FUNDAMENTALS OF EMERGENCY MEDICINE.

Unit 4: Respiratory Emergencies.

--There are 3 major parts of the respiratory system:
the airway, the lungs, and the muscles of respiration.
The airway, which includes the nose, (mouth), pharynx,
larynx, trachea, bronchi, and bronchioles, carries air
between the lungs and the body's exterior.
--The respiratory epithelium in trachea and bronchi is
pseudo-stratified and primarily consists of three main cell
types – cilia cells, goblet cells, and basal cells.
The ciliated cells are located across the apical surface and
facilitate the movement of mucus across the airway tract.
--The respiratory tract is divided into two main parts:
the upper respiratory tract, consisting of the nose, nasal
cavity and the pharynx; and the lower respiratory tract,
consisting of the larynx, trachea, bronchi and the lungs.
--In normal conversation, it refers to breathing, the
movement of air in and out of the lungs. In medicine the
process of moving air is called ventilation, respiration is
specifically the exchange of oxygen and carbon dioxide
inside the alveoli of the lungs.
--The lung parenchyma is that portion of the lungs
involved in gas exchange. The most prominent structure
in this region is the alveolus. Each alveolus in the lung
parenchyma opens directly into an alveolar duct or
occasionally, in a limited number of species, into a
respiratory bronchiole.

4.1. Airway obstruction.

--An airway obstruction is a blockage in any part of the
airway. The airway is a complex system of tubes that
transmits inhaled air from the nose/or (mouth) into the
lungs. An obstruction may partially or totally prevent air
from getting into the lungs.
--The tongue is the most common cause of upper airway
obstruction, a situation seen most often in patients who
are comatose or who have suffered cardiopulmonary
arrest. Other common causes of upper airway obstruction
include edema of the oropharynx and larynx, trauma,
foreign body, and infection.
--When something keeps the air from moving in and
out of the airways in the lungs, it's called an airway
obstruction. When someone has asthma, the airways may
become obstructed, or blocked, because they are swollen,
narrow, or clogged with thick mucus.
--An airway obstruction is a blockage in the airway. It
may be partially or complete totally preventing air from
getting into the lungs. Some airway obstructions are life-
threatening.
Causes:
a) Aspiration (breathing in) of an object/liquids.
b) Obstruction - when something is swallowed and gets
caught in the pharynx.
c) External compression of the trachea –strangulation,
hanging etc.
Signs and symptoms:
a) Violent choking.
b) Alarming attempts at inspiration.
c) Unable to speak.
d) Cyanosis of face, neck and hands.
e) Cessation of breathing.
f) Unconscious.
Let’s now discuss some common causes of airway
obstruction.
4.2. Choking.
--Choking is a blockage of the upper airway by food
or other objects, which prevents a person from
breathing effectively. Choking can cause a
simple coughing , but complete blockage of the
airway may lead to death.
--It happens when the windpipe is blocked.
--This could be due to food, vomits or any other
object suddenly slipping down the trachea.
--In case of strangulation, the windpipe is blocked
by a tight band round the neck.
A choking patient may be coughing; he will be
struggling for breath and blue in the face.
Shock [shok]
1. A sudden disturbance of mental equilibrium.
2. A condition of acute peripheral circulatory failure due to dera
ngement of circulatory control or loss of circulating fluid. It is m
arked by hypotension and coldness of the skin, and often by ta
chycardia and anxiety. Untreated shock can be fatal. Called als
o circulatory collapse.

