Respiratory Emergencies:

CHF, Pulmonary Edema,

COPD, Asthma
CPAP & Albuterol Nebulizer
Condell Medical Center EMS System
September, 2007
Site Code#10-7200E1207
Prepared by: Sharon Hopkins, RN, BSN, EMT-P

Objectives
Upon successful completion of this program, the EMS
provider should be able to:
review the presentation and intervention for the patient
presenting with CHF, pulmonary edema, COPD, and
asthma.
review criteria for the use of CPAP.
discuss the set-up for CPAP.
review the SOP for Acute Pulmonary edema,
Asthma/COPD with Wheezing, and Conscious Sedation

Objectives contd
review the Whisperflow patient circuit for
CPAP.
actively participate in return-demonstration
of the albuterol nebulizer and in-line set-up.
successfully complete the quiz with a score
of 80% or better.

Heart Failure
A clinical syndrome where the hearts
mechanical performance is compromised and
the cardiac output cannot meet the demands
of the body
Considered a cardiac problem with great
implications to the respiratory system
Heart failure is generally divided into right
heart failure and left heart failure

Heart Failure
Etiologies are varied
valve problems, coronary disease, heart disease
dysrhythmias can aggravate heart failure

Variety of contributing factors to

developing heart disease
excess fluid or salt intake, fever (sepsis),
history of hypertension, pulmonary embolism,
excessive alcohol or drug usage

Deoxygenated Blood Flow

Through The Heart
Deoxygenated blood returns to the right heart via
inferior and superior vena cavas
Blood flow thru the right side of the heart
right atrium
right ventricle
pulmonary artery to the lungs
arteries always carry blood away from the heart
pumped to the lungs to be oxygenated

Oxygenated Blood Flow Through

The Heart
Oxygenated blood from the lungs returns to the
heart via the pulmonary veins to the left atrium
Blood flow thru the left side of the heart
left atrium
left ventricle
thru aortic valve to the aorta
to aorta for distribution to the body

Left Side of the Heart

High pressure system
Blood needs to be pumped to the entire
body
Left ventricular muscle needs to be
significant in size to act as a strong pump
Left sided failure results in backup of blood
into the lungs

Right Side of the Heart

Low pressure system
Blood needs to be pumped to the lungs right
next to the heart
Right ventricle is smaller than the left and
does not need to be as developed
Right sided failure results in back pressure of
blood in the systemic venous system (the
periphery)

Left Ventricular Heart Failure

Causes
failure of effective forward pump
back pressure of blood into pulmonary circulation
heart disease
MI
valvular disease
chronic hypertension
dysrhythmias

Left Ventricular Failure

Pressure in left atrium rises
increasing pressure is transmitted to the
pulmonary veins and capillaries
increasing pressure in the capillaries forces blood
plasma into alveoli causing pulmonary edema
increasing fluid in the alveoli decreases the lungs
oxygenation capacity and increases patient
hypoxia

As MI is a common cause of left ventricular

failure:

Until proven otherwise, assume

all patients exhibiting signs and
symptoms of pulmonary edema
are also experiencing an acute MI

Right Ventricular Heart Failure

Causes
failure of the right ventricle to work as an
effective forward pump
back pressure of blood into the systemic
venous circulation causes venous congestion
most common cause is left ventricular failure
systemic hypertension
pulmonary embolism

Congestive Heart Failure

A condition where the hearts reduced stroke
volume causes an overload of fluid in the
bodys other tissues
Can present as edema
pulmonary
peripheral
sacral
ascites (peritoneal edema)

Compensatory Measures Starlings Law

The more the myocardium is stretched, the greater
the force of contraction and the greater the cardiac
output
The greater the preload (amount of blood returning to
the heart), the farther the myocardial muscle
stretches, the more forceful the cardiac contraction
After time or with too much resistance the heart has
to pump against, the compensation methods fail to
work

Acute Congestive Heart Failure

Often presenting in the field as:
Pulmonary edema
Pulmonary hypertension
Myocardial infarction

