Adult respiratory emergencies

Protocol 2.2

Adult

Respiratory

Emergencies

ASTHMA

This protocol is used for patients

complaining of Dyspnea AND who are

wheezing.

Allow patients to assume a position of

comfort, when possible.

Remember a patient with a history of CHF

and no asthma history that has wheezing

should not be automatically classified as

an “asthma patient,” the more prudent

assessment would be that of CHF (cardiac

asthma).

Treating The Asthma

Patient

BASIC LEVEL: EMT and PARAMEDIC

1. Initial Patient Assessment Protocol 2.1.1

2. Airway Assessment/Management Protocol

2.1.2 Oxygen via nasal cannula @2 - 4 LPM to

maintain pulse ox at ≥ 94% (non-rebreather

@15 LPM if SpO2 < 90%).

3. Attach cardiac monitor and pulse oximeter.

4. Transport to designated hospital.

ALS LEVEL 1: PARAMEDIC ONLY

1. If severe distress consider CPAP with in-line nebulized medication may

or may not help (keep in mind, it is the medications that will work best

to break the bronchospasm)

2. Administer Albuterol (Ventolin) 2.5mg (in 2.5cc normal saline) by

nebulizer. May repeat twice PRN. DO NOT GIVE ALBUTEROL OR

IPRATROPIUM BROMIDE IF THE HEART RATE IS > 140

3. May add Ipratropium Bromide (Atrovent) 0.5 mg (0.5ml) to the first

Albuterol neb only.

4. If indicated, start IV of Lactated Ringer’s or Normal Saline at TKO

5. For persistent respiratory distress, give Methylprednisolone Sodium

Succinate (Solu-Medrol) 125mg IV.

6. For severe dyspnea, Epinephrine (1:1000) 0.4 ml IM Adult

(Peds: 0.01 ml/kg.) Caution should be used with administration of

Epinephrine when the patient has a history of hypertension or heart

disease (call med control if you have any concerns)

7. Consider need for endotracheal intubation

ALS LEVEL 2: MEDICAL CONTROL

1. Repeat Epinephrine (1:1000)

0.4 mg IM

2. If patient still has dyspnea

after SubQ Epi, 3 Albuterol

nebs (first with Atrovent), and

Solu-Medrol, Medical Control

may order Magnesium Sulfate

2 gms IV (mixed with 50ml of

D5W given over 10 – 15

minutes)

AND Dyspnea Protocol

2.2.3

This protocol is used for patients with a

history of emphysema and/or chronic

bronchitis that complain of dyspnea.

If at any point, the patient’s respiratory

status deteriorates, consider CPAP or

endotracheal intubation and

administration of Albuterol via the ET

tube as a mist, and transport

immediately.


1. Initial Patient Assessment 2.1.1

2. Airway Assessment/Management Protocol 2.1.2. Oxygen via

nasal cannula @2 - 4 LPM to maintain pulse ox at ≥ 94% (non-

rebreather @15 LPM if SpO2 < 90%).

3. Attach cardiac monitor and pulse oximeter.

Treatment


1. If patient is in moderate to severe distress and is still alert and

cooperative, consider CPAP (with in-line nebulized medication) per

CPAP Protocol .

2. Administer Albuterol 2.5 mg in 2.5ml of normal saline and Atrovent

(Ipratropium) 0.5mg via nebulized breathing treatment.

3. Repeat Albuterol (only) every 15 minutes as needed x 3 doses total.

Discontinue therapy if patient develops marked tachycardia (HR >

140) or chest pain.

4. If signs of severe hypoventilation despite CPAP and/or Nebulized

bronchodilators: (See Airway Assessment Protocol, 2.1.2)

a. Assist ventilations with BVM with 100% oxygen.

b. Consider endotracheal intubation

5. Initiate IV lactated Ringer's or normal saline TKO.

6. For persistent respiratory distress, give Methylprednisolone Sodium

Succinate (Solu-Medrol) 125 mg IV. (NOTE: If patient already on a

steroid, give 80 mg of Solu-Medrol IV).


1. Contact medical control or

medical director for any

questions or

problems.

2. Consider (per med control)

Valium 2-5 mg or Versed 2-4 mg

IVP for

anxiety, however patient may

then need to be intubated.

