Respiratory Emergencies Respiratory Emergencies and the Rapid Response and the Rapid Response

TeamTeam

Lauri Stephens RRT-NPS, RPFTLauri Stephens RRT-NPS, RPFT

Why Was RRT Called?Why Was RRT Called?• Patient not breathing Patient not breathing

enoughenough– SedationSedation– Central Nervous System Central Nervous System

DepressionDepression• Patient increased WOB - Patient increased WOB -

DyspneaDyspnea

• Dyspnea results from 3 Dyspnea results from 3 generalized abnormalities of generalized abnormalities of respiration:respiration:– Changes in ability to maintain Changes in ability to maintain

normal respiratory “work”normal respiratory “work”• Neuromuscular disease-Neuromuscular disease-

weaknessweakness• Cachexia/MalnutritionCachexia/Malnutrition• Decreased respiratory muscle Decreased respiratory muscle

strength - deconditioningstrength - deconditioning– An increase in effort/work loadAn increase in effort/work load

• COPDCOPD• Pleural EffusionPleural Effusion• RestrictionRestriction

– An increase in ventilatory An increase in ventilatory requirementsrequirements

• AnemiaAnemia• Metabolic acidosisMetabolic acidosis• FeverFever• HypercapniaHypercapnia

Evaluation of DyspneaEvaluation of Dyspnea• Pulmonary CausesPulmonary Causes

– Pulmonary EmbolismPulmonary Embolism– PneumothoraxPneumothorax– COPD/Asthma ExacerbationCOPD/Asthma Exacerbation– Pleural EffusionPleural Effusion– Pulmonary EdemaPulmonary Edema– Airway ObstructionAirway Obstruction– AspirationAspiration– HypoxemiaHypoxemia– PneumoniaPneumonia– Infection Infection – FeverFever

Other- SepsisOther- Sepsis Anemia (Hgb <10)Anemia (Hgb <10) Metabolic AcidosisMetabolic Acidosis

HyperthyroidismHyperthyroidism Chronic Liver FailureChronic Liver Failure

Remember ABC’s Remember ABC’s

• Psychogenic CausesPsychogenic Causes– Panic AttackPanic Attack– AnxietyAnxiety– ““Spiritual Distress”Spiritual Distress”– HyperventilationHyperventilation

• PainPain• FearFear

• Cardiac CausesCardiac Causes– Acute MIAcute MI– CHFCHF– Unstable AnginaUnstable Angina– PericarditisPericarditis– Early Mitral StenosisEarly Mitral Stenosis

46 yo male, 3 days post admission and 46 yo male, 3 days post admission and treatment for pneumonia + acute on chronic treatment for pneumonia + acute on chronic renal failure. RRT called for tachypnea/SOB renal failure. RRT called for tachypnea/SOB and fever.and fever.

• VS - HR 128, RR 30, BP VS - HR 128, RR 30, BP 127/82 Temp 39.3127/82 Temp 39.3

91% on 2 lpm91% on 2 lpm• Labs – RBC 1.85, WBC Labs – RBC 1.85, WBC

9.44, HCT 21% Hgb 7.5 9.44, HCT 21% Hgb 7.5 Creatinine 1.7Creatinine 1.7• ABG 7.38 24 85 14ABG 7.38 24 85 14• Why is this patient Why is this patient

dyspneic?dyspneic?• Pt placed on 40% V-MaskPt placed on 40% V-Mask• Lasix givenLasix given

Second RRT called about 5 hours later. Second RRT called about 5 hours later. Patient having increased cough, sputum Patient having increased cough, sputum specimen obtained. VS about the same.specimen obtained. VS about the same.

• ABG – 7.40 20 86 12ABG – 7.40 20 86 12

• Patient just wants to go homePatient just wants to go home

• Denies any increase in SOB or WOBDenies any increase in SOB or WOB

• Lungs have decent aeration, bronchial BSLungs have decent aeration, bronchial BS

• Decision made to leave him on the floorDecision made to leave him on the floor

• Identify PNA pathogen to guide antibiotic txIdentify PNA pathogen to guide antibiotic tx

Third RRT in 24 hours called ~ 4 hours later.Third RRT in 24 hours called ~ 4 hours later.

