Respiratory Emergencies

  • Croup
  • Obstructive or Reactive Airway Diseases Adult
  • Obstructive or Reactive Airway Diseases Pediatric
  • Pulmonary Edema
  • Smoke Inhalation
    Responsive
  • Smoke Inhalation
    Unresponsive
  • Carbon Monoxide Poisoning

Croup

CRITERIA: If the patient with difficulty breathing is at least 6 months of age and the cause is suspected to be croup (e.g., the patient has stridor at rest with retractions and/or accessory muscle use):

 

BLS

 

  1. Begin Initial Medical Care.
  2.  

  3. Follow Airway Management protocol.
  4.  

  5. Follow Oxygen Administration Protocol.
  6.  

  7. If the patient is in moderate to severe respiratory distress per the Oxygen Administration Protocol, call for a paramedic unit.
  8.  

  9. If possible, administer humidified oxygen via the blow-by method.
  10.  

    ALS

     

    1. Administer one of the following treatments:
    2.  

      1. The preferred treatment is 0.5 ml of 2.25% racemic epinephrine (Vaponephrine) diluted with 4.5 ml of 0.9% normal saline (for a total volume of 5 ml) and administered by nebulizer with 5-6 lpm oxygen.
      2.  

      3. If racemic epinephrine is unavailable administer 5 ml of 1:1,000 epinephrine by nebulizer with 5-6 lpm oxygen.

       

    3. Apply the cardiac monitor.
    4.  

    5. If the patient becomes unresponsive or is markedly short of breath, a nebulizer may be connected to a BVM using a "flex connector" to administer racemic epinephrine or epinephrine. Two oxygen connections will be required. The nebulizer will require an oxygen connection at 5-6 lpm in addition to a high flow connector for the BVM.

     

Obstructive or Reactive Airway Disease

  1. Administer oxygen as indicated - (See Oxygen Administration Protocol)

 

BLS

 

  1. If the patient presents with shortness of breath related to a known diagnosis of COPD or asthma, determine if the patient has physician-prescribed hand-held inhaler or nebulizer. If available, assist with one of the following:
  2.  

    1. Metered Dose Inhalers **Use with spacer device if possible**
      1. Albuterol (with or without Ipratropium) – one dose (2-4 puffs)
      2. Levalbuterol – one dose (2 puffs)

       

    2. Nebulizers (EMTs may connect nebulizer to oxygen at 6 LPM)
      1. Albuterol, Albuterol/Ipratropium (Combivent), or Levalbuterol – one dose as prescribed by patient’s physician.

     

  3. Reassess patient. Anticipate need for assisting ventilations with BVM and high flow O2.

     

  4. Request ALS if not already en route. If the BLS crew is able to deliver the patient to an emergency room within the same time it would take for the ALS crew to respond to the scene, the BLS crew should transport the patient.
  5.  

  6. If a treatment was initiated by a fire department, you must document the exact dose given in the assessment/treatment of EMR.

 

Common Inhaled Medications
 

    Albuterol aka: Proventil, Ventolin, Combivent
    Ipratropium bromide aka: Atrovent
    Xoponex aka: levalbuterol

 

ALS

 

If difficulty breathing is suspected from reactive airway disease or obstructive airway disease and there is no improvement from prescribed inhaler or if no inhaler was administered:

 

  1. Administer albuterol, 2.5 mg and ipratropium 0.5 mg nebulized with 5-6 lpm of oxygen
  2.  

      No more than three doses of ipratropium should be administered.
      Albuterol dose should be increased to 5 mg if the patient uses an albuterol nebulizer regularly.
      Nebulizer treatments should be repeated as needed.
      If you suspect the SOB is due to CHF, refer to the CHF protocol

     

  3. Apply the cardiac monitor, pulse oximeter, and waveform capnography to the patient.
  4.  

  5. Initiate a peripheral IV, if necessary.
  6.  

    If the patient has a history of asthma and presents in
    respiratory arrest, impending respiratory failure
    (such as altered mental status, poor respiratory effort),
    or status asthmaticus administer epinephrine IM.
    For Adults, administer 0.3mg Epinephrine 1:1,000 IM.

