Medication Review - Advocate Health Care
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Transcript Medication Review - Advocate Health Care
Altered Mental Status
Medication Review
Lung Sounds
MAD Device
ECRN Module I
2010 CE
Condell EMS System
Prepared by Sharon Hopkins, RN, BSN, EMT-P
Objectives
Upon successful completion of this module, the
ECRN will be able to:
Describe elements of normal mental status.
Describe components of the neurological
examination.
List the three components of the Glasgow
coma scale.
Calculate the GCS.
List common causes of an altered mental
status.
Objectives cont’d
Review Cincinnati Stoke Scale
Describe the FAST concept
Review Region X SOP Altered Mental Status
Explain the differences between the adult and
the pediatric airway.
Describe the assessment of the airway and
respiratory system.
Describe the various lung sounds auscultated
during assessment.
Objectives cont’d
Discuss the methods for measuring oxygen
and carbon dioxide in the blood in the
prehospital setting.
Identify pre-hospital indications,
contraindications, dosing, side effects, and
special considerations of Dextrose,
Glucagon, Narcan, Albuterol, Epinephrine
1:1000, Benadryl, Lasix, and Morphine.
Objectives cont’d
Describe the indications, contraindications,
dosing, side effects, and special
considerations for administering Narcan via
the MAD tool.
Describe the MAD tool and the procedure for
using the MAD tool.
Describe the indications, contraindications,
complications, and the process for performing
a cricothyrotomy in the field.
Normal Mental Status
Consciousness
Person is fully responsive to stimuli and
demonstrates awareness of the
environment
Altered level of consciousness
Some form of dysfunction or interruption
in the central nervous system
Normal Mental Status
Patient
is awake
Patient is alert – aware of surroundings
Patient is oriented to person, place, & time
Patient is cooperative
Patient carries on normal conversation
Patient able to follow/obey commands
Gait is even and steady
Altered Level of
Consciousness
Hallmark sign of
central nervous
system injury or
illness
Did You Know?
When
perfusion is declining, the first
indicator is a changing level of
consciousness
The
last indicator is a falling blood pressure
Assessing Mental Status - AVPU
A–
awake
V – responds to verbal stimuli
P – responds to painful stimuli
U- unresponsive
A – “Awake”
Patient
is awake, alert and aware of
surroundings
OR
Patient may be awake but confused
Report what the patient is oriented to
• “Oriented to person but not place or
time”
Key
is watching for a change in level of
consciousness from the baseline taken
V – Verbal Response
This
would need to be evaluated prior to
touching the “unconscious” patient
Problem: If trauma is involved, need to
manually control the C-spine before
causing the patient any movement of
the c-spine
If possible, call the patient’s name to
check for response to verbal stimuli
prior to making physical contact
P – Painful Response
Does not necessarily mean you have to
perform a painful task to check for response
Start with simple tactile contact – touch
Add deeper stimulation if needed
• Sternal rub
• Pinch of thumb web space
• Trapezius muscle squeeze (near neck)
Do not cause so much trauma as to leave
marks/bruises
Observe for some kind of response with muscles
Patient Response
Patient
response can include:
Opening of eyelids even briefly
Fluttering of eyelids
Wrinkling of brows
Most
important is looking for changes in
the patient’s response from one
evaluation/assessment to the next
U - Unresponsive
The
patient has NO response at all
No moaning
No muscle twitch at all
• No eyelid flutter
• No wrinkling of the eyebrow
Muscles are flaccid with absolutely no
response regardless of stimuli
Neurological Exam In the Field
AVPU – what is level of consciousness?
