# You're sitting there, minding your own business...



## mycrofft (Mar 23, 2014)

Just like the ARC training video, when suddenly someone behind you starts making gasping noises.

Pt is in tripod stance, moving some air but not enough, unable to speak, and with each attempted inhalation there is a sound of a constricted airway.:wacko:

NO medic alert wristband, not answering or responding to questions (a little preoccupied) , no facial swelling. 

Before the pt falls out, you pull out your stethoscope (or put an ear to their chest or even mouth or both) and you hear one of two things:

1. Expiratory wheeze, or 
2. Inhalatory wheeze. 

OK, especially new guys, what is the significance of a fresh respiratorially challenged field pt with one, then the other? How would they affect treatment?:huh:


----------



## NightHealer865 (Mar 23, 2014)

Okay. Using my scope of practice of EMT-IV I would call for an ALS intercept, administer Epi 1:1000, SQ, maintain an open airway and administer O2 at 15 liters via NRB. If epi doesn't help, then High flow O2 and immediate transport to closest facility, maintaining an open airway en route. 
Any input from you experienced guys would be helpful


----------



## UnkiEMT (Mar 23, 2014)

I think it's pretty clear from such a classic and concise pt presentation what's going on here.

I've wandered into a training video shoot.

The first step is to track down the producer and negotiate for residuals, once that's accomplished, come back to the scene and state loudly and clearly, "Everyone stand back, I'm a trained professional!.". Once you have an air gap of about 10 feet around the pt (so your elbow won't be jostled.), pull out your phone and call 911.

Then go outside for a cigarette.

I think you might have to say "Hey, hey, are you okay?" in there somewhere, too.


----------



## mycrofft (Mar 23, 2014)

Expiratory wheeze=true wheeze= maybe asthma.

Inhalation wheeze (called strider, not wheeze) early in the trouble= maybe foreign object.

No mention here of rales, rhonchii, absent sounds (yet), hives, swelling around the mouth, antebutials, popliteals, or other likely places to see hives.

ASTHMA: help pt with their medicine (first aid level and up) or get them to  hospital ASAP and follow any protocols you have.

FOREIGN OBJECT: basic first aid, be ready to follow protocols and transport if abdominal thrusts and maybe back blows (ARC) are unsuccessful.

The key is to know that _*early in*_, _inspiratory_ noise is almost never asthma, although advanced asthma will give you wheezing in and out not long before they collapse. Noise _*only on expiration*_ is rarely a foreign object.

PS: check that medic alert for the pt who might be jeopardized by epinephrine (like atrial fib, WPW, etc etc). Epi won't help a foreign object and actually increases oxygen hunger.


----------



## teedubbyaw (Mar 23, 2014)

Good little reminder. Thanks


----------



## mycrofft (Mar 23, 2014)

There are many folks with stethoscopes at many levels of licensure whom can't get that straight.

It's the little things that count.

Like not trying to blanch the nails on an artificial limb.:wacko:


----------



## UnkiEMT (Mar 23, 2014)

mycrofft said:


> Like not trying to blanch the nails on an artificial limb.:wacko:



Although if you can, you've got one hell of a technique.


----------



## Brandon O (Mar 23, 2014)

Stridor refers not to the phase of respiration (inspiratory vs expiratory), but to the level of obstruction. Stridor comes from the upper airway, wheezes from the lower.


----------



## mycrofft (Mar 24, 2014)

*Matter of definition and application.*



Brandon O said:


> Stridor refers not to the phase of respiration (inspiratory vs expiratory), but to the level of obstruction. Stridor comes from the upper airway, wheezes from the lower.



Strictly speaking, yes. But stridor is _usually _heard on inhalation (air moving faster/trachea) and wheezes _mostly_ on exhalation (slower air/constricted or gooped-up bronchioles) until airways are just about shut; then, heard on both.

Actually, I've auscultated inhalatory wheezes in an asthmatic and he was in _serious_ trouble. Needed epi, susphrine, oxygen, and when loaned enough, albuterol neb. 

I hate training videos where the actor uses an inhalatory stridor to depict a wheeze, when almost anyone can wring an end-expiratory wheeze out if they try, but what actor wants to almost pass out on every take until it's right?


----------



## mycrofft (Mar 24, 2014)

UnkiEMT said:


> Although if you can, you've got one hell of a technique.



Yeah, while your partner's making Orville Reddenbacher with the Lifepak.


----------



## Akulahawk (Mar 24, 2014)

mycrofft said:


> Yeah, while your partner's making Orville Reddenbacher with the Lifepak.


Just put a defib pad on each side of the box....


----------



## mycrofft (Mar 24, 2014)

Eliminate greasy box fire.


----------



## exodus (Mar 24, 2014)

mycrofft said:


> There are many folks with stethoscopes at many levels of licensure whom can't get that straight.
> 
> It's the little things that count.
> 
> Like not trying to blanch the nails on an artificial limb.:wacko:



I did put electrodes on a false limb once.


----------



## mycrofft (Mar 24, 2014)

There used to be a "rite of passage" on my first job. We had a frequent flier IFT with bilat below the knee amputations. You weren't considered oriented until your preceptor had you go and try to transfer this guy to a wheelchair. The pt was in on it and usually had some blankets folded and under the blankets where his lower legs used to be.


----------

