Friday, April 22, 2016

Week 3

Week 3
Reflection:

Using the Gibb's Reflective Model, i will be reflecting on the practical session we had on the 15th of February, 2016.
Description: I had a case of a 60 y/o male patient suffering from difficulty of breathing. I conducted a primary survey and took the patient’s history. Through this I found out that the patient had a history of asthma and hypertension. Moreover, the patient was not able to speak in full sentences. He was only able to say a few words. This showed me that the patient was suffering from a severe asthma attack. Therefore, following the JRCALC guidelines for severe asthma, I administered Salbutamol and Ipratropium bromide. I tried to convince the patient to take his corticosteroid pill, however, he refused. I continued trying to persuade him for about 3 minutes. He persisted on refusing to take the pill, and this exchange caused me to sidetrack and delay taking the patient’s vital signs. After this, I conducted a VSS and found: SpO2 : 90%, BP: 150/95, HR: 116, and his skin was pale, cool and clammy. Since the SpO2 was <94%, according to the JRCALC, I increased the oxygen flow rate to 12L/min. After this, I initiated rapid transport of the patient to the hospital.
Feelings: At first I was happy with my primary assessment and history taking. Also, I felt good about my early management of the patient. However, once the patient kept refusing to take the corticosteroid I started feeling a little irritated. Since the patient insisted on not taking the pill, I just let it be. Once I started taking the VS I felt it was a little late, and regretted spending so much time on convincing the patient to take the corticosteroid. However, I felt sure and in control again once I realized the oxygen saturation was low. I felt confident when I increased the oxygen flow to 12L/min and initiated rapid transport.
Evaluation: I started the scenario really good, by conducting a primary survey and taking the patient’s history. Also, it was really good that I started the patient’s treatment early on, since he was suffering from a severe asthma attack. In addition, it was great that I got the correct treatment. However, spending so much time trying to convince the patient was a negative. This is because it distracted me and made me lose sight of more important things, such as taking the patient’s VS. Once I took the VS and recognized the need for me to administer oxygen to the patient was a positive moment. However, my mistake here was increasing the oxygen flow through the nebulizing mask, which contained the salbutamol and ipratropium bromide. This is a major negative, since the maximum oxygen flow is 8L/min when giving nebulizing drugs. Finally, me deciding to initiate rapid transport was good.
Analysis: The time I used convincing the patient to take the corticosteroid, I should have used to do a VSS. This is because the VS will tell me so much about the patient, and I might find something that would have been critical. If in fact there was something critical within the VS, I would have found it too late. Moreover, administering the patient’s corticosteroid tablet would take 1-2 hours until it’s effect starts (Skidmore-Roth, 2015), therefore, it’s not that crucial to give it on scene. Furthermore, for the oxygen administration, I should have waited for the nebulization to finish, before providing high flow oxygen. There was no need to rush to give the 12 L/min since the patient is still getting 8L/min of supplemental oxygen through the nebulization.
Conclusion: I could have focused on my systematic approach and not stayed too long trying to persuade the patient to take a medicine that won’t have a rapid effect. Instead I should have tried only a couple of times. Once the patient persistently refused, I should have stayed focused and continued my assessment. Moreover, after the nebulization was finished, I could have proceeded to changing the nebulizing mask to a nonrebreather mask, and provided the 12 L/min of oxygen.
Action Plan: I plan to stick to the systematic approach to the patient and not get distracted by minor obstacles. I will try my best to focus on the bigger picture of the patient assessment and treatment. Moreover, I plan to never increase the oxygen flow rate more than 8L/min during a nebulization again. Also, in the case of hypoxia, I plan to change the nebulizing mask to a nonrebreather mask to provide supplemental oxygen.

Reference
Skidmore-Roth, L. (2015). Mosby’s 2015 nursing drug reference (28th ed.). St. Louis: Mosby Elsevier. 




Photo 1: Me assessing the patient and gathering his history 


Learned Concepts


In this section i will be highlighting what we learned in the lecture for this week.

Around 15% of the UAE population is asthmatic. Moreover, the burden of asthma is greatest in adolescents and the elderly. After learning some epidemiology of asthma. we revised some anatomy and physiology which we learned in week 1.






Photo 2: Mind map about asthma and its symptoms 


Photo 3: List of asthma triggers 

The inflammatory response mentioned in the picture above is usually a normal response to pathogens in the body. However, in asthma, this immune response is produced in excess of normal.