Pupillary response
Movement of distal extremities
Sensation of distal extremities
Wiggling fingers and toes
Ability to feel contact with fingers and toes
GCS
<10 or deteriorating mental status patient is
considered critical and categorized as Category I
trauma
Glasgow Coma Scale - GCS
The best score possible is given
More important is watching the trend than
relying on any one score
Objective tool
All using the tool on the same patient should get
the same score
Evaluate
Best eye opening
Best verbal response
Best motor response
GCS – Eye Opening
4 – Spontaneous; patient’s eyes are open
3 – Eyes open or motion is made to verbal
stimuli
Start with soft voice, may have to yell at patient to
open eyes
2 – Eyes open with tactile or painful stimuli
Does not have to be focusing
Start with gentle touch; may need to add more
intense stimuli
1 – No eye opening; no muscle motion at all
GCS – Verbal Response
– Oriented to person, place, and time
4 – Pleasantly confused
3 – Inappropriate words
5
2
1
You can understand the word(s) spoken
but they are not within context
– Incomprehensible words – sounds
No intelligible word understood; moans and
groans; makes noises
– Silent; no noise is made at all
GCS – Motor Response
– Obeys commands
5 – Localizes pain / purposeful movement
6
4
Can push you away or grab at the noxious
stimuli (IV, collar, bandaging, your hands)
– Withdrawal
No longer localizing, just withdraws/pulls
away to get away from annoying/painful
stimuli (IV, collar, bandaging, your hands)
Motor cont’d
3
2
1
– Flexion to pain
Arms flex/bend slowly toward center of chest
when any stimuli applied
– Extension to pain
Arms slowly extend and curl inward and legs
straighten when any stimuli applied
– No movement at all
GCS Results
range 3 – 15
Minor head injury – 13 – 15
Moderate head injury – 9 – 12
Severe head injury (coma) - <8
Score
Significant mortality risk
Consider intubation or other means to secure
the airway
GCS Practice
Read the following case scenarios
Determine the best eye opening, verbal
response, motor response
When the response is asymmetrical, award
the highest points possible
Don’t guess or assume what you think they
really can do
Award points for what is performed
Be objective
Note: Answers follow the practice slide
GCS Case #1
Patient
lying in the bed (no trauma), eyes
are closed
You need to yell the patient’s name and
then the eyelids flicker
They are mumbling
They are grabbing at your hands and
pushing you away. They have pulled out
the IV.
GCS Case #1 Score
Eye
opening – 3
Responded to loud voice
Verbal
Mumbling is incomprehensible words/sounds
Motor
response – 2
response – 5
Patient can recognize (localize) what feels
obnoxious and what he wants to stop so they
are grabbing at you and pulling at equipment
Total
GCS - 10
GCS Case #2
Patient
is lying in the street watching you
approach
They mumble as you talk to them
They are grabbing at your hands and
pushing you away
GCS Case #2 Score
Eye
opening – 4
Spontaneous; doesn’t necessarily indicate
focusing
Verbal
Mumbling, moaning, groaning
Motor
response – 2
response – 5
Purposeful movement by grabbing at what
the patient perceives as noxious stimuli
Total
GCS - 11
GCS Case #3
Patient
watches your approach and
acknowledges your presence
Patient answers most questions and thinks
you are their relative come to visit
Patient able to move left arm to command
but not able to move right arm (new onset
– possible stroke)
GCS Case #3 Score
Eye
opening – 4
Spontaneous
Verbal
Pleasantly confused
Motor
response – 4
response – 6
Highest possible score based on the arm that
can and does move
Total
GCS - 14
GCS Case #4
Child’s
eyelids flicker when deformed
extremity is manipulated
Child moans out when painful areas are
manipulated
Child pulls away when touched and tries to
turn away from EMS
GCS Case #4 Score
Eye opening – 2
Response to painful stimuli
Verbal response – 2
Moans and groans are incomprehensible
words / sounds
Motor response – 4
Withdrawing from what is sensed as painful
stimuli
Flexion would be slow flexing of arms toward
center of chest – this patient’s response is not
flexion
Total GCS – 8 (Protect airway; consider intubation)
GCS Case #5
Patient’s
eyes remain closed; no eyelid
movement at all
There are no sounds heard from the
patient
The patient straightens their arms, twists
their wrists, arches their back, and
straightens their legs when stimulated
GCS Case #5 Score
opening – 1 (no response)
Verbal response – 1 (no response)
Motor response – 2
Eye
Abnormal extension
The worse level of response prior to no
response at all
Total
GCS – 4
Patient is critical; Category I
Patient usually needs some airway
