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"I can't breathe!" Respiratory Problems in the ED by Tom Trimble, RN CEN


Introduction:

This is a review, in a case-based problem-solving way, of breathing problems which you may confront in the Emergency Department .

Additional scenarios are planned for inclusion in this article; be sure to return for the additions.

What this article will do: Provide an opportunity to challenge oneself by analyzing cases (both real and realistically synthesized)
of respiratory problems  that appear in EDs.

The aim is to: Analyze clinical situations with critical thinking, applying Emergency Nursing knowledge and skills, to determine
the most important impacts that Emergency Nurses can provide.

Utilization & Target Audience: These cases, while intended originally as a presentation to an Emergency Department Training
Program for new graduates and nurses new to the emergency setting, can be used as a self-review, didactic presentation,
interactive discussion between mentor and learner, or as general study material to prepare for CEN exam. The focus should be to
analyze the problem, find the immediate essential thing to understand or do, and understand why.

What this article is not: It is not a comprehensive treatise on each such case, nor does it describe all pathophysiology, examine
or prescribe diagnostic & therapeutic pathways, and certainly may be at variance with the reader's local practice.
Our DISCLAIMER completely applies to each and every part of this article.

 


Case One:

     A heavy-set 24 year old woman is rushed to the triage window by a friend: "Help her!" The patient, herself, says "I can’t breathe!"
She looks pale, shaky, and frightened, but is able to answer your questions as you examine her. "I’m dizzy, --Oh, and my face is
tingling and my hands are cold? Am I going to die?"
As you check her blood pressure, she complains that the cuff is making
her arms hurt, and you notice that the distal hand is cramping into a pointed cone. Her SpO2 is 100%

What is your diagnosis?

      1. Acute Hyperventilation Syndrome (there may be other DDX).

      What is your treatment?

          1. An unflustered calm and soothing interaction, emphasizing positive outcome, with a brief explanation
          of how the symptoms arise and suggesting deliberate slowing of breathing.

          2. Modern practice discourages CO2 rebreathing. When worrisome differential diagnoses are excluded,
          and anxiety remains a significant component of the patient's present condition, a mild dose of a
          benzodiazepine may be useful.

          3. If the patient remains "full-blown" despite the above, try carbon dioxide rebreathing by having the
          patient breathe through a length of mist tubing or the traditional paper bag.

      If you undertake CO2 rebreathing treatment, what precautions should you observe?

        • Stay with the patient.
        • Continuous pulse oximetry.
        • Supplemental Oxygen by nasal cannula
        • Terminate efforts, if not successful, within a short time.

      Why is supplemental oxygen necessary to do CO2 rebreathing in a hyperventilating patient (the SpO2 is 100%)?

          The problem is a respiratory alkalosis from overbreathing which "blows off" CO2 from the system, this leads
           to shifts of calcium ions in the blood which induces nerve tetany and carpopedal spasm. Restoring CO2
          balance will nullify these effects, but if the patient is truly hypoxic for some as yet undiscovered reason
          (and this is masked by the overbreathing), we do not wish her to become hypoxic, nor should we "overcorrect" by
          increasing CO2 retention above normal levels  that might depress her consciousness so that she does not breathe sufficiently.
          Oxygen won’t hurt and it will prevent harm; it can also be calming to the patient who still believes that she "can’t breathe."

          The ideal way would be to monitor SPO2 and ETCO2 simultaneously. Thus, the patient's own oxygenation (remember, there's
          a two minute time lag in the SPO2 reading), and ventilatory effort (with waveform capnography), and CO2 levels can be followed.
          If there is a possibility of metabolic acidosis, than a blood gas specimen should be sent. With an adequate SPO2 being monitored,
          supplemental oxygen would not be necessary unless hypoxia develops.
          [This section modified 10/30/2012 to reflect contemporary prevalence of
          waveform capnography in emergency departments.  TT]

 


Case Two:

     Paramedics bring in by ambulance a man "Found On Sidewalk". He vocalizes some unintelligible sounds, eyes are open,
and he is agitated and restless moving all extremities equally and does not respond to soothing efforts nor answers any questions
or performs any commands. He appears to have been well-dressed and well-kempt. There is no obvious trauma but his hands
are abraded and scratched which could have come from resisting his restraints. He has a 100% Oxygen Non-Rebreather Mask.
There are no IVs; the medics were too close to have time to start any.

What are your immediate actions?:

      1. Continue oxygen while assessing breathing
      2. Apply monitors beginning with pulse oximetry [SpO2=100%]
      3. Insert double IV access; draw & send labs.

      The patient becomes more agitated and heart rate drops into 40s. What’s going on?

      1. Impending neurologic disaster demonstrated by Cushing Reflex due to increased intracranial pressure.

      What do you expect the physician to do next (after initial exam)?

      1. Prepare for Rapid Sequence Intubation {Why is this important?}
      2. Prepare for CT scan of the head.

      What is the physician’s rationale for the choice of RSI drugs in the case of this 70kg. Patient?

      1. Lidocaine, IV 100mgm (minimize increases of Intracranial Pressure due to stresses of laryngoscopy and intubation).
      2. Succinylcholine for paralysis; there are theoretical contraindications as the fasiculations that it causes can increase
        Intracranial Pressure; however, it is the most rapid and shortest agent
        and this patient needs intubating conditions now!
      3. Etomidate for sedation provides unconsciousness with the least adverse hemodynamic effects.