Chronic Congestive Heart Failure

Often presenting in the field as:
Cardiomegaly - enlargement of the heart
Left ventricular failure
Right ventricular failure

Patient Assessment
Scene size-up
Initial assessment
airway
breathing
circulation
disability
AVPU
GCS
expose to finish examining

 Identify priority patients, make transport decisions

Additional assessment
vital signs, pain scale
determine weight
room air pulse ox, if possible, and oxygen PRN
cardiac monitor; 12 lead ECG if applicable
establish 0.9 NS IV, TKO
determine blood glucose if indicated
unconscious, altered level of consciousness, known diabetic with diabetic
related call

reassess initial assessment findings and interventions started

Closest Appropriate Hospital

Hospital of patients choice within the departments transport area
The patient who is alert and oriented has the right to request their
hospital of choice
EMS can have the patient sign the release for transport to a farther
hospital
If EMS does not feel comfortable transporting farther away, you
can communicate this to the patient to get your point across in a
diplomatic manner (ie: Im very concerned about your condition
and I would feel more comfortable taking you to the closest
hospital)

Refusals
A conscious and alert patient has the right to refuse care and/or
transportation
A refusal, though, with a patient in CHF might prove
devastating

worsening of signs and symptoms

increased and unnecessary myocardial damage
severe pulmonary edema
death

Avoid refusals in these patients at all costs

Document well the efforts taken to encourage transportation

Signs and Symptoms CHF

Progressive or acute shortness of breath
Labored breathing especially during exertion (ie: standing up,
walking a few steps)
Awakened from sleep with shortness of breath (paroxysmal
nocturnal dyspnea)
increasing episodes usually indicate the disease is worsening

Positioning
tripod - resting arms on thighs, leaning forward
inability to recline in bed without multiple pillows
using more pillows to be comfortable in bed

 Changes in skin parameters

pale, diaphoretic, cyanotic
mottling present in severe CHF
Increasing edema or weight gain over a short time
early edema in most dependent parts of the body first (ie: feet,
presacral area)
Generalized weakness
Mild chest pain or pressure
Elevated blood pressure sometimes
to compensate for decreased cardiac output

 Typical home medication profile

diuretic - to remove excess fluids
hypertension medications - to treat a typical comorbid factor
digoxin - to increase the contractile strength of the
heart
oxygen

Worst of the worst complications edema

pulmonary

Progression of Acute CHF

Left ventricle fails as a forward pump
Pulmonary venous pressure rises
Fluid is forced from the pulmonary capillaries into
the interstitial spaces between the capillaries and the
alveoli
Fluid will eventually enter & fill the alveoli
Pulmonary gas exchange is decreased leading to
hypoxemia ( oxygen in blood) & hypercarbia (
carbon dioxide in blood)

Progression of CHF contd

Hypercarbia ( carbon dioxide retained in
the blood) can cause CNS depression
slowing of the respiratory drive
slowing of the respiratory rate

 Wheezes heard in any

geriatric patient should be
considered pulmonary
edema until proven
otherwise (especially in
the absence of any history
of COPD or asthma)

Progression of Pulmonary Edema

Untreated, leads to respiratory failure
Oxygen exchange inhibited due to excess serum fluid in alveoli
hypoxia death
Presentation
tachypnea
abnormal breath sounds
crackles (rales) at both bases
rhonchi - fluid in larger airways of the lungs
wheezing - lungs protective mechanisms
bronchioles constrict to keep additional fluid from entering
the airway

Acute Pulmonary Edema SOP

Routine medical care
patient assessment
IV-O2-monitor
cautiously monitor IV fluid flow rates

Place patient in position of comfort

often patient will choose to sit upright
dangle the feet off the cart to promote venous pooling

Determine if the patient is stable or unstable

evaluate mental status, skin parameters, and blood pressure

Stable Acute Pulmonary Edema

Patient alert
Skin warm & dry
Systolic B/P > 100 mmHg
Nitroglycerin 0.4 mg sl - maximum 3 doses
Consider CPAP
Lasix 40 mg IVP (80 mg if already taking)
If systolic B/P remains >100 mm Hg give Morphine Sulfate 2
mg IVP slowly
If wheezing, obtain order from Medical Control for Albuterol
nebulizer

