Transcript Document
Concepts and Use Presented and adapted by Todd Lang, MD Improve survival Stabilize patient/relieve symptoms Decrease need for other interventions By EMS In ED Specifically, intubations Decrease ICU (and transfers out of area) Reasonably well studied and seems to: Be safe—very rare complications, EMT-B in MI, WI Be effective—several studies show effects above both pre- and in-hospital Boussignac device seems to be best current option to decrease up front cost for this rare intervention CPAP Non-invasive Easily discontinued Easily adjusted Use by EMT-B Minimal complications Does not require sedation Comfortable Intubation Invasive Intubated stays intubated Requires highly trained personnel Significant complications Can require sedation or RSI Potential for infection Conscious patients Transient intervention In the “pre-crash” phase of illness No risk of complications that RSI brings No downstream healthcare implications like intubation/RSI Easier to do with limited people Airway pressure maintained at set level throughout inspiration and expiration Maintains patency of small airways and alveoli Improves gas exchange Improves delivery of bronchodilators Moves extracellular fluid into vasculature Reduces work of breathing Adult Respiratory Distress (Age greater than 12) Routine Medical Assessment Oxygen 2 LPM via Nasal Cannula Titrate to maintain Pulse ox of >92% Is Patient a candidate for Mask CPAP? -Respiratory Rate > 25 / min -Retractions or accessory muscle use -Pulse ox < 94% at any time Yes See CPAP Protocol No Is the Patient wheezing and/or does the Patient have a history of Asthma/COPD? Yes Administer Albuterol / Atrovent by Nebulizer No Does the Patient have rales and/or does the Patient have a history of congestive heart failure (CHF)? No Contact Medical Control Yes Contact Medical Control, consider sublingual NTG if systolic BP is >100mmHg, possible furosemide if long transport Mask CPAP for EMS CPAP Inclusion Criteria (2 or more of the following) -Retractions or Accessory muscle use -Respiratory Rate > 25 / minutes -Pulse Ox < 94% at any time CPAP Exclusion Criteria -Unable to follow commands -Apnea -Vomiting or active GI bleed -Major trauma / pneumothorax Conditions Indicated for CPAP Congestive Heart Failure COPD / Asthma Pneumonia Patient condition is stable or improving Continue CPAP Reassess patient every 5 minutes Asses Patient, record vital signs and pulse ox before applying oxygen Does the Patient meet two or more Inclusion Criteria? No Yes Does the Patient meet any Exclusion Criteria? Yes Continue standard Respiratory Distress Protocol No Administer CPAP 5 cm H2O of pressure AND Patch to Medical Control Respiratory Distress Protocol Reassess patient, vital signs, and respiratory distress scale every 5 min. Patient condition is deteriorating Decreasing LOC Decreasing Pulse Ox Notify Medical Control Complete Airway Data Form and submit PHC for each patient placed on CPAP Remove CPAP Apply BVM Ventilation CHF Pulmonary Edema Near Drowning Inhalation Exposure COPD Asthma Pneumonia Code/cardiac arrest Trauma to face Unable to get a seal with mask Pneumothorax Vomiting/upper GI bleeding Patient intolerance (despite treatment with midazolam) Oxygen supply is rapidly depleted at higher pressure rates Pressure level Most studies show 5cm H20 sufficient Complication rate goes up with pressure 5cm is probably best place to start EMS CPAP and titrate if needed from there CPAP is a non-invasive procedure that is easily applied and can be easily discontinued without untoward patient discomfort Data supports its use in CHF, pulmonary edema, COPD/Asthma, and pneumonia Data support EMS CPAP use and its safety and benefits to patients Boussignac CPAP System Instructions for Use Select the appropriate size face mask for your patient: - Child Mask (Size 3) - Small Adult Mask (Size 4) - Medium Adult Mask (Size 5) - Large Adult Mask (Size 6) Set Oxygen flow to deliver CPAP in cmH2O of water pressure: - 15 liters = 5cmH2O - 20 liters = 7.5 cmH2O - 25 liters = 10 cmH2O Attach the head strap to the hook rings on one side of the Boussignac CPAP mask. Explain to the patient how the Boussignac CPAP will help their breathing. Gently hold the mask to the patients face insuring a good face/mask seal. Turn the flow control device to the desired liters/min, generally 15 l/min, to begin the CPAP. Gradually adjust the flow to achieve the desired level of CPAP. Move the head strap around the patient’s head. Insure that the round disk on the head strap is located on the crown of the patient’s head. Attach the head strap on the hook rings. Check around the mask for any leaks. Adjust the mask and/or head strap accordingly to insure the patient’s comfort. Monitor patient’s vital signs. If the patient requires suctioning of the oral cavity, insert French size suction catheter through the open end of the Boussignac CPAP System. CPAP pressure will not be affected. Fill the nebulizer with the prescribed medication. Insert the 22 mm male end of the nebulizer into the face mask. Insert the 22 male end (white) of Boussignac CPAP into the nebulizer. Monitor patient’s vital signs. Connect the funnel end of the nebulizer’s gas delivery tube to a gas source. Turn on gas source to 6 liters/min. to power the nebulizer. Maintain O2 flow to Boussignac CPAP System at 15 l/min. (5cmH2O).