      After intubation, and confirmation of endotracheal placement, as the tube is being secured and the patient resumes
      breathing on his own, you notice that the respiratory rate is 40+, full and deep;--but he’s 100% SpO2 and the EtCO2 is 35.
      What’s going on?

      1. The patient is showing the respiratory pattern of Central Neurogenic Hyperventilation which "usually indicates damage
        to the brainstem tegmentum between midbrain and pons."1

      You send the patient to the scanner with qualified personnel while the physician calls Neurosurgery. As you make
      the room ready for the next patient, someone runs in to fetch a bag of Mannitol and says only "We’re going to the O.R.!"
      Why are you not surprised.

          1. The patient was already showing signs of brain herniation in the ED, and you surmise that the CT s
          can has shown an Intracranial Hemorrhage with progressive signs of herniation for which the Mannitol will
          be given to osmotically diurese the patient rapidly so as to decrease ICP temporarily while preparing for
          surgical decompression.

      Discussing the case afterwards, it is commented that no portable chest x-ray was done to confirm endotracheal tube
      placement.
      How serious is this omission?

          1. Not serious, but actually a responsible and deliberate decision to benefit the patient. Endotracheal
          intubation was confirmed clinically and the patient was satisfactorily ventilated with the tube. A CXR is
          unlikely to give any useful information in an apparently healthy 35 year old man; and any additional delay
          could cost him his life or caused irreparable brain damage.


          Confirmation was by:

        • Direct view of the tube passing through the cords.
        • Palpation of the tube’s passage through the larynx and into the trachea.
        • Good natural chest compliance and symmetrical thoracic rise with ventilation.
        • Misting of the ETT with each exhalation.
        • Auscultating effective and equal ventilation of each lung and no gastric ventilation.
        • EtCO2 and SpO2 showed good continuing numbers indicating effective oxygenation and ventilation.

Diagnosis & Outcome: Epidural Hematoma - Central Neurogenic Hyperventilation & Head Injury
[Full Recovery]

 


Case Three:

     A 27 year old woman arrives short of breath. "I don’t think my inhaler’s working." (Gasp, Gasp)
"I don’t ever (Gasp) get like this (Gasp)." History of 12 years of mild asthma with rare episodes "only when sick";
never hospitalized or intubated; no previous ED visits for asthma; no other medications; never on steroids; doesn’t
use a "spacer" with the inhaler; doesn’t know what a "peak flow meter" is;, smokes; and thinks that the trigger for this
episode was "the cat" in her friend’s apartment.

    1. Take immediately to care area, & notify MD.
    2. Apply Pulse Oximetry first, then other monitors. SpO2=89% at room air.
    3. Give oxygen titrating flow rate to SpO2= high 90’s.
    4. Defer first peak flow reading, as patient is distressed (Tripod position, diaphoretic, pale), and has no experience of it;
      relief is needed now.
    5. Give bronchodilator nebulizer treatment (the patient’s breathing is too labored and the patient too anxious to coordinate
       treatment by MDI & spacer).

      As the physician examines the patient, he asks "Is there a Pulsus Paradoxus?"
      What is this? Why is it significant? How do you check for it?

    1. It is an indirect measure of the "work of breathing."
    2. It reflects altered intrathoracic pressure dynamics.
    3. With a manual sphygmomanometer, increase the pressure of the cuff above the point at which the pulse disappears.
      Listen carefully for the 1st Korotkoff sound as the cuff is deflated slowly (» 2 torr/mmHg per second). Note if the
      1st Korotkoff sound "drops out" and is silent for an interval before resuming the 1st Korotkoff sound; that range of torr
      at which it was silent is the Pulsus Paradoxus; thus "30 points" (of silence) indicates severe derangement of
      intrathoracic pressures due to excessive working of the bellows function of the chest.

      The physician comments "I think we should give steroids." Why?

    1. Wheezing is the symptom. Inflammation is the cause. In severe asthma, it is essential to treat the inflammation
      with steroids.

      Which will take effect quicker, oral prednisone, or intravenous Solu-Medrol® , methylprednisolone?

    1. Neither. Onset will be 4 to 6 hours irrespective of route. In severe asthma, steroids should be started early due
      to the delay in effect.

      Despite treatment, the patient is still very "tight" with poor aeration and continuing distress.
      What additional modalities might be used?

    1. Subcutaneous Terbutaline or Epinephrine might be used to open up distal airways that the bronchodilator nebulizer
      treatment can’t yet reach because the patient is too tight. In extreme cases, an Epinephrine infusion (1 mgm of 1:1000
      added to 25o ml NS) might be run titrating to response. If a small amount is to be given IV, the 1:10,000 dilution
      (the "code" epinephrine pre-loaded syringes) must be given very slowly. Department policy requires the physician to be
      present for intravenous epinephrine excepting only during Cardiac Arrest.
    2. HeliOx is an 80:20 mixture of Helium and Oxygen which due to the lower density of Helium allows smoother "laminar" flow
      into tighter airways than the heavier Nitrogen in room air. This can ease the work of the patient and give better delivery of
      Oxygen. Call Respiratory Care Services to set up as the flow meters are not calibrated for this mixture. A simple way to
      explain this to the patient is that "we’re going to give you a special lightweight slippery Oxygen to make it easier for you to
      breathe."
    3. The patient might need to be intubated so that the ventilator can take over the work of breathing.
    4. Ketamine is a dissociative sedating agent that can be used for RSI as it also has the ability to bronchodilate the patient
      through a different chemical pathway that releases endogenous catecholamines. If the patient "crashes", having exhausted
      catecholamines, then epinephrine will need to be given.
      [Modified 10/30/2012 to clarify pathway.  TT]
    5. Once the patient is in the ICU, it is sometimes necessary for Anesthesia to use Halothane anesthesia to overcome the
      bronchoconstriction
      . [Modified 10/30/2012 as no longer common practice, nor Halothane readily available. Consult a Critical Care reference
      regarding the extended management of severe asthma.  TT]

