Respiratory Failure
Presence Regional
EMS System
Objectives
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Review the anatomy and physiology of the
respiratory system.
Describe how carbon dioxide is created in
the body.
Outline the assessment of patients with
respiratory complaints
Compare and contrast the signs and
symptoms of Respiratory Distress and
Respiratory Failure.


Outline the use of end tidal capnography
to determine disease specific signs of
Respiratory Distress, Respiratory Failure
and Respiratory Arrest.
Discuss the management of a variety of
diseases that might result in Respiratory
Distress and Respiratory Failure
What we know
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Air is good
Pink is good
Blue is bad
Air goes in
Air goes out
Ventilation vs Respiration
First: Get the terms straight. What most
people call respirations are actually
ventilations
 Ventilation = Movement of air in and out
 Respiration = Exchange
of oxygen and carbon
dioxide (in the lung or
at the cell level)

How does air get in the body?

Upper airway
• Structures above
vocal cords
• Breathe in through
nose or mouth

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Warms air
Humidifies air
Cleans air
Lower Airway

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Structures below
vocal cords
Trachea = “C”
shaped cartilage
rings, posterior
wall is muscle (allows for passage of material through
esophagus)

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Cartilage prevents trachea from collapsing
when coughing
Walls lined with mucus producing cells
Lower Airway
Bronchi: Branch off
trachea
 Bronchioles: divide 32
times, get progressively
smaller
 Muscle lined to expand &
contract, inner surface of
mucus producing cells

Alveoli
Functional Respiratory Unit
 Where oxygen/carbon dioxide exchange
occurs
 One cell thick
 Muscles and elastic fibers
to expand and contract
 Covered with capillaries
 Surfactant =chemical
that increases surface
tension & keeps alveoli open

Alveolar/Capillary/Cell Gas
Exchange
Remember
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No gas exchange takes place till the gas
gets to the alveoli.
No gas exchange in the upper airway,
trachea, bronchi or bronchioles.
The passage way from the outside to the
alveoli is dead air space.
Must inhale enough air to get oxygen to
the alveoli = tidal volume
How?
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How do you know if the patient has
an adequate tidal volume?

Assess for good rise and fall of the
chest.
What???

What makes oxygen and carbon
dioxide exchange across capillaries?
Diffusion
Movement of particles (gas) from an area
of high concentration to an area of low
concentration
 Oxygen leaves the alveoli and goes into
the low oxygen area of the pulmonary
capillary
 Carbon dioxide leaves the capillary and
goes into the low CO2
area of the alveoli.

What

What causes the impulse to take a
breath?
Inspiration
The impulse to begin inspiration is
from the pons of the brain stem
 Receptor cells sensitive to
carbon dioxide levels control
inspiration.
 When CO2 goes up,
inspiration is initiated, when
CO2 goes down, inspiration is
inhibited.

Ventilation
Is a mechanical process of gas
following changing pressures
 Similar to the air
movement through bellows
 When the ventilation
process begins the
pressure in the alveoli is
equal to the outside
atmospheric pressure.

Ventilation

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As ventilation begins the spaces between
the ribs expand and the diaphragm drops
resulting in a vacuum in the chest.
Air rushes in from the atmosphere to fill
the space.
Ventilation
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Once the pressure in the alveoli is equal to
the atmospheric pressure, air movement
stops.
Then the spaces between the ribs
contract and the diaphragm moves up
increasing the pressure in the alveoli
above the atmospheric pressure, forcing
air to move from the alveoli into the
atmosphere.
Hemoglobin
98% of inspired oxygen is
transported from the alveoli by the
red blood cells on hemoglobin.
 Carbon dioxide is
transported back
to the alveoli
dissolved in plasma.

Perfusion

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Oxygen in the alveoli does the
patient no good, until it is
transported to the cells.
The purpose of oxygen is to combine
with glucose (sugar) to create carbon
dioxide, water and lots of energy.
To Have Perfusion You Need
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Two sided pump = heart
System of tubes = circulatory system
Conduction medium = blood
Fuel = glucose (sugar)
Oxygen Source = respiratory system
Perfusion
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The process of getting oxygen and
(sugar) glucose to the cells is
perfusion.
Oxygen + Sugar ↔(the Cell)
CO2 + H2O + ENERGY
Carbon Dioxide


The only way to get carbon dioxide
in the body is to break down glucose
(sugar) with oxygen.
If glucose (sugar) is broken down
without oxygen, the by product is
not carbon dioxide, but lactic acid.

