Transcript cardiac output - Advocatehealth.com

Shock
April 2013 CE
Condell Medical Center
EMS System
Site Code: 107200E-1213
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Rev 4.24.13
1
Objectives
Upon successful completion of the program the
EMS provider will be able to:
 1. Review the circulatory system.
 2. Describe the stages of shock and the signs and

symptoms of the stages as the patient progresses

from compensated shock through decompensated

shock to irreversible shock.
 3. Describe the pathophysiology, signs and
symptoms of different mechanisms of shock.
2
Objectives cont’d
 4. Describe unique elements of shock in special

populations (i.e.: pregnancy, elderly, children).
 5. Discuss appropriate interventions and treatment of

the various mechanisms of shock.




6. Actively participate in case scenario review.
7. Actively participate in identifying the pre-tibial
and humeral sites and inserting an IO needle.
8. Successfully complete intubation skills with the
King airway.
9.Successfully complete the post quiz with a score of
80% or better.
3
Circulatory System
 Closed system for transport of oxygen and
nutrients dissolved in blood and for the
removal of waste material
 Comprised of 3 components
The pump = heart
 The fluid = blood
 The container = blood vessels

 Any one of these functioning poorly will affect
the whole system
4
The Pump
 The heart is the pump
 Functions under 2 systems
 High power system


Arterial side
Lower power system

Venous side
 Body’s function dependent on an adequate
stroke volume

Amount of blood pumped with each
contraction

Approximately 70 ml for the average adult
5
Influences on Stroke Volume
 Preload
 Amount of blood returning to the heart
 Dependent on venous return

Venous system functions as a storage container
 Cardiac contractile force
 The greater the stretch (i.e.: volume) the greater
the recoil the better the strength of contraction
 Influenced by circulating catecholamine's


Epinephrine and norepinephrine
Controlled by sympathetic nervous system
6
Stroke Volume cont’d
 Afterload
 Resistance against which ventricles have to
contract


Determined by degree of peripheral vascular
resistance met
 Dictated by degree of vasoconstriction
present
The greater the resistance (degree of
vasoconstriction) the smaller the volume of
blood (i.e.: stroke volume) able to be pumped
out of the heart due to higher pressures met in
the vascular system
7
Cardiac Output
 Amount of blood pumped out of the heart in
one minute is the cardiac output
 Calculated on a formula

Stroke volume x heart rate = cardiac output
Ex: 70ml x 80 bpm = 5600 ml blood/minute
A change (reduction or increase) in stroke
volume and/or heart rate will impact cardiac
output
8
Blood Pressure
 Dependent on cardiac output and degree of vascular
resistance
 Calculation of B/P:

B/P = cardiac output (CO) x peripheral vascular
resistance (PVR)
 To increase B/P
  cardiac output or peripheral vascular resistance
 To decrease B/P
  cardiac output or peripheral vascular resistance
9
Perfusion
 All body cells require constant supply oxygen
and nutrients
 Waste products must be removed

Build-up is harmful to the functioning of the
body
 Multi-system coordination needed to supply
oxygen & nutrients and remove waste
Circulatory system
 Respiratory system
 Gastrointestinal system

10
Hypoperfusion
 This is shock!
 Inadequate delivery of oxygen and
essential nutrients to all tissues
 Inadequate removal of wastes from tissue
 Most critical tissues in the body
 Brain
 Heart
 Kidneys
11
Pathophysiology of Hypoperfusion
 Usually a result of inadequate cardiac output
 Factors that could affect cardiac output
 Inadequate pumping
  preload
  cardiac contractile strength
  heart rate
 Excessive afterload (high resistance in arterial
system decreasing stroke volume that gets pumped out)
Inadequate fluid level
 Inadequate container



Dilated vessels (poor systemic vascular resistance)
Leaking vessels
12
Pathophysiology of Shock
 A very complex process
 Causes can vary
 Signs and symptoms can vary
BUT…
 Basic definition holds across the span
Shock = inadequate tissue perfusion!
 Ultimate outcome = impaired cellular metabolism
13
Pathophysiology Impaired Cellular Metabolism
 All cells dependent on adequate supplies of
oxygen and glucose to function
 In any type of shock, there is a disconnect in
the use of oxygen and glucose


