Transcript Respiratory Emergencies and the Rapid Response Team

Respiratory Emergencies and
the Rapid Response Team
Lauri Stephens RRT-NPS, RPFT
Why Was RRT Called?
• Patient not breathing enough
– Sedation
– Central Nervous System
Depression
• Patient increased WOB Dyspnea
• Dyspnea results from 3 generalized
abnormalities of respiration:
– Changes in ability to maintain
normal respiratory “work”
• Neuromuscular disease-weakness
• Cachexia/Malnutrition
• Decreased respiratory muscle
strength - deconditioning
– An increase in effort/work load
• COPD
• Pleural Effusion
• Restriction
– An increase in ventilatory
requirements
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Anemia
Metabolic acidosis
Fever
Hypercapnia
Evaluation of Dyspnea
• Pulmonary Causes
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Pulmonary Embolism
Pneumothorax
COPD/Asthma Exacerbation
Pleural Effusion
Pulmonary Edema
Airway Obstruction
Aspiration
Hypoxemia
Pneumonia
Infection
Fever
Other- Sepsis
Anemia (Hgb <10)
Metabolic Acidosis
Hyperthyroidism
Chronic Liver Failure
Remember ABC’s
• Psychogenic Causes
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Panic Attack
Anxiety
“Spiritual Distress”
Hyperventilation
• Pain
• Fear
• Cardiac Causes
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Acute MI
CHF
Unstable Angina
Pericarditis
Early Mitral Stenosis
46 yo male, 3 days post admission and treatment
for pneumonia + acute on chronic renal failure.
RRT called for tachypnea/SOB and fever.
• VS - HR 128, RR 30, BP
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127/82 Temp 39.3
91% on 2 lpm
Labs – RBC 1.85, WBC 9.44,
HCT 21% Hgb 7.5
Creatinine 1.7
ABG 7.38 24 85 14
Why is this patient dyspneic?
Pt placed on 40% V-Mask
Lasix given
Second RRT called about 5 hours later. Patient
having increased cough, sputum specimen
obtained. VS about the same.
• ABG – 7.40 20 86 12
• Patient just wants to go home
• Denies any increase in SOB or WOB
• Lungs have decent aeration, bronchial BS
• Decision made to leave him on the floor
• Identify PNA pathogen to guide antibiotic tx
Third RRT in 24 hours called ~ 4 hours later.
• Pt moved to private room
• Now in isolation for
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“whooping cough”
Initial presentation of
pertussis presents as
typical URI, runny nose,
cough & conjunctival
irritation (most
contagious at this point)
Characteristic cough
occurs after 7-10 days
• Many patients will not
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have the classic “whoop”
On the rise
Most deadly in infants
less than 6 months
Pertussis in the Adult Patient
• Up to 32% of adolescents & adults w/cough > 6
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days have serologic evidence of pertussis
In adults w/confirmed pertussis, 80% had a
cough for at least 3 weeks
Vomiting post cough common
We become susceptible 6-10 years post
vaccination
New strains emerging
New DPT booster vaccines for adolescents and
adults recently approved
17 yo male, fractured tib/fib sustained in a soccer
game. Family visiting re-positioned patient’s leg
because he was uncomfortable.
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Pale appearance, normal build
Respiratory rate 36 HR 140
BS clear, diminished in bases
Patient c/o severe SOB “I can’t
breathe”
• Patient c/o chest pain
“Someone sitting on chest”
• Patient placed on 100% NRB
Mask, SpO2 100%
• Patient now c/o “I
can’t feel my legs”
• “My face hurts, I can’t
open my mouth”
• “Am I going to die?”
• ABG
7.77 17 352 22
Family asked to leave the room
Pain meds and anti-anxiety Rx given
Patient relaxed, dyspnea relieved
• Symtoms of hyperventilation:
– Numbness or tingling in
hands, feet or lips
– Lightheadedness/dizziness
– Cofusion
– SOB
– Slurred speech
– Headache
– Chest pain
– Spasms & cramps
– Muscle twitching
– Trismus
• Causes of
hyperventilation
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Stress or anxiety
Pain
Hypoxia
Sepsis
Head injury
Metabolic acidosis
Fever
66 yo, restrained passenger involved in a MVC w/ multiple
trauma and fractured pelvis. 11 days out. Patient became
very SOB and desaturated post working with PT.
