For best results, patient needs to be coached while inhaling • Encourage slower breaths • Encourage deeper breaths • Encourage inhaled breaths to be held longer • Medication needs to get to the lungs to be effective

  21. Acute Pulmonary Edema • Lungs swell up with fluid that migrated from the blood plasma into the walls of the capillaries and alveoli of the lungs • Gas exchange is compromised before signs and symptoms are evident • One of the most common causes of pulmonary edema is acute MI

  22. Signs and Symptoms Acute Pulmonary Edema • Crackles in lung bases at end of inspiration – early sign • Alveoli popping open as lungs reach maximum inflation • As condition worsens, crackles heard higher up in the lung fields • Productive cough of watery sputum often pink tinged (red blood cells) • Bubbling and foaming froth • From air forced out of fluid filled lungs

  23. Signs and Symptoms cont’d • Dyspnea at rest • Extreme restlessness • Tachypnea • Tachycardia • Diaphoresis • Cyanosis • Decreased SpO2 • Stable if B/P >100; unstable if B/P <100

  24. Region X SOP – Stable Acute Pulmonary Edema • Patient alert; skin warm & dry; B/P >100 • Nitroglycerin 0.4 mg sl • Repeated every 3-5 minutes • Maximum 3 doses • Consider CPAP • Lasix 40 mg IVP • 80 mg if patient takes oral Lasix at home • Morphine 2 mg slow IVP (over 2 min) • May repeat every 2 min as needed to a maximum of 10 mg total • If wheezing, contact Medical Control to consider Albuterol nebulizer • Transport

  25. Lasix • Loop diuretic that inhibits reabsorption of sodium and chloride and acts as a diuretic • Diuretic effect takes about 20 minutes • Produces venodilation and pools blood away from the heart to decrease preload • Venodilation effect almost immediate

  26. Lasix cont’d • Used in CHF and pulmonary edema • First as venodilator • Second as diuretic • Small potential of allergic reaction in patients with allergy to antibiotic sulfa drugs • Cautious use in hypotensive conditions • Administer 40 mg slow IVP • Give 80 mg if patient takes at home • May cause hearing loss or ringing in ears if given rapidly over repeated doses

  27. Nitroglycerin • Strong venodilator • Relaxes smooth muscles causing dilation of venous and arterial blood vessels • Reduces blood volume return to the heart (preload) reducing the work-load of the heart • Onset within minutes • Useful in pulmonary edema due to vasodilation effect

  28. Nitroglycerin cont’d • Avoid using if patient has taken a viagra type drug within past 24-36 hours • Combination may produce irreversible hypotension leading to shock or death • Administer 0.4 mg sl • May repeat up to 3 doses total • Carefully monitor B/P response before and after each dose

  29. Nitroglycerin cont’d • Side effects • Headache – venodilation • Hypotension – venodilation • Dizziness – venodilation • Postural syncope – venodilation • Nausea and vomiting – catecholamine effect • Metallic taste – effect of medication

  30. Morphine Sulfate • Narcotic analgesic, opioid • Depresses CNS activity • Creates sense of euphoria • Venodilator • Increases venous capacity pooling blood away from returning to the heart (decreased preload) • Used in pulmonary edema to reduce preload

  31. Morphine cont’d • If systolic B/P >100 can give Morphine 2 mg IVP slowly over 2 minutes • May repeat every 2 minutes as needed • Maximum dose 10 mg • Evaluate blood pressure and respiratory status prior to each dose

  32. Region X SOP – Unstable Acute Pulmonary Edema • Altered mental status; B/P < 100 • Contact Medical Control • CPAP on orders of Medical Control • Consider Cardiogenic Shock Protocol • Dopamine drip to improve blood pressure • Treat dysrhythmias per protocol • If wheezing, contact Medical Control to consider Albuterol nebulizer

  33. Diabetes Mellitus • Impairment of the body’s ability to metabolize simple carbohydrates (glucose) • Pancreas does not produce enough insulin or cells do not respond to insulin produced • Develop elevated levels of glucose in the blood and urine • Typical presentation • Urinating large quantities of urine containing large amounts of glucose • Extreme thirst • Deterioration of body functions

  34. Diabetes Mellitus • There is no cure • Treatment focuses on maintaining glucose levels in the normal range • Dietary habits and activity must be monitored • Will have the biggest impact on improving quality of life and avoiding complications