Aerobic metabolism changes to anaerobic
In the absence of oxygen, breakdown of
glucose hindered

Primary source of energy, glucose, not available
to the cell
 Glucose does not provide energy until it is
broken down inside the cell
14
Impaired Use of Oxygen
 Harmful by-products produced
 Lactic acid & other metabolic acids accumulate

Acidic condition of blood not favorable to normal
bodily function
 Hemoglobin not able to bind with and carry oxygen
 Cellular stores of ATP used up and not replaced

Energy production, essential for metabolism of cells,
decreases
 Sludging of blood develops
 Slowed blood flow due to  pumping of heart
and vasodilation of vessels
15
Impaired Use of Glucose
 Glucose must be transported into the cell
 Step necessary for a process where glucose
produces energy
 Glucose remaining in blood results in
hyperglycemia
 Alternative sources used to produce energy


Breakdown of fats (lipolysis)
Amino acids from protein

Depletion of proteins in the system leads to organ
failure
16
Classifications of Shock
 Generally classified based on cause

Cardiogenic


Hypovolemic


Decrease in blood volume
Obstructive


Impaired pumping of heart
Obstruction interferes with return of blood to
heart (i.e.: tension pneumothorax, tamponade)
Distributive

Abnormal distribution and return of blood
17
Semantics of Shock
 Alternative classifications of shock
Cardiogenic – pump problem
 Hypovolemic – volume problem
 Neurogenic – container/tank problem
(distributive)
 Anaphylactic - container/tank problem
(distributive)
 Septic - container/tank problem
(distributive)

18
Identification of Shock
 Need to identify the underlying cause of
shock

Correcting the cause is key element in
providing the right intervention for reversing
the process


Many interventions can be universally applied
to a variety of shock conditions
Some interventions have limited applications
 Ex: fluid challenges given aggressively in
hypovolemic shock could be harmful in the
setting of cardiogenic shock
19
Stages of Shock
 3 stages
 Based on ability of body to compensate at
that point in time
 Based on signs & symptoms present

Reflect what is happening internally
 Stages are progressive and become more
serious



Compensated
Decompensated
Irreversible
20
Stages of Shock - Compensation
 Initial stage of shock; body compensating
 Activated when a need triggered (i.e.: threat to
cardiac output)

Patient can still maintain their blood pressure!!!
 Sympathetic nervous system
 Secretes epinephrine & norepinephrine
 heart rate (1st indicator to notice!)
  cardiac contractility
 Vasoconstriction (seen as paleness)

21
Stages of Shock - Compensation
 Renin-angiotensin system
 Kidneys

release renin
Triggers production of angiotensin II – a strong
vasoconstrictor
 Angiotensin
II stimulates production of
aldosterone

Kidneys reabsorb sodium and therefore water
 Noticed as a decrease in urine output
22
Stages of Shock - Compensation
 Antidiuretic hormone (ADH) secreted
 Kidneys triggered to reabsorb more water
 Spleen
 Expels extra blood volume being stored

Approximately 200 ml of blood can be added to
existing blood volume
 Passive activity
 Fluid shifts from interstitial spaces into the
capillaries
 Skin feels drier
23
Stages of Shock - Decompensation
 Conditions causing shock are too serious or
too rapidly progressing and compensatory measures
can no longer maintain preload
 Perfusion inadequate


Heart weakens
 Cardiac output falls even more
Reduced blood flow to the brain and vital function
stimulation ceases
 Appropriate interventions may still correct condition if
applied early enough and body can respond
 KEY: Blood pressure cannot be maintained and
begins to fall
24
Stages of Shock - Irreversible
 Blood becomes even more acidic and
hypoxic

