EMS Airway Management - Lungs Sounds

EMS Providers should have a solid understanding of normal lung sounds and be able to recognize those that are adventitious lung, as these can provide crucial information about a patient's respiratory status. 

Here’s an overview of the key points regarding lung sounds:

1. Normal Lung Sounds

• Vesicular Breath Sounds: These are the standard breath sounds heard over most of the lung fields. They are soft, low-pitched, and have a longer inspiratory phase than expiratory phase.
  • Characteristics: "Gentle rustling" sound, more prominent in the bases of the lungs.
  • Cause: Normal airflow through the large and small bronchi and alveoli.

2. Adventitious (Abnormal) Lung Sounds

Adventitious Sounds are additional lung sounds superimposed on normal breath sounds. They indicate an underlying pathology. They include:

Stridor

• Description: A high-pitched, harsh sound heard during inspiration.
• Cause: Caused by a partial obstruction of the upper airway (i.e., larynx).
• Common Conditions:
• Croup: Typically in children, caused by a viral infection that leads to inflammation.
• Epiglottitis: Life-threatening condition caused by bacterial infection.
• Airway Obstruction: Foreign body or severe anaphylaxis.
  
• Sound File: Stridor

Wheezing

• Description: High-pitched, musical sounds, typically heard during expiration (but can be heard on inspiration as well).
• Cause: Narrowing or obstruction of the lower airway (i.e., trachea)
• Common Conditions:
  • Asthma: Due to bronchospasm and inflammation.
  • COPD: From chronic airway obstruction.
  • Bronchiolitis: Inflammation of the small airways, common in infants.
• Sound File: Wheezing

Rhonchi

• Description: Low-pitched, snoring or gurgling sounds, often cleared with coughing.
• Cause: Secretions or mucus in the larger airways (i.e., bronchi; bronchioles)
• Common Conditions:
  • Chronic Bronchitis: Increased mucus production and obstruction.
  • Pneumonia: Accumulation of mucus and fluids.
  • Bronchiectasis: Chronic enlargement and inflammation of bronchi.
• Sound File: Rhonchi

Rales (Crackles)

• Description: Fine or coarse, popping or crackling sounds, more prominent during inspiration.
  • Fine Crackles: High-pitched, short, and intermittent.
  • Coarse Crackles: Low-pitched, bubbling or rattling.
• Cause: Fluid in the small airways (i.e., alveoli)
• Common Conditions:
  • Heart Failure (Pulmonary Edema): Fluid accumulation in the alveoli.
  • Pneumonia: Fluid or pus within alveoli due to infection.
  • Fibrosis: Stiffening of lung tissue.
• Sound File: Fine & Course

Pleural Friction Rub

• Description: Low-pitched, grating sound, like creaking leather, heard during both inspiration and expiration.
• Cause: Inflammation of the pleural layers causing them to rub together.
• Common Conditions:
  • Pleuritis: Inflammation of the pleura, often due to infection or autoimmune disorders.
  • Pulmonary Embolism: Can lead to pleuritic inflammation and pain.
• Sound File: Pleural Friction Rub

3. Other Abnormal Lung Findings

Pleural Effusion

• Description: Presence of fluid in the pleural space, usually causing a decrease in normal lung sounds over the affected area.

• Common Conditions:

  • Heart Failure: Increased hydrostatic pressure causes fluid leakage into the pleural space.
  • Infection (e.g., Pneumonia): Inflammatory fluid accumulation.
  • Cancer: Malignant pleural effusions.

• Physical Exam Findings:

  • Decreased breath sounds over the affected area.
  • Dullness to percussion due to fluid presence.

Key Points for EMS Providers

• Stridor is a red flag indicating upper airway obstruction — immediate airway assessment is critical.

• Wheezing typically suggests lower airway narrowing; listen carefully to both inspiratory and expiratory phases.

• Rhonchi may indicate the need for airway clearance (e.g., suctioning).

• Crackles (rales) suggest fluid in the lungs — think about causes like heart failure or infection.

• Pleural Friction Rub can indicate pleuritic pain and requires assessment for underlying conditions like pleuritis or PE.

• Assess for Patient Symptoms: Correlate lung sounds with symptoms (e.g., shortness of breath, cough, sputum production, chest pain) for a more complete clinical picture.

Recognizing and differentiating these sounds can help EMS providers make critical early decisions about management and transport.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bickley, L. S., & Szilagyi, P. G. (2020) Bates' Guide to Physical Examination & History Taking (13th Ed). Philadelphia, Pennsylvania: Wolters Kluwer.

Bohadana, A., Izbicki, G., & Kraman, S. S. (2014) Fundamentals of Lung Auscultation. New England Journal of Medicine, 370(8): 744-751. Accessed October 8, 2024

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins.