• Pt moved to private Pt moved to private roomroom

• Now in isolation for Now in isolation for “whooping cough”“whooping cough”

• Initial presentation of Initial presentation of pertussis presents as pertussis presents as typical URI, runny nose, typical URI, runny nose, cough & conjunctival cough & conjunctival irritation (most irritation (most contagious at this point)contagious at this point)

• Characteristic cough Characteristic cough occurs after 7-10 daysoccurs after 7-10 days

• Many patients will not Many patients will not have the classic have the classic “whoop”“whoop”

• On the riseOn the rise• Most deadly in infants Most deadly in infants

less than 6 monthsless than 6 months

Pertussis in the Adult PatientPertussis in the Adult Patient

• Up to 32% of adolescents & adults Up to 32% of adolescents & adults w/cough > 6 days have serologic evidence w/cough > 6 days have serologic evidence of pertussisof pertussis

• In adults w/confirmed pertussis, 80% had a In adults w/confirmed pertussis, 80% had a cough for at least 3 weekscough for at least 3 weeks

• Vomiting post cough commonVomiting post cough common• We become susceptible 6-10 years post We become susceptible 6-10 years post

vaccinationvaccination• New strains emergingNew strains emerging• New DPT booster vaccines for adolescents New DPT booster vaccines for adolescents

and adults recently approvedand adults recently approved

17 yo male, fractured tib/fib sustained in a 17 yo male, fractured tib/fib sustained in a soccer game. Family visiting re-positioned soccer game. Family visiting re-positioned patient’s leg because he was uncomfortable.patient’s leg because he was uncomfortable.

• Pale appearance, normal Pale appearance, normal buildbuild

• Respiratory rate 36 HR Respiratory rate 36 HR 140140

• BS clear, diminished in BS clear, diminished in basesbases

• Patient c/o severe SOB “I Patient c/o severe SOB “I can’t breathe”can’t breathe”

• Patient c/o chest pain Patient c/o chest pain “Someone sitting on chest”“Someone sitting on chest”

• Patient placed on 100% Patient placed on 100% NRB Mask, SpO2 100%NRB Mask, SpO2 100%

• Patient now c/o “I Patient now c/o “I can’t feel my legs” can’t feel my legs”

• ““My face hurts, I My face hurts, I can’t open my can’t open my mouth”mouth”

• ““Am I going to die?”Am I going to die?”

• ABGABG

7.77 17 352 227.77 17 352 22

Family asked to leave the roomFamily asked to leave the roomPain meds and anti-anxiety Rx givenPain meds and anti-anxiety Rx givenPatient relaxed, dyspnea relievedPatient relaxed, dyspnea relieved

• Symtoms of hyperventilation:Symtoms of hyperventilation:– Numbness or tingling in Numbness or tingling in

hands, feet or lipshands, feet or lips– Lightheadedness/Lightheadedness/

dizzinessdizziness– CofusionCofusion– SOBSOB– Slurred speechSlurred speech– HeadacheHeadache– Chest painChest pain– Spasms & crampsSpasms & cramps– Muscle twitchingMuscle twitching– TrismusTrismus

• Causes of Causes of hyperventilationhyperventilation– Stress or anxietyStress or anxiety– PainPain– HypoxiaHypoxia– SepsisSepsis– Head injuryHead injury– Metabolic acidosisMetabolic acidosis– FeverFever

66 yo, restrained passenger involved in a MVC w/ 66 yo, restrained passenger involved in a MVC w/ multiple trauma and fractured pelvis. 11 days out. multiple trauma and fractured pelvis. 11 days out. Patient became very SOB and desaturated post Patient became very SOB and desaturated post working with PT. working with PT.

• HR 136, RR 32, SpO2 HR 136, RR 32, SpO2 90% on 100% NRB 90% on 100% NRB Temp 38Temp 38

• BS unremarkableBS unremarkable• Pt c/o stomach pain Pt c/o stomach pain

and it hurts to take a and it hurts to take a deep breathdeep breath

• Pt has occasional Pt has occasional spontaneous dry spontaneous dry coughcough

• Edema noted in left legEdema noted in left leg• Pt is in isolation, wants Pt is in isolation, wants

something to drinksomething to drink

What would you recommend at this point?What would you recommend at this point?