Systemic acidosis develops

Further deterioration of cells & tissues
 Sludging of blood occurs in capillaries
 Minute blood clots formed
 Capillaries leak fluid into interstitial space
 Correction of the condition is no longer
possible; cells beginning to die
25
Evaluating Signs and Symptoms
 “Classic” shock
 Altered mental status






1st change to be noted
Anxiousness moving to lethargic
Skin pale, cool, clammy
Pulse moving from normal to increasingly
faster and then slowing and disappearing
Cardiac dysrhythmias develop and deteriorate
into asystole
Blood pressure maintained until it finally falls

When B/P falls, compensation is over!
26
Neurogenic/Distributive Shock
 Injury to brain or spinal cord


Loss of sympathetic tone
Relative hypovolemia due to dilation of
arteries
 Warm, red, dry skin (vasodilation)
 Low B/P and pulse (no catecholamine
stimulation)
 Key: hypotension, bradycardia, warm/dry skin
27
Anaphylactic/Distributive Shock
 Response of immune system to foreign
substance
 Usually the faster the reaction the more
severe the case
 Skin flushed, itchy, hives, swelling
 Respiratory distress

Coughing, wheezing, stridor
 Vasodilation, heart rate,  B/P
 Nausea/vomiting, cramping
 Altered mental status
28
Septic/Distributive Shock
 Infection of bloodstream
 Signs and symptoms progressive
 Toxins cause vasodilation
 High fever

Often absent in elderly and very young
 Skin flushed to pale to cyanotic
 May have altered level of consciousness
 May have respiratory distress and abnormal
breath sounds
29
Elderly Population & Shock
 Some body system changes over time can
increase risk factors for the elderly who are
traumatically injured
 Influence on changes




Vulnerability increased for injury
Body response to injury not as effective or
dramatic
Less tolerant of interventions received
Increased time of recovery of health status
30
Elderly System Changes
 Altered mental status common
 Poor historian
 Hypertension common
 What looks like a “normal” B/P may be
hypotension in the person with hypertension
 Atherosclerosis and arteriosclerosis more
prevalent

Stiffer blood vessels less able to respond with
adequate degree of vasoconstriction
 Impaired swallowing increases risk for
aspiration
31
Elderly Changes cont’d
 Bones more brittle
 Cough reflex diminished

Increased risk for aspiration
 Less air and gas exchange in lungs
 General decline in efficiency of renal system
 Less ability to fight infection via immune
system
 Perspires less
 Skin tears more easily; heals slower
32
Physiological Changes of Pregnancy
 Respiratory system

 oxygen demand & consumption
 Cardiovascular system


Cardiac output increases
Maternal blood volume increased




Due to changes patient has a relative anemia
May lose 30-35% of volume before signs &
symptoms of shock are evident
Maternal heart rate  by 10 - 15 beats per
minute
Maternal B/P  til end of 3rd trimester
33
Supine Hypotensive Syndrome
 Usually occurs in 3rd trimester
 Large weight of uterus compresses inferior
vena cava when patient supine

Reduces return of blood flow to the heart
 Goal – avoid decrease in return of blood to
the heart

Transport patient tilted or turned to side



Preferably left side (Remember: “lay left”)
Especially important after 5th month
If patient must remain flat (i.e.: CPR), then
manually displace uterus to side
34
Pediatric Population & Shock
 Body systems less developed
 Decreased capacities compared to the adult
 Dehydration most common cause of
hypovolemia





Pale, cool skin
Diminished peripheral pulses
Delayed capillary refill
Change in mental status
Decreased urination (i.e.: dry diapers, dark urine)
35
Pediatric Population
 Average blood volume is by body size
 Typical infant 80 ml/kg

Typical adult male 75 ml/kg

Typical adult female 65 ml/kg
By formula then:
 Infant = 300 ml total blood volume
 200# adult male = 6,800 ml total blood volume
 160# adult female = 4700 ml total blood volume
36
Average Blood Volume by Size
 Infant
Child
Adult
37
Interventions for Shock
 Frequent reassessments watching for
changes/trends