“CO2 is the smoke from the flames
of metabolism (sugar breakdown)”
• Ray Fowler M.D. Dallas: Street Doc’s
Society
Hypoxia
Hypoxia (poor delivery of oxygen to cells)
can be caused by a variety of problems.
 Hypoxic – not enough oxygen
 Anemic – not enough
hemoglobin
 Stagnant – not enough
perfusion
 Histotoxic – unable to download

Normal Oxygen Transport

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Plenty of oxygen
Plenty of hemoglobin
Good perfusion
Cells able to take up oxygen and use it
The Physiology Coloring Book Kapit, Macey and Meisami
Harpercollins College Publishing 1987
Hypoxic Hypoxia
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Not enough oxygen
Plenty of hemoglobin
Good perfusion
Cells able to take up oxygen and use it
Anemic Hypoxia
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Plenty of oxygen
Not enough hemoglobin
Good perfusion
Cells able to take up oxygen and use it
Stagnant Hypoxia
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Plenty of oxygen
Plenty of hemoglobin
Poor perfusion
Cells able to take up oxygen and use it
Histotoxic Hypoxia
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Plenty of oxygen
Plenty of hemoglobin
Good perfusion
Cells unable to take up oxygen and use it
Causes/Pathophysiology
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All Respiratory Distress/Disease is
caused by a failure of:
Ventilation: moving air in/ air out
or
Diffusion: movement of gases across
alveolar/capillary membrane
or
Perfusion: movement of blood to
get oxygen to the cells

Respiratory Distress/Disease can
be:
• Relieved by: Adrenalin based
agents
• Compounded by:
 Inflammation
 Mucus production
Assessment

Scene size up
• Safety
• Environment
Living conditions
 Presence of oxygen
delivery devices
 Presence of nebulizers

General Impression
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Position
Color
Mental Status
Ability to Speak
Respiratory Effort
Resting Comfortably:
Good
Pursed Lip Breathing:
Forcefully
pushing out CO2: (Tolerating)
Tripod Position:
Helps expand the
chest (Not good)
Altered Level of Consciousness:
(Bad)
Cyanosis:
Poorly oxygenated
hemoglobin close to the surface of the skin
Ability to Speak
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Speaks in complete sentences =
Good
Speaks only 1 or 2 words between
breaths = Having difficulty
Unable to speak and breath at the
same time = Bad
Respiratory Effort

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Easy: Normal rise and fall of the
chest = good
Labored: Using accessory muscles
= not good
Absent: No respiratory effort = bad
Primary Survey:
Fix immediately what can be fixed
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Airway: able to speak
Breathing: rise and fall of the chest
Circulation: radial pulse
Disability – mental status
Vital Signs
Focused History
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Signs and symptoms
Allergies
Medications
Past Medical History
Last Meal
Events prior to EMS arrival
PASTE History
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Progression: Did the respiratory problem start
suddenly or did it get worse over time?
Associated Chest Pain?
Sputum: What is the patient coughing up? What
is the color? What is the amount?
Talking Tiredness: Is the patient able to speak
in sentences, or does he have to take a breath
between words?
Exercise Tolerance: Is the patient able to move
around the room without getting more short of
breath?
Associated Symptoms/
Pertinent Negatives

Respiratory distress can be
associated with:
• Chest pain
• Fever/chills
• Wheezing
• Smoking
• Trauma
Absence of these associated symptoms is
significant!! (Pertinent Negative)
Medications Associated with
Respiratory Distress

Is the patient taking:
• Antibiotics
• Oxygen
• Steroids
• Inhalers/nebulizers
• Cardiac drugs
Examination

Head and Neck
• Pursed lip breathing
• Cyanosis
• Distended jugular veins

Extremities
• Edema of the ankles
What are you listening to?