     

  7. If the patient is still markedly short of breath, hypoxemic (oxygen saturation <92% on non-rebreather), or in the judgment of the Paramedic immediate CPAP would be beneficial CPAP may be initiated immediately in conjunction with medication therapies (see specific protocol). Alternatively, provide BVM ventilations with in-line treatments.
  8.  

  9. If the patient has a history of asthma and continues to decline with treatment (e.g. if you have initiated CPAP or BVM ventilations with in-line nebulized treatment) administer 0.3mg Epinephrine 1:1,000 IM if not already given
  10.  

  11. For patients 18 years or older who are receiving a 2nd nebulized treatment OR are being placed on CPAP, give ONLY ONE of the following treatments.
  12.  

    1. Oral Prednisone 50-60mg.
    2. Methylprednisolone 125mg IV/IM.

     

  13. (Optional) Consider the following if the patient does not improve after two (2) albuterol and ipratropium treatments, is still in respiratory distress or begins to worsen, and has been given Corticosteroids AND Epinephrine,
  14.  

    1. Normal Saline 500-1000mL Bolus
    2. Administer Magnesium Sulfate 2g over 20 minutes

     

  15. If a treatment was initiated by a fire department, you must document the exact dose given in the assessment/treatment of EMR.
  16.  

     In-Line BVM Setup

Medication Guidelines

 

For patients 18 years or older who are receiving a 2nd nebulized treatment OR are being placed on CPAP, give ONLY ONE of the following treatments.

 

  1. Oral Prednisone 50-60mg.
  2.  

    1. This treatment should be used for patients with mild-moderate symptoms who can swallow the medication without difficulty.
    2.  

    3. Do not give this medication if you believe the SOB is due to a mechanism other than an Asthma or COPD exacerbation.

     

  3. Methylprednisolone 125mg IV/IM.
  4.  

    1. This treatment should be used for patients with severe symptoms and who are unable to swallow oral medications.
    2.  

    3. If the patient is being placed on CPAP due to CHF symptoms DO NOT administer methylprednisolone.
    4.  

    5. Do not administer this medication if you believe the SOB is due to mechanism other than an Asthma or COPD exacerbation.

     

  5. Magnesium Sulfate (Adults Only)
  6.  

    1. Administer 2g over 20 minutes
Table is for 2g in 50mL
Drop set
10
15
20
gtt/min
25
38
50

Pediatric
Obstructive or Reactive Airway Diseases

  1. Administer oxygen as indicated - (See Oxygen Administration Protocol)

 

BLS

 

  1. If the patient presents with shortness of breath related to a known diagnosis of COPD or asthma, determine if the patient has physician-prescribed hand-held inhaler or nebulizer. If available, assist with one of the following:
  2.  

    1. Metered Dose Inhalers **Use with spacer device if possible**
      1. Albuterol (with or without Ipratropium) – one dose (2-4 puffs)
      2. Levalbuterol – one dose (2 puffs)

       

    2. Nebulizers (EMTs may connect nebulizer to oxygen at 6 LPM)
      1. Albuterol, Albuterol/Ipratropium (Combivent), or Levalbuterol – one dose as prescribed by patient’s physician.

     

  3. Reassess patient. Anticipate need for assisting ventilations with BVM and high flow O2.

     

  4. Request ALS if not already en route. If the BLS crew is able to deliver the patient to an emergency room within the same time it would take for the ALS crew to respond to the scene, the BLS crew should transport the patient.