Every 5 minutes (or sooner) for unstable
patient
If not documented, then not done
 Follow ABC’s (CAB’s if arrested)
 Assess airway
 Assess quality of breathing
 Assess circulation / pulses / perfusion
 Assess neurological function
38
Interventions for Shock
 Begin transport as soon as possible
 Alert receiving hospital as soon as possible
 Rapid trauma assessment




Trying to identify life threats
A quick head to toe examination
Obtain vital signs and history
Begin interventions as soon as possible


Do not delay transport to initiate additional
interventions
IV/O2/monitor enroute in critical situation
 Fluid challenge is at 200 ml increments
39
Interventions for Shock
 Management of life threats

Interventions performed if situation found





Airway opened
Ventilations supported
 Via BVM – 1 breath every 5 – 6 seconds
 Via ETT or King airway – 1 breath every
6 – 8 seconds
Needle decompression if tension pneumothorax
Sucking chest wound sealed
Major bleeding controlled
40
Interventions for Shock
 If failure to secure peripheral IV access, IO is
the backup
 If failure to place an endotracheal tube, King
airway is the backup
 These are urgent skills and each paramedic
must be capable of using these tools without
delay if necessary
41
IO Access
 Available when other alternatives are not





Sites provide non-collapsible space when
peripheral veins have collapsed in shock
Sites can be rapidly accessed
Fluids and medications are rapidly absorbed
into the bloodstream
Large amounts of fluid can be delivered
quickly (i.e.: 125 ml/min)
Bony cortex provides stable base when
securing inserted IO needle
42
Region SOP – IO Insertion Skill
 Indications



Shock, arrest, impending arrest
Unconscious/unresponsive or conscious
critical patient without IV access
2 unsuccessful IV attempts or 90 second
duration or no visible sites
43
IO Insertion Skill cont’d
 Contraindication





Insertion into extremity with a fracture
Infection at insertion site
Previous orthopedic procedure (knee
replacement, previous IO within 480)
Pre-existing medical condition (tumor near
site, peripheral vascular disease)
Inability to locate landmarks (significant
edema)
44
Primary Complication IO Insertion
 Extravasation into soft tissue from infiltrated
site

Could cause compartment syndrome

Reference June 2012 CE for review of
compartment syndrome
 Bone fracture during insertion – rare
 Could occur with excessive force applied
 Osteomyelitis – uncommon
 Generally from poor technique
 Leaving IO needle in >24 hours
 Multiple attempts at same site
45
Equipment for IO Insertion
 IV start pak
 Pre-filled syringe
 10 ml 0.9 NS for adult insertion
 5 ml 0.9 NS for pediatric insertion
 IO kit
 Needle
 Primed EZ connect tubing
 Wristband
 Drill
 Cleansing material
 Chloraprep ampule; alcohol wipe
 Primed IV tubing inserted into IV bag
 Pressure bag
46
IO Needle Sizing
Note: Gauge same for all sizes (15 G)
 Pink for 3 – 39 kg (up to 88 pounds)

15 mm; 15 G
 Blue for >40 kg (>88 pounds)

25 mm; 15 G
 Yellow for excessive tissue over site & humeral head
site
 45 mm; 15G
47
IO Needle Sizing Hint/Tip
 Need to evaluate the site to determine the
size needle to use
 If you feel bone immediately under the site
palpated, use the pink 15 mm needle

Ex: palpate over wrist at base of thumb
 If you palpate tissue over the site and not
bone, use the blue 25 mm needle
 If there is excessive tissue over the site or
use of the humeral site, use the 45 mm
needle
48
Proximal Tibial IO Landmarks
 Need to identify the tibial tuberosity – a rounded
projection below knee cap

Sits approximately 2 finger widths below the patella
49
IO Site Identification – Proximal Tibia
 Site must be viewed AND palpated
 Locate tibial tuberosity - bump over shin 2 fingers
below patella