  35. Type I Diabetes Mellitus • Most patients do not produce any insulin • Generally strikes children more than adults • Requires daily injections through out their lives • Requires strict diet control • Requires a balance of activity

  36. Type 2 Diabetes Mellitus • Most common form of diabetes • Glucose levels are elevated • Typically develops later in life • Becoming more common in younger people • Body cannot effectively use the insulin produced • Onset of signs and symptoms is usually slow/gradual and often go unrecognized by the patient

  37. Type 2 Diabetes Mellitus • Signs and symptoms • Fatigue • Nausea • Frequent urination • Thirst • Unexplained weight loss • Blurred vision • Frequent infections that heal slowly • Being cranky, confused, or shaky • Unresponsiveness • Seizures

  38. Hyperglycemia • Elevated levels of sugar • Excessive food intake • Insufficient insulin dosage • Infection or illness present • Stresses (ie: surgery, stress events) • Gradual onset (hours to days) • If untreated, will lead to diabetic ketoacidosis • Life threatening condition of high levels of certain acids in the body

  39. Hypoglycemia • Too much insulin taken • Not enough food eaten • Brain is starved when it’s energy source (glucose) is lacking • Cerebral dysfunction becomes evident • Headache, confusion, slurred speech, irritability, seizures, coma

  40. Field Treatment Goals • Hyperglycemia • Patient is dehydrated and needs fluid resuscitation • Hypoglycemia • The brain is starving for glucose and the patient needs sugar as quickly as possible

  41. Signs and Symptoms Hyperglycemia • Hours to days to develop • Warm and dry skin (dehydrated) • Normal to low B/P (dehydrated) • Normal to rapid pulse (dehydrated) • Very thirsty (dehydrated) • Deep, rapid breathing (Kussmauls) (attempting to blow off excess acid CO2) • Sweet, fruity smell to breath (acetone) • Restless, just doesn’t feel well

  42. Signs and Symptoms Hypoglycemia – Insulin Shock • Quick onset within minutes • Pale and moist skin • Low B/P • Rapid, weak pulse • Normal or rapid breathing • Irritable, confused, seizures, or coma • Rapid response to treatment

  43. Region x SOP - Hyperglycemia • Routine Medical Care • History of last med dose and if patient has eaten and when • Obtain capillary blood glucose level • Use lancet and fingertip or forearm site • IV fluid challenge 200 ml • Reevaluate condition • May repeat fluid challenge 200 ml 2 more times • Transport

  44. Region X SOP - Hypoglycemia • Routine Medical Care • History of last med dose and if patient has eaten and when • Obtain capillary blood glucose level • Use lancet and fingertip or forearm site • If blood sugar <60, administer Dextrose • Adult 16 and over – 50 ml 50% IVP/IO • 1 – 15 years – D25% IVP/IO 2ml/kg • <1 year old – D12.5% IVP/IO 4ml/kg

  45. Dextrose • A carbohydrate used to supply glucose (sugar) • Rapid onset • Useful in known hypoglycemic case and unresponsiveness for unknown cause • Better to over treat the hyperglycemic patient than to under treat the hypoglycemic patient

  46. Dextrose cont’d • Dose related to age • Adult 16 and over – 50 ml 50% • 1 – 15 years old – D 25% 2 ml/kg • Under 1 – D 12.5% 4 ml/kg • Dilute D 25% 1:1 to make D 12.5% • Administer Dextrose slowly • Drug is hypertonic and acidic and can be irritating to veins • Can be damaging to tissue if IV/med infiltrates

  47. Glucagon • A hormone to stimulate breakdown of glycogen (stored form of glucose) in the liver • Helpful when an IV cannot be established and Dextrose is desired • Administer 1 mg / 1 unit • May take up to 20 minutes to work IF there are glucose stores available

  48. IV Established After Glucagon • IV established after Glucagon given • Recheck glucose level • If glucose level remains < 60, administer Dextrose • Drug must be reconstituted prior to administration • Roll reconstituted drug in hands • Check that all flecks have dissolved

  49. Hypoglycemia Treatment • If no response to Dextrose in the adult patient, repeat 50 ml D50% IVP • If unable to establish an IV, administer Glucagon 1 unit (1 ml) IM • Glucagon may take up to 20 minutes to work if glucose stores are available in the liver

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