Shock is a medical emergency in which the organs and tissues of the

body are not receiving an adequate flow of blood. This deprives the orga
ns and tissues of oxygen (carried in the blood) and allows the buildup of
waste products. Shock can result in serious damage or even death.
Treatment.
1) If possible, remove the obstruction (tongue, food,
vomit) with your finger or a cloth wrapped around
your finger.
2) If the victim is a child, hold him upside down and
slap him between the shoulder blades.
3) If the victim is an adult, and is breathing,
encourage to continue coughing and sit him in a
chair (or drape him over the back of the chair) and
bend him forwards.
Then hit him five sharp blows using the heal of your
hand between the shoulder blades. Support the
upper body with one hand & help him to lean well
forward. Stop if the obstruction clears. Check the
mouth.
If the obstruction is not cleared, repeat the steps up
to three time.
4) Heimlich Maneuvers (Abdominal thrust) - this is
a very effective procedure at successfully clearing a
blocked airway.
--a) Stand behind the victim with your feet apart for
stability.
--b)Place the fist of your right hand, thumb facing
inwards, just above the umbilicus and below the
xiphoid process.
--c) Clasp this fist with the other hands so that your
arms now encircle the victim.
--d) Pull your fist into the abdomen in an upward
and inward thrusting movement.
The aim of this maneuvers is to apply sudden,
abrupt, upward pressure on the diaphragm, thus
producing sudden forced expiration.
The air pushing up behind the obstruction should
dislodge it. This manoeuver can be repeated until
the obstruction is successfully dislodged.
The Heimlich maneuvers can be used on the
choking victim who has fallen unconscious:
a) Place the victim in the prone position.
b) Straddle him by placing your feet either side of
the patient’s chest so that you are facing the
victim's head.
c) Place your hands in the same position as above
and thrust your clasped fist up and inward as above.
If obstruction persists the obstruction can be
removed by ENT specialist under sedation or
anesthesia.
Figure: Abdominal thrusts on unresponsive casualty.
4.3. Asphyxia (suffocation).
--Suffocation occurs when air cannot pass in and out
of the lungs.
--We must breath to live but without oxygen to die
is assured. Without getting rid of carbon dioxide, we
die easily.
A foreign object stuck in the throat, may block it
and cause spasms. If blockage is mild, the casualty
may be able to clear it and if the blockage is severe,
he will be unable to speak, cough or breathe & will
eventually lose consciousness.
Definition.
A deficiency of oxygen in the blood and an increase
in carbon dioxide in the body tissues.
--Breathing is necessary to transfer oxygen from the
lungs to the blood and on to the tissues to keep
them alive and functioning.
--If breathing stops, the brain, the control center of
the body, is starved of oxygen and the brain cells
will die. This means that the centers in the brain
which control the heart beat and respiration will
stop functioning, So breathing and heart beat will
cease. Those centers that control respiration will
cause breathing to stop first, followed by failure of
the heart.
Causes.
--Anything that causes disruption in the normal
exchange of oxygen and carbon dioxide between
the lungs and the outside air and can involve:
a) Airway obstruction, partial or complete blocking
of the airway by blood, vomit or other
debris/foreign bodies or plastic papers covering the
nostrils.
b) Gross chest/lung damage caused by trauma e.g.
fracture of the ribs caused by crushing of the chest
will puncture the lungs and/or heart.
c) Disease of lung tissue /trachea e.g. asthma.
d) Damage to the respiratory center of the brain
e.g. head injury, stroke.
e) Paralysis of the respiratory muscles e.g. polio.
f) Drowning.
g) Electric shock.
h) Inhalation of smoke and poisonous gases as in
wells, cisterns, sewers, mines, explosion hazards,
and silos.
Signs and symptoms.
1) Irregular labored respirations.
2) Complete or absence of breathing.
3) Pallor and cyanosis.
Management.
This includes immediate remedy by:
--i) Instituting artificial respiration.
--ii) Removal of the underlying cause whenever
possible.
Respiratory Resuscitation include Mouth-to-Mouth
Resuscitation performed by checking to see if the
patient is breathing.
If he/she is not breathing start mouth-to-mouth
resuscitation as follows:
a) Place victim in supine (recumbent position) on a
firm surface.
b) Loosen tight clothing from around the neck, chest
and waist.
c) Lift the jaw of the victim extending his neck to
allow the tongue to fall forward. Check the mouth
for any obstruction.
d) Holding the head in position by the jaw with one
hand, pinch the nostrils shut with the other hand.
e) Take a deep breath, place your mouth over the
mouth of the victim ensuring you make a good seal
with your lips so that no air escapes around the
edges.
f) Blow into the victim's mouth. Turn your head to
watch the chest rise and fall in response to the
inflation and to allow exhalation to occur.
g) Take another deep breath and repeat the