• ABG 7.48 30 68 21ABG 7.48 30 68 21

• CXR unchanged from CXR unchanged from previousprevious

• CT ordered – Will patient fit CT ordered – Will patient fit in scanner? Can she lay in scanner? Can she lay flat?flat?

• ???? Isolation???? Isolation

• Patient just wants apple Patient just wants apple juicejuice

• Risk Factors for PERisk Factors for PE– Prior History DVT or PEPrior History DVT or PE– Recent Surgery, Pregnancy, Recent Surgery, Pregnancy,

Trauma, Fractures or Trauma, Fractures or ImmobilzationImmobilzation

– Malignancy, ChemotherapyMalignancy, Chemotherapy– CHF or MICHF or MI– BurnsBurns– Old Age, Obesity, Oral Old Age, Obesity, Oral

Contraceptives or Estrogen Contraceptives or Estrogen ReplacementReplacement

– Varicose VeinsVaricose Veins– IV Drug AbuseIV Drug Abuse– Polycythemia, Hemolytic Polycythemia, Hemolytic

Anemia, Fibrinogen Anemia, Fibrinogen Abnormality, Early Coumadin Abnormality, Early Coumadin Therapy and Heparin Therapy and Heparin Associated ThrombocytopeniaAssociated Thrombocytopenia

– Type A bloodType A blood

Pulmonary Emboli FactsPulmonary Emboli Facts

• First or second most First or second most common cause of common cause of unexpected death in unexpected death in most age groupsmost age groups

• Most commonly (80%) Most commonly (80%) diagnosed on autopsy diagnosed on autopsy (~60% of pt’s dying in (~60% of pt’s dying in the hospital + for PE)the hospital + for PE)

• 10% of patients 10% of patients diagnosed w/PE will die diagnosed w/PE will die within 1 hourwithin 1 hour

• Only 1/3 of the rest will Only 1/3 of the rest will be diagnosed & treatedbe diagnosed & treated

• Incidence & findings of Incidence & findings of massive PEmassive PE– 96% Tachypnea96% Tachypnea– 58% Rales/Crackles58% Rales/Crackles– 53% Accentuated 253% Accentuated 2ndnd Heart Heart

SoundSound– 44% Tachycardia44% Tachycardia– 43% Fever (>37.8C)43% Fever (>37.8C)– 36% Diaphoretic36% Diaphoretic– 24% LE Edema24% LE Edema– 23% Cardiac Murmur23% Cardiac Murmur– 19% Cyanosis19% Cyanosis

640# Paraplegic in for treatment of 640# Paraplegic in for treatment of decubitus ulcers, history of ostructive sleep decubitus ulcers, history of ostructive sleep apnea.apnea.• RRT called for acute desaturation and RRT called for acute desaturation and

patient decreased LOCpatient decreased LOC

• Patient supine in FluidAir/Clinitron bedPatient supine in FluidAir/Clinitron bed

• Patient recently had “wound care”Patient recently had “wound care”

Patient lethargic, with shallow respirations. Will Patient lethargic, with shallow respirations. Will take deep breaths when stimulated and then falls take deep breaths when stimulated and then falls asleep and RR decreases to 4. On 100% NRB Mask asleep and RR decreases to 4. On 100% NRB Mask SpO2 =82% SpO2 =82%

• Do we need a gas?Do we need a gas?

• 7.26 82 54 267.26 82 54 26

• What do you want What do you want to do now?to do now?

• Stay on floor or Stay on floor or transfer to unit?transfer to unit?

Patient OutcomePatient Outcome

• Transferred to unitTransferred to unit

• Placed in Bariatric air Placed in Bariatric air bedbed

• BiPAP 25/8BiPAP 25/8

• Patient woke up Patient woke up ~6hours later~6hours later

• Patient recognized RCP Patient recognized RCP from previous episodefrom previous episode

• Patient reported that he Patient reported that he had lost ~150 since last had lost ~150 since last hospitalizationhospitalization

68yo male, chronic renal failure, Hx 68yo male, chronic renal failure, Hx IVDA & ETOH, Hep C+, admitted via IVDA & ETOH, Hep C+, admitted via the ED overnight with a nosebleed.the ED overnight with a nosebleed.

