Difficulty in Breathing Basic Emergency Care Course - PowerPoint Presentation

1. Difficulty in BreathingBasic Emergency Care Course

2. Objectives Recognize the signs of difficulty in breathing (DIB) List the high-risk causes of DIB Perform critical skills for high-risk causes of difficulty in breathing

3. Essential SkillsBasic airway manoeuvres Basic airway device insertionManagement of choking Oxygen administrationBag-valve-mask ventilationNeedle decompression for tension pneumothorax Three-sided dressing for sucking chest wound

4. The ABCDE Approach REMEMBER …………Always start with the ABCDE Approach AND treat life-threatening conditionsThen take a SAMPLE historyThen do a Secondary Exam !

5. Breathing:Signs/ symptoms of tension pneumothorax Absent breath sounds on one side with hypotensionDistended neck veinsTracheal shiftingListen: wheezing may indicate asthma or allergic reactionAirway: Swelling (allergic reaction)Choking (foreign body obstruction)Listen for stridor (serious airway narrowing) Key Elements in the ABCDE Approach

6. Disability Check level of consciousness with AVPUPatients with decreased level of consciousness may not be able to protect their airwaysDrugs/infection/injury can affect the part of the brain that controls breathingCheck for paralyzing conditions that can affect breathing muscles Circulation: Check capillary refill, heart rate, rate of breathing and blood pressure for signs of poor perfusionShock, heart attack, heart failure or severe infection can present with poor perfusion and difficulty in breathing Check for leg swelling or lung crackles which may be signs of heart failureExposureLook at chest wall movement Check for penetrating traumaKey Elements in the ABCDE Approach

7. The SAMPLE History

8. S: Signs and SymptomsASK:When did the symptoms start?Was the onset sudden?Do they come and go?How long do they last?Have they changed over time?Any similar episodes? ect… ?

9. SUDDEN onset shortness of breath THINK: Obstruction of the airwayForeign bodySwelling of the airwayTrauma to the airway, lung, heart or chest wallToxic inhalationSudden heart problemsHeart attackAbnormal rhythmValve problemsRapid deep breathingPoisoningHigh acid levels (diabetic ketoacidosis)Anxiety

10. SLOWER onset shortness of breath THINK: Infections Fluid in the lungsTB and heart failureFluid around the heartTB or kidney diseaseLung cancerDiseases affecting muscles of chest wallAsthma or COPD

11. S: Signs and SymptomsASK:Was there anything that triggered the difficulty in breathing?What makes it better or worse?THINKAllergies-> airway blockage from swellingInhalation (fire or chemicals) -> airway swellingChemicals and pesticides -> fluid in lungs or muscle weaknessIf lying flat worsens breathing this suggests fluid in the lungs?

12. S: Signs and SymptomsASK:Is there any tongue or lip swelling or voice changes?THINKSwelling to mouth, lips, tongue, upper throat and voice changes suggest severe allergic reaction and inflammation in the airwayWATCH CLOSELY?!

13. S: Signs and SymptomsLISTENAre there any abnormal breath sounds?THINKStridor (high pitched ”squeaking” sound during inhalationUPPER AIRWAY swelling or blockage Wheezing (high pitched sound during exhalation) LOWER AIRWAY narrowing or spasms in the lungsAsthma, COPD, heart failure, allergic reactionsGurgling: (low pitched bubbling)Mucous or fluid in the airway

14. S: Signs and SymptomsASKIs there any pain associated with the difficulty breathing?THINKIf the patient has chest pain with difficulty in breathing:Heart attackPneumothoraxPneumoniaTrauma to lungs, ribs or musclesPleuritic pain (worse with deep breaths) InfectionBlood clot in lung (pulmonary embolism) ?

15. S: Signs and SymptomsCHECK Is there a fever?Is there a cough?THINKFever suggests an infectionCough with fluid sounds could be pneumonia or oedemaCough with a wheeze suggests asthma or COPD

16. S: Signs and SymptomsCHECK Foot and leg swellingFor recent pregnancyTHINKOedema to both feet and legs suggests heart failureSwelling and pain to one leg suggests a blood clot that could travel to lung (pulmonary embolism) Pregnancy is a risk factor for both pulmonary embolism and heart failure

17. A: AllergiesASKAllergies to medications or other substances?Recent insect bites or stings?THINKSevere allergic reactions can cause airway swelling and difficulty breathingPeople can have allergic reactions to almost anythingFoodPlantsMedicationsInsect bites/stings ?

18. M: MedicationsASKCurrently taking any medications? THINKNew medications or change in dosages can cause allergies and difficulty breathingAccidental overdose of some medications can slow or stop breathing?

