Respiratory Emergencies

Pulmonary embolism, asthma, pneumo- and haemothorax, pneumonia and anaphylaxis.

Respiratory Emergencies

Pulmonary Embolisms

• A blood clot obstructs blood flow in the pulmonary arteries. The potential for rapid deterioration increases depending on the blood clots location and on its size. This blood clot will obstruct blood flow, leading to less oxygenated blood, less blood reaching the left ventricle and increases in pressure within the pulmonary arteries. o As a result, patients can present hypoxic and Short of breath. Also tachycardic, with chest pain and with signs of low perfusion like dizziness, altered, diaphoretic. Ultimately, if the obstruction is severe and or worsening, hypotension and shock, with ultimate death as a result of poor cardiac output and low oxygenation. o A very common cause is a DVT that broke off and ended up in the lungs. DVT occurs as a result of venous pooling (long flights or car rides) or hypercoagulable conditions like cancer, pregnancy or even recent surgery. • Specifics of the workup o D-Dimer: Forms when there is active breakdown of clots within the body, if elevated it does not confirm a PE, however, it further increases its likelihood, prompting the provider to perform additional testing o CT Pulmonary Angiogram: Directly visualize pulmonary vascular to assess for blood clots, their location and size ▪ If the patient is severely allergic to contrast, a V/Q scan may be ordered if the patient is stable enough o ECG: Will most likely show sinus tachycardia and may show signs of right heart strain (blood backs up into the R side of the heart, placing strain) o Bedside Echocardiogram: your provider can look at the right ventricle looking for dilation and strain o To cover the general workup related to the patients presenting symptoms: a cbc, cmp, troponin will most likely also be ordered • Treatment o If hypotensive, administration of fluids may be ordered. If hypotension persists, vasopressors may be ordered. If rapidly deteriorating, the blood clot needs to be rapidly broken down with a thrombolytic and or removed by interventional radiology. o Oxygen to help improve oxygenation and alleviate symptoms ▪ High flow nasal cannula is preferred o If stable, Heparin Bolus and Infusion ▪ An anticoagulant that prevents the occlusion from getting worse, giving the body time to start breaking down the clot on its own. When on the heparin drip, you will repeat the ptt(might be all the coags at your facility) at a set amount of time, to ensure that the patient is at a therapeutic level of heparin. Before starting the heparin infusion, you will need a baseline hgb, hematocrit and coags, plus ensuring there are no signs of bleeding such as dark black stools prior to infusion. (You dont want to make bleeding worse, however, sometimes benefits vs risks play a role) o If rapidly deteriorating, in shock or unstable, a thrombolytic should be administered to rapidly break down the clot. • Nursing o Ensure you place a large bore IV for the CT Pulmonary Angiogram o Have multiple IV's for these patients, at least 2 o Know your facilities heparin infusion protocol o Know the contraindications for thrombolytics o If heparin and or TNK were given, monitor closely for bleeding o You can assess if your patient will tolerate being flat for CT by simply lowering the head of the bed briefly. If they immediately becoming symptomatic, communicate with the team to form a plan

Asthma Exacerbation

• Characterized by inflammation, bronchoconstriction and mucus production that lead to patients having difficulty getting oxygen in and carbon dioxide out as the airways are inflamed, constricted and filled with mucus. o Symptoms can include shortness of breath and wheezing, chest tightness and coughing. As it progresses, there will be little air movement (less wheezing), unable to speak, cyanotic, and increasing altered as they go into respiratory failure if nothing is done. • Specifics of the workup o The diagnosis of asthma is typically done from the history and physical examination, not labs or radiology. However, the general workup will still most likely be ordered to help rule out other issues and or possibly help identify causes/triggers o Chest Xray, CBC, BMP, Bedside Ultrasound • Treatment o Oxygen: Alleviates hypoxia o Albuterol and Ipratropium ▪ Albuterol is a short acting beta agonist that helps relax bronchial smooth muscle, resulting in improved airflow from bronchodilation ▪ Ipratropium Bromide is also typically administered with albuterol as it also helps with bronchodilation, further alleviating bronchospasm o Corticosteroids are given to help decrease the inflammation and edema present in the airways, further improving airflow o Magnesium: Also promotes bronchodilation by helping relax bronchial smooth muscle o Noninvasive Ventilation (Cpap/Bipap) helps improve ventilation and oxygenation through the constant positive airway pressure provided, helping alleviate hypoxia and hypercapnia. • Nursing o Learn to work closely with the respiratory therapists o If you are working in a small ER, learn how to give a breathing treatment (albuterol/ipratropium) o Closely monitor and promptly communicate with the team ▪ Listen to the lungs, ensuring there is improvement in air flow ▪ If you do not hear much and the patient is in obvious distress, it means there is no movement of air as a result of the inflammation, bronchoconstriction and mucus