Diagnosis: Asthma

 


Case Four:

     A basic life support ambulance brings a patient from a SNF with "fever & weakness." No other history is available.
The patient is 86 years old, female, appears to be s/p CVA with LUE flexion contracture, and a nasogastric feeding tube.
She has a diaper. T=39° C, p.o., Pulse= 116 bpm, RR= 36 BP= 157/90 SpO2=92%
Your next actions after informing the Charge Nurse and the physicians are
:

    1. Apply Monitors, order CXR and EKG.
    2. Arterial Blood Gas specimen obtained from Radial Artery after satisfactory Allen’s Test.
    3. Administer Oxygen, titration of flow rate to SpO2 ³ 97%
    4. Start IV, with "culture prep" so that one of the two sets of Blood Cultures can be drawn from the IV line. Draw BC first,
      then regular lab tubes. Arrange for second BC draw.
    5. Start IV fluids at a rate commensurate with degree of dehydration and cardiac status.
    6. Get an Acetaminophen order for a suppository.
    7. Obtain urine specimen by either "straight cath" or inserting a Foley catheter; after which give Acetaminophen suppository.
    8. If wheezing is present, start a bronchodilator nebulizer treatment.
    9. If aeration of lung fields is poor without wheezing, and patient appears dehydrated, consider administering heated mist by
      mask at an FIO2 that provides satisfactory oxygenation. If a high FIO2 is required by the patient, a special high-flow
      high-FIO2 nebulizer may be needed as the ordinary nebulizer entrains room air through a port to correctly "meter" the oxygen
      concentration. Thus,  less room air is entrained by the Venturi port if more of the port is closed to prevent dilution of the high
      concentration leading to less absolute gas flow to carry more particles of water to the patient
    10. If the patient is able to provide a sputum specimen or one can be suctioned, send to Microbiology laboratory for stat.
      Gram’s Stain, Culture & Sensitivity. If urine "dips" +Esterase for leukocytes, send for stat. Gram’s Stain as well as
      Culture & Sensitivity.
    11. Give antibiotics at earliest opportunity. Arrange admission.

Diagnosis: Pneumonia; Possible Aspiration

 


Case Five:

     A 3 ½ year old boy who has had a URI is brought in by parents because "he’s having trouble breathing!"
They report coughing spells, a little vomiting, no fever at present. Upon questioning, they say, "yes, it did sound like
a barking seal!" They add "it got better on the way once we were in the cool night air.
You surmise the diagnosis is
:

    1. Croup (Acute laryngotrachealbronchitis)

      Then you notify the pediatrician, and

    1. Administer cool saline mist blow-by
    2. Be prepared to change mist to Racemic Epinephrine (0.25-0.5ml in 2.5ml NS –use plastic dropper or syringe
      without needle to measure –no metal)
    3. Dexamethasone, IM, 0.6mg/kg may be needed at discharge to minimize recurrence)
    4. If diagnosis is doubtful, soft-tissue Neck X-Ray looking for a "Steeple" sign of a trachea narrowed by mucosal
      swelling {may be needed to rule out epiglottitis}.

Diagnosis: Croup (Acute LaryngoTrachealBronchitis)

 


Case Six:

     A 3 ½ year old boy, newly arrived in the country, is brought in with fever of 102° F, drooling, and leaning forward on his forearms
in "tripod position" with his head hanging down. He appears ill. His voice is muffled –a "hot potato voice".
The highest differential diagnosis you have is:

    1. Acute Epiglottitis in a child who has probably not been immunized against Hemophilus Influenza bacteria.

      Your greatest concern is:

    1. Airway closure; avoiding any instrumentation of the throat or agitation of the child.
    2. Some children may be admitted for observation; some may need to be taken to OR for intubation under anesthesia.

      The most likely diagnostic study is:

    1. Soft-tissue Neck X-Ray, looking for a "thumb" sign of the swollen epiglottis.

Diagnosis: Epiglottitis

 


Case Seven:

     A 73 year old man with a history of hypertension and two MIs complains of "picking up a cold" a couple of days ago
and feeling unusually tired "just stayed in a chair all day, and couldn’t sleep last night because of having to get up
and sit in a chair." Brought to the care area, monitors are applied, nasal oxygen begun, EKG is done, and IV access
placed with labs sent. Pausing to reassess the patient, you note that the chest seems to rise and fall with greater effort
and depth than is usual for persons at rest, auscultation reveals diminished breath sounds throughout with distinct crackling
in the lower half bilaterally. The patient asks to sit up higher and denies chest pain, "but it does feel ‘heavy’."
No physician has come to see the patient yet.
What are your next actions
?

      1. Notify the Attending Physician and Charge Nurse of your concern.

      2. Recheck the patient.

      In the last five minutes, the SpO2 (on 2 lpm NC) has gone from 97% to 92%, the patient looks pale and appears to be breathing with greater effort and does not look about the room to track activities.
      What do you do now
      ?

      1. Apply a 100% O2 Non-Rebreather Mask which seems to perk up the patient and SpO2 rises to 96%.

      2. Take the patient (with O2, etc.) to the "Code Room." Summon the Attending Physician, repeat the EKG, and call for a stat. portable CXR.

