Overdose/poisoning

Respiratory Distress/Failure - General

Criteria:

Treatment:
EMT-B:
¾ V/S and SpO2 (with and without Oxygen therapy if possible) ¾ Blood glucose analysis: if less than 80 mg/dL, refer to hypoglycemia protocol
¾ Albuterol 2.5 mg via nebulizer (6L/min.)
¾ IV NS at TKO (if hypotensive, titrate to SBP of greater than 100 mmHg)
General:
As soon as reasonably possible, reference a more specific protocol. Consider these
differentials:
♦ Foreign Body Airway Obstruction - sudden onset, stridor or snoring, cyanosis, no air
♦ Asthma - relatively rapid onset, wheezing or silence, history of asthma ♦ COPD - gradual onset, history of COPD or long-term cigarette use ♦ Pneumonia - gradual onset, recent history of upper respiratory infection, fever, chest ♦ Pulmonary edema - sudden onset, history of hypertension, or cardiac or renal problems, presents with hypertension and/or irregular HR ♦ Pulmonary embolus - sudden onset, chest or back pain, history of recent surgery, childbirth, long-term immobility, or irregular HR ♦ Allergic reaction - sudden onset, urticaria, itching, edema, history of allergies ♦ Hyperventilation - recent history of anxiety/emotional upset, facial tingling and/or ♦ Myocardial infarction - chest pain, accompanied by nausea, diaphoresis, radiating pain PEDIATRIC Consideration: Cardiopulmonary arrest in infants and children is not usually a sudden event. Instead, it is often the end-result of a progressive deterioration in respiratory and circulatory function, the common pathway of which is cardiopulmonary failure, regardless of the underlying disease. Respiratory failure and shock may begin as two distinct syndromes, but they progress to an indistinguishable state of cardiopulmonary failure in the final moments before arrest. Their common denominator lies in the insufficient oxygen delivery to tissues and reduced clearance of metabolites. In shock, low cardiac output rates may deliver well-oxygenated blood to the tissues, but it is delivered too slowly to meet the tissues' metabolic demand. In advanced respiratory failure, poorly oxygenated blood may be delivered at a normal or elevated flow rate to the tissues. In both cases, hypoxia is present. Respiratory Distress/Failure (continued)

Respiratory failure may occur because of intrinsic lung or airway disease or because of
inadequate respiratory effort. As with shock, respiratory failure is often preceded by a
"compensated" state (respiratory distress) in which the patient is able to maintain adequate
gas exchange at the expense of an increase in the work of breathing. This is seen in the
use of accessory muscles of respiration, inspiratory retractions, tachypnea, and
tachycardia.
Any child manifesting the following conditions requires immediate attention and
treatment:
• Heart rate greater than 180 or less than 80 (under 5 years) Greater than 160 or less than 60 (over 5 years) EVERY EMS PROVIDER WORKING WITH SICK CHILDREN SHOULD BE ABLE TO DIAGNOSE PULMONARY AND CIRCULATORY FAILURE AND IMPENDING CARDIOPULMONARY ARREST BASED ON A RAPID CARDIOPULMONARY This assessment should take less than half a minute to complete and, by integrating important physical findings, is designed to evaluate pulmonary and cardiovascular integrity. Respiratory Distress (continued)
Asthma/ COPD /Pneumonia

Criteria:
¾ Shortness of breath AND
¾ Auscultated findings of bronchospasm (wheezes or silence)
¾ Exacerbation of chronic bronchitis or emphysema WITH:
¾ Shortness of breath or dyspnea
¾ History of COPD

Treatment:
EMT-B:
¾ V/S
¾ Albuterol 2.5 mg via nebulizer. May repeat once in 5 min if dyspnea not relieved.
¾ Pediatric treatment: Albuterol 2.5 mg via nebulizer.
¾ Blood glucose analysis: if less than 80 mg/dL refer to hypoglycemia protocol
¾ If febrile (greater than 100.5º F), Acetaminophen (see dosage chart)
¾ IV NS TKO ¾ Consider endotracheal intubation if patient condition warrants (especially when SpO2 <90%)
General:
See BRONCHIOLITIS/PNEUMONIA: PEDIATRIC for further pediatric treatment details.
Asthma:
¾ The asthma treatment regimen may be thought of as oxygenate, dilate, and hydrate. o IV should be NS at 250-500 ml/hr. o Bronchial/alveolar dehydration (due to tachypnea) is a component of an o Hydration will often allow the patient to clear mucous plugs and may result in ¾ The severely dyspneic and hypoxic asthma patient may require intubation. ¾ CO2 retention and hypercarbia resulting in a respiratory acidosis are major culprits in COPD. Hypercarbia can be managed ONLY by increasing tidal volume by PPV with a BVM. BVM assist should be used in the patient with marked obtundation or respiratory insufficiency (rate less than 12/min or greater than 40/min).
¾ COPD patients can be very difficult to "wean" from the ET tube and/or ventilator. If
the patient's airway and ventilatory status can be managed without intubation, try to do so. DO NOT, however, jeopardize the patient's survival in order to avoid intubation.
Respiratory Distress (continued)