19. P: Past Medical HistoryASKHistory of asthma or chronic obstructive pulmonary disorder (COPD)?History of heart disease or kidney disease?History of tuberculosis or cancer? THINKAsthma and COPD cause episodes of DIBHeart or kidney failure can cause a fluid build-up in the lungsHeart attacks may present with difficulty in breathingPericardial effusions and pleural effusions can be caused by cancer, tuberculosis or kidney problems ?

20. P: Past Medical HistoryASKHistory of diabetes?History of smoking? History of HIV? THINKDiabetics can have fast breathing from diabetic ketoacidosis Smoking increases the risk of asthma, COPD, lung cancer, heart attackHIV increases the risk of infection?

21. L: Last Oral IntakeASKWhen did the patient last eat or drink?THINKFull stomach puts the patient at risk for vomiting and aspiration ?

22. E: Events Surrounding Illness ASKWhat was the person doing when the difficulty in breathing started? THINKDIB after eating, think chokingDIB with exercise and chest pain, think heart attack?

23. E: Events Surrounding Illness ASKWas the patient found in or near water? THINKConsider drowning (inhalation of water) if a person is found in or near waterEven a small amount of inhaled water can cause serious lung damageWorsens over time. WATCH CLOSELY ?!

24. E: Events Surrounding Illness ASKHas there been any exposure to pesticides or inhaled chemicals?THINKPesticides used in farming can be absorbed through the skin and cause fluid in the airways and lungsExposure to gases from a fire can cause chemical inhalation ?

25. E: Events Surrounding Illness ASKHas there been any recent trauma? THINKRib fracturesPneumothoraxHaemothroaxHeart or lung bruising?

26. Workbook Question 1Using the workbook section above, list 5 questions about PAST MEDICAL HISTORY you would ask when taking a SAMPLE history1.2.3.4.5.

27. Secondary Exam FindingsLook, listen and feel Difficulty in breathing may present with: Changes in the respiratory rateChanges in the respiratory effortLow oxygen levels in the blood*Remember you should have ALREADY completed the ABCDE Exam and treated life-threatening conditions BEFORE doing this extensive examination*If the secondary exam identifies an ABCDE condition, STOP AND RETURN IMMEDIATELY TO ABCDE to manage it. !

28. Secondary Exam FindingsLook for signs of respiratory failure Accessory muscle use and increased work of breathing Difficulty speaking in full sentencesInability to lie down or lean backDiaphoresis and mottled skinConfusion, irritability, agitationPoor chest wall movementCyanosis

29. Secondary Exam FindingsLook at pupil size and reactivitySmall pupils suggest possible medication overdose or exposure to chemicals (usually pesticides)Unequal or abnormally shaped pupils suggest head injury which can cause abnormal breathingSource: WHO Pocket Book for Hospital Care of Children. 2nd Ed. 2013.P168

30. Secondary Exam FindingsLook at the face, nose and mouthCyanosis around the lips or nose suggests low oxygen levels in the bloodPale lower eyelids may suggest anaemiaSwelling of the lips, tongue and back of mouth suggest allergic reactionSoot around the mouth or nose, burned facial hair or facial burns suggests smoke inhalationBleeding, swelling or abnormal airway shape may be due to trauma

31. Secondary Exam FindingsLook at the neck and chestDistended neck veins suggests heart failure, tension pneumothorax or pericardial tamponadeExcessive muscle use of neck and chest suggests significant respiratory difficulty Tracheal shift suggests tension pneumothorax or tumourSwelling of the neck suggests infection or traumaExamine the entire neck and chest carefully for signs of trauma

32. Secondary Exam FindingsLook at the rate and pattern of breathingLonger exhalation time due to narrowing of lower airwaysAsthmaFast breathingDehydrationSevere infectionChemical imbalances in the bloodPoisoningAnxietySlow and shallow breathing Opioid overdoseFlail chestOccurs with multiple rib fractures when a segment of rib cage separates from the rest of the chest wall

33. Secondary Exam FindingsLook at both legsSwelling to both legs (heart failure)Swelling to one leg with pain (blood clot)Look at the skinBites (allergic reaction)Rashes (allergic reaction or systemic infection)HivesPallor (anaemia)Burns that wrap around torso Can restrict chest wall expansion

34. Secondary Exam FindingsListen to breath soundsStridor Partial upper airway obstruction-Foreign body SwellingTraumaInfectionDecreased breath sounds Something preventing air from entering the lung PneumothoraxHaemothoraxFluidForeign bodyInfection inside the lungs or tumour

35. Secondary Exam FindingsListen to breath soundsWheezingLower airway obstructionAsthmaAllergic reactionTumourForeign objectCrackles Fluid build-up in the airways of the lungsTry to listen to breath sounds often so you can know what is normal and what is not!