Pulmonary Edema Medications

Nitroglycerin
venodilator; reduces cardiac workload and dilates
coronary vessels
do not use in the presence of hypotension or if Viagra
or Viagra-type drug has been taken in the past 24 hours
can repeat the drug (0.4 mg sl) every 5 minutes up to 3
doses total if blood pressure remains > 100 mmHg
onset 1 - 3 minutes sl (mouth needs to be moist for the
tablet to dissolve & be absorbed)

 Lasix (Furosemide)

diuretic; causes venous dilation which decreases

venous return to the heart
avoid in sulfa allergies & in the presence of
hypotension
dose 40 mg IVP (80 mg IVP if the patient is taking
the drug at home)
vascular effect onset within 5 minutes; diuretic
effects within 15 - 20 minutes

 Morphine sulfate
narcotic analgesic (opioid)
causes CNS depression; causes euphoria
increases venous capacity and decreases venous return to the
heart by dilating blood vessels
used to decrease anxiety and to decrease venous return to the
heart in pulmonary edema
give 2 mg slow IVP; titrate to response and vital signs and give 2
mg every 2 minutes to a maximum of 10 mg IVP
effects could be increased in the presence of other depressant
drugs (ie: alcohol)

 Albuterol
bronchodilator
reverses bronchospasm associated with COPD
dose is 2.5 mg in 3 ml solution administered in the
nebulizer
the patient may be aware of tachycardia and tremors
following a dose
Albuterol must be ordered by Medical Control for
the acute pulmonary edema patient

Using CPAP With Medications

Medications and CPAP are to be administered
simultaneously
The use of CPAP buys time for the medications to
exert their effect
CPAP and medications used (Nitroglycerin, Lasix,
and Morphine) can all cause a drop in blood pressure
CPAP and medications must be discontinued if the
blood pressure falls
< 100 mmHg

Case Scenario #1
A 68 year-old female calls 911 due to severe
respiratory distress which suddenly woke her up
from sleep. She is unable to speak in complete
sentences and is using accessory muscles to
breathe. Lips and nail beds are cyanotic; ankles are
swollen.
B/P 186/100; P - 124; R - 34; SaO 2 - 88%
Crackles are auscultated in the lower half of the
lung fields.

Case Scenario #1
History: angina and hypertension; smokes 1
pack per day for the past 30 years
Meds: Cardizem, nitroglycerin PRN; 1 baby
aspirin daily; furosemide, Atrovent inhaler
as needed
Rhythm:

Case Scenario #1

What is your impression?

What will be your intervention(s)?
What is the rationale for your interventions?
What is this patients rhythm and do you
need to administer any medications for the
rhythm?

Case Scenario #1
Impression: congestive heart failure with pulmonary
edema
paroxysmal nocturnal dyspnea (sudden shortness of breath at
night)
bilateral crackles in the lungs
peripheral edema
cardiac history - hypertension and angina

Rhythm - sinus tachycardia

do not treat this rhythm with medication
determine and treat the underlying cause

Case Scenario #1
Interventions
Sit the patient upright, have their feet dangle off the sides of
the cart
promotes venous pooling of blood and decreases the
volume of return to the heart
Oxygen via non-rebreather face mask
Prepare to assist breathing via BVM
have BVM reached out and ready for use
IV-O2-monitor
Meds: NTG, Lasix, Morphine, consider CPAP

Unstable Acute Pulmonary Edema

Altered mental status
Systolic B/P < 100 mmHg
Contact Medical Control
medications given in the stable patient are now contraindicated due to a
lowered blood pressure

CPAP on orders of Medical Control

Consider Cardiogenic Shock protocol
Treat dysrhythmia as they are presented
Contact Medical Control for Albuterol if wheezing; possibly inline with intubation

CPAP

Continuous
Positive
Airway
Pressure
A means of providing high flow, low pressure oxygenation to
the patient in pulmonary edema