• RRT called for inability to awaken patientRRT called for inability to awaken patient

• Respirations very irregular, with frequent Respirations very irregular, with frequent apnea and no respiratory effort observed apnea and no respiratory effort observed (was not obstructing) Cheyne-Stokes (was not obstructing) Cheyne-Stokes respirationsrespirations

• BS essentially clearBS essentially clear

• SpO2 93% on 3 LpmSpO2 93% on 3 Lpm

• HR 130. BP 90/52HR 130. BP 90/52

What do you want to know? Any labs? CXR?What do you want to know? Any labs? CXR?

• Received Xanax ~ 8 hours ago for agitationReceived Xanax ~ 8 hours ago for agitation

• ABG 7.30 61 70 22ABG 7.30 61 70 22

• Pinpoint pupilsPinpoint pupils

• Arouses with stimulation and becomes very Arouses with stimulation and becomes very agitatedagitated

• Mumbling about his friend who visited ‘this Mumbling about his friend who visited ‘this morning”morning”

• RN wants nasal airway placedRN wants nasal airway placed

Decision made to try Narcan/Naloxone (opioid Decision made to try Narcan/Naloxone (opioid antagonist). Patient responded, becoming antagonist). Patient responded, becoming combative and agitated, but breathing.combative and agitated, but breathing.

• Should he stay on floor or Should he stay on floor or transfer to unit?transfer to unit?

• Narcan takes effect in Narcan takes effect in about 2 minutes and lasts about 2 minutes and lasts ~45 minutes~45 minutes

• Duration of action of Duration of action of narcotics may exceed that narcotics may exceed that of Narcanof Narcan

• Dose to response- .4mg-Dose to response- .4mg-2mgQ2-3 minutes up to 2mgQ2-3 minutes up to 10mg10mg

88 yo edentulous male, status post CVA. 88 yo edentulous male, status post CVA. RRT called for SpO2 of 77% on 3 LPM and RRT called for SpO2 of 77% on 3 LPM and increased WOB.increased WOB.

• Rhonchorus BS heard Rhonchorus BS heard from bedsidefrom bedside

• Loose, wet coughLoose, wet cough

• Intercostal retractions Intercostal retractions and use of accesory and use of accesory muscles present muscles present

• Patient lethargic, Patient lethargic, breathing with mouth breathing with mouth “open“open””

• RR 28, HR 112 BP RR 28, HR 112 BP 102/70102/70

What is your first “move”?What is your first “move”?

• ““A” for airway!A” for airway!

• Secretions pooling Secretions pooling back of throatback of throat

• Oral mucosa noted to Oral mucosa noted to be very drybe very dry

• Huge oral cast cleared Huge oral cast cleared from pharynxfrom pharynx

• Patient needs Patient needs hydration & frequent hydration & frequent oral careoral care

44yo 5 days post motorcycle vs car. C-2 fracture, 44yo 5 days post motorcycle vs car. C-2 fracture, pelvic fracture and left clavicle fracture. Some pelvic fracture and left clavicle fracture. Some concern over possible vertebral artery injury.concern over possible vertebral artery injury.

• RRT called for Mental RRT called for Mental status changesstatus changes– Doesn’t recognize Doesn’t recognize

wifewife– Speaking gibberishSpeaking gibberish– Vital signs all WNLVital signs all WNL– Difficult to assess Difficult to assess

BS/Chest due to HaloBS/Chest due to Halo– Wife reports difficult Wife reports difficult

night and patient night and patient being very anxiousbeing very anxious

What are your concerns?What are your concerns?

• ABG 7.53 28 112 ABG 7.53 28 112 22 on room air22 on room air

• Now what?Now what?

• Head CT normalHead CT normal

• Can he stay on Can he stay on floor or does he floor or does he need to transfer?need to transfer?

The EndThe End