36. Secondary Exam FindingsListen to heart soundsAbnormal heart rhythms can cause the heart to pump blood poorlyPoor perfusionHeart murmurs with difficulty breathing Heart valve disease or injuryMuffled or distant heart sounds with low blood pressure, fast heart rate and distended neck veins suggests pericardial tamponade

37. Secondary Exam FindingsFeel the chest wall (ribs)Deformities or abnormal movements suggests rib fracturesCrepitus suggests underlying fracture or pneumothorax Unequal chest expansionPneumothorax, haemothorax, flail chestPercuss the chest wall Hollow sounds (hyperresonance) PneumothoraxDull sounds Fluid or blood

38. Workbook Question 2 Using the workbook section above, List 3 signs you should LOOK for in a patient with difficulty in breathing:1.2. 3.

39. Workbook Question 2 List 4 things you should LISTEN for in a patient with difficulty in breathing: 1.2.3.List 3 things you should FEEL the chest wall for in a patient with difficulty in breathing:1.2.3.

40. Possible Causes of Difficulty in Breathing

41. Key AIRWAY causes of DIBForeign body obstructionAcute difficulty breathingVisible secretions, vomit or foreign bodyAbnormal sounds from the airway (stridor, snoring, gurglig)CoughingDroolingSevere allergic reactionSwelling of lips, tongue and mouthStridor and/or wheezingRash or hivesMay have tachycardia and hypotension Exposure to known allergen

42. Key AIRWAY causes of DIBAirway swelling (inflammation or infection)StridorHoarse voiceDrooling or difficulty swallowing (indicates severe swelling)Unable to lie downMay have fever (with infection)

43. Key AIRWAY causes of DIBAirway burnsHistory of exposure to chemical or fireFacial burns (singed facial hair)StridorChange in voice

44. Key LUNG causes of DIBPneumoniaFever and coughGradually increasing work of breathingWorsening pain with breathing (pleuritic)Abnormal lung exam (LISTEN for crackles)

45. Key LUNG causes of DIBAsthma/ COPDWheezingCoughAccessory muscle useTripod positionMay have history of smoking or allergiesTripod position

46. Key LUNG causes of DIBPneumothoraxDecreased breath sounds on one sideSudden onsetHyperresonance with percussion on affected side Pain worse with breathingMay have history of trauma or evidence of rib fractureHypotension, distended neck veins and decreased breath sounds on one side indicate tension pneumothorax An untreated pneumothorax can develop into a tension pneumothorax!

47. Key LUNG causes of DIBHaemothoraxDecreased breath sounds on affected sideDull sounds with percussion May have history of trauma, cancer or tuberculosisMay have symptoms of shock if large haemothorax

48. Key LUNG causes of DIBPleural effusionDecreased breath sounds on one or both sidesDull sounds with percussionMay have history of cancer, tuberculosis, heart disease or kidney diseaseAcute or chronic difficulty breathing

49. Key LUNG causes of DIBAcute chest syndrome (sickle cell patients)History of sickle cell diseaseChest painFeverHypoxia

50. Key CARDIAC causes of DIBHeart attackChest pressure, tightness or crushing feeling in the chestDiaphoresis and mottled skinNausea or vomitingSigns of heart failureHistory of smoking, cardiac disease, hypertension, diabetes, high cholesterol, family history of heart problems

51. Key CARDIAC causes of DIBHeart failureDifficulty in breathing with exertionDifficulty in breathing when lying flatSwelling to both legsDistended neck veinsCrackles may be heard in the lungsMay have chest pain

52. Key CARDIAC causes of DIBCardiac tamponade Signs of poor perfusion (shock)Tachycardia, tachyponea, hypotension, pale skin, cold extremities, capillary refill greater than 3 secondsDistended neck veinsMuffled heart soundsMay have dizziness, confusion or altered mental statusMay have history of tuberculosis, trauma, cancer, kidney failure

53. Key SYSTEMIC causes of DIBAnemiaPale skin and inner lower eyelidsTachycardiaTachypnoeaHistory of haemorrhage, malnourishment, cancer, pregnancy, infections (tuberculosis or malaria), renal failureOpioid overdoseClinical or recreational opioid use Altered mental statusChange in pupil sizeSlow, shallow breathing

54. Key SYSTEMIC causes of DIBDiabetic Ketoacidosis (DKA)History of diabetesRapid or deep and slow breathing (Kussmaul breathing)Frequent urinationSweet smell to breathHigh glucose in blood or urineDehydrated

