Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

36

Wilderness and Rescue Medicine

If respiratory failure is not corrected, the patient will inevitably deteriorate into respiratory arrest. An early sign of respiratory failure is the inabil- ity to speak more than a few words between breaths. This is called one- or two-word dyspnea. To illustrate what this looks like, imagine trying to speak easily after sprinting hard for 500 meters or so. A patient in this condition at rest, without having sprinted anywhere, is in serious trouble. Conversely, a patient who can talk at length about his or her shortness of breath is probably okay for the time being. Respiratory distress that you cannot fix in the field is a serious problem. The progression to failure may be rapid or slow. The treatment and evacuation may be a desperate emergency or a careful and low-stress process depending on the rate of progression. Generic Treatment for Respiratory Distress Respiratory distress is one of the most frighten- ing problems you will encounter in emergency medicine. Your immediate response should be to initiate treatment while you develop a more specific assessment and plan. You can use the acronym PROP to help you remember the gener- ic treatment for all forms of respiratory distress: Position and protection, Reassurance, Oxygen, and Positive pressure ventilation. PROP Position and Protection. Any patient in respi- ratory distress who can move will have already found the best position in which to breathe. This is usually sitting up or leaning forward to allow gravity to assist the diaphragm and to help keep fluids out of the upper and lower airway. In uncon- scious or immobile patients, special care must be taken to position them in a way that protects the airway from obstruction or aspiration of vomit, blood, and secretions. Reassurance. Encourage the patient to breathe slower and deeper, rather than panting like a dog. This brings in fresh oxygen rather than simply

moving the old carbon dioxide back and forth in the airways. Oxygen. If available, giving supplemental oxy- gen from a tank or concentrator may increase the amount of oxygen getting into the blood, and ulti- mately to the brain. Positive Pressure Ventilation. A patient in respiratory distress will fatigue rapidly. You may need to provide positive pressure ventilation to assist the patient’s efforts. You do not need to wait until the patient goes into respiratory arrest to use this technique. Specific Treatments for Respiratory Distress Although PROP may significantly improve symp- toms in some cases, it may be nearly ineffective in others. If you can identify part of the respiratory system in which the primary problem lies, you can initiate a more specific and effective treat- ment. This is one of the many places where a well- practiced, calm, and disciplined exam will really pay off.

General Principles

Respiratory Failure

4

Ventilation: • Pocket mask • Suction device • Bag-valve-mask • Intraoral airway • Oxygen

©2018WMA

Upper Airway Obstruction Obstruction is usually due to position, a piece of food, fluids, or swelling from trauma or infection. The obstruction may be partial or complete. With partial obstruction, the patient will have noisy and labored respiration characterized by wheez- ing, whistling, or stridor—the high-pitched raspy sound made by inhalation against an obstruction.