Pulmonary Edema/ CHF

This protocol is used for patients who are exhibiting signs/symptoms of pulmonary

edema – CHF including: tachypnea, orthopnea, JVD, edema, dyspnea with rales

and/or wheezing (cardiac asthma). The patient may also have diminished air

exchange. In severe case, patient may be pursed lip breathing. Other treatment for

the causes of pulmonary edema-CHF should be considered (e.g. supraventricular

tachycardia, myocardial infarction and cardiogenic shock).

Protocol 2.2.4


1. Initial Patient Assessment Protocol.

2.1.1

2. Airway Assessment/Management

Protocol.2.1.2. Put patient in position

of comfort. Oxygen via nasal cannula @2 -

4 LPM to maintain pulse ox at

≥ 94% (non-rebreather @15 LPM if SpO2 <

90%).

3. Attach cardiac monitor and pulse

oximeter.


1. Administer CPAP (if available). Titrate to 10cm of pressure (see

CPAP Protocol)

2. If patient’s respiratory status deteriorates (fatigues, does not respond to

CPAP, obvious persistent distress), assist ventilations with BVM with

100% oxygen and consider endotracheal intubation. If patient has endstage

disease and has previously expressed to family (verbally or in

writing) he/she does not want to be intubated, and then continue

assisting with BVM or CPAP.

3. Initiate IV lactated Ringer’s or Normal Saline TKO.

4. If systolic BP > 100 mm Hg; give Nitroglycerine 0.4mg sublingual

(spray or tablet) followed by Nitroglycerin paste 1 inch to chest wall

Avoid if patient used Viagra, Cialis, Levitra or other ED drugs. (May

repeat sublingual Nitro every 3 minutes up to 3 doses total if patient is

hypertensive or has chest pain).

5. Do 12 Lead EKG. Transmit if abnormal and time permits


1. Lasix 40-80 mg IV.

2. Consider Morphine Sulfate slow IV in

2mg increments titrate to systolic

BP > 100 (or signs of respiratory

depression) up to10 mgs. Carefully

monitor blood pressure and respirations.

Be prepared to reverse with

Narcan if needed.

3. Contact medical control or medical

director for any concerns or

questions.

Pneumonia (Suspected)

Protocol 2.2.5

Patients complaining of dyspnea should be suspected of

having pneumonia when they present with fever, productive

cough, and possible pleuritic chest pain, history of being

bedridden, known immune-compromise, diabetes, elderly

and lung sounds indicative of consolidation (rales and/or

rhonchi with egophony over area of consolidation).


1. Initial Patient Assessment Protocol

2.1.1

2. Airway Assessment/Management

Protocol 2.1.2. Oxygen via nasal

cannula @2 - 4 LPM to maintain pulse ox

at ≥ 94% (non-rebreather @15

LPM if SpO2 < 90%).

3. Attach cardiac monitor and pulse

oximeter

4. Check temperature if able


1. Consider CPAP (per CPAP protocol) for severe dyspnea/air hunger. It

may or may not help but will not harm.

2. Initiate IV lactated Ringer’s or Normal Saline at 125ml/hr. If patient

hypotensive (systolic < 90 mm Hg) and/or tachycardic (HR > 110) bolus

with 1- 2 liters of IV fluid in 250ml increments until systolic BP > 90 mm

Hg (20 ml/kg for children). Recheck vital signs and lung exam inbetween

each increment. Discontinue bolus if signs of pulmonary edema

or development of respiratory distress.

3. If dyspnea noted, administer Albuterol 2.5 mg in 2.5ml of normal saline

and Atrovent (Ipratropium) 0.5mg via nebulized breathing treatment.

Do not give if HR ≥ 140

4. Repeat Albuterol (only) every 15 minutes as needed x 3 doses total.

Discontinue therapy if patient develops marked tachycardia (HR > 140)

or chest pain.

5. If signs of severe hypoventilation despite CPAP and/or Nebulized

bronchodilators: (See Airway Assessment Protocol 2.1.2)

a. Assist ventilations with BVM with 100% oxygen.

b. Consider endotracheal intubation

6. AVOID USE OF DIURETICS!!


1. Notify medical control or medical director for any problems

or concerns.

Adult respiratory emergencies

Health & Medicine