In asthma there is constriction of the bronchi which increases resistance to airflow. This increased resistance causes hypoventilation at the alveolar level. This leads to a ventilation/perfusion mismatch. This means that there will not be enough oxygen to oxygenate the blood, which is used for perfusion of the body. (decreased oxygen, with same amount of blood-> not enough oxygen compared to amount of blood).

After the air moves into the lungs, since the airways are constricted, it cannot move out. This failure to expire the air leads to a build up of pressure in the thoracic cavity. This causes reduced blood flow and blood pressure, since blood also moves from an are of high pressure to an are of low pressure. since the thoracic cavity will have more pressure, blood will tend to move away from the thoracic cavity and the heart. This hypotension and bradycardia is a very bad sign. Air trapping can also lead to tension pneumothorax.

Asthma management involves 6 steps:
  • Assess asthma severity 
  • Assess best lung function 
  • Maintain best lung function by identifying and avoiding triggers 
  • Maintain best lung function by optimizing medication program 
  • Develop an action plan in case of exacerbations 
  • Educate and review 

Asthma, depending on its severity, is managed using the following drugs:
  • Inhaled beta-2 agonists (salbutamol, salmeterol) 
  • Inhaled anticholinergic agents (Ipratropium bromide) 
  • Inhaled, oral, IV or IM corticosteroids (aerovent, hydrocortisone, solu-cortef, prednisolone) 
  • Adrenaline (IM) 
Initial improvement due to inhaled beta-2 agonists is not indicative of future course of exacerbation!!
Asthmatics have he potential to deteriorate rapidly.

Questions to ask asthmatics:
  • Hx of asthma 
  • Previous hospital admissions 
  • ED visits in last year 
  • ICU admissions/ intubation 
  • Trigger factors 
  • Usual response to Mx 
  • Use of steroid in last 6 months 
  • How long the exacerbation been 
  • How does it compare to other attacks 

Assessment of Asthmatic includes a thorough RSA and chest auscultation.
S&S: Tripod position/sitting upright (to help them breath), dyspnea, wheezing, chest tightness, cough, use of accessory muscles, increased RR, prolonged expiratory phase, lethargy, exhaustion, confusion, agitation.
Usually you can hear wheezing upon auscultation of asthmatics. However, mat not hear wheezing if patient already fatigued or there is extremely decreased airflow. Usually expiratory wheezes (lower airways) but can also be inspiratory( larger airways).
We used the peak flow meter last week but we learned more about it in this week's lecture.
The peak flow meter measures the expiratory flow rate. Can help determine severity of attack and help check effectiveness of treatment. Must NOT be used if patient is in severe respiratory distress, treatment takes priority in this case.

To use the peak flow meter must ask patient to inflate their lungs fully. Then get the patient to forcefully exhale as quick as possible into the meter, making sure they completely seal the mouth piece. Reading is in L/min and usually must take 3 readings and take the best one. You can also ask the patient for their usual peak flow meter measurement for comparison.


Photo 4: Note about how to recognize severity of asthma 
Pulsus Paradoxus is an abnormally large reduction in SBP and pulse wave amplitude during inspiration. This occurs due to the large swings in intrathoracic pressure that occur in severe asthma. Also, Pulsus Paradoxus is a clue that air is trapped. However, if there is respiratory muscles fatigue, the changes in pressure can no longer be generated. Therefore, Pulsus Paradoxus may not be evident.

Arrhythmias in life threatening asthma are due to hypoxia. Air trapping can cause cardiac tamponade which affects cardiac filling.
Status Asthmaticus is a severe and prolonged attack that is not relieved despite repeated doses of bronchodilators. Patient will be at risk of respiratory failure. The treatment of this patient will be the same as that of asthma but there is increased priority on transport in this case.
Differential Dx of Asthma:

  • COPD 
  • Bacterial pneumonia 
  • Aspiration 
  • CHF 
  • Pneumothorax 
  • PE 
  • Toxic inhalation 
We then discussed the first case study and learned how to manage and treat this case.Following this we learned more about the drugs we discussed in the first week's lab session. We learned that Salbutamol causes bronchodilation by stimulating the binding of intracellular calcium to cell membranes. This reduces myoplasmic calcium concentration and results in the relaxation of bronchial smooth muscle. Salbutamol also inhibits mediator release, protects against bronchoconstrictors, inhibits microvascular leakage and increases mucociliary clearance. This drug can cause adverse effects including: Fine tremor, anxiety, headache, muscle cramps, dry mouth, palpitation, tachycardia, arrhythmia, flushing, and allergic reactions that can cause paroxysmal bronchospasm.