inflation.
h) Inflate the chest 6 times as quickly as possible.
i) Check for a pulse using the carotid pulse in the
neck. If there is a pulse, continue chest inflations at
a rate of 10 inflations per minute (approximately
every 6 seconds) until the victim starts to breath
spontaneously.
j) If there is no pulse, start cardiac compressions
and alternate with chest inflations (see below).
Guidelines for the administration of mouth-to-
mouth resuscitation:
a) Speed is essential in order for resuscitation to be
effective and brain damage prevented.
b) If the lungs fail to inflate, this means that the
airway is obstructed at some point. (Make sure that
no air is escaping from the sides of your mouth and
that the head has not slipped forward.
These are two other reasons for failure to inflate
the lungs) and therefore you have to check for:
-the head is extended allowing the tongue to fall
forward.
-look for vomit or other obvious obstruction in the
mouth. Remove by sweeping your finger through
the mouth.
 -if no obstruction is seen, attempt to remove the
unseen obstruction by rolling the patient onto his
side and slapping him smartly between the shoulder
blades. A child can be held upside down and the
back slapped.
c) If, on initial assessment the patient has a pulse,
continue to check the pulse at regular intervals
during mouth to mouth to ensure that the heart is
still beating.
4.4. Acute severe asthma.
--Asthma is an acute or recurrent reversible
obstructive airway disease characterized by
increased responsiveness of the tracheobronchial
tree to a variety of stimuli resulting into obstruction
of the lower airways.
--The attacks can be precipitated by allergy,
(especially to cat, horse or other animal hair or
pollens), infection or exercise.
--The obstruction can be reversed by treating with
beta adrenergic agents such as Salbutamol.
Clinical features.
Symptoms.
-Wheezing
- Difficulty in breathing
- Coughing
- Restlessness.
Signs.
- Prolonged expiration.
- Cyanosis if severe.
- Rapid pulse.
- Dehydration.
- Sticky, clear sputum.
- Wheezing.
If the pulse is over 120/min, the patient's condition
must be regarded as serious and admission to
hospital is urgent. Chest X-ray is necessary to
exclude cardiac problems, pneumothorax or foreign
body in the upper airway.
--Asthma and COPD are both chronic lung diseases.
COPD is mainly due to damage caused by smoking,
while asthma is due to an inflammatory reaction.
COPD is a progressive disease, while allergic
reactions of asthma can be reversible.
--Acute severe asthma, formerly known as status
asthmaticus is an acute exacerbation of asthma
that does not respond to standard treatments of
bronchodilators (inhalers) and steroids.
--The signs and symptoms of acute severe asthma
include, silent chest, cyanosis, confusion, coma,
hypotension, acidosis, pulse> 120/minute.
--Emergency care plan for acute severe asthma:
R/ O2 to keep saturation > 92%.
R/Antibiotics if pyrexia; or pneumonia on x ray.
Sedatives are contra indicated.
R/Beta 2 agonists and anticholinergic (Ipratropium)
by inhalation.
E.g. salbutamol or fenoterol nebulized.
Steroids, administer
--Hydrocortisone 200mg immediately and then
6 hourly IV for 24 hours.
--There after give prednisolone 0.5mg/kg daily
for 14 days.
-- MgSO4 2g intra venous infusion over 20 min.
Repeat once if necessary.
-- Intubation and mechanical ventilation may
be needed if the patient becomes exhausted and or
if life threatening features appear.
4.5. Foreign body in the throat, nose and ear.
--If a foreign material is lodged in the ear it causes
temporary deafness by blocking the ear canal.
--In some cases the foreign body may damage the
ear drum. As a way of playing, children often push
small objects into the ears.
--The common objects pushed in include cotton
wool buds, stones and seeds.
--Insects particularly cockroaches can fly or crawl in
the ear.
--Equally, children may push small objects up the
nose. These objects can block the nose and cause
infection.
Emergency care plan for throat, nose and ear.
--Calm and reassure the casualty.
--Make him comfortable in bed or chair.
--If an insect is in the ear, support his head with the
affected ear uppermost.
--Gently flood the ear with tepid water. The insect
should float out.
--If not, under good lighting, remove the foreign
body with a small straight artery force forceps.
If the child is uncooperative this should be done
under sedation or anaesthesia.
Treatment of foreign body in the nose.
a) Instruct the victim to blow his nose making sure
that he inspires through his mouth.
b) This is made more effective by blocking the
unaffected nostril and blowing out of the affected
nostril.
c) Instruct the victim to breathe through his mouth.
d) Take the victim to hospital if the object has not
been dislodged by the above measures.
Similarly, foreign body in the nose should be
removed with a small straight artery forceps in the
emergency room. Put his fingers in his nose. This
will push the object further up with the risk of
inhalation of the object.
4.6. Procedures
Heimlich maneuver:
-- (abdominal thrust).
-- (Chest thrust).