Chest Sounds
• Crowing/Stridor: swelling
of upper airway/larynx
• Wheezes: swollen
muscles in the bronchioles
(constricted airways)
• Rhonchi: thick fluid in bronchioles and
bronchi
• Rales/crackles: moisture/stickiness in
alveoli
Monitoring Technology

Pulse Oximetry
• Measures oxygen saturation of available
hemoglobin
• Measures amount of oxygen delivered
to cells
• Goal > 94%
• 91-94% mild hypoxemia
• 85 – 90% moderate
hypoxemia
• < 85% severe hypoxemia
Inconsistent Pulse Oximetry
Readings
Poor perfusion
 Cold extremities
 Elevated carbon monoxide levels
 Low levels of hemoglobin
 Black, blue or green
fingernail polish

Capnography

End Tidal Carbon dioxide (EtCO2)
• Measures level of CO2 in exhaled breath
• Non invasive
• Can give information about:
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Ventilation (movement of CO2 out of
lungs)
Perfusion (delivering O2 and sugar to cells
and carrying away CO2)
Metabolism (creating CO2 by breaking
down sugar with oxygen)
Capnography

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Normal levels of EtCO2: 35-45
Capnography can also be expressed
in a wave form
• Normal waveform
• Measure numerical mmHg of CO2
• Distinctive plateau (flat top) waveform
Abnormal Capnography

Low EtCO2
• Shock (perfusion failure, no creation of
CO2)
• Cardiac Arrest (perfusion failure, no
creation of CO2 and/or no ventilation)
• Pulmonary Embolism (obstructed
perfusion to or from the lung)
• Complete airway obstruction from
mucus plugging or foreign body (no
ventilation)
Abnormal Capnography

High EtCO2
• Hypoventilation (CO2 build up due to
ventilation failure)
• Respiratory Depression (CO2 build up
due to ventilation failure)
• Hyperthermia (accelerated metabolism
with over production of CO2)
Abnormal Waveforms

Bronchospasm from asthma, COPD
or airway obstruction can change the
capnography wave form to a “shark
fin” shape
Management of Respiratory
Disorders
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Open and secure airway
Improve ventilation
Improve diffusion
Improve perfusion
Tools for Management of
Respiratory Disorders

Oxygen delivery devices
• BVM: Bag Valve Mask Ventilation
• CPAP: Continuous positive airway
pressure
• Nebulizer bronchodilators
• Fluids
Management 1:Oxygen
Administration

Delivery Devices
• Nasal Cannula: 2-6 liters/minute

Non-rebreather mask: 10-15
liters/minute
REMEMBER!!!
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Must be able to breathe
spontaneously
Must have good rise and fall of the
chest
Management 2: Ventilation
Support

Use Bag-Valve-Mask
ventilation if patient
shows signs of fatigue
• Slowing ventilations
• Poor rise and fall of the chest
• Altered level of consciousness with poor
ventilation
• Use supplemental oxygen
Management 3: CPAP:
Continuous Positive Airway Pressure
A means of providing high flow, low pressure
oxygenation to the patient in severe respiratory
distress or respiratory failure
Goals of CPAP
• Increase the amount of inspired
oxygen
• Decrease the work of breathing
CPAP
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Increases the airway pressures allowing for better
gas diffusion & for re-expansion of collapsed
alveoli
Allows the refilling of collapsed, airless alveoli
Expands the surface area of the collapsed alveoli
allowing more surface area to be in contact with
capillaries for gas exchange
Without CPAP
With CPAP
CPAP
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CPAP is applied during the entire
respiratory cycle (inhalation &
exhalation) via a tight fitting mask
applied over the nose and mouth
The patient must be able to maintain an
upright sitting position
Indications for CPAP Application
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Patient has severe respiratory distress
and/or respiratory failure
To ease significant labored respirations
and work of breathing in patients on
supplemental oxygen who may
otherwise require intubation
Patient exhibiting hypoxemia (O² sat
<94% at any time) not responsive to
supplemental oxygen therapy
Criteria for CPAP(all must apply)
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Age ≥ 14
Fully cooperative patient, exhibiting a
reliable respiratory rate and effort, and
able to protect their airway.
Medical patient with SBP≥90 mmHg
No presence of nausea or vomiting
Patient Monitoring
During CPAP Use
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Patient tolerance; mental status
Respiratory pattern
• rate, depth, subjective feeling of
improvement
• B/P, pulse rate & quality, SaO2,EtCO2
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

