Emergency Medical Services – July 2024

As the patient is 15 years old he is managed using adult protocols.

He appears to be in severe respiratory distress and needs immediate vital signs to evaluate for hypoxia, arrhythmia, or other signs of shock. If concerned for immediate impending respiratory collapse it would be reasonable to place him on high-flow Oxygen 15 L/min while the remainder of his vital signs are obtained and he is being assessed. Diaphoresis, speaking in short sentences, and increased work of breathing (flexed neck muscles) indicate severe respiratory distress and possible impending respiratory failure.

The appropriate treatments and hospital disposition will depend highly on your assessment and the chosen Provider Impression.

For a young person with respiratory distress and chest pain, some causes that EMS should consider include:

• Acute bronchospasm/asthma
• Anaphylaxis
• Pneumothorax
• Pericarditis with pericardial effusion/tamponade
• Pneumonia
• Cardiac arrhythmia or ischemia (cardiac ischemia is rare in this age group but should always be considered; cardiac arrhythmia is not uncommon)
• Pulmonary embolism
• Acute Chest Syndrome (in a patient with a history of sickle cell disease)
• Flash pulmonary edema (uncommon in this age group)
• E-Cigarette or Vaping-associated pulmonary injury (VAPI/EVALI)

The diagnosis of many of these requires testing in the Emergency Department. However, in the field you will need to think about the most likely diagnoses to guide your prehospital treatment.

You may evaluate for:

• Stridor on inhalation may indicate partial foreign body obstruction, or airway swelling that may respond to nebulized or IM epinephrine.
• Wheezing may indicate bronchospasm from asthma or severe allergic reaction, and may benefit from albuterol or IM epinephrine.
• Other signs of allergic reaction (rash, nausea/vomiting, facial swelling, or hypotension) may indicate a need for immediate IM epinephrine to treat anaphylaxis.
• Unilateral lung sounds and upper airway swelling must be excluded – while TP 1237, Respiratory Distress advocates CPAP for severe respiratory distress, this would be contraindicated, and possibly dangerous, if his chest pain and respiratory symptoms are due to a pneumothorax, airway obstruction, or if there is crepitus over the neck or chest wall on exam.

The patient has equal breath sounds with poor air movement throughout as well as scattered crackles and wheezes. His heart sounds are fast but normal. He has no rashes or facial swelling and his abdomen is soft and non-tender. He does not have any leg edema.

Vital Signs show a heart rate of 138 bpm, Blood pressure 148/105, RR 30, and SpO2 of 87% on room air, which increases to 94% on 15L face mask.

The patient has poor air movement and both crackles and slight wheezing. Crackles are rare in young people, but in general are a sign of fluid/edema in the alveoli of the lungs. Wheezes are often a sign of bronchospasm, such as from asthma or anaphylaxis, which narrow the medium sized airways, creating this sound as the patient tries to forcefully expel air past these narrowed, partially obstructed bronchioles. However, in some patients, particularly those with Congestive Heart Failure (CHF), “wet” lungs can cause a “cardiac wheeze” without bronchospasm.

Given the wheezing and respiratory distress, you initiate treatment for possible bronchospasm per TP 1237, Respiratory Distress with Albuterol 5mg (6mL) via neb. But as the patient has no history of asthma, also has crackles and endorses chest pain, you are unsure if you should be treating for pulmonary edema (TP 1214, Pulmonary Edema/CHF), Allergy (TP 1219, Allergy) or Bronchospasm.

Nasal cannula side-stream waveform capnography may be helpful in differentiating between a problem in the lungs, and a problem in the airways. To use and interpret the capnography, you will need to gather and assess 4 pieces of information:

• What is the patient’s respiratory rate and tidal volume?
• What is the shape of the waveform, and what does that shape tell us about potential causes?
• What is the patient’s EtCO₂ value?

With these three pieces of information, you can ask (and answer) the question: Does the EtCO2 value make sense in the context of the patient’s respiratory rate and other assessments?

For more information on capnography in respiratory distress, check out this month’s video.

