“Sometimes a Wheeze is Not Just a Wheeze…” COPD and CHF Silver Cross EMS System February 2013 1st Trimester CME 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 Quick A & P Review Anatomy of the Upper Airway Internal Anatomy of the Upper Airway Anatomy of the Lower Airway Anatomy of the Pediatric Airway COPD vs. CHF •One is respiratory •One is cardiac •They may seem the same, but their treatments are very different! COPD – Bronchitis – Emphysema – Asthma – Varying degrees/combination – Long-term tobacco abuse, exposure to inhaled toxins 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 Normal Lung Bronchitis COPD - Emphysema – – – – – Involves alveoli Alveolar destruction Alveolar coalescence Destruction of elastin fibers surrounding alveoli Chronic hypoxia, hypercarbia Emphysema –Blebs on lung surface, possible pneumothorax –Polycythemia –Muscle wasting, malnourished appearance –Barrel chest Emphysema – Chronic dyspnea – Little/no cough, little mucus production – Tripod position – Mental status changes – Heart problems, cor pulmonale, ventricular failure COPD-Asthma –Bronchiole hyperstimulation, constriction –Wheezing, dyspnea –Mucus production 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 Congestive Heart Failure - CHF CHF • Congestive heart failure can involve one side of the heart, or both. 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 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 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 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 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. Continuous Positive Airway Pressure (CPAP) 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. 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 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 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 When Not To Use Mask CPAP Hypercapnia Pneumothorax Hypovolemia Severe facial injuries Patients at risk of vomiting Common Complications With CPAP Pressure sores Gastric distension Pulmonary barotrauma Reduced cardiac output Hypoventilation Fluid retention 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 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) More treatments if necessary… • Albuterol if wheezing continues from comorbid 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 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 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 engorgement History Prior MI / Chronic Pump Failure Lasix / Lanoxin 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 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 Some New Airway Procedures and Gadgets • Wave-form capnography • Quick-trach • King vision laryngoscope Using capnography in intubation… Capnography • Phase I – Beginning of exhalation when air from anatomic dead space being exhaled – Baseline 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 Capnography • Phase III – Alveolar plateau – CO2-rich alveolar air passing sensor – Flat, straight/slightly angled upward 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 Approach to Patient Normal Capnogram 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. Inline Capnography Bottom Line There are too many esophageal intubations in the field. If you have access to waveform capnography, use it! 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. Colorimetric end-tidal CO2 detector. Quick Trach Cricothyroidotomy Indications • 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. Anatomical Landmarks for Cricothyroidotomy Cricothyroid Membrane Thyroid Cartilage Cricoid Cartilage 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. Quicktrach syringe hub of catheter Picture courtesy Christ Medical Center neck strap stopper Quicktrach Procedure • Patient supine with head slightly extended if no cervical spine trauma suspected • Locate the cricothyroid membrane • Cleanse the overlying skin 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 Quicktrach Procedure cont’d • Ventilate the patient • Secure catheter in place using the strap provided • Confirm placement – Auscultation, bilateral chest rise and fall King Vision Video Laryngoscope 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 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. EKG Strip O’ the Month • AV Blocks Review - AV Junction • AV Junction = AV Node and Bundle of His • Pacemaker cells located throughout AV Junction 62 Review - Functions of AV Node • Backup pacemaker for SA Node • Creates delay between atrial and ventricular depolarizations • Physiologic block for rapid supraventricular rhythms 63 Degrees of AV Blocks • First Degree - Delay in conduction • Second Degree - Some impulses blocked • Third Degree - All impulses blocked 64 First Degree AV Block • An abnormal slowing of AV Junction conduction 65 First Degree AV Block ECG Criteria • Rate - Dependent on underlying rhythm – Interpretation must include underlying rhythm • Rhythm - Dependent on underlying rhythm • P-Waves - Normal morphology with one PWave for each QRS • PRI - > .20 seconds and constant • QRS - Dependent on underlying rhythm 66 First Degree AV Block Clinical Significance • Not usually detrimental and often resolves when ischemia corrected • Must consider entire patient 67 Second Degree AV Blocks • Type I – Also called “Wenckebach” – Also called Mobitz I • Type II – Also called Mobitz II 68 Second Degree AV Block, Type I • Intermittent block in which AV conduction gradually slows until an impulse is blocked • “Long, longer, longer, drop! Long, longer, longer, drop!” 69 Second Degree AV Block, Type I ECG Criteria Rate - Atrial rate unaffected but ventricular rate is less than atrial rate Rhythm - Atrial rhythm usually regular. Ventricular rhythm is irregular with more PWaves 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 70 Second Degree AV Block, Type I Etiology • Often caused by increased parasympathetic tone or drug effect • Can be caused by MI 71 Second Degree AV Block, Type I Clinical Significance • Usually transient with good prognosis • Can reduce cardiac output due to bradycardia 72 Second Degree AV Block, Type II • Intermittent block in which not all P-Waves are conducted to ventricles but there is no progressive prolongation of PRI • “Extra” p-waves. 73 Second Degree AV Block, Type II Etiology • Usually due to MI or other organic heart disease • Rarely the result of increased parasympathetic tone or drug effect 74 Second Degree AV Block, Type II Clinical Significance • Poorer prognosis than Type I • Usually requires pacemaker • Frequently develops into Complete Block 75 Second Degree AV Block, Type II ECG Criteria 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 PWaves than QRS Complexes PRI - Constant for consecutively conducted PWaves QRS - Usually wide but may be narrow if block is at His level or above 76 Second Degree AV Block, Type II Example 77 Third Degree AV Block • 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” 78 AV Dissociation • No relationship between P-waves and QRS complexes 79 Third Degree AV Block Etiology • MI • Increased parasympathetic tone • Drug toxicity 80 Third Degree AV Block ECG Criteria • • • • 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 81 Questions? • Recording of this session will be sent out shortly. • Please feel free to type questions in the text box to the right before we sign off. • Or email questions to [email protected] • Thank you!