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Hemodynamic instability
• B/P drops below 90 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
Management 4: Nebulized
Bronchodilators

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For bronchoconstriction
For management
of wheezing
breath sounds
DuoNeb

Blended solution of
• Albuterol Sulfate (Albuterol)
• Ipratropium Bromide (Atrovent)

Two medications work in different
ways to achieve bronchodilation
Albuterol

Albuterol• Synthetic sympathetic nervous
system stimulant
• Beta 2 agonist – bronchodilation
• Less cardiac effect ( Beta 1, Alpha 1)
than epinephrine
• Reduces mucus secretion, pulmonary
capillary leaking and edema in the lungs
in allergic reactions
Ipratropium (Atrovent)

Ipratropium
• Anticholinergic blocks the
acetylcholine receptors of the
parasympathetic nervous system
• Bronchodilation
• Drying of respiratory tract secretions
DuoNeb Dosage

Comes pre-mixed
• 0.5 mg Ipratropium
• 3 mg Albuterol
• In 3 ml solution
Nebulize with
6-8 L Oxygen

May repeat once
Management 5: Fluids

Patients with respiratory failure are
frequently dehydrated due to
• Illness
• Mouth breathing

IV fluids
• Hydrate the system
• Helps thin mucus
How Bad is the Respiratory
Problem?
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Respiratory Distress
Respiratory Failure
Respiratory Distress
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From “I feel short of breath” to obvious labored breathing
Slightly elevated respiratory rate > 16-24/minute
Elevated pulse rate > 100/minute
Anxious
Pale color
Pursed lips breathing
Use of accessory muscles, tripod position
Abnormal respiratory sounds (wheezing, rales, rhonchi)
Oxygen saturation slightly low 90-94%
Able to speak in short sentences (or 1-2 words) between
breaths
Able to tolerate some activity
If patient becomes fatigued may lead to respiratory failure
Management of Respiratory
Distress

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Correct the underlying problem
Apply oxygen to keep SaO2 >94%
Ventilation assistance
• CPAP
• BVM ventilation
Bronchodilation with nebulized medications
Perfusion
• Improve circulation
Respiratory Failure

Inability of the body to meet the
basic demands for tissue
oxygenation
Early Respiratory Failure
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Respiratory rate > 30/minute
Heart rate > 140/minute
Oxygen saturation < 94%
Use of multiple accessory muscle groups
Inability to lie supine
Altered level of consciousness
Inability to clear airway of secretions/mucus
Cyanosis of nail beds and lips
Unable to speak more than 1 word between breaths
Unable to tolerate physical activity
If patient becomes fatigued may lead to end stage
respiratory failure
Late Respiratory Failure
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Respiratory rate < 6/minute
Heart rate < 60/minute
Oxygen saturation < 90%
Poor rise and fall of the chest
Able to lie supine
Stuporus or Unconscious (may respond to pain)
Inability to clear airway of secretions/mucus
Gray color
Unable to speak
Unable to tolerate any physical activity
If patient becomes fatigued may lead to respiratory arrest
Respiratory Failure

Gradual Onset
• Inadequate oxygen delivery
• Inadequate carbon dioxide removal
• Tachycardia (fast heart rate)
• Tachypnea (fast breathing) with poor
rise and fall of chest
Respiratory Failure