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Sarkar, M., Madabhavi, I., Niranjan, N., & Dogra, M. (2015) Auscultation of The Respiratory System. Annals of Thoracic Medicine 10(3):158-168. Accessed October 8, 2024

EMS Medication Administration - Inhalation Route

EMS Providers need to have a thorough understanding of inhaled medication administration to ensure patient safety and effective treatment. 

Here are some key points they should know:

1. Indications and Contraindications

Indications:

• Respiratory distress due to conditions like asthma, chronic obstructive pulmonary disease (COPD), or anaphylaxis.
• Administration of medications such as bronchodilators (e.g., albuterol), corticosteroids, and emergency medications (e.g., epinephrine via nebulizer for severe allergic reactions).

Contraindications:

• Allergy to the medication.
• Inability of the patient to effectively inhale the medication (e.g., severe respiratory distress, altered mental status).
• Situations where the administration method (e.g., nebulizer, metered-dose inhaler) is not suitable due to specific patient conditions or environmental factors.

2. Types of Inhaled Medications

Metered-Dose Inhalers (MDIs): 

Pressurized canisters that deliver a specific dose of medication in aerosol form.

Dry Powder Inhalers (DPIs): 

• Devices that deliver medication in powder form which the patient inhales.

Nebulizers: 

• Devices that convert liquid medication into a fine mist for inhalation over several minutes.

Breath-Actuated Inhalers: 

• Devices that release medication automatically when the patient inhales.

3. Preparation and Technique

Medication Preparation:

• Verify the “Six Rights” of medication administration: right patient, right medication, right dose, right route, right time and right documentation.
• Ensure the inhaler or nebulizer is properly assembled and medication is correctly loaded.

Patient Preparation:

• Ensure the patient is in an upright position to maximize lung expansion and facilitate proper inhalation.
• Instruct the patient on how to use the inhaler or nebulizer correctly.

4. Administration Techniques

MDIs:

• Shake the inhaler well before use.
• Attach a spacer if recommended, which helps in delivering more medication to the lungs.
• Have the patient exhale fully, place the mouthpiece in their mouth, and inhale slowly and deeply while pressing the canister to release the medication.
• Instruct the patient to hold their breath for about 10 seconds before exhaling slowly.
• Wait about a minute between puffs if a second dose is needed.

DPIs:

• Load the dose according to the inhaler’s instructions.
• Have the patient exhale fully away from the inhaler, place the mouthpiece in their mouth, and inhale quickly and deeply.
• Instruct the patient to hold their breath for about 10 seconds before exhaling slowly.

Nebulizers:

• Assemble the nebulizer and add the prescribed medication to the medication cup.
• Attach the mouthpiece or mask to the nebulizer.
• Turn on the nebulizer and have the patient inhale the mist steadily until the medication is finished (usually 5-10 minutes).

5. Patient Communication and Education

Explain the Medication: 

• Inform the patient about the purpose of the medication, how it will help, and any potential side effects.

Instructions: 

• Provide clear instructions on how to use the inhaler or nebulizer, including breathing techniques and the importance of taking slow, deep breaths.

6. Monitoring and Follow-Up

Observe for Effects: 

• Monitor the patient for the expected therapeutic effects and any adverse reactions.

Reassessment: 

• Regularly reassess the patient’s respiratory status, including breath sounds, respiratory rate, and oxygen saturation, to determine the effectiveness of the medication and any need for additional intervention.

7. Complications and Management

Incorrect Usage: 

• Ensure the patient understands and correctly follows the administration technique to avoid ineffective dosing.

Adverse Reactions: 

• Be prepared to manage potential adverse reactions, such as tachycardia, tremors, or paradoxical bronchospasm.

Device Malfunction: 

• Recognize and troubleshoot any issues with the inhaler or nebulizer.

8. Special Considerations

Pediatric and Geriatric Patients: 

• Adjust instructions and consider additional challenges in administering inhaled medications to these populations, such as the use of spacers for children or coordination issues in the elderly.

Environmental Factors: 

• Ensure the environment is suitable for nebulizer use, especially in situations where power sources may be limited or there is a risk of spreading infectious aerosols.

Patient Condition: 

• Be aware of any conditions that might affect inhaled medication administration, such as severe respiratory distress, altered mental status, or inability to follow instructions.

9. Training and Proficiency

Simulation Training: 

• Regular practice using simulation models to maintain proficiency in inhaled medication administration techniques.

Continuing Education: 

• Stay updated on best practices, new medications, and techniques for inhaled administration.

10. Legal and Ethical Considerations

Scope of Practice: 

• Adhere to the legal scope of practice for their certification level and local regulations.

Informed Consent: 

• Obtain informed consent from the patient or guardian whenever possible.

Documentation: 

• Accurate documentation of medication name, dose, route, time of administration, and any observed effects or adverse reactions.

Conclusion

Effective inhaled medication administration requires EMS providers to combine theoretical knowledge with practical skills. 

Continuous training, adherence to protocols, and understanding the indications, techniques, and potential complications are essential for safe and effective patient care.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Particular Patient Populations - Geriatric Emergencies

EMS providers play a crucial role in managing geriatric emergencies, as the elderly population often presents with unique medical challenges.