After this we discussed Ipratropium Bromide which reduces parasympathetic mediated cholinergic tone of the airway, causing bronchodilation. This drug also lessens mucosal edema and secretions. This drug affects larger, central airways, whereas Salbutamol acts on smaller airways. Ipratropium Bromide has a slow onset of action (20-60mins). This is why it is not used as a first line of treatment but rather as an adjunct to Salbutamol. Ipratropium Bromide can cause dry mouth, thirst, difficulty swallowing, tachycardia, restlessness, confusion, irritability, dysuria, bowel obstruction, blurred vision (increased intraocular pressure).

Adrenaline acts on both alpha and beta receptors and is used in life threatening situations.
Finally, Hydrocortisone is a short-acting synthetic steroid affecting nearly all systems of the body. This drug enhances beta-adrenergic response to relieve muscle spasm, reversing mucosal edema, decreasing vascular permeability, and inhibiting the release of leukotrienes. This drug inhibits the inflammatory response and interferes with chemotaxis. After this we did a little quiz to test what we learned in this lecture. I learned one new fact from this quiz and that is the Salbutamol can cause hypokalemia. Also, we discussed Case 2 and debated on what the best management of this patient would be. Since it was a severe asthma attack we decided to give the patient a nebulization of Salbutamol and Ipratropium Bromide, and administer Hydrocortisone. Following this we said we would rapidly transport the patient to the hospital.
Moreover, we analyzed the case study in the tutorial and discussed what the appropriate treatment would be for the case at hand.

Additional Readings

For this week we had one article for our recommended readings. I learned a few things about how to differentiate between asthma and COPD. In asthma, it is common to have chemically and exercise induced hyperresponsiveness. This is not usually associated with COPD. Moreover, COPD is typically associated with more severe increases in resting lung volume, whereas, in asthma this only occurs during attacks. I also learned that lung compliance is decreased in COPD while, on the other hand, it is normal in asthma (Sciurba, 2004).

My teacher provided us with handouts from a book which i found very informative and helped me better understand asthma and its effects.


Photo 5: Highlighted notes about asthma and its epidemiology. Adopted from (Moore, 2013). 


Photo 6: Highlighted notes about bronchospasm and components of asthma. Adopted from (Moore, 2013).


Photo 7: Highlighted notes about components of asthma and life-threatening asthma. Adopted from (Moore, 2013). 
I also checked the JRCALC(2013) for guidelines on how to treat asthma patients and read about the drugs used and their doses. This helped me get a complete picture of how i can help an asthmatic patient, and what and how to use the drugs needed.



Photo 8: Flow chart of treatment depending on severity of asthma. Adopted from (JRCALC, 2013). 


Photo 9: Details of the drug Salbutamol. Adopted from (JRCALC, 2013). 

The dosage of Salbutamol is 5mg and there is no maximum dose for this drug. The dose interval is every 5 minutes.




Photo 10: Details and dosages of the drug Ipratropium Bromide. Adopted from (JRCALC, 2013).




Photo 11: Details and doses of Hydrocortisone. Adopted from (JRCALC, 2013). 


Photo 12: Details and dosages of adrenaline related to asthma. Adopted from (JRCALC, 2013). 
References
Join Royal Colleges Ambulance Liaison Committee. (2013). UK ambulance services: Clinical practice guidelines 2013(4th edition). Bridgwater: Class Professional Publishing.
Moore, S.W. (2013). Respiratory emergencies. In A.N. Pollak (Ed.), Nancy Caroline’s emergency care in the streets(pp.39.27-39.36). Burlington, MA: Jones and Bartlett Learning.
Sciurba, F.C. (2004). Physiologic similarities and differences between COPD and asthma. Chest, 126, 117-124. doi: 10.1378/chest.126.2_suppl_1.117S


Stand Out Moment
I found this week simple and to the point. The only thing i had difficulty with was the dosages of the different drugs. However, after checking the guidelines, now i know how much to give of each drug. Also, this search helped me learn the right route of administration for each drug, which is crucial.

Biggest Impression
The guidelines made the biggest impression on me as a paramedic because they dictate exactly what I should do when faced with an asthmatic patient.

Strengths and Limitations
I believe my strengths are my understanding of the pathophysiology. This helps me make sense of the treatment pathway that i should follow, according to the guidelines. However, my weakness would be drug dosages. I find it a little hard to remember the different doses of each drug. To improve this i will constantly revise the drug dosages until i can differentiate between them and know them by heart.



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