      In these five minutes, it seems that you can now hear an audible sound of wet breathing pervade the room. Another nurse arrives at the same time as the physician, you ask the nurse for a second IV access.
      What are the orders you expect to hear from (or ask for) the physician
      ?

      1. Nitroglycerin, sub-lingual, or spray.

      2. Chewable Aspirin, (81 mgmsX4=324 mgms)

      3. Lasix® (Furosemide), IV, (40mgms, if not taking, or double the daily dose if already taking).
      {What drug allergy should you be aware of? [Sulfa—Lasix is a sulfonamide]}
      { What precaution should you take in administration? [Push slowly due to ototoxicity]}

      4. Morphine 2 – 4 mgms IV

      Now the patient’s breathing is louder and more distressed. You ask for a Foley Catheter order
      (thinking how your preceptor said "As the Lasix goes in, the Foley goes in!"). The MD looks worried.
      The next order is for
      :

      1. Nitroglycerin infusion, titrate to effect.

      SpO2 is 93%, extremities are cool and pale with some lenticular mottling noticeable. The patient moves
      somewhat with noxious stimulus but is no longer verbal.
      The next actions should be
      :

      1. "Call for Respiratory!"

      2. Move to the patient’s head and apply a close-fitting resuscitation mask with a Modified Jackson Rees circuit
      (flow-inflating non-self-refilling anesthesia bag) to give CPAP (constant positive airway pressure) to maximize
      O2 delivery and saturation, open collapsed alveoli, "push-back" pulmonary edema, and decrease cardiac pre-load
      by decreasing venous return through reversal of the normal intrathoracic pressures. The patient may need continuous
      verbal reassurance with the mask; speak softly, slowly, and soothingly to the patient’s ear, explain what you are doing
      and that you will not let him smother, etc., provide the focus he needs.

      3. Prepare for endotracheal intubation.

      After the patient is intubated, while the tube is being secured, you notice a pink frothy fluid in the endotracheal tube.
      What is this
      ?

      1. Pulmonary edema fluid.

      What should you do about it?

      1. Suction thoroughly, in short intervals to minimize the periods of negative pressure within the airway and to
      maximize periods of oxygenation and positive pressure.

      2. Expect, or have the Respiratory Therapist ask for, ventilator orders to include values for PEEP
      (positive end-expiratory pressure)
      and Pressure Support (inspiratory positive pressure).

      3. Expect further orders regarding cardiac drips. Keep an eye on the patient’s blood pressure to avoid
      precipitous drops.

      4. Determine the Physician’s disposition for the patient, Intensive Cardiac Care Unit or Cardiac Catheterization Laboratory.

      Diagnosis: Acute Fulminating Pulmonary Edema


Case Eight:

     A 22 year old male drug addict is brought in by ambulance after being "found down" with miotic ("pin-point") pupils,
RR of 4 BPM, and perioral cyanosis. While being "bag-breathed" he was given a single intramuscular dose of Naloxone 2 mg;
following this, he awoke. You assess him, and tell him that he needs to be examined by the doctor and observed for a relapse
when the Narcan® wears off before he can be released. It’s a busy night, and after the first few checks, as he is behaving himself,
 it is 1 ¼ hours before he is examined again. He is awake, and does not seem to be re-narcotized, his pupils remain 4mm,
but he doesn’t look well. He is pale with a trace of duskiness at the lips, and his breathing seems full, 24 BPM, and a little labored.
Your presumptive diagnosis as you examine him further is
:

    1. Non-Cardiogenic Pulmonary Edema of Heroin Overdose

      You do feel that his "work of breathing" is greater and the breath sounds are diminished and crackling ½ up bilaterally.
      Your next steps are
      :

    1. Apply Oxygen, titrating flow rate to SpO2 ³ high 90s%
    2. Sit the patient up.
    3. Notify the Physician.
    4. Order a CXR.
    5. Consider an ABG if the patient does not improve promptly.
    6. Insert IV access if none has been present.

Diagnosis: Non-Cardiogenic Pulmonary Edema of Heroin Overdose
Abstract
   Heroin-related noncardiogenic pulmonary edema : a case series.
                         Sporer KA, Dorn E.
                         Chest 2001 Nov;120(5):1628-32

 


Case Nine:

     A message is received from an oncology on-call physician to expect a patient they haven’t seen in a while with a history
of lymphoma whose family have called to say that he is "weak", has decreased activity, and says that his breathing is difficult.
Upon arrival, he seems to have lost weight, to be dehydrated, and to be "working hard" with each breath. He denies any
fever, chills, nausea, or vomiting; admits to some cough "but it’s hard to bring up anything." Inspiratory and expiratory
phases seem prolonged, breath sounds are diminished, and as you auscultate the thoracic tracheal area, it seems that there
is stridor.
As you continue your assessment and treatment, which differential diagnoses are of highest concern
?

    1. Extrinsic compression of trachea by tumor.
    2. Superior Vena Cava Syndrome (may be complicated by cerebral edema)

      Your actions are:

    1. Notify Attending Physician & Charge Nurse
    2. Order stat. Portable Chest X-Ray
    3. Apply Pulse Oximetry and Monitors
    4. Apply Oxygen, titrating flow rate to SpO2=100%
    5. Intravenous access; two lines if possible.