• HR 136, RR 32, SpO2
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90% on 100% NRB Temp
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BS unremarkable
Pt c/o stomach pain and
it hurts to take a deep
breath
Pt has occasional
spontaneous dry cough
Edema noted in left leg
Pt is in isolation, wants
something to drink
What would you recommend at this point?
• Risk Factors for PE
• ABG
7.48 30
68 21
• CXR unchanged from previous
• CT ordered – Will patient fit in
scanner? Can she lay flat?
• ???? Isolation
• Patient just wants apple juice
– Prior History DVT or PE
– Recent Surgery, Pregnancy,
Trauma, Fractures or
Immobilzation
– Malignancy, Chemotherapy
– CHF or MI
– Burns
– Old Age, Obesity, Oral
Contraceptives or Estrogen
Replacement
– Varicose Veins
– IV Drug Abuse
– Polycythemia, Hemolytic Anemia,
Fibrinogen Abnormality, Early
Coumadin Therapy and Heparin
Associated Thrombocytopenia
– Type A blood
Pulmonary Emboli Facts
• First or second most
common cause of
unexpected death in most
age groups
• Most commonly (80%)
diagnosed on autopsy
(~60% of pt’s dying in
the hospital + for PE)
• 10% of patients
diagnosed w/PE will die
within 1 hour
• Only 1/3 of the rest will
be diagnosed & treated
• Incidence & findings of massive PE
– 96% Tachypnea
– 58% Rales/Crackles
– 53% Accentuated 2nd Heart
Sound
– 44% Tachycardia
– 43% Fever (>37.8C)
– 36% Diaphoretic
– 24% LE Edema
– 23% Cardiac Murmur
– 19% Cyanosis
640# Paraplegic in for treatment of decubitus
ulcers, history of ostructive sleep apnea.
• RRT called for acute desaturation and patient
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decreased LOC
Patient supine in FluidAir/Clinitron bed
Patient recently had “wound care”
Patient lethargic, with shallow respirations. Will take deep
breaths when stimulated and then falls asleep and RR
decreases to 4. On 100% NRB Mask SpO2 =82%
• Do we need a gas?
• 7.26 82 54 26
• What do you want to
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do now?
Stay on floor or
transfer to unit?
Patient Outcome
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Transferred to unit
Placed in Bariatric air bed
BiPAP 25/8
Patient woke up ~6hours
later
• Patient recognized RCP
from previous episode
• Patient reported that he
had lost ~150 since last
hospitalization
68yo male, chronic renal failure, Hx IVDA &
ETOH, Hep C+, admitted via the ED
overnight with a nosebleed.
• RRT called for inability to awaken patient
• Respirations very irregular, with frequent apnea
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and no respiratory effort observed (was not
obstructing) Cheyne-Stokes respirations
BS essentially clear
SpO2 93% on 3 Lpm
HR 130. BP 90/52
What do you want to know? Any labs? CXR?
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Received Xanax ~ 8 hours ago for agitation
ABG 7.30 61 70 22
Pinpoint pupils
Arouses with stimulation and becomes very agitated
Mumbling about his friend who visited ‘this morning”
RN wants nasal airway placed
Decision made to try Narcan/Naloxone (opioid antagonist).
Patient responded, becoming combative and agitated, but
breathing.
• Should he stay on floor or
transfer to unit?
• Narcan takes effect in about 2
minutes and lasts ~45 minutes
• Duration of action of narcotics
may exceed that of Narcan
• Dose to response- .4mg2mgQ2-3 minutes up to 10mg
88 yo edentulous male, status post CVA. RRT
called for SpO2 of 77% on 3 LPM and increased
WOB.
• Rhonchorus BS heard
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from bedside
Loose, wet cough
Intercostal retractions
and use of accesory
muscles present
Patient lethargic,
breathing with mouth
“open”
RR 28, HR 112 BP
102/70
What is your first “move”?
• “A” for airway!
• Secretions pooling back
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of throat
Oral mucosa noted to be
very dry
Huge oral cast cleared
from pharynx
Patient needs hydration &
frequent oral care
44yo 5 days post motorcycle vs car. C-2 fracture, pelvic
fracture and left clavicle fracture. Some concern over
possible vertebral artery injury.
• RRT called for Mental
status changes
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Doesn’t recognize wife
Speaking gibberish
Vital signs all WNL
Difficult to assess
BS/Chest due to Halo
– Wife reports difficult
night and patient
being very anxious
What are your concerns?
• ABG 7.53 28 112 22
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on room air
Now what?
Head CT normal
Can he stay on floor
or does he need to
transfer?
The End