Pneumo/Hemothorax

• A pneumothorax is air in the pleural space while a hemothorax is blood. These can collapse the lung or impede it, ultimately affecting ventilation and gas exchange (hypoxia and hypercapnia). As they worsen, both will compress surrounding structures including the vena cava and heart, leading to decreased cardiac output. With hemothorax, if the bleeding is severe into the pleural space, blood loss will further cause hemodynamic instability. Tracheal deviation is a late sign. o These patients will present with absent breath sounds on one side, shortness of breath, hypoxic, tachypnea, tachycardia and if severe, will start showing additional signs of shock like hypotension, pallor and ALOC. • Specifics of the workup o The physical examination is a very good indicator, specifically if there are absent breath sounds on one side. o Chest Xray: For a hemothorax, there would be no lung markings on the affected side while with a hemothorax, there would be opacity/whiteness on the affected side. o Bedside Ultrasound by ER provider: Can visualize the lung and or fluid collection o If the findings of the above are inconclusive, additional testing like a CT chest may be necessary for more detailed images. However, when severe enough, which prompt immediate treatment in the ER, they will be easily seen on a chest xray by your provider. ▪ Hemothorax is commonly caused by trauma and these patients may receive a variety of CT scans to also assess for other injuries • Treatments o Pneumothorax ▪ A tension pneumothorax (severe version) will require immediate needle decompression to quickly allow air to escape the chest cavity, stabilizing the patient by decreasing the pressure on the lungs, heart and surrounding structures. • A chest tube will still be necessary to help restore the pressures within the pleural space. This will help the lung fully reexpand and eventually fully heal. ▪ If the pneumothorax is small and not causing any instability, the patient may simply be placed on oxygen and monitored. o Hemothorax ▪ A tension hemothorax (severe version) will require a chest tube to properly drain the blood from the pleural space. • If needed, to help with hypotension and hypoperfusion as a result of the blood loss, blood may be administered. A small fluid bolus may also be initially given. • If after chest tube placement, bleeding is ongoing, the patient may need to go to surgery to locate and control the source of the bleeding. o Oxygen Administration ▪ I commonly place my patients on a nonrebreather initially until stabilized • Nursing o Ensure chest tube drainage device is placed somewhere where it will not get accidentally damaged or pulled ▪ If accidentally pulled, place petroleum gauze or xeroform over it, ideally on exhale ▪ Immediately call the team and let them know (It happens. Learn from it and be more careful next time) o Monitor for continued bleeding with hemothorax on the chest tube drainage. If the output begins to increase rapidly with more than 200ml per hour, or the color suddenly changes to bright red, notify the team o Ensure supplies are ready for chest tube placement including chest tube, suction, drainage system, antiseptic, sterile gloves, gown and so forth. o Ensure patients get pain medications (or at least ensure a local anesthetic is used) o Be proactive with calling xray after the chest tube is placed. The new chest xray will verify correct placement