Here are some key considerations, common presentations, and possible treatment plans for geriatric emergencies in the prehospital setting:

Key Considerations:

Physiological Changes: Aging leads to physiological changes, such as decreased organ function, altered drug metabolism, and reduced reserve capacity. Be mindful of these changes when assessing and treating elderly patients.

Atypical Presentations: Geriatric patients may present with atypical symptoms, making diagnosis challenging. For example, myocardial infarction may manifest as confusion or weakness rather than classic chest pain.

Polypharmacy: Elderly individuals often take multiple medications, increasing the risk of drug interactions and adverse effects. Obtain an accurate medication history and be alert to potential complications.

Frailty and Fall Risk: Falls are a common geriatric emergency. Assess for frailty, perform fall risk assessments, and address environmental factors that may contribute to falls.

Cognitive Impairment: Cognitive conditions like dementia can complicate patient assessment and communication. Collaborate with family members or caregivers for additional information.

Common Presentations:

Falls: Assess for injuries, especially head injuries and fractures. Consider the possibility of syncope, medication-related issues, or environmental factors contributing to the fall.

Chest Pain and Cardiac Issues: Look beyond classic symptoms; consider fatigue, shortness of breath, or altered mental status. Monitor for signs of heart failure or arrhythmias.

Respiratory Distress: Evaluate for pneumonia, chronic obstructive pulmonary disease (COPD) exacerbation, or heart failure. Be aware of potential complications related to decreased respiratory reserve.

Altered Mental Status: Determine the cause, considering infectious, metabolic, or neurological etiologies. Hypoglycemia, infections, and medication side effects are common contributors.

Abdominal Pain: Assess for gastrointestinal issues, urinary tract infections, or other abdominal pathologies. Consider the possibility of atypical presentations.

Common Treatment Plans:

Airway Management: Be prepared for airway management challenges, especially if the patient has altered anatomy or decreased respiratory reserve.

Pain Management: Manage pain appropriately, considering the potential for undertreatment due to fears of side effects or drug interactions.

Medication Administration: Administer medications cautiously, considering altered pharmacokinetics and potential drug interactions. Be aware of medications that may cause or exacerbate falls.

Fluid Management: Monitor fluid status carefully, especially in patients with heart failure. Adjust fluid administration based on the patient's hemodynamic status.

Transport to Appropriate Facilities: Consider transporting geriatric patients to facilities with expertise in the care of the elderly, as they may have specialized resources and staff.

Collaboration with Family and Caregivers: Communicate effectively with family members or caregivers to gather crucial information and involve them in the decision-making process.

Prevention Strategies: Provide education on fall prevention, medication management, and strategies to maintain overall health and well-being.

Conclusion:

EMS providers should approach geriatric emergencies with a comprehensive understanding of the unique challenges associated with the elderly population.

By considering the physiological changes, atypical presentations, and specific needs of geriatric patients, EMS providers can deliver more effective and tailored prehospital care.

Ongoing education and training in geriatric emergency medicine are essential for improving outcomes in this vulnerable population.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Medical Emergencies - COPD

EMS providers should be aware of several key points regarding Chronic Obstructive Pulmonary Disease (COPD).

COPD is a chronic respiratory condition characterized by airflow limitation and difficulty breathing. Here are some important aspects to consider:

1. Presentation: Patients with COPD typically experience symptoms such as shortness of breath, wheezing, coughing (often with sputum production), and chest tightness. These symptoms may vary in severity and can be exacerbated by triggers like respiratory infections or exposure to irritants.

2. Prehospital Treatment: The primary goals of prehospital treatment for COPD exacerbations are to relieve symptoms, improve oxygenation, and prevent further deterioration.

This can be achieved through various interventions, including:

- Administering Supplemental Oxygen: High-flow oxygen should be provided to maintain oxygen saturation above 90%.

- Bronchodilator Therapy: Albuterol is a commonly used bronchodilator that helps relax the airway smooth muscles, improving airflow. It can be delivered via nebulization or metered-dose inhalers (MDIs) with a spacer.

- Corticosteroids: Oral or intravenous corticosteroids (e.g., prednisone) help reduce airway inflammation and improve lung function.

3. Potential Care: In addition to the immediate treatments mentioned above, EMS providers should consider the following aspects of care:

- Assessing and monitoring vital signs, including oxygen saturation, heart rate, and respiratory rate.

- Ensuring patient comfort and positioning, such as allowing the patient to sit upright or in a position that aids breathing.

- Transporting the patient to an appropriate healthcare facility, especially if symptoms are severe or if the patient's condition is not improving with initial interventions.

- Collaborating with the receiving facility's healthcare professionals to provide a smooth transition of care.

Remember, COPD is a chronic condition, and EMS providers should be prepared to manage acute exacerbations while considering long-term management strategies and the patient's overall care plan.