      This patient may need the "Code Room" because:

    1. Available airway lumen may have reached a critical stenosis.
    2. The patient may need intensive respiratory therapy (Bronchodilators, Racemic Epinephrine, Heli-Ox may be temporizing)
    3. Intubation may be difficult.
    4. Anesthesia may need to be paged for "Difficult Airway Cart".
    5. Optimal airway investigation and control may need to be fiberscopic.

      Other measures may be:

    1. Stat. Thoracic CT scan
    2. Potential emergent radiation therapy
    3. Potential emergent chemotherapy
    4. Potential emergent surgery or tracheostomy.

Diagnosis: Extrinsic Airway Compression by Tumor

 


Case Ten:

     Several youths bring in a friend saying "We were just minding our own business but some guys jumped us, and he got cut!"
There is an incised wound of the right palm, assorted abrasions and swellings. Pulse oximetry is normal, and vital signs are OK,
although pulse is 116 bpm (but they’re all still pretty excited); still, he looks a little pale and anxious.
"Did you get hurt
anywhere else?" "Nah." You take him back to an exam room. "Take off your clothes and put on this gown." "Do I gotta? I only got cut"
"Yes!" As he takes off his football team stadium coat, you notice a tear in the fabric, and his skinny chest does not seem to be
symmetrical in its rise and fall; the right chest seems to lag behind corresponding with the side of the jacket hole.
Your next actions are
:

      1. Inspect the chest. (You find a small wound just medial to the right scapula. It seems to hiss and splatter a
      little blood with respirations.)

      2. Cover the wound. (Gauze and tape is all that you have on hand.)

      3. Auscultate the chest. (No breath sounds on the right.)

      4. Notify the Attending Physician.

      5. Call for a stat. portable chest X-ray.

      6. Apply oxygen by 100% non-rebreather mask.

      What is the most likely thing that has happened?

      1. He has either been stabbed or shot during the fracas which may not have been noticed during the scuffle.
      He has a "sucking chest wound."

      Why bother with a CXR? You already know the problem.

      1. It’s the only way to determine if there are any metal fragments in the chest (broken knife blade or bullets) or
      any other traumatic pathology.

      By the time the chest X-ray is done, the patient is more restless, with a slight sheen of diaphoresis on his skin which
      seems a little cooler. You now have (with the help of another nurse) two large bore IV lines. You reassess the
      patient, his pressure is down, breathing is more labored, and the trachea is now moved somewhat over to the left.
      You tell the physician.
      What happens next
      ?

      1. A colleague is grabbing a thoracostomy tray, tube, and Pleur-Evac™.

      2. The physician opens up the dressing and tries to insert a gloved finger into the wound to enlarge it
      (convert the tension pneumothorax to an open pneumothorax and decompress the chest to allow better cardiac
      output)
      but is unsuccessful.

      3. "Get me a needle!" Betadine™ is poured on the chest wall, and a 14 gauge needle is inserted into the
      Anterior 2nd Intercostal Space at the Mid-Clavicular Line with a rewarding "Hisssssss" into the room. The heart rate of
      136 slows to 110, and the patient looks less pale.

      4. A tube thoracostomy is placed and the Pleur-Evac™ is connected to suction.

      The heart rate is 125 bpm and the BP is 90 torr systolic. The breath sounds are decreased on the left base 1/3rd up,
      you quickly percuss the chest (listening carefully because of background noise) and feel that the percussion note
      sounds dull. You now surmise, and a doctor bursts in to report on the
      CXR . . .

      1. "There’s a small caliber bullet on the left side and a hemothorax!"

      You now expect, and help to make happen the following activities:

      1. Tube Thoracostomy, low on the left side(5th Intercostal Space in the Mid-Axillary Line).

      2. Insert Foley Catheter.

      3. Repeat CXR.

      4. Call Cardio-Thoracic Surgery.

      5. Prepare a "Pre-Op Check List".

      6. Notify the Nursing Supervisor to obtain a critical care bed, if not already done by the Charge Nurse.

      7. Ask the physicians if the patient is going to OR, if so, they may wish to have a Cell-Saver™ set up to permit
      autotransfusion.

      8. Verify that "Type & Cross-match" for 6 units of packed red blood cells has been sent, and that a "Check Specimen"
      to reconfirm ABO typing has been obtained by a second individual, and that both tubes have been correctly labeled
      and signed.

      9. Ask the physicians if the patient is to be transfused now, do they wish type-specific blood without waiting for
      cross-match (if so, a licensed physician must sign the "Emergency Cross-Match Release" on the blood bank form).

      10. If the patient is going to OR, call ahead and warn them, give report if possible even if the patient
      is already en route out the door.

      11. If the patient is going to a critical care unit rather than OR, the ICU resident will need to be notified.

      What else hasn’t been done, and must be done?

      1. If the hand wound was bleeding, it too should have been bandaged earlier.

      2. The police must be notified of the GSW.

      3. The patient’s clothes must be placed in labeled and stapled paper bags for evidence.
      {Why paper
      ?  --Plastic bags create a "greenhouse atmosphere" that can degrade forensic trace evidence.}

      Diagnosis:  Assault with Occult Wound, Pneumothorax; Tension Pneumothorax; & Hemothorax

 


Case Eleven:

     A cancer patient is brought in by family for "she’s so weak" which comprises increasing lethargy, inattention, confusion,
and "won’t eat", "she sleeps all the time—I can’t get her up", "She hasn’t gone "poo" in two days". Examination reveals
the above, dehydration (dry membranes, furrowed tongue, and slack skin), pupils are 1.5-2mm and sluggish. Her medications
are several Duragesic® patches of Fentanyl and MS Contin®. Respiratory rate is 9 – 10 bpm.
Your actions include
:

      1. Apply pulse oximetry and other monitors. Notify MD.

      2. Give oxygen titrating to SpO2 ³ 95%

      3. Intravenous access; Draw & Send Labs.

      What do you do now?