1 finger width
medial (towards
big toe)
In the very
young, may not
have a prominent
tibial tuberosity
50
Proximal Tibia
 Preferred site of choice 2 fingers BELOW
patella (kneecap) at tibial tuberosity
 MUST avoid epiphyseal plate of developing
child - could interfere with growth of that limb
51
IO Site Identification – Humeral Head
 Site must be viewed AND palpated
52
Greater Tubercle IO Site
 Start palpating the mid-humeral shaft
 Work upwards toward the proximal aspect or
humeral head

You will notice a protrusion



This is base of greater tubercle insertion site
Move 1 cm (1/2 inch) above this point for insertion
Can place fingers on either side of humeral head
to help identify the midline
53
Humeral Site
 Palpate 2 finger widths below acromium
 Find the most prominent spot of the humeral
head / greater tubercle
 YOU MUST BE ANTERIOR TO MIDLINE!!!
 Could also palpate to
the end of the clavicle

Move 2 finger widths
toward the elbow
54
Humeral Site Hints
 Arm must be flexed with
elbow tucked back
 Site is anterior to
midline
 Site feels like a golf ball
55
IO Access
 Prep the identified site

Chloraprep or alcohol wipe from IV start kit
 Insert needle into site WITHOUT drilling


Needle very sharp and will insert easily
The needle stops when it touches bone
 LOOK

5mm mark
You must be able to see the
5mm mark to verify
appropriateness of length of
needle
56
Visualizing 5 mm Marking

Is the 5 mm mark visible? If yes, begin to drill

If no, the needle length is too short
 Move up to the next length needle and reinsert
57
Angle of Insertion Tibial Site
 Can insert needle at 900 angle
 Can insert needle at 10-150 angle toward the
foot – avoids growth plate (epiphyseal plate)
 Growth plate active while child still growing
58
Using the IO Drill
 You are drilling into a bone; not drywall!!!
 Insert needle until needle stops at bone
 Verify 5 mm mark
 Begin to drill
 Stop when you feel lack of resistance or “pop”
 Remove stylet
 Attach EZ connect tubing & confirm placement
 Connect primed IV tubing & secure tubing
 Confirm placement of pressure bag over IV bag
 Apply wrist band to same-side wrist
59
Drilling Into Humeral Site
 Humeral head NOT a weight bearing bone
 Bone density is softer than tibial area
 Needle may not be as secure in this site
 Hold needle in place as you remove the drill
 Immobilize the arm (i.e.: cot straps will work) to prevent
movement of arm & inadvertent dislodgment of needle
 Patient cannot be allowed to raise arm up
 DO NOT ALLOW PATIENT TO RAISE ARM
OVERHEAD!!!
 Use 45 mm yellow needle for humeral head site
60
Confirming Insertion
 One of the biggest complications of IO is
extravasation due to faulty placement
 All insertions MUST be confirmed

After removal of stylet, aspirate with primed
10 ml syringe


You may or may not see bone marrow
Regardless of what is aspirated, inject the
saline

Observe for infiltration while feeling for any
resistance to the injection
61
Faulty IO Insertions
 Always confirm site and continue to monitor
placement
 Bilateral IO in infant; through and through
insertion
62
How Would You “Catch” This Faulty
Placement???
 Did you choose the correct length needle for
the site chosen?
 Did you stop drilling when you felt the “pop”
or lack of resistance?
 Did you observe the calf area for signs of
infiltration?
 Did you observe how well the IV fluid
infused?
63
Pain Control for IO Infusion
for Conscious Critical Patient
 Inserting the IO needle is relatively painless

Rated 3/10 compared to peripheral IV start
 Infusing of fluids causes discomfort
 Medicating with Lidocaine  patient tolerance
 After confirmation of IO placement, slowly
inject Lidocaine over 60 seconds; wait 60
seconds; then begin fluid infusion

Without waiting, the Lidocaine would be
washed out of the area and not be effective
64
IO Infusion Reminder
 Fluids and medication given via the IO site
has rapid absorption into central circulation