CPAP
CPAP, if applied early enough, is an effective way to
treat pulmonary edema and a means to prevent the need
to intubate the patient
CPAP increases the airway pressures allowing for better
gas diffusion & for reexpansion of collapsed alveoli
CPAP allows the refilling of collapsed, airless alveoli
CPAP allows/buys time for administered medications to
be able to work

CPAP expands the surface area of the

collapsed alveoli allowing more surface area
to be in contact with capillaries for gas
exchange

Before
CPAP

With CPAP

 CPAP is applied during the entire respiratory cycle

(inhalation & exhalation) via a tight fitting mask applied
over the nose and mouth
The patient is assisted into an upright position
The lowest possible pressure should be used
the higher the pressure, the risk of barotrauma
(pneumothorax, pneumomediastinum) rises
increased pressures in the chest decrease ventricular filling
worsening cardiac output (less coming into the heart, less
going out of the heart)

Goal of Therapy With CPAP

Increase the amount of inspired oxygen
Decrease the work load of breathing
In turn to:
Decrease the need for intubation
Decrease the hospital stay
Decrease the mortality rate

Indications & Criteria for

Use

CPAP

Patient identified with signs & symptoms of

pulmonary edema or, in consultation with
Medical Control, exacerbation of COPD with
wheezing
Patient must be alert & cooperative
Systolic B/P >100 mmHg
No presence of nausea or vomiting; absence
of facial or chest trauma

Patient Monitoring During CPAP Use

Patient tolerance; mental status
Respiratory pattern
rate, depth, subjective feeling of improvement
B/P, pulse rate & quality, SaO2, EKG pattern

Indications the patient is improving (can be noted in as little as

5 minutes after beginning)
reduced effort & work of breathing
increased ease in speaking
slowing of respiratory and pulse rates
increased SaO2

Discontinuation of CPAP
Hemodynamic instability
B/P drops below 100 mmHg
The positive pressures exerted during the use
of CPAP can negatively affect the return of
blood flow to the heart

Inability of the patient to tolerate the tight

fitting mask
Emergent need to intubate the patient

Patient Circuits
Complete package includes
mask tubing
head strap
Whisperflow CPAP valve
corrugated tubing
air entrapment filter

Patient Circuit

Oxygen Tank Duration

D sized tank - 30 minutes*
typical small portable tank kept on patient cart

H sized tank - 508 minutes* (8+ hours)

typical large tank kept in locker on rig

Other tank sizes:

E sized tank - 50 minutes*
typically used in hospitals during patient transports

M sized tank - 253 minutes*

* Based on 50 psi output & approx 30% FIO 2

Case Scenario #2
You have initiated CPAP and simultaneous
medication administration (NTG, Lasix and
Morphine) to a 76 year-old patient who EMS has
assessed to be in acute pulmonary edema
The patient begins to lose consciousness and the
blood pressure has fallen to 86/60.
What is the appropriate response for EMS to
take?

Case Scenario #2
This patient is showing signs of deterioration
The CPAP needs to be discontinued
No further medications (NTG, Lasix, Morphine)
can be administered due to the lowered B/P
Prepare to intubate the patient following the
Conscious Sedation SOP
support ventilations with BVM prior to
intubation attempt

COPD
Chronic obstructive pulmonary disease - a progressive
and debilitating collection of diseases with airflow
obstruction and abnormal ventilation with irreversible
components (emphysema & chronic bronchitis)
Exacerbation of COPD is an increase in symptoms
with worsening of the patients condition due to
hypoxia that deprives tissue of oxygen and
hypercapnia (retention of CO2) that causes an acidbase imbalance

Obstructive Lung Disease COPD & Asthma

Abnormal ventilation usually from obstruction in
the bronchioles
Common changes noted in the airways
bronchospasm - smooth muscle contraction
increased mucous production lining the respiratory tree
destruction of the cilia lining resulting in poor
clearance of excess mucus
inflammation of bronchial passages resulting in
accumulation of fluid and inflammatory cells