      4. If patient is deeply unresponsive, hypoxic, or hypoventilating, consider going to the Code Room or using an O2BVM.

      5. Naloxone trial with incremental doses titrating to level of respirations and level of consciousness seeking to avoid Acute Withdrawal Syndrome and "giving back the pain".

      6. The patient may need admission for Naloxone drip and pain management.

Diagnosis: Excess Narcotics

 


Case Twelve:

     Paramedics bring in an unconscious patient from home with chronic debilitating illness and whose partner unexpectedly
came home early to find the patient with a plastic bag tied around the head, and a copy of "Final Exit" by Derek Humphrey of
"The Hemlock Society" in the room. It is unclear why the patient is unconscious as the bag has been removed and he’s breathing
OK. You notice that as you draw your finger across the skin, a curious trail of welting occurs with which you can actually
write or draw a picture.
What questions must you ask
?

      1. Were there any medication bottles or alcohol found at the scene?

      What agent do you expect to be culprit?

      1. Barbiturates are the likely cause of the "dermatographia" and a recommended agent for self-euthanasia. Alcohol is
      likely to be a co-ingestant to increase effect and solubility. Any other drug or agent is likely to be used as multiple drugs
      may have been hoarded to accumulate a potentially lethal dose. Remember, that this is an extremely determined attempt
      with high suicidality and intended lethal outcome.

      What procedures do you anticipate?

      1. Endotracheal intubation to protect the airway.

      2. Laboratory toxicology studies.

      3. Activated Charcoal may be instilled via nasogastric tube after endotracheal intubation to prevent or minimize
      aspiration.

      4. Possible Gastric Lavage if it is thought that concreted "bezoars" may have formed in the stomach or that gastric
      emptying has been delayed. While Gastric Lavage has a lesser role than in years past, it may well be indicated in
      such instances after consultation with the Poison Control Center.

      5. Possible whole-bowel decontamination by instilling a continuous nasogastric "drip" of Go-Lytely™.

      6. This patient will probably be admitted to Medicine Service with Psychiatric Consult on an involuntary "hold" such
      as California. Welfare & Institutions Code section 5150, or if awakens and medically cleared will require psychiatric
      evaluation.

Diagnosis: "Self-Deliverance" type attempted suicide by poly-intoxication & plastic bag

 


Case Thirteen:

     A two year old girl is running at home, slips, and strikes her head, becomes unconscious, and stops breathing.
Mom is left at home with the baby, as Dad scoops up the child, runs to the car, places the child on the front seat, and
reaches speeds of 60 mph in a quiet suburban neighborhood in the evening. At the hospital, "the doctors saved her life."
No airway care was needed and recovery was spontaneous and uneventful.
What occurred to cause the breathing to stop
?

      1. Simple concussion with temporary flaccidity, and tongue obstruction of the upper airway. Probably the frantic
      carrying of the child caused a fortuitous and happenstance opening of the airway, and muscle tone spontaneously
      returned.

      What are the immediate nursing needs, and primary objective for this patient visit?

      1. Assess level of consciousness, ABCs, and any neurologic impairment.

      2. Prepare for possible CT scan.

      3. The principle objective is to give assurances, explain the events, and the simple first aid measures by which
      to control the situation, how to access EMS & 911, and the dangers of carrying an unsecured child (with no one
      attending the airway) on the seat of a high-speed vehicle, the danger to others in the neighborhood, and the danger
      of driving when too distracted to be safe, and how when EMS arrives, medical care begins immediately, and
      contracting with the parents to enroll in Basic Life Support and First aid classes.

      Diagnosis: Post-Concussive Obstructed Airway

 


Case Fourteen:

     It’s 1:30 AM, the overhead page is unnaturally urgent "Nurse to triage –stat!" As you approach several cold, wet
disheveled youths, there are strong odors of alcohol, marijuana, wet sea sand, and wet firewood, and a peculiar
"burnt flesh" odor. One youth has singed and burnt hair, peeling skin with raw flesh and white areas on his face and neck,
and from his butt up his torso his clothes are burned rags with visible areas of burn. It doesn’t take Sherlock Holmes to realize
their story of a bonfire on the beach and "partying" and games of leaping across the fire with the unlucky one tripping and falling
in the fire and being set alight! Completely aflame, he ran thirty yards to the water and jumped in to quench the fire.
What are your actions now
?

      1. Immediately take the victim and one witness historian to the "Code Room" sending the others to register the patient.

      2. Immediately call out for "Attending Physician and Nurses to Code Room, stat.! Call Respiratory!"

      3. Inspect the nares and pharynx for soot and burns, assess neck for circumferential burns or swelling.
      Ask "Is this your normal voice?"

      4. Give 100% O2 by non-rebreather mask, and prepare for intubation.

      5. Have other staff insert two large bore IVs.

      6. Keep patient reasonably covered to conserve body heat.

      Why is rapid intubation important for this patient?

      1. The patient’s airway may imminently close due to inhalational burn injury and resultant swelling, exudate, and
      sloughing. Lower airway units may lose fluid and be difficult to ventilate. Any circumferential burns may constrict
      the airway. Delay in intubation may lose the last possible moment to get the tube in.

      What historical factors contribute to his injuries?

