Airway Management Case Study 4
- May 15, 2008
Airway Management Case Study 4
You receive a call from an elderly man, who experienced a sudden onset of sharp chest pain and shortness of breath. When you arrive, you find the man nervously pacing in his front yard. As you get out of the ambulance and approach him, you can see that he is grossly cyanotic in the facial area. You ask him what happened, and in minimal word sentences, he responds, "I can't breathe!" When you attempt to place a non-rebreather mask on the patient, he rips it from his face.
- What is your alternative to the non-rebreather mask when he will not tolerate it?
- What is the adequacy of this patient's respirations?
- How will you manage his obvious hypoxia?
- Hypertension
- Acute myocardial infarction
- Pulmonary embolism
- Based upon his past medical history, which of the following do you suspect to be the cause of his problem?
- What is your best approach to management of this patient at this point?
The only vital signs that you are able to obtain due to the man's restlessness are his respirations, which are 38 and labored, and his heart rate, which is weakly present at the radial artery at a weak and thready rate of 150.
You place the man in the ambulance and quickly prepare him for transport. He remains extremely restless and you notice that his cyanosis is worsening. You place a pulse oximeter on him and it reads 77% and a heart rate of 150, which corresponds with his radial pulse. You proceed to the hospital code 3. En route to the hospital, the man gives you a piece of paper that lists his past medical history. It includes:
You are approximately 15 minutes from the nearest hospital, when you notice that the man appears to be "sleepy." He is not near as restless as before. You reassess him and find his breathing to be extremely shallow at a rate of 32.
Case Study 4 Answers
Answer 1: Being that the man will not tolerate a non-rebreather, he will most likely not allow you to place him supine in order to assist his breathing, your only choice is to place him on a nasal cannula. Patient's who are this restless and uncomfortable will not allow the oppressive feeling of a mask over their face.
Answer 2: At the rate at which he is breathing, as well as his profound restlessness, he is not breathing effectively. The signs of hypoxia that he is exhibiting, such as restlessness, and a weak, thready radial pulse confirms his severe hypoxia.
Answer 3: At this point, the patient is still too restless and combative to allow you to provide him the volume and percentage of oxygen that he requires (assisted ventilation with a bag-valve mask), nor will he allow you to place a non-rebreather; therefore, your only choice is to continue oxygen therapy with the nasal cannula and notify the hospital early as you are transporting code 3. This man will require endotracheal intubation in order to provide him the oxygen content that he obviously needs.
Answer 4: An acute onset of sharp chest pain and difficulty breathing as well as the worsening cyanosis are classic signs of an acute pulmonary embolism. There is a blockage of a major pulmonary artery that is not allowing his blood to be oxygenated in the lungs. Because the pulse oximeter is corresponding with his heart rate, 77% is probably a true reading.
Answer 5: Unfortunately, this patient has become so hypoxic that his level of consciousness is diminished. This sudden deterioration is most likely due to both the low levels of oxygen in his blood and increased levels of carbon dioxide. You must be very aggressive at this point as you place a nasopharyngeal airway (he still has a gag reflex) and assist ventilations with a bag-valve mask with a reservoir and 100% oxygen attached. This man is dangerously close to cardiac arrest.
Case Study 4 Synopsis
There are times when you will have to manage a patient who is in obvious need of 100% oxygen and assisted breathing, but their restlessness will not allow you to do this. At this point, any amount of oxygen that the patient will tolerate should be given. In this case, it is with a nasal cannula and although this will not provide him with the concentration of oxygen that he needs, it is certainly better than nothing.
This was a typical case presentation of an acute pulmonary embolism, where the patient is extremely restless due to profound cerebral hypoxia. In addition, the following signs also indicate inadequate perfusion:
- Weak and thready radial pulse with tachycardia
- A pulse oximeter reading of 77%
- Profound, rapidly worsening cyanosis
The EMT should expect this type of situation in patients with acute pulmonary embolism and must provide the highest concentration of oxygen that the patient will allow. The history of acute MI and hypertension are risk factors for a pulmonary embolism. You must monitor the patient carefully and be prepared to intervene rapidly should the patient stop breathing or lose consciousness to a point where he will tolerate assisted breathing.
Due to the extent of this patient's hypoxia, he is at an extremely high risk for cardiac arrest; therefore, you must have the AED ready as well. Rapid transport with aggressive airway management is the management modality of choice.