The Ventilation Process

Normal inspiration - the working phase
bronchioles naturally dilate

Normal exhalation - the relaxation phase

bronchioles constrict

Exhalation with obstructive airway disease

exhalation is a laborous process and not efficient or
effective
air trapping occurs due to bronchospasm, increased
mucous production, and inflammation

Emphysema
Gradual destruction of the alveolar walls distal to the
terminal bronchioles
Less area available for gas exchange
Small bronchiole walls weaken, lungs cannot recoil as
efficiently, air is trapped
in number of pulmonary capillaries which resistance
to pulmonary blood flow which leads to pulmonary
hypertension
may lead to right heart failure & cor pulmonale (disease of the
heart because of diseased lungs)

Alveolar Sac and Capillaries

Emphysema
in PaO2 leads to in red blood cell production (to carry
more oxygen)
Develop chronically elevated PaCO 2 from retained carbon
dioxide
Loss of elasticity/recoil; alveoli dilated
More common in men; major contributing factor is cigarette
smoking; another contributing factor is environmental
exposures
Patients more susceptible to acute respiratory infections and
cardiac dysrhythmias

Assessment of Emphysema

Pink puffer - due to excess red blood cells

Recent weight loss; thin bodied
Increased dyspnea on exertion
Progressive limitation of physical activity
Barrel chest (increased chest diameter)
Prolonged expiratory phase (usually pursed lip breathing
noted on exhalation)
Rapid resting respiratory rate
Clubbing of fingers

Diminished breath sounds

Use of accessory muscles
One-to-two word dyspnea
Wheezes and rhonchi depending on amount of
obstruction to air flow
May have signs & symptoms of right heart failure
jugular vein distention
peripheral edema
liver congestion

Case Scenario #3
The patient is a conscious, restless, and anxious 68 year-old male
with respiratory distress that has progressively worsened during the
past 2 days.
The patient has cyanosis of the lips and nail beds
B/P 138/70; P - 116 & irregular; R - 26; SaO 2 82%
Rhonchi and rales are auscultated in the lower right lung field;
patient feels warm to the touch
The patient has had a cold for 1 week with a productive cough of
yellow-green sputum
Hx: emphysema, angina, osteoarthritis

Case Scenario
Case Scenario #3
What is this patients rhythm?
What influence would this rhythm have on this
patients health history & current condition?
Do you need to intervene?

Atrial fibrillation diminishes the efficiency of

the pumping of the heart which can further
compromise the cardiac output

Case Scenario #3
Impression & intervention?
The patient has COPD most likely complicated by pneumonia

a cold over the last week

productive cough of yellow-green sputum
warm to the touch (temperature 100.60F)
rhonchi & rales in the right lung field base

Routine medical care

supplemental oxygen
heart rate most likely due to pneumonia and does not need
specific treatment

Chronic Bronchitis
An increase in the number of mucous-secreting
cells in the respiratory tree
Large production of sputum with productive
cough
Diffusion remains normal because alveoli not
severely affected
Gas exchange decreased due to lowered alveolar
ventilation which creates hypoxia and hypercarbia

Assessment of Chronic Bronchitis

Blue bloater - tends to be cyanotic
Tends to be overweight
Breath sounds reveal rhonchi (course gurgling sound)
due to blockage of large airways with mucous plugs
Signs & symptoms of right heart failure
jugular vein distention
ankle edema
liver congestion

Drive to Breath & COPD

Normal driving force to breathe
decreased oxygen (O2) level
increased carbon dioxide (CO2) level

Chemoreceptors sense:
too little O2 ( resp rate to improve) or
too much CO2 ( resp rate to blow off more CO2)

Patients with COPD have retained excess CO 2 for so long that

their chemoreceptors are no longer sensitive to the elevated CO 2
levels
COPD patients breathe to pull in O 2

O2 Administration & COPD

Never withhold oxygen therapy from a patient who
clinically needs it
Monitor all patients receiving O2 but especially the patient with
COPD
Normal O2 sat for COPD patient is around 90%
If the patient with COPD is supplied all the oxygen they need,
this might trigger them not to work at breathing anymore and
may result in hypoventilation and/or respiratory arrest