Pneumonia

• An infection of the lungs. When it occurs in susceptible populations like the elderly or immunocompromised, it can lead to sepsis, respiratory failure, shock and death if left untreated. o The inflammation can damage alveoli, leading to increased permeability that allows substances (fluids, proteins, wbcs) to accumulate in lung tissue. This leads to impaired gas exchange which may lead to hypoxia and co2 retention. As this progresses, worsening respiratory failure and septic shock can occur. o These patients will present with signs of an infection such as fever, chills, tachycardia and fatigue. For pneumonia specifically, symptoms can include cough, sob, chest pain upon breathing. • Specifics of the workup o Chest Xray: Helps identify presence of pna o Labs ▪ CBC: assess level of wbc's and if with differential, can see type of white blood cells (whether mature or immature wbc's) or whether a viral etiology is more likely ▪ BMP (Chemistry): helps assess for any abnormalities with electrolytes, kidney function and overall imbalances ▪ ABG/VBG/Lactate: Help assess oxygenation, ventilation, acid base and perfusion status • If the patient is critical, an ABG is preferred over a VBG to obtain accurate values. Otherwise, VBGs may be used as they are easier to obtain and less painful for patients. But anytime, oxygenation and ventilation need to be accurately assessed, an ABG is preferred for its more accurate values. ▪ Blood Cultures and Sputum Culture: help identify bacteria causing infection and help choose appropriate Antibiotic ▪ CT Chest: If chest xray shows anything inconclusive, a chest ct may be ordered to obtain more detailed images. It can help assess for an abscess or pus collection. • Treatment o Oxygen administration to assist with treating hypoxia o Fluid Administration when signs of sepsis are present such as tachycardia and hypotension. The adult initial resuscitation is 30ml/kg. Typically, normal saline is used. ▪ If needed, for hypotension and shock, vasopressors should be used. o Antibiotics. Obtain blood cultures first, then broad spectrum antibiotics immediately after. This will treat the infection present. Blood cultures are important so we can figure out which antibiotic the organism is more susceptible to. o If viral source, the appropriate antiviral may be ordered. o Supportive care such as pain management and correction of any abnormalities that may arise from the derangement of septic shock if present. • Nursing o Ensure timely and rapid administration of antibiotics once ordered. The earlier the better patient outcomes tend to be. ▪ Do your best to obtain blood cultures prior. o Be aware of your facilities sepsis bundle and what it encompasses. It will most likely prioritize antibiotic and fluid resuscitation within a timeframe of suspicion. o Ensure patient comfort including appropriate pain management and antipyretics when needed. o Continuously monitor respiratory status to ensure improvement, and if worsening, promptly communicate with the team. o When elderly or immunocompromised patients come into the ER, be mindful of the main sources when severe infection can occur. These are the chest, abdomen and pelvis.

Anaphylaxis

Mini Pathophysiology: Anaphylaxis is a severe, life-threatening allergic reaction in which the immune system overreacts to an allergen, triggering the release of inflammatory mediators. This leads to: • Bronchoconstriction → airway narrowing and respiratory distress • Vasodilation and capillary leakage → low blood pressure and potential cardiovascular collapse Nursing Recognition: Watch for signs of respiratory and cardiovascular compromise: • Angioedema (swelling of lips, tongue, face) • Hives and itchiness • Shortness of breath, wheezing, or stridor • Tachycardia, hypotension, dizziness, syncope

Common Triggers:

• Food allergies • Medications • IV contrast • Insect stings • Blood transfusions

Key Questions to Ask:

• What triggered the reaction? Any known allergies? • Has this happened before? • Has the patient ever needed to be intubated for it? • Were any new medications started recently? • Was epinephrine already given? If so, how long ago?

Nursing Essentials

• Remove the allergen if possible • Support ABCs: Airway, Breathing, Circulation • Epinephrine is the first-line treatment: o IM (via EpiPen) is most common for early intervention o May escalate to IV epinephrine for severe or refractory cases • Supportive Measures: o Oxygen and IV fluids for respiratory and circulatory support o Medications to reduce symptoms: ▪ Diphenhydramine (Benadryl) ▪ H2 blockers (e.g., famotidine) ▪ Steroids (e.g., methylprednisolone) ▪ Albuterol (for bronchospasm) • Be prepared for airway intervention: o Early intubation may be needed if swelling progresses o If intubation is not possible due to severe airway swelling, be prepared for an emergency cricothyrotomy

Updated 2 Sep 2026