      1. Heat rises, and fire burns upward. The patient fell into the fire for a period of time until he could escape, his
      rising and running fanned the flames and brought them close to his respiratory tract; essentially, he became the
      wick of a human candle.

      Before the patient can be placed in intensive care or transferred to a Burn Center, he becomes increasingly
      difficult to ventilate requiring higher pressures and delivered tidal volumes are decreasing.
      What procedure may be indicated
      ?

      1. Escharotomy or incision of the constricting thoracic circumferential burns that are restricting chest expansion.

Diagnosis: Airway Burns & Body Burns

 


Case Sixteen:

     A 41 year old white male drinking alcohol is playing with his pet rattlesnake and showing it off. As the snake flicks his
tongue sensing the air, the pet owner mimics this and the snake responds by biting his owner’s tongue. He is brought
to the ED with progressive tongue swelling.
What must be done
?

1. He must be intubated immediately, as the swelling and ecchymosis from a crotaline bite clearly indicates
actual envenomation. He is at risk for immediate airway closure. (The actual patient remained intubated for
three days with the only available airway space being the lumen of his plastic endotracheal tube.)

Diagnosis: Rattlesnake Bite to Tongue
Ann Emerg Med 1987 Jul;16(7):813-816
Life-threatening airway obstruction from rattlesnake bite to the tongue.
Gerkin R, Sergent KC, Curry SC, Vance M, Nielsen DR, Kazan A

 


Case Seventeen:

     You are transporting a gurney patient to another floor. The elevator stops during a power failure while in-between floors.
The patient starts to vomit.
What are your actions
?

      1. Turn the patient forward if sitting or to the side if recumbent.

      2. If a bowl is not available, direct the vomitus to the floor or to any extra linen.

      3. If the patient is poorly responsive, and no suction is available, pull up his gown or any linen wrapped around your
      fingers to swab out his oropharynx as needed.

      4. Reassess breathing, as needed.

      5. Use the emergency alarm if needed.

      6. Consider this possibility ahead of time when transporting obtunded patients with unsecured airways, and
      bring portable suction with you!

Diagnosis: Vomiting Patient in Elevator

 


Case Eighteen:

     A 68 year old man en route to the bathroom at night checks on a noise the dog is making and slips on a staircase falling
hard against his right side down several steps. He complains that "I hurt all over, but it really hurts when I breathe." His
hands guard his right anterolateral chest wall. You inspect the breathing and think that the chest looks funny; it seems that
the right hemithorax doesn’t move as much and that a portion lags behind. There are abraded contusions with ecchymosis
over the ribs, and the area is crepitant when palpated.
Your actions are
:

    1. Apply Oxygen, titrating flow rate to an SpO2 in the high 90s%.
    2. Notify the Physician and Charge Nurse.
    3. Order a CXR and EKG.
    4. Place IV access for analgesia and hydration.
    5. Coordinate with the Physician the need for an ABG.
    6. Be prepared for the possibility of intubation if breathing is severely deranged.

Diagnosis: Elder Fall on Stairs; Multiple Rib Fractures  with Flail Segment

 


Case Nineteen:

        A 42 year old man, 5'9" and 260 pounds, complaining of low back pain from work with right side radiation in a
Sciatic nerve distribution, who states his pain severity is "12" on a 0-10 scale, is brought to your care area for treatment.
As ordered, you place an IV, and give Ketorolac 30 mg., Morphine 10 mg., intravenously, and Cyclobenzaprine 10 mg. orally. 
As you adjust his position for comfort --knees cranked up, head of bed up, and place a pillow, you notice that is neck is thick
and short, and the double-chin is partly due to a slightly receding jaw.

        Upon recheck, fifteen minutes later, he appears more comfortable and, in fact, is asleep and snoring loudly. As you watch,
he appears to have cycles of loud snoring, quieter breathing followed by what seems to be some breathing movement but you're
not sure, then the forehead becomes sweaty, there is loud snorting gasping inhalation efforts then breathing  seems to settle
into regular snoring again.

         Based upon your observations, you make which inferences and plans?

  1. He appears to have sleep-related hypopneas and possibly apnea.

  2. This is probably obstructive type Sleep Apnea Syndrome, due to risk-factor profile of obesity, short jaw, thick
    and short neck, middle-age, and male.

  3. You continue observation with pulse oximetry applied, and other monitors.

  4. You plan to inform the physician of these observations, and to question the patient, when he awakes,
    about symptoms of excessive daytime sleepiness. You also plan to continue close observation of
    the patient for airway status.

What further diagnostic test do you need to do?

  1. Assess actual airflow during a quiet phase (between snoring and snorting) by placing the back of your
    hand or stethoscope diaphragm near the nares and mouth. Inadequate or absent airflow during inspiratory
    effort confirms hypopnea and apnea, respectively.

With the "bedside" diagnosis of OSA confirmed, what must be done?

  1. Correct any hypoxia or other physiologic change.

  2. If admitted, ensure that the admitting physicians and caregivers are aware of the OSA in their planning.

  3. If an outpatient, assess the patient and family for awareness of OSA, its potential impact on health,
    presence of excessive daytime sleepiness, and provide a referral for a sleep specialist or
    pulmonologist. Question also specifically for drowsiness during driving, work, or other hazardous
    activities; include in the discharge instructions a written strict caution to not drive or perform other risky
    tasks when drowsy

What further significance of your findings must be kept in mind for the remainder of the visit?