 

Common Inhaled Medications
 

    Albuterol aka: Proventil, Ventolin, Combivent
    Ipratropium bromide aka: Atrovent
    Xoponex aka: levalbuterol

 

ALS

 

If difficulty breathing is suspected from reactive airway disease or obstructive airway disease and there is no improvement from prescribed inhaler or if no inhaler was administered:

 

  1. Administer albuterol, 2.5 mg and ipratropium 0.5 mg nebulized with 5-6 lpm of oxygen
  2.  

      No more than three doses of ipratropium should be administered.
      Albuterol dose should be increased to 5 mg if the patient uses an albuterol nebulizer regularly.
      Nebulizer treatments should be repeated as needed.
      If you suspect the SOB is due to CHF, refer to the CHF protocol

     

  3. Apply the cardiac monitor, pulse oximeter, and waveform capnography to the patient.
  4.  

  5. Initiate a peripheral IV, if necessary.
  6.  

    If the patient has a history of asthma and presents in
    respiratory arrest, impending respiratory failure
    (such as altered mental status, poor respiratory effort),
    or status asthmaticus administer epinephrine IM.
    For Pediatric patients over 2 years old,
    administer 0.01 mg/kg Epinephrine 1:1,000 IM.
    (Max 0.3 mg)

     

  7. If the child is markedly short of breath, hypoxemic (oxygen saturation <92% on non-rebreather), BVM ventilations may be initiated immediately in conjunction with medication therapies with in-line treatments
  8.  

  9. If the patient is over the age of 2 years with a KNOWN history of asthma and continues to decline despite treatments administer
    0.01 mg/kg Epinephrine 1:1,000 IM. (Max 0.3 mg) if not already given
  10.  

  11. If the patient is over the age of 2 years with a KNOWN history of asthma AND are receiving a 2nd nebulized treatment, give ONLY ONE of the following treatments.
    1. Oral Prednisone 50-60 mg IF able to swallow pills and >30kg
    2. Methylprednisolone 2 mg/kg IV (maximum dose 125 mg IV)

     

  12. If a treatment was initiated by a fire department, you must document the exact dose given in the assessment/treatment of EMR.
  13.  

Pulmonary Edema

ALS

 

If difficulty breathing is suspected from pulmonary edema:

 

  1. If SBP is 90 mm Hg or greater, administer up to three (3) 0.4 mg doses of nitroglycerin sublingually (SL) and repeat up to three 0.4 mg SL doses every 3 minutes until the patient’s respiratory distress is relieved or the SBP is < 90 mm Hg.
  2.  

  3. See note below – Nitroglycerin and Viagra, etc.
  4.  

  5. If the patient is still markedly short of breath and hypoxemic (oxygen saturation < 92% on 100% oxygen) after the first dose of nitroglycerin dosing, CPAP may be initiated (see specific protocol)
  6.  

  7. Nitroglycerin should continue to be administered as above every 3 minutes as long as the patient remains dyspneic and systolic BP > 90 mm Hg.
  8.  

  9. Apply the cardiac monitor, pulse oximeter, and waveform capnography to the patient.
  10.  

  11. Initiate an IV.
The combination of nitroglycerin and Viagra®, Revatio® (sildenafil), Levitra® (vardenafil), or Cialis® (tadalafil) have been found to cause precipitous and irreversible hypotension.

 

    Ask every chest pain patient whether or not he/she has been on Viagra, etc. and, if so, when was the last dose? Document this on every run sheet involving the cardiac chest pain patient (even those who deny using Viagra or similar medications).

     

    DO NOT automatically administer nitroglycerin to any patient who has had Viagra, etc. within the past week. Consult with the receiving physician for appropriateness.

Smoke Inhalation - Responsive

BLS

 

  1. Assess for and manage trauma or burns per the appropriate protocol.
  2.  

  3. Carbon monoxide and cyanide toxicity should be considered for any patient who experiences smoke inhalation in an enclosed space. See Carbon Monoxide Poisoning Protocol.
  4.  