Asthma
Chronic inflammatory disorder of the airways
Airflow obstruction and hyperresponsiveness
are often reversible with treatment
Triggers vary from individual
environmental allergens
cold air; other irritants
exercise; stress
food; certain medications

Asthmas Two-Phase Reaction

Phase one - within minutes
Release of chemical mediators (ie: histamine)
contraction of bronchial smooth muscle
(bronchoconstriction)
leakage of fluid from bronchial capillaries (bronchial edema)

Phase two - in 6-8 hours

Inflammation of the bronchioles from invasion of the mucosa of
the respiratory tract from the immune system cells
additional swelling & edema of bronchioles

Assessment of Asthma
Presentation
Dyspnea
Wheezing - initially heard at end of exhalation
Cough - unproductive, persistent
may be the only presenting symptom
Hyperinflation of chest - trapped air
Tachypnea - an early warning sign of a respiratory
problem
Use of accessory muscles

Severe Asthma Attack

One and two word dyspnea
Tachycardia
Decreased oxygen saturation on pulse
oximetry
Agitation & anxiety with increasing
hypoxia

Obtaining a History

Very helpful in forming an accurate impression

Will have a history of asthma
Home medications indicate asthma
A prior history of hospitalization with intubation
makes this a high-risk patient for significant
deterioration
Note: unilateral wheezing is more likely an aspirated
foreign body or a pneumothorax than an asthma
attack

Treatment Goals COPD & Asthma

Relieve and correct hypoxia
Reverse any bronchospasm or
bronchoconstriction

Asthma/COPD with Wheezing SOP

Routine medical care

Pulse oximetry (on room air if possible)
Albuterol 2.5 mg / 3ml with oxygen adjusted to 6 l/minute
May repeat Albuterol treatments if needed
May need to consider intubation with
in-line
administration of Albuterol based on the patients
condition
Contact Medical Control for possible CPAP in patient with
COPD

Albuterol Nebulizer Procedure

Medication is added to the chamber which must be kept
upright
The T-piece is assembled over the chamber
The patient needs to be coached to breath slowly and as
deeply as possible
this will take time and several breathes before the patient can slow
down and start breathing deeper; the patient needs a good coach to
talk them through the slower/deeper breathing
the medication needs to be inhaled into the lungs to be effective
the patient should be sitting upright

Add medication to the chamber

Connect the mouthpiece to the

T-piece

Connect the corrugated tubing to

the T-piece

Kit connected to
oxygen and run
at 6 l/minute
(enough to
create a mist)

Encourage slow, deep breathing

Albuterol Nebulizer Mask

For the patient
who is unable to
keep their lips
sealed around the
mouthpiece, take
the top T-piece
off the kit and
replace with an
adult or pediatric
nebulizer mask

Pediatric
patient
using
nebulizer
mask.
Caregiver
may assist
in holding
the mask.

Case Scenario #4
7 year-old with history of asthma has sudden onset of
difficulty breathing and wheezing while playing
outside
Patient has an increased respiratory rate and is using
accessory muscles
B/P - 108/70; P - 90; R - 20; SaO2 - 97%
Upon auscultation, left lung is clear and wheezing is
present on the right side
Impression and intervention?

Case Scenario #4
Sounds like asthma, looks like asthma, has a
history of asthma but why should you not
suspect asthma?
Asthma is not a selective disease - the patient will
have widespread, not localized, bronchoconstriction
and have bilateral wheezing, not unilateral

Dig into the history more - what was the patient

doing prior to the development of symptoms?