End Stage Respiratory Failure
• Bradycardia (slow heart rate)
• Bradypnea (slow breathing)
• Cyanosis
• Poor chest wall movement
• Profound acid build up
Respiratory Arrest
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No spontaneous respirations
No rise and fall of the chest
Unconscious; no response to pain
Cold, cyanotic/gray skin
If unresolved will lead to death
Respiratory Failure/Arrest
Management
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Open airway
Mechanically ventilate
Work to correct underlying problem
Review
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Answer the following questions as a group.
If doing this CE individually, please e-mail your
answers to:
shelley.peelman@presencehealth.org
Use “January 2016 2015 CE” in subject box.
You will receive an e-mail confirmation. Print
this confirmation for your records, and
document the CE in your PREMSS CE record
book.
IDPH site code # 067100E1216
Scenario Review


Read the assessment for each scenario.
Determine:
• What is wrong with the patient?
• Is the patient in respiratory distress or
respiratory failure?
• Is the problem one of ventilation, diffusion or
perfusion or a mix?
• Which of the 5 management tools will be
helpful for this patient?
Scenario 1
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You are called for a 63 year-old man named Jim.
Jim has been sick with the “flu” for 3 days.
Jim is alert and oriented X 4 but he is anxious.
His airway is open and he can speak in short
sentences between breaths.
His respiratory rate is 24 with good rise and fall
of the chest.
He is pale, sweaty and very warm to touch.
Assessment
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Jim is sitting upright in tripod position using
accessory muscles.
Jim complains of chest pain on the right side of
his chest. The pain is worse when he coughs or
tries to take a deep breath.
Breath sounds on the right are diminished with
rales and rhonchi. Breath sounds on the left are
clear.
Jim states he feels too weak to move.
No other significant findings on head to toe
assessment
SAMPLE History
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Allergies: Penicillin
Medications: Lisinopril 10 mg daily, Proscar 5 mg
daily
Past History: hypertension, enlarged prostate
Last Meal: No appetite. Has been drinking fluids
mostly
Events: Feeling bad and unable to get a deep
breath
Vital Signs

BP 140/94
Pulse 98
Respirations 24
EtCO2 46

Blood sugar: 112

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SaO2 91% on room air
• What is wrong with the patient?
• Is the patient in respiratory distress or
respiratory failure?
• Is the problem one of ventilation, diffusion or
perfusion or a mix?
• Which of the 5 management tools will be
helpful for this patient?
• What is wrong with the patient?
Probably pneumonia
• Is the patient in respiratory distress or
respiratory failure? Respiratory distress
• Is the problem one of ventilation, diffusion or
perfusion or a mix? Mix of ventilation and
diffusion (alveoli are full of fluid from
pneumonia)
• Which of the 5 management tools will be
helpful for this patient? Oxygen and/or CPAP
and fluids. (No wheezing so no need for
nebulized medications)
Scenario 2
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You are called to a local long term care facility for
an 86 year-old man.
You find Bill in bed lying semi-flat, unresponsive
to touch and voice.
Bill has mucus in his airway.
His respirations are irregular, shallow and panting
at a rate of 8. Poor rise and fall of the chest
Pulses are hard to find at a rate of 60. Skin is
pale, cool and sweaty.
Staff tells you he has been getting worse since
yesterday.
Immediately!!


Suction airway
Begin ventilation with BVM at 10-12
breaths per minute
Assessment

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Staff reports altered level of consciousness began
this morning.
Bill has been ill with a urinary tract infection for 3
days.
Bill is slow to respond to pain only.
Breath sounds have rales on both sides with no
wheezing and no rhonchi.
Edema noted of face, hands and legs. Skin cool
and diaphoretic to touch
SAMPLE
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Allergies: morphine
Medications: Capoten 25 mg tid, Diabinese 100
mg daily, Pyridium 200 mg tid, Gantrisin 1 gm
qid
Past History: hypertension, type II diabetes and
urinary tract infection
Last Meal: lunch yesterday, sips of fluid since
then
Events: getting more difficult to arouse and
breathing is getting worse.
Vital Signs

BP: 84/60
Pulse: 60 and irregular
Respirations: < 8 without assistance
SaO2 on room air: 84%
EtCO2: 24