  5. Apply the cardiac monitor, pulse oximeter, and waveform capnography to the patient. (Pulse oximetry monitors may give false readings in patients exposed to carbon monoxide.)
  6.  

    1. Provide high flow O2
    2.  

    3. Request ALS if not already en route
ALS

 

No evidence of significant cyanide toxicity

 

  1. Provide high flow O2 by NRB mask
Soot in airway and 1) altered level of consciousness or 2) hypotension

 

  1. Ensure an airway and provide high flow O2
  2.  

  3. For wheezing or stridor, treat with 2.5-5 mg nebulized albuterol as needed.
  4.  

  5. Establish an IV
  6.  

  7. Draw blood samples
  8.  

  9. Adult:
  10.  

    1. If available, mix both Cyanokit® 2.5 g vials, each with 100 cc of 0.9% NaCl, and administer all of the fluid over 15 minutes (~15 ml/minute).

     

  11. Pediatric
  12.  

    1. If available, mix one or both Cyanokit® 2.5 g vials, each with 100 cc of 0.9% NaCl, and administer 70 mg/Kg over 15 minutes.

     

  13. If hypotensive, consider fluid challenge(s)
  14.  

  15. Transport emergently to closest appropriate hospital

Smoke Inhalation - Unresponsive

BLS

 

  1. Assess for and manage trauma or burns per the appropriate protocol.
  2.  

  3. Carbon monoxide and cyanide toxicity should be considered for any patient who experiences smoke inhalation in an enclosed space. See Carbon Monoxide Poisoning Protocol.
  4.  

  5. Apply the cardiac monitor, pulse oximeter, and waveform capnography to the patient. (Pulse oximetry monitors may give false readings in patients exposed to carbon monoxide.)
  6.  

    1. Establish airway with OP, NP or non-visualized airway
    2.  

    3. Provide high flow O2 by NRB mask or BVM
    4.  

    5. Request ALS if not already en route
    6.  

    7. If BLS can transport the patient before ALS can arrive at the scene, do so.
ALS

 

  1. Ensure an airway and provide high flow O2
  2.  

  3. For wheezing or stridor, treat with 2.5-5 mg nebulized albuterol as needed.
  4.  

  5. Establish an IV; if patient is in cardiac arrest, establish 2 IVs
  6.  

  7. Draw blood samples
  8.  

  9. Adult:
  10.  

    1. If available, mix both Cyanokit® 2.5 g vials, each with 100 cc of 0.9% NaCl, and administer all of the fluid over 15 minutes (~15 ml/minute).

     

  11. Pediatric
  12.  

    1. If available, mix one or both Cyanokit® 2.5 g vials, each with 100 cc of 0.9% NaCl, and administer 70 mg/Kg over 15 minutes.

     

  13. If hypotensive, consider fluid challenge(s)
  14.  

  15. Transport emergently to closest appropriate hospital

Carbon Monoxide Poisoning

Patients suffering from exposure to byproducts of combustion should, when feasible, have a carbon monoxide (CO) level recorded using a co-oximeter device. These situations include fire victims or smoke inhalation exposure to CO, firefighters during rehab activities, patients or families with complaints of general illness or headache. EMS providers should make efforts to assure that firefighters are assessed for elevated levels of CO after structural firefighting activities.

 

BLS

 

  1. Refer to Airway Management protocol.
  2.  

  3. Obtain vital signs.
  4.  

  5. Obtain CO determination using a co-oximeter device if available.
  6.  

  7. CO level 10% or greater and/or symptomatic - 100% NRB O2 and transport to nearest appropriate hospital

 

ALS

 

  1. Initiate IV Access when appropriate.
  2.  

  3. Treat arrhythmias per appropriate protocol when present.

 

Notes

 

  1. Remember that pulse oximetry should not be used as a determination of oxygenation in the patient with elevated carboxyhemoglobin.
  2.  

  3. Smokers may have a baseline CO level as high as 5-6%