Comparable to IVP route
65
EZ IO Pearls
 Pressure bag is required for flow to overcome
pressure in marrow cavity
 Will improve infusion rate
 DO NOT apply pressure to the drill
 Let the drill do the drilling
 Putting pressure on the needle may cause
the needle to bend
66
Securing the Airway
 A generic term that indicates the patient is
being ventilated

Ventilating = breathing
 Positioning is simplest maneuver and most
often overlooked
 Measurement and placement of
oropharyngeal or nasopharyngeal airways
can help
 Advanced airways include endotracheal
tubes and King airways for Region X
67
King Airway Access
 Indications
Cardiac or respiratory arrest
 Unresponsive medical or trauma patient
without gag reflex
 Inability to place an endotracheal tube

68
King Airway Contraindications
 Height less than 4 feet
 Presence of gag reflex
 Ingestion of caustic substance
 Known esophageal disease
69
King Airway Equipment
 BVM
 O2 source
 King airway



Size 3 (yellow) for patients 4 – 5 feet tall
Size 4 (red) for patients 5 – 6 feet tall
Size 5 (purple) for patients over 6 feet tall
 Water soluble lubricant
 Large sized syringe
 Method to secure airway (i.e.: tape,
commercial holder)
70
King Airway Insertion
 Lubricate distal tip back side of tube
 Avoid placing lubricant over
port holes
 Place patient in supine position
 Use non-dominate hand to perform chin lift
holding mouth open

Might want to grab tongue with gauze
 Insert airway with dominant hand
 Start tip at corner of patient’s
mouth
 Keep blue line toward patient;
away from you
71
King Airway Insertion cont’d
 Advance tube tip to base of tongue and then
rotate to midline

Blue line still facing chin of patient
 Without excessive force, advance tube until
base of colored connector even with teeth or
gums
 Inflate pilot balloon



Size 3 = 50 ml air
Size 4 = 70 ml air
Size 5 = 80 ml air
72
King Airway Insertion cont’d
 Attach BVM and begin to ventilate
 Should meet with resistance
 While ventilating, gently withdraw tube until
ventilations become easy and without
resistance
 Adjust cuff inflation as needed

Obtain seal at peak of ventilatory pressure
 Confirm placement
 Bilateral chest rise and fall
 Bilateral breath sounds
 No sounds over epigastric area
73
King Airway Positioning
 Airway in position

Air passes into trachea from point between the
two cuffs
74
ETT vs King Airway
 ETT a superior piece of
equipment in securing the
airway
 More expertise to place,
though
 King an acceptable
backup
 Blind insertion
technique
75
Scenario Discussion
 Review the following case studies
 Discuss your general impression
 Discuss what your treatment would be
 Discuss your rationale

Know why you chose the intervention you did
76
Scenario #1
 27 year-old patient involved in a MVC
 Restrained driver involved in T-bone on driver’s
side
 A & O x3; cooperative; looks uncomfortable
 C/o left sided abdominal pain
 Has bilateral lower leg closed fractures
 VS: B/P 126/82; P – 88; R – 18; SpO2 98%
 Abdomen firm; no bruising noted
 What care would you provide?
77
Scenario #1
 Care to initiate
 Extrication with attention to spinal
immobilization
 Rapid head to toe assessment looking for life
threats
 Decision made regarding transport urgency
 Obtaining history and vital signs
 Consider IV access – at scene vs enroute
 O2– no resp distress, SpO2 98%; consider on
case-by-case basis if O2 indicated
 Cardiac monitor appropriate
78
Scenario #1
 Reassessment



Increased agitation
Paler; slightly diaphoretic
VS: B/P 102/78; P – 104; R – 24; SpO2 95%
 What do these changes indicate?

Early signs of shock





Changing level of consciousness (agitation)
Becoming tachycardic
B/P holding (watch for decrease)
Watch for narrowing pulse pressure
Pale & clammy
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Scenario #1 – Narrowing Pulse Pressure
 Difference between systolic & diastolic B/P
 Normal = 40 (i.e.: 120/80 = 120 – 80 = 40)
 < 40 = poor heart function
 Most common cause is drop in left ventricular
stroke volume
 In presence of trauma, suggests blood loss
with insufficient pre-load (blood volume
returning to the heart) and therefore creating a
decrease in cardiac output
 Note: Helpful detail to monitor in serial vital
signs
80
Scenario #1
 What injuries might be considered?
 Spleen injury on left


Injury to a solid organ could cause heavy
bleeding
Rib fractures causing pulmonary issues
 How was this patient initially categorized?
 Category II trauma patient
 Need to provide condition update to receiving
hospital
 May need to re-categorize as a Category I
with deteriorating vital signs
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Scenario #1
 What type of shock would this patient be
experiencing?

Hypovolemic
 What compensatory mechanisms were in
place?


maintaining peripheral vasculature resistance to maintain B/P and circulation
Increased pulse rate – to maintain blood flow
and perfusion

Sometimes confused with response to pain,
excitement, flight-or-fight response
82
Scenario #1
 You are unable to establish a peripheral IV
 You are preparing to establish IO access
 Can you use the tibial site?

No, bilateral fractures present
 What would be an alternate site?

Humeral head
 How do you identify the humeral site?
 Identify the humeral site on your neighbor
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Scenario #1 – Humeral Site ID
 Elbow MUST be resting posteriorly in tucked
back position (i.e.: resting on the backboard)
 Hand rests over navel
 Palpate “golf ball”
sized target over
humeral head
 Insert needle at 900 angle
 Document placement,
confirmation, and
placement of wrist band
84
Scenario #2 Roll over – 1 victim
85
Scenario #2
 Responded for a call for a 56 year-old male
involved in a rollover
 Patient was ejected; found on side of road
 Patient moaning, thrashing about (GCS 9)
 Obvious deformities noted right upper and
lower extremities
 In respiratory distress; uneven movement of
chest wall; crepitation palpated on left
 What category trauma is this patient?
 Category I
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Scenario #2
 Care is initiated in field and enroute
 What are your options if unable to establish
peripheral IV access?
 If you need IV access, insert an IO
 What could be contraindications to an IO
site?
 Injuries/fractures to the same side
 Evidence of infection at site
87
Scenario #2
 How do you know the IO is successful?
 Feel “pop” entering bone
 Needle stands up by self
 Able to aspirate bone marrow
 Able to flush without resistance
 Fluid flows effortlessly (using pressure bag)
 What is the formula for an adult fluid
challenge?


Calculate 20 ml / kg
Administer in 200 ml increments with frequent
reassessments
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Scenario #2
 Evaluate this IO
placement


Is it okay???
NO!
 Where is the proper
insertion site???
 Everybody palpate
your tibial site
 Now palpate
someone else’s
x
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Scenario #2
 Needle
appearance
when removed
in ED
 Excess
pressure
during insertion
may
bend/break the
needle
90
Scenario #3
 74 y/o patient presented with severe chest
pain 9/10 for past 4 hours
 Pain radiates toward back and down left arm
 VS: B/P 142/92; P – 84; R – 22 SpO2 98%
 Rhythm strip as below; what’s rhythm?
NSR
91
Scenario #3- Is There ST Elevation?
V1 – V5
92
Scenario #3
 The patient proceeds to arrest and go into VF
 What is your first action after confirming VF?




Defibrillate
Immediately begin CPR
Establish IV access
Secure the airway
 What medications are used for VF?


Epinephrine 1:10,000 1 mg IVP/IO every 3-5 min
Alternated with Amiodarone 300 mg IVP/IO

Repeated in 5 minutes with 150 mg IVP/IO
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Scenario #3
 If patient cannot be intubated, what are your
options?


BVM (30:2 during CPR)
King airway

One breath every 6 seconds via advanced airway
 How do you decide on the size of the King?

By patient height:



Size 3 (yellow) for 4-5 foot tall
Size 4 (red) for 5-6 foot tall
Size 5 (purple) for over 6 foot tall
94
Scenario #3
 A King airway is placed
 You are unable to bag the patient via the King
 Trouble shoot – what do you think the
problem is?
 Has the airway been backed out far
enough?
 Try repositioning the airway until
bagging is easy and chest rise and fall is
observed
95
Scenario #4
 Your patient is 27 year old male stabbed
multiple times
 Scene is safe
 Blood is evident on patient’s clothing

No wounds are spurting blood
 Patient is awake, agitated, pale, diaphoretic
 VS: B/P 110/70; P – 102; R – 24; SpO2 96%
 Breath sounds diminished throughout but you
feel they are present
96
Scenario #4
 Stab wounds evident upper R arm
 2 sites noted upper anterior chest wall
 1 site noted rib margin lower chest wall
 What injuries are you suspicious of?
Pulmonary
 Cardiac
 Abdominal
 Soft tissue/orthopedic

97
Scenario #4
 Immediate care?
 Cover open chest wounds
 Will need baseline vital signs at some point
 Evaluating level of consciousness and radial pulses
can provide helpful information on status of
perfusion
Level of consciousness 1st thing to change when
perfusion starts dropping
B/P last change when compensation no longer
possible
 To palpate a radial pulse one needs
adequate cardiac output to a peripheral site
which indicates level of blood pressure
98
Scenario #4
 Wounds are covered
 Appropriate care provided
 Transport already underway



Patient’s agitation increasing
Becoming more tachycardic
Having increased respiratory difficulty
 What is your next action???


Return to evaluation of ABC’s
Be suspicious for tension pneumothorax
99
Scenario #4 – Tension Pneumothorax
 What is field treatment for tension
pneumothorax?

Needle decompression
 This patient already has chest wounds
 What would you do if you suspect tension
pneumothorax?
 Can lift edges of dressings
nd intercostal
 Can insert a needle into the 2
space (ICS) middle of the clavicle, over top of
rib
 Evaluate all interventions provided
100
Scenario #4 – Needle Decompression
 Need to be more lateral than you expect
 Typically in vertical line with male nipple
101
Documentation
 If a traumatic injury
 Need detail of mechanism of injury (MOI)
Fall – WHY did patient fall (Trip?
Dizziness?)
 MVC – what hit patient?/what did patient
hit?
 What damage is there to vehicle?
 Include the safety components
used/not used (i.e.: seat belts, airbags,
etc)

102
Documentation cont’d
 Need detail of signs and symptoms


If ANY complaint, what did assessment find?
NOT good enough to chart “assessment done”



Does not provide details of what was found
If a release, NOT helpful if patient later
presents to ED or calls 911
 NO comparison data can be done; can’t tell
if there was a change in condition
For extremity issue, include description of
injury and distal CMS/PMS/SMV
103
Sample Documentation – What do you
think???
 27 y/o M involved in MVC; signed a release






A & O x3; ambulatory.
Struck from behind; wearing seatbelt
c/o abdominal pain; has abrasion on L knee
Denied loss of consciousness
Advised of risks by not seeking medical
attention
Signed a release
So, what do you think???
104
Sample Documentation Critique
 No description of MOI

Helpful for anticipation of injuries
 No detailed assessment of abdominal pain or
knee abrasion


If patient were to later call 911 or present to
the ED, no comparison for changes to the
abdominal area can be made
No comparison for changes to the extremity
can be made without baseline details of the
initial evaluation
105
Bibliography
 Bledsoe, B., Porter, R., Cherry, R. Paramedic Care






Principles & Practices, 4th edition. Brady. 2013.
Region X SOP’s; IDPH Approved January 6, 2012.
http://ccn.aacnjournals.org/content/31/2/76.ful
emsstaff.buncombecounty.org (EZ IO for Buncombe
County)
http://www.youtube.com/watch?v=WuKVibUGNM&feature=player_detailpage
http://emedicine.medscape.com/article/908610overview#aw2aab6b7
http://www.vidacare.com/EZ-IO/Clinical-ApplicationsOnline-Training.aspx
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