  1. Due to airway concerns, analgesia and sedation should be carefully planned and responses monitored.

  2. Should the patient need airway support or ventilatory support, there may be difficult mask ventilation,
    difficult intubation, and additional personnel and  equipment may be needed.

Diagnosis: Obstructive Sleep Apnea Syndrome

 


Case Twenty:

     The 24 year old hyperventilating woman has responded to your assurances. She is breathing calmly.
However, as you recheck her periodically, she says she still feels a little short of breath. SpO2=98% on room air.
You notice that her heart rate is 105 bpm and her respiratory rate is 24-28 each time you check. She denies any
URI, flu, or asthma. She does smoke and takes oral contraceptives. She became aware of her breathing during
the last portion of her fifteen hours of airplane flight and layovers while returning this morning from her
vacation. She thought it was just because she really doesn’t like flying.

      What is now the leading differential diagnosis to be ruled out?

1. Pulmonary embolism from risk factors of obesity, tobacco, OCs, and relative immobility coupled with
dehydration by dry cabin air.

What is the next most likely diagnostic strategy?

1. Spiral CT scan of the lungs to see if blood flow is cut off or any wedge-shaped infarcts. This is faster
and more readily available than nuclear isotope V-Q scans, and pulmonary angiography is invasive and risky.

What preparations must you make?

1. A 20 gauge or 18 gauge IV must be inserted.

2. Screen the patient for allergy to Contrast Dye, Iodine, or seafood.

3. Patient teaching about what the scan does, what the contrast feels like (hot all over, and woozy feeling,
but transient), and position in the scanner (supine with arms secured above head).

Diagnosis: Pulmonary Embolism

 


Case Twenty-One:

     A "Code Three" paramedic ambulance brings you a 73 year old man with acute shortness of breath and coughing
and a history of emphysema. He appears severely distressed and barely able to speak. As he is being moved to a
hospital gurney, the oxygen mask is briefly removed, the patient becomes as cyanotic as "stone-washed blue jeans."

What is the first therapeutic action that must be taken?

1. Replace the oxygen mask immediately.

What one historical fact must you elicit?

1. This was sudden onset of shortness of breath; did it begin before or after the coughing spell?

What one test of examination can you do to determine what must next be done?

1. Auscultation bilaterally will take time to retrieve and fit your stethoscope, and time to listen with the patient
poorly able to cooperate. OK, but . . .

2. Percuss the two hemi-thoraces. It takes just moments and no equipment.

What sound was elicited and diagnosis confirmed?

1. A resonant drum-like "tympanitic" sound. Tension pneumothorax from rupture of an
emphysematous bulla related to the strain of coughing.

What action and therapy must be done next?

1. He is brought to the "Code Room" while a Pleur-Evac and thoracostomy tray is set up for placement of a chest tube.

He is given strong doses of analgesia and sedation for the uncomfortable procedure. After the tube is in and
the tension is relieved, and he is breathing easier, he becomes somnolent and is breathing slowly and shallowly.

What just went wrong?

1. With the stress response stimulus removed by the correction of the tension pneumothorax, the on-board level
of analgesia and sedation is not competing against the stress, thus altering his mental status and lowering
respiratory drive.

How do you fix this and control the situation?

1. Prepare to intubate the patient and send him to the ICU to deal with his several problems.

Diagnosis: Spontaneous Post-Tussive Tension Pneumothorax in COPD;
Apnea during Sedated Procedure

 


Non-Invasive Ventilation [Bi-PaP™];
Do Not Resuscitate-Do Not Intubate
& End of Life Issues
:

     There are patients in whom it is desired to give temporary maximal support to their respiratory status, but in whom due
to wakefulness, ability to presently maintain their own airway, and perhaps good reason to avoid the stresses and invasiveness
of endotracheal intubation. Typically, the patient may have an exacerbation of COPD, pulmonary edema, or pneumonia, and it
is hoped that a few hours of pressure support and PEEP may carry the patient over the hump of immediate need and
improvement can be expected. For some patients, there may have been a declaration of DNR-DNI yet may recover from this
illness with some respiratory support.

     Non-Invasive Ventilation using a close-fitting mask and straps may provide this support. A bi-level positive air pressure
device is used or a ventilator might be used with settings adjusted to the circumstances.

     As for disposition within this institution, the wards may only take patients with stable Obstructive Sleep Apnea Syndrome
using their own or institution-provided CPAP/Bi-PaP™ machines. The Transitional Care Unit may take patients who are being
ventilated with Bi-Pap™ at stable settings. Very ill patients with Bi-Pap™ ventilation requiring adjustments must  go to a
critical care unit.

     Intubated patients, within this institution, may only go to wards for "comfort care" at "end of life" and must be spontaneously
breathing.

 


Keeping Your Own Good Health During The "Flu Season":

1. Get your Flu vaccine faithfully.

2. Get plenty of rest.

      3. Stay "upwind" of patients who are sneezing and coughing. Provide them with tissues and firm instructions.

      4. Wash your hands frequently or use a foaming alcohol hand sanitizer.

      5. Keep a positive attitude.

      6. Drink plenty of fluids.

      7. If you find that you have "a cold coming on", stay home and do not come to work.
      You’ll recover more quickly, and you won’t pass your infection to a high-risk or immune-compromised patient.

 



1) Neurology for the House Officer; 2nd Edition; Howard L. Weiner, MD & Lawrence P. Levitt, MD; Ó 1978, 1982 printing; The Williams & Wilkins Company; Baltimore, Maryland


"I can't breathe! - Respiratory Problems in the Emergency Department"
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