Pneumonia:
¾ Signs and symptoms of pneumonia are as follows: ¾ Dyspnea WITH one or more of the following: ¾ Pneumonia has a high mortality rate, especially among the elderly. EMS personnel must recognize this as a serious chief complaint. EMS personnel often confuse pneumonia, especially severe cases, with pulmonary edema. Pneumonia may present with a wide variety of auscultated breath sounds, including rales. History and associated signs/symptoms are the best tools to differentiate pneumonia from other sources of respiratory distress. o Gradual onset of symptoms, usually over a few days o A recent history of upper respiratory infection symptoms, including a productive (sometimes purulent) cough, fever, and chest wall pain ¾ Some pneumonia patients may present with wheezing (as may acute MI, severe allergic reactions, etc.); this may be a product of reactive bronchospasm (in response to the presence of the bacteria), or (more likely) an indication of narrowing of the small airways from the physical obstruction of infectious material. o Occasionally, these patients may show some improvement with the administration of bronchodilators. Most often, however, the bronchodilators will have no appreciable affect, as these are usually not true cases of reversible bronchospasm. Respiratory Distress (continued)

Bronchiolitis/Pneumonia: Pediatric
Criteria: Pediatric patient with:
¾ Dyspnea ¾ WITHOUT evidence of upper airway obstruction ¾ WITH evidence of lower airway involvement (wheezes, crackles, forced exhalation)
Treatment:
EMT-B:
¾ V/S
¾ Maintain normothermia
¾ Albuterol 2.5 mg via nebulizer for mild to moderate dyspnea
¾ If febrile, administer Acetaminophen (see reference for medication doses)
¾ IV: NS, titrated to resolve dehydration (initial 20 ml/kg bolus for the child, 10 ml/kg

General:
Typically, an affected child has had a preceding upper respiratory infection, followed by
rapid onset of respiratory distress with tachypnea, tachycardia, and a hacking cough.
Increasing distress is evidenced by circumoral cyanosis and audible wheezing. The child
often appears markedly lethargic, but fever is not always present. Dehydration may
develop from vomiting and decreased oral intake.
Bronchiolitis is a viral or bacterial infection of the bronchioles themselves. It generally
occurs in children under 2 years of age.
Pneumonia is a more general infection of the lung, including the large airways and the
alveoli. It may occur at any age. In severe cases, it can be confused with pulmonary
edema. It may present with a wide variety of breath sounds on auscultation, including
rales. History and associated signs/symptoms are the best tools to differentiate pneumonia
from other sources of respiratory distress.
Pneumonia is characterized by:
o Gradual onset of symptoms, usually over a few days o Recent history of upper respiratory infection symptoms, including a productive Respiratory Distress (continued)
Croup: Pediatric

Criteria: Pediatric patient with:
¾ Dyspnea AND
¾ Inspiratory stridor AND
¾ Recent history or current symptoms of URI

Treatment:
EMT-B:
¾ If febrile, Acetaminophen or Ibuprofen (see reference for medication doses)
General:
Croup is usually preceded by an upper respiratory infection. A "barking," often spasmodic
cough and hoarseness may mark the acute onset of inspiratory stridor, which commonly
occurs at night. The child often awakens during the night with respiratory distress and
tachypnea. The obvious respiratory distress and the harsh inspiratory stridor are the most
dramatic physical findings.
Auscultation reveals prolonged inspiration and stridor, often with some expiratory rhonchi
and wheezes. Rales also may be present. Fever is present in about 1/2 of the children.
The illness usually lasts 3-4 days and generally occurs in children between the ages of 6
months and 4 years.
IF THERE IS ANY DOUBT AS TO WHETHER THE PATIENT IS SUFFERING FROM CROUP OR EPIGLOTTITIS, TREAT AS EPIGLOTTITIS, and do everything possible to minimize the child's agitation. Respiratory Distress (continued)

Epiglottitis: Pediatric

Criteria: Pediatric Patient with
¾ Dyspnea ¾ Evidence of upper airway obstruction (inspiratory stridor, drooling, or hoarseness) ¾ AND any one or more of the following: o Fever o Recent history of upper respiratory infection symptoms o Dysphagia or severe sore throat
Treatment:
EMT-B/EMT-I:

General:
Onset of epiglottitis is frequently acute and fulminating. Sore throat, hoarseness, and
usually high fever develop abruptly in a previously well child. Dysphagia and respiratory
distress characterized by drooling, dyspnea, tachypnea, and inspiratory stridor develop
rapidly and cause the child to lean forward and hyperextend the neck. Acute epiglottitis
usually presents before 5 years of age.
It is IMPERATIVE that oxygen administration not result in increased agitation.
Great care must be taken not to agitate the child, as agitation may result in sudden,
complete airway obstruction.
As long as the child has adequate respiratory volume, DO NOT place any instrument in the
child's mouth or attempt to visualize the epiglottis with a laryngoscope or tongue blade,
since severe laryngospasm and swelling may result.
Respiratory arrest can occur from total airway obstruction or a combination of partial airway
obstruction and fatigue. If respiratory arrest occurs, PPV with a BVM with 100% oxygen
should precede any attempt to intubate the patient.

Respiratory Distress (continued)
Foreign Body Airway Obstruction

Criteria: Pediatric Patient with
¾ Partial or complete airway obstruction secondary to foreign body aspiration WITH:

Treatment:
EMT-B:
¾ CABC's ¾ Abdominal/chest thrusts ¾ Reassess airway ¾ Direct laryngoscopy ¾ Attempt to visualize object and remove with Magill forceps ¾ Intubate as needed
General:
Foreign body aspiration is the most common cause of sudden respiratory distress or arrest
in a previously healthy child and should be the provider's initial suspicion in such patients.
In the conscious patient, chest or abdominal thrusts are used (as per AHA guidelines).
In the unconscious patient, appropriately certified EMS personnel should attempt to
ventilate and intubate. If unable to ventilate with the BVM, go directly to direct
laryngoscopy and Magill forceps to remove the foreign object.
Respiratory Distress (continued)

Pulmonary Edema
Criteria:
¾ Shortness of breath WITH
¾ Evidence of pulmonary edema (auscultated findings, history, etc.) AND
¾ Cardiac history WITH
¾ Systolic BP of greater than 100 mmHg

Treatment:
EMT-B:
¾ V/S with SpO2 if available ¾ If hypotensive, place in modified Trendelenburg (elevated feet while sitting upright) Consider intubation via endotracheal or alternative airway device, if indicated
General:
Pulmonary edema often presents as simply dyspnea with wheezes or silence on
auscultation; rales may not be heard. Use other signs and history to differentiate CHF from
other etiologies.
Pulmonary edema is often associated with these indicators:
¾ Sudden onset, frequently at night
¾ Hypertension
¾ Previous cardiac history
Be aware that hypotensive patients (systolic BP of less than 90 mmHg) with pulmonary
edema may actually be in cardiogenic shock.
Oxygen must be by NRB at 10-15 L/min or by BVM.
IV fluid should be NS at TKO rate. Watch the fluid administration rate carefully.
Seizures

Criteria:
¾ Patient experiencing active seizures or in a postictal state
Treatment:
¾ CABCs ¾ O2, assist with BVM if necessary ¾ Temperature ¾ Blood glucose analysis: if less than 80 mg/dL refer to hypoglycemia protocol ¾ If actively seizing, protect head from trauma ¾ Position patient in left lateral recumbent position if decreased level of consciousness ¾ IV NS TKO
¾ Naloxone for persistent altered mental status
ƒ May repeat every 2-5 min if patient responds to initial dose. Maximum ¾ Consider Thiamine 50 mg IV and 50 mg IM OR 100 mg IV in suspected alcohol

General:
Active airway maintenance, the use of airway adjuncts, and ventilatory support with the
BVM are essential to the early management of the actively seizing patient.
Temperature can be a major factor in seizures. Increased body temperature lowers the
seizure threshold (makes a seizure more likely), while lowered temperature raises it. The
seizure patient who is hyperthermic or febrile will benefit from external cooling procedures.
Seizures generally are classed into four categories:
• Tonic-Clonic (generalized, "grand-mal" convulsion)
• Focal (non-generalized or localized convulsion) Aggressive, early oxygenation is a must in the seizure patient. Oxygen alone will shorten the postictal state and raise the seizure threshold. Blood glucose should always be assessed in the seizure patient. Hypoglycemia will significantly lower seizure threshold and represents a life-threatening cause of convulsions. Additionally, convulsions may cause hypoglycemia in an otherwise normoglycemic patient. Thiamine is to be given as 50 mg IV and 50 mg IM OR 100 mg IV only in the event of suspected alcohol abuse.

Source: http://www.ruf.rice.edu/~rems/files/protocols-4.pdf