55. Workbook Question 3History and Physical Findings:Likely Cause:A 20 yr male presents with difficulty breathing, wheeze and: Swelling of lips, tongue and mouthRach or hives (patches of pale or red, itchy, warm, swollen skin)Tachycardia and hypotensionHistory of allergiesExposure to known allergenA 50 yr woman presents with difficulty breathing, signs of poor persusion (tachycardia, tachypnoea, hypotesion, pale skin, cold extremities, capillary refill greater than 3 seconds) and:Distended neck veinsMuffled heart soundsHistory of tuberculosisUsing the workbook section above, list the possible cause of Difficulty In Breathing next to the history & physical findings below:

56. Management of Difficulty in Breathing REMEMBER treat ABCDE problems and life-threatening conditions first

57. ManagementIf suspected airway inflammation or burns:Keep patient calm Give OXYGEN if it does not upset the patient If patient is alert without other injuries, seated upright may make the patient more comfortableConsider early advanced airway management Delays in intubation-> worsening swelling-> increased difficulty breathing -> difficult intubation Plan for rapid HANDOVER/TRANSFER

58. ManagementIf suspected choking:Use age-appropriate chest thrusts/abdominal thrusts/back blows

59. ManagementIf suspected choking in infants:In infants, alternate between 5 back blows and 5 chest thrusts

60. ManagementIf suspected allergic reaction:Remove allergenFor severe allergic reaction with difficulty breathing Give intramuscular ADRENALINE without delayGive OXYGEN If suspected asthma/COPDGive SALBUTAMOLGive OXYGEN if indicatedIf suspected DIB from feverGive ANTIBIOTICS as soon as possibleIf signs of poor perfusion, give IV FLUIDS

61. ManagementIf suspected heart attack:Give ASPIRINWith symptoms of shock or difficulty breathing give OXYGENIf patient has NITROGLYCERIN, assist them in taking itIf suspected chronic, severe anaemia:Give IV FLUIDS slowly Listen frequently for crackles in the lungs (fluid overload) Prepare for handover/transfer for possible BLOOD TRANSFUSIONIf suspected diabetic ketoacidosis (DKA):Give IV FLUIDSPrepare for urgent transfer

62. ManagementIf suspected opioid overdoseSupport breathing with a BAG-VALVE-MASK as neededGive NALOXONEIf suspected large pleural effusion or haemothorax:Give OXYGENArrange for urgent HANDOVER/TRANSFERPatient requires CHEST TUBE or drain

63. ManagementIf suspected trauma:Give OXYGENIf tension pneumothorax or cardiac tamponade give IV FLUIDSIf tension pneumothorax is suspected perform NEEDLE DECOMPRESSION as soon as possiblePrepare for rapid transfer for chest tube insertionTreat sucking chest wounds with a 3-sided occlusive dressingPrepare for rapid transfer for chest tube insertion

64. ManagementIf suspected acute chest syndromeGive OXYGENGive IV FLUIDSMay need HANDOVER/TRANSFER

65. Workbook Question 4DIB, coughing and you suspect choking1.2.DIB, high fever, cough and you suspect serious infection1.2. Using the workbook section above, list what you would DO to manage a person who presents with:

66. Workbook Question 4DIB, hoarse voice and stridor on breathing in. You suspect airway inflammation1.2.3. Using the workbook section above, list what you would DO to manage a person who presents with:

67. Special Paediatric Considerations: Danger Signs Signs of airway obstruction (unable to swallow, drooling, stridor) Increased breathing effortCyanosisAltered mental statusPoor feedingVomiting everythingSeizures/ConvulsionsLow body temperature

68. Special Paediatric Considerations:Wheezing in children can be a viral infection or a foreign objectStridor can be caused by airway swelling or a foreign object Rapid breathing may be the only sign of pneumoniaRapid breathing can indicate DKA as the first sign of diabetes in children

69. Workbook Question 5Using the workbook section above, list the paediatric danger signs:1.2.3.4.5.6.7.8.

70. Disposition of the PatientOngoing MonitoringInhaled medications such as salbutamol only last approximately 3 hoursA severe allergic reaction can return when adrenaline wears offNaloxone only lasts about 1 hour and may require repeat dosesMost opioid medications last longer than thisFollowing submersion injuries, a person may develop breathing problems later on Remember these patients need to be monitored closely!

71. Transport Considerations Never leave a patient who might need definitive airway placement unmonitored during handover/transferMake transfer arrangements as early as possible for any patient who may require assisted ventilation

72. RememberPerform ABCDEs firstTreat life-threatening conditionsTake a SAMPLE historyDo an extended physical examinationThink about causesThink about considerations in childrenThink about disposition and transport!

73. Questions?

74. Quick Cards

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