Case Scenario #4
This patient was playing with friends, running
around while eating food
Possibly aspirated a foreign body
sudden onset of unilateral wheezing

Albuterol would not be indicated in this situation

Transport with supplemental oxygen if indicated,
position of comfort, reassessment watching for
increase in airway obstruction

Aerosol Medication via BVM or ETT

with BVM (In-line)
Place Albuterol in the chamber as usual
Connect the chamber to the T-piece
Once the nebulizer kit is assembled and the clear adaptor(s)
are in place, you may begin to bag the patient prior to
completion of intubation
the clear adaptor on the corrugated tubing is attached to the BVMs
mask
any medication that can be delivered as soon as possible to the
target organ (the lungs) will be helpful in promoting bronchodilation

 Nebulizer with white T-piece (CMC pyxis)

Remove the white mouth piece; the BVM will be connected
to this port
Add a clear adaptor to the distal end of the corrugated tubing
Intubate the patient as usual and connect the clear adaptor on
the corrugated tubing to the proximal end of the ETT placed
in the patient
Begin to bag the patient
Supplemental oxygen must be connected to the nebulizer and
the BVM

 Nebulizer with blue T-piece

Remove the mouthpiece from the T-piece and connect a clear
adaptor in its place
The BVM will attach to the clear adaptor on the T-piece
Add a second clear adaptor to the distal end of the corrugated
tubing
This clear adaptor will be connected to the proximal end of
the ETT after intubation is performed in the usual manner
Supplemental oxygen must be connected to the nebulizer and
the BVM

 Remove mouthpiece from Tpiece and replace with BVM

Connect nebulizer to oxygen
source
Place clear adaptor at distal
end of corrugated tubing (to
connect to ETT)

 Intubate the patient

Connect the clear adaptor on the distal end of the
corrugated tubing to the proximal end of the ETT
Confirm placement in the usual manner
visualization
chest rise & fall
5 point auscultation
ETCO2 detector

Case Scenario #5
EMS has responded to a 14 year-old child in severe
respiratory distress with audible wheezing. The
complaints have been present for the past 3 hours.
Inhalers used have not been effective.
B/P - 112/60; P - 120; R - 32; SaO2 - 89%
Patient is very anxious, pale, cool, and diaphoretic. The
lips and nail beds are cyanotic.
What is your impression?
What is your greatest concern?

Case Scenario #5
This patient is experiencing a severe asthma attack that
is not responding to medication - status asthmaticus
This patient is in danger of going into respiratory arrest
due to exhaustion
Begin supportive oxygen therapy
Set up the albuterol nebulizer kit and simultaneously the
BVM
Anticipate intubation with administration of Albuterol
via the in-line method

Case Scenario #5
Patients experiencing an asthma attack are in
need of bronchodilators (Albuterol) and IV
fluids (they are usually dry from the rapid
respirations and inability to have been taking
in fluids)
If the patient is losing consciousness, you may
need to follow the Conscious Sedation SOP to
intubate and administer Albuterol via in-line

Conscious Sedation
Would Lidocaine bolus be indicated?
What is the dose of Versed and the purpose
of Versed?
What would be the effects of Morphine?
How do you know if the patient needs
Benzocaine (Hurricaine, Cetacaine)?

Conscious Sedation
Lidocaine is not indicated
there is no presence of head injury or insult

Versed is an amnesic and will relax the patient

Versed does not take away any pain
The dose of Versed is 5 mg slow IVP
If not sedated within 60 seconds, Versed 2 mg slow IVP
every minutes until sedated
Following sedation, may give Versed 1 mg IVP every 5
minutes for agitation (total dose 15 mg)

Conscious Sedation
Morphine can help increase the effects of Versed and assist in
improving patient sedation
Morphine 2 mg slow IVP over 2 minutes
May repeat Morphine every 3 minutes
Max dose Morphine 10 mg

Benzocaine eliminates the gag reflex

The conscious patient will have a gag reflex
For the unconscious patient, stroke at the eyelashes or tap the space between
the eyes
The gag reflex disappears with the blink reflex
Minimize the duration of spray (<2 seconds)

Bibliography
Bledsoe, B., Porter, R., Cherry, R.
Essentials of Paramedic Care. Brady.
2007.
Kohlstedt, D. Sales Representative. Tri-Anim.
Region X SOPs, March 1, 2007.
Sanders, M. Mosbys Paramedic Textbook,
Revised Third Edition. 2007.
Via Google: Respiratory Module Part I
Via Google: Respiratory Module Part II