intervention
Common Causes of Altered Mental
Status
A – acidosis, alcohol
E – Epilepsy
I – Infection (brain, sepsis)
O – Overdose
U – Uremia (kidney failure)
T – Trauma, tumor, toxins
I – Insulin – hypo or hyperglycemia
P – Psychosis, poison
S – Stroke, seizure
Initial Patient Assessment
Airway
Open or obstructed
Maneuvers needed to open
• Head tilt / chin lift
• With trauma, modified jaw thrust
Breathing
Quality
Quantity (eyeball assessment at this time)
Initial Assessment cont’d
Circulation
Quality
Quantity (don’t count; get estimate of
range)
Disability
AVPU
GCS
Expose
– need to obtain baselines
to examine
Can’t evaluate or fix what you can’t see
Assessment Tools
AVPU
Alert (interpreted as an awake patient)
Responds to verbal stimuli
Responds to painful stimuli
Unresponsive
Assessment Tools
GCS
Best eye opening response
Best verbal response
Best motor response
Scores
range from the lowest of 3 to
highest of 15
Obtain and document GCS on all patient
calls
Cincinnati Stroke Scale
Obtain
for suspicion of TIA or stroke
Evaluate for facial droop
Check the patient’s symmetry during a
broad, big smile (teeth showing)
Evaluate for arm drift
Check for weakness in holding arms
outstretched, palms up, for 10 seconds
Evaluate for clear speech
Have patient repeat words listening for
clear speech patterns
Airway Protection and the Stroke
Patient
Crucial
- high mortality rate for aspiration
Is airway patent and can patient protect
their own airway?
Check if patient is able to handle & swallow
own saliva
• Detailed/involved swallow study done in-hospital
Patient speaks in clear unobstructed voice
Interventions
to consider
Have suction on and ready
Ability to quickly turn patient onto their side
FAST - Public
Educational
Tool
Tool
developed by
organizations
for public
recognition of
stroke and to
encourage
FAST action
Region X SOP –
Altered Mental Status
Consider
etiology
If cause of problem can be identified, then
interventions can be focused
• Diabetes – check blood sugar
• Drug overdose – what are the
environmental clues
• Poisoning – environmental evidence
around
• Alcohol related – environmental
evidence; use your nose
SOP – Altered Mental Status
Maintain airway
Patency extremely important
Evaluate rate and quality
If respirations inadequate, ventilate
• 1 breath every 5-6 seconds all patients –
infancy to elderly
Intubate as necessary
Use C-spine precautions as indicated
If any doubt, err on side of extra precautions
Provide Routine Medical Care
IV – O2 - monitor
SOP – Altered Mental Status
Obtain
blood glucose level
If <60 – treat
• Adult - Dextrose 50% 50 ml IVP
• Child 1 – 15 – Dextrose 25% 2 ml/kg
• Infant <1 – Dextrose 12.5% 4 ml/kg
Dilute 1:1 ratio D 25% with normal
saline
Equal amounts of product make 1:1
dilution (Dextrose and normal saline)
Treating Altered Mental Status
In absence of IV access
• Adult – Glucagon 1 unit (1 ml) IM
• Pediatrics < 15 – Glucagon 0.1 mg/kg IM
Max dose of 1 mg
Practice math: 44 pound child with no IV access
• How many kg?
44# 2.2 = 20 kg
• 20 kg x 0.1mg/kg = 2 mg
• How much Glucagon do you give?
Max of 1 mg (max drugs at adult dose)
Altered Mental Status cont’d
If patient not alert, respirations decreased, or
narcotic overdose suspected:
Narcan 2mg IN/IVP/IO
• Repeat every 5 minutes as needed until
desired effect
Quality of respirations have improved
Don’t need patient to be 15 on GCS
Don’t need patient awake necessarily
• Maximum total dose 10 mg
Transport
Altered Mental Status cont’d
Note:
Attempt to identify substances involved
If not a safety hazard, obtain and transport
substance container with the patient
Consider use of restraints prior to
administration of Narcan
• Patient may become violent when level
of consciousness improves
Adult Airway
Note
Pediatric airway
funnel shaping of pediatric airway
Notice Difference in Tongue Size
Adult airway
tongue
Pediatric airway
Pediatric airway Differences
Jaw smaller
Teeth softer and more fragile
Tongue relatively larger
Potential to produce more obstruction
Epilgottis floppier and rounder
Recommend straight Miller blade over curved Macintosh
for intubation
Larynx more superior & anterior
Higher and more forward
Funnel shaped due to underdeveloped cricoid cartilage
• Under age 10 cricoid cartilage narrowest part of airway
Ribs and cartilage softer and more pliable
Children rely on diaphragm muscle for breathing
Airway Assessment
Inspection
Begin as you are approaching the patient
Auscultation
Listen for audible sounds, then use
stethoscope
Palpation
Can gather a lot of information through the
art of touch
Assessment of Airway
Initial assessment
ABC’s
• Airway open?