Blood sugar: 200




• What is wrong with the patient?
• Is the patient in respiratory distress or
respiratory failure?
• Is the problem one of ventilation, diffusion or
perfusion or a mix?
• Which of the 5 management tools will be
helpful for this patient?
• What is wrong with the patient? Sepsis from
urinary tract infection
• Is the patient in respiratory distress or
respiratory failure? Respiratory failure
• Is the problem one of ventilation, diffusion or
perfusion or a mix? Ventilation and perfusion
• Which of the 5 management tools will be
helpful for this patient? BVM ventilation with
oxygen (keep the airway clear of mucus),
fluids
Scenario 3
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You are called to the high school for a 17 yearold female, Emily.
Emily is in the gym sitting on the bleachers. She
is in tripod position in obvious distress.
Emily is very anxious and alert, but can only
speak 1-2 words between breaths.
Her airway is clear.
Respirations are labored at a rate of 32. You can
hear wheezing when she breathes.
Skin is warm and moist, pulse is 118 and regular.
Assessment

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Emily is using accessory muscles to
breathe.
Lips are blue tinged
Her lungs have musical wheezing on both
sides.
She has jugular vein distension.
No edema noted of extremities.
Emily states she is too short of breath to
move.
SAMPLE
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Allergies: dust, mold, peanuts and cheese
Medications: prednisone 10 mg tid,
terbutaline inhaler 2 puffs every 4 hours
Past Medical History: Asthma
Last Meal: Lunch 1 hour ago
Events: Emily was playing volley ball in
PE class when she suddenly got very short
of breath. She feels like her inhaler is not
working.
Vital Signs

BP: 138/74
Pulse: 118 and regular
Respirations: 32
SaO2 on room air: 89%
EtCO2: 44

Blood sugar: 100




• What is wrong with the patient?
• Is the patient in respiratory distress or
respiratory failure?
• Is the problem one of ventilation, diffusion or
perfusion or a mix?
• Which of the 5 management tools will be
helpful for this patient?
• What is wrong with the patient? asthma
• Is the patient in respiratory distress or
respiratory failure? Respiratory distress
• Is the problem one of ventilation, diffusion or
perfusion or a mix? ventilation
• Which of the 5 management tools will be
helpful for this patient? Oxygen (CPAP may
help) Nebulized DuoNeb, fluids to break up
mucus
Scenario 4
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You are called to transfer a 67 year-old woman
from a local facility to a comprehensive stroke
center an hour away.
ED Staff tell you Linda has had a brain stem
stroke.
Linda is lying in the ED unresponsive.
She is intubated on a ventilator with ventilations
set at 12/minute.
Her color is good, skin is warm and dry and her
pulse is slow at a rate of 66.
Assessment
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Linda is unresponsive to any stimuli.
Pupils are dilated and slow to react.
Jugular veins normal.
Breath sounds are clear and equal on both
sides with good rise and fall of the chest
with the ventilator.
No edema of extremities. Good pulses at
all extremities.
SAMPLE
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No allergies
Medications: Catapres 0.3 mg bid, diabeta 20
mg daily, premarin 1 mg daily
Past Medical History: hypertension, type II
diabetes, hormone replacement therapy
Last Meal: breakfast 5 hours ago
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Events: The patient, Linda, had complained of
feeling weak and dizzy at home approximately 3
hours ago. She was brought to the Emergency
Department by her husband. While having a CT
scan, she lost consciousness and stopped
breathing effectively. The neurologist suspects
she has had multiple stroke events including a
stroke in the pons of her brainstem. She was
immediately intubated and placed on a ventilator.
Vital Signs
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BP 188/110
Pulse 62
Respirations 12 on ventilator
SaO2 97% on ventilator
EtCO2 41
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Blood sugar: 92
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• What is wrong with the patient?
• Is the patient in respiratory distress or
respiratory failure?
• Is the problem one of ventilation, diffusion or
perfusion or a mix?
• Which of the 5 management tools will be
helpful for this patient?
• What is wrong with the patient? Stroke and
brain damage in the respiratory control center
of her brain
• Is the patient in respiratory distress or
respiratory failure? Respiratory failure/arrest
• Is the problem one of ventilation, diffusion or
perfusion or a mix? Ventilation
• Which of the 5 management tools will be
helpful for this patient? Oxygen by ventilator,
will need continued ventilation during transport
either by ventilator or BVM.