The albuterol improves the wheezing somewhat, but the patient remains tachypneic to 30, now with increased tachycardia at 145, and SpO2 91% on nebulizer. You place side-stream nasal cannula capnography as recommended in TP 1237, Respiratory Distress. Capnography shows a box-like rectangular waveform with an EtCO₂ of 29.

The box-like rectangular waveform argues against bronchospasm as the cause of the patient’s symptoms. In asthma, the waveform is upsloping, or “sharkfin” because of the  prolonged/obstructed exhalation. In addition, while in early and mild-moderate bronchospasm the EtCO₂ would be decreased, in a patient with severe bronchospasm the value is more likely to approach normal as the partially obstructed airways cause a build-up of CO₂ in the lungs.

In this patient, the absence of a sharkfin waveform and the low EtCO₂ appropriate to his fast breathing both argue against bronchospasm, despite the initial wheezing.

You initiate CPAP and the patient begins to endorse some improvement in his breathing.

12-Lead ECG demonstrates sinus tachycardia at 132 bpm without any ST segment elevations or depressions.

The patient was in severe respiratory distress. But he is now responding to CPAP. Therefore, base contact is not strictly required per TP 1237, Respiratory Distress.

However, given the unclear diagnosis, and the patient’s young age, it is advisable to discuss with the Base:

• Whether they agree with the assessment and/or suggest additional treatments, and/or
• Whether to consider transport to a PMC rather than to the MAR. While all Emergency Departments can treat pediatric and adult respiratory distress, it is likely that this patient is going to require admission to a monitored setting. Given his borderline age, and depending on the current status of the nearby hospitals and drive time, initial transport to a PMC would allow for evaluation at a facility that is more likely to have pediatric pulmonology, cardiology, and intensive care services and may avoid need for secondary transfer at the time of admission.

You make base contact and report an estimated drive time of 8 minutes to the MAR and 15 minutes to the nearest PMC. Given his improved respiratory status on CPAP, you are comfortable transporting the extra distance to the PMC.

The patient is transported with CPAP and arrives to the Emergency Department at the PMC with vital signs of heart rate 122, respiratory rate 25, and SpO2 of 94%.

While patient endorses improved status with CPAP, he remains unable to tolerate lying flat. Given that pulmonary embolism remains a possible diagnosis, he is intubated for respiratory failure and to enable the CT scan. CT shows normal pulmonary arteries, no pericardial effusion, and no blood clots in the lung vasculature. However the CT does show bilateral ground glass lung infiltrates with subpleural sparing. The patient tests negative for COVID. Antibiotics are started for possible pneumonia. Given the appearance of the CT, the history of vaping unregulated marijuana products, and the exclusion of several other diagnoses, the patient is treated with steroids for presumed E-Cigarette or Vaping Product Associated Lung Injury (VAPI/EVALI) and admitted to the ICU. He improves gradually over the next several days, is extubated on hospital day 3, and discharged home after an 8 day admission. His symptoms continue to improve, and he returns to baseline lung function within 2 months of his initial presentation.

VAPI/EVALI is a constellation of severe lung diseases in patients using e-cigarette products. Clinical criteria include pulmonary infiltrates on chest x-ray or CT, history of using e-cigarette/vape pens within the previous 90 days, and the exclusion of other causes. Since 2019 over 2600 cases have presented in the United States, with more than 60 deaths. Vitamin E acetate, a synthetic form of vitamin E that has been found in unregulated THC vaping products, has been associated with many of these cases.  Treatment for VAPI/EVALI includes steroids, ventilatory support and other supportive care, and avoidance of further vaping.

In the case above, you evaluated a young adult patient in respiratory distress with the tools at your disposal to determine the Provider Impression, initiate fitting prehospital treatments, and prevent respiratory failure. Great job!

Respiratory distress is a common complaint in children and adolescents receiving EMS care. Recognizing the severity of distress and completing a thorough assessment while also providing temporizing treatment are crucial to determining the best treatment options.

Nasal cannula side-stream capnography is a tool that can help determine the cause of respiratory distress and can assist in monitoring response to treatment or deterioration.

Base contact and discussion can be useful for vetting provider impression and treatments in complicated patients, and for determining disposition of patients who may be served best in facilities not clearly defined in policy.