Fully open with adequate air exchange?
Partially or fully obstructed with poor air
exchange?
• Are they breathing?
Look for chest rise and fall
Listen for air movement
Feel for air movement
• Do they have a pulse?
Airway Assessment cont’d
Inspection
Evaluate adequacy of breathing
Note any signs of trauma
Assess skin color
• Paleness and diaphoresis due to sympathetic
stimulation in early respiratory compromise
• Cyanosis if deoxygenated (LATE SIGN!!!)
Patient positioning
• Tripod – leaning forward (CHF? Asthma?)
• Orthopnea – can’t lay down (CHF? Asthma?)
Inspection cont’d
Observe for dyspnea
• May cause or be caused by hypoxia
• Prolonged dyspnea can lead to anoxia
(absence of oxygen)
• Is dyspnea a new onset or perhaps chronic
in the patient with long standing COPD
Abnormal Respiratory Patterns
Kussmaul’s
Deep, slow or rapid, gasping breathing
Commonly found in diabetic ketoacidosis in
attempt to blow off excess CO2 (acid)
Cheyne
–Stokes
Progressively deeper, faster breathing
alternating with gradually shallow and slower
breathing
Indicates brainstem injury
Respiratory Patterns cont’d
Biot’s
Central neurogenic hyperventilation
Irregular pattern of rate and depth with sudden,
periodic episodes of apnea
Indicates increased intracranial pressure
Deep, rapid respirations
Indicates increased intracranial pressure
Agonal
Shallow, slow, or infrequent breathing
Indicates brain anoxia, impending death
Respiratory Assessment cont’d
Auscultation
Listen 1st audibly for any abnormal sounds
Have patient cough to clear loose secretions
Then listen with stethoscope
• Right and left apex (under clavicles)
• Right and left bases (8th – 9th intercostal
space, midclavicular)
• Right and left lower thoracic back or right
and left midaxillary line (lateral chest wall)
Auscultation cont’d
Posterior
aspect preferable to anterior surface
Less tissue mass
Lungs closer to the surface
Less interference with heart sounds
Anterior and lateral sections of the chest are
more accessible especially in supine patients
Evaluate for symmetrical equality
Keep stethoscope in place long enough to
hear end of exhalation
Many abnormal sounds heard first at end of
exhalation
Abnormal Lung Sounds
Snoring
Partial obstruction of upper airway, usually
from tongue
Patient needs airway repositioned
Gurgling
Accumulation of fluids (blood, vomitus,
other secretions) in upper airway
Stridor
Harsh, high-pitched sound heard on
inhalation; usually indicates laryngeal
edema or constriction
Lung Sounds cont’d
Wheezing
Musical, squeaking, or whistling sound
heard in inspiration and/or exhalation
Indicates bronchiolar constriction
• Asthma, COPD
Quiet
Diminished or absent breath sounds
ominous
Indicates serious problem with airway,
breathing, or both
Lung Sounds cont’d
Crackles (rales)
Fine, bubbling sound heard on inspiration,
sounds like velcro ripping
Indicates fluid in smaller airways
• CHF
• Pneumonia
Gas exchange may be compromised
Rhonchi
Course, rattling noise heard on inspiration
Associated with inflammation, mucus, or fluid in
bronchioles
Gas exchange may be compromised
• Chronic bronchitis
Airway Assessment
Palpation
Often forgotten assessment tool
Palpate chest wall for
• Tenderness
• Symmetry
• Abnormal motion
• Crepitus (bone crunching)
• Subcutaneous emphysema
Air leakage into tissue
Pulse Oximetry
Measures
hemoglobin oxygen
saturation in peripheral tissue
Non-invasive means to measure
effectiveness of oxygenation and
ventilation
Continually reflects changes
May detect changes faster than
assessment of vital signs
Pulse Oximetry
Place
probe over a peripheral capillary bed
Fingertip, toe, earlobe
2 sensors take measurements of light
reaching them from 2 light emitting diodes
Oximeter calculates ratio of light received
• Influenced by amount of oxygenated
versus deoxygenated hemoglobin
SpO2 determined
Suggested SpO2 Results
– 99% - normal
91 -94% - mild hypoxia
95
Perform additional evaluation
Administer supplemental oxygen
86
– 91% - moderate hypoxia
Perform additional evaluation
Administer 100% supplemental oxygen
<85%
- severe hypoxia
Immediate intervention required
SpO2 Error Results
Current equipment more accurate; less error
readings
False readings possible
Carbon monoxide exposure – false high
High-intensity lighting near sensors
Hemoglobin abnormalities
Absent peripheral pulses
Hypovolemia; severe anemia
• SpO2 may be normal but the amount of
hemoglobin available is low
Coordinate readings with patient assessment
Capnography
Graphic
recording or display of
measurement of expired CO2 over time
End-tidal CO2 (ETCO2) – measurement of
CO2 concentration at end of expiration
Provides information
Systemic metabolism (production of CO2)
Circulation
Ventilation
How Does CO2 Circulate?
CO2
is normal end product of
metabolism
Transported by venous system to right
side of heart
Pumped from right ventricle
pulmonary artery lungs and
pulmonary capillaries
Diffuses into alveoli
Removed from body via exhalation
Poor Perfusion States
Shock,
cardiac arrest, pulmonary
embolism, bronchospasm, incomplete
airway obstruction (ie: mucous
plugging)
Perfusion decreased
ETCO2 will reflect pulmonary blood
flow and cardiac output
Will not reflect ventilation in poor
perfusion states
End Tidal CO2 Detector
Contains
pH sensitive chemically
impregnated paper to estimate ETCO2
level
Color change is reversible
Will reflect changes breath to breath
Paper will be unreliable if
contaminated with acidic
drugs or gastric contents
Tool placed near elbow on
BVM
Interpreting the ETCO2
– indicates measured CO2 being
exhaled
Yellow
Evaluate after 6 breaths
Tan
– low levels of CO2 measured
Misplaced tube or poor carbon dioxide
production
• Evaluate tube positioning
• Evaluate patient perfusion
Blue
or purple – no CO2 being measured
Suspect unsuccessful intubation
ETCO2
Applications
Verify placement of endotracheal tube
Assess effectiveness of CPR
• CO2 levels fall abruptly at onset of
cardiac arrest
• CO2 levels begin to rise with effective
CPR
Medication Review
(Information based on Region X EMS usage)
Indication
Contraindication
Dosing
Side effects
Special considerations
Dextrose
Carbohydrate used to raise the sugar level
No contraindication in suspected hypoglycemia
Administered when the blood sugar level is less
than 60
Dose based on age
Adult 16 and over – 50% 50 ml slow IVP
1 – 15 – D 25% - 2 ml / kg slow IVP
<1 – D 12.5% - 4 ml / kg slow IVP
• Mix 1:1 dilution with D25% and normal
saline
Dextrose cont’d
Local
vein irritation may occur
especially when small veins are used
If glucagon was administered and then
an IV site is secured, retest the blood
sugar level
If blood glucose remains <60 and patient
condition not improved, administer
Dextrose
Glucagon
Hormone
to stimulate breakdown of
glycogen (stored form of glucose)
Patient may have an allergic reaction if they
have allergies to proteins
Adult dosing – 1 mg (1 unit) IM
Pediatric dosing up to 15 years old –
0.1 mg/kg (max dose 1 mg – 1 unit)
Glucagon cont’d
Observe
for nausea and vomiting
May take up to 20 minutes for Glucagon
to be effective
Will not have any effect if there are no
stores of glycogen in the liver
Patient requires rapid transport and
continued efforts at IV access
Drug must be reconstituted prior to
administration
Albuterol
Ventolin,
Proventil
Bronchodilator with onset 5 – 15 minutes
after inhalation
Used in asthma, to reverse bronchospasm
in COPD, and bronchospasm & laryngeal
edema of an allergic reaction
All patients inhale 2.5 mg via nebulizer
Albuterol cont’d
May
cause tachycardia & restlessness
Has greater influence in the lungs than
on the heart
Less effective if patient taking beta
blockers at home (usually for
hypertension; meds end in “alol”)
Beta blockers block bronchodilation
response
Offer
aerosol mask if patient unable to
keep mouthpiece sealed between lips
Albuterol Kit and Masks
2.5 mg / 3 ml
Connected
to O2
source
Watch
Available in
adult and
pediatric sizes
for
signs of
exhaustion
May need to
be bagged
Epinephrine via Nebulizer
In
presence of croup/epiglottits
If patient not responding to 2 doses of
Albuterol, provide alternate treatment
• Epinephrine 1:1000 1 ml mixed with
2 ml normal saline
• Mix in nebulizer
• Connect to oxygen to create a mist
• Assist patient while inhaling the mist
Nebulized Epinephrine for moderate to
severe cases
Epinephrine 1:1000
A drug that mimics the sympathetic nervous system
Stimulation on the vessels trigger
vasoconstriction
• Will raise the blood pressure
Stimulation in the lungs triggers bronchodilation
• Will improve air exchange
Useful in asthma, COPD, allergic reactions with
airway involvement, and anaphylaxis
Epinephrine 1:1000 cont’d
Use
with caution in the elderly and
those with heart disease
Can strain the heart by increasing the
workload of the heart (rate and force of
contractions)
Adult
dosing allergic reaction with
airway involvement – 0.3 mg SQ
Adult dosing anaphylaxis – 0.5 mg IM
Faster absorption in poor perfusion
Epinephrine 1:1000 cont’d
Pediatric
dosing up to 15 years of age
Allergic reaction with airway involvement
• Epi 1:1000 - 0.01 mg/kg SQ
• Max single dose 0.3 ml (0.3 mg)
• May repeat every 15 minutes
Anaphylaxis
•
•
•
•
Epi 1:1000 – 0.01 mg/kg IM
Max single dose 0.3 ml (0.3 mg)
IM faster absorption in poor perfusion state
May repeat every 15 minutes
Epinephrine 1:1000 cont’d
May
Tachyarrhythmias
Palpitations
Restlessness
Anxiety
Headache
May
cause:
increase oxygen demand in the heart
Use cautiously in elderly and those with heart
disease
Benadryl - Diphenhydramine
Antihistamine
to block the release of
histamine in allergic reactions
Max effect in 1 – 3 hours
Duration of effect 6 -12 hours
Medication must be continued over several
days or symptoms will rebound
Useful
in allergic reactions including
anaphylaxis
Benadryl cont’d
Avoid
use in severe, uncontrolled asthma
and COPD
Adult dosing
Stable allergic reaction – 25 mg slow IVP or IM
Allergic reaction with airway involvement &
anaphylaxis – 50 mg slow IVP or IM
Pediatric
dosing – 1 mg/kg IVP
Stable allergic reaction – max dose 25 mg
Allergic reaction with airway involvement or
anaphylaxis – max dose 50 mg
Benadryl cont’d
May
cause drowsiness, headache,
confusion, wheezing, palpitations,
hypotension, nausea, vomiting, drying of
secretions
Elderly particularly sensitive to effects of
Benadryl
Watch for hypotension and drowsiness
Lasix (furosemide)
Diuretic
that stops reabsorption of
sodium and chloride in the kidneys
Triggers dilation of the venous system
Could drop blood pressure
Decreases pre-load
Amount of blood returning to the heart
Onset
of venodilation immediate
Onset of diuretic effect within 15 – 20
minutes
Lasix (furosemide) cont’d
Useful
in CHF and pulmonary edema
Venodilation useful in hypertensive
crisis
Slight risk in persons allergic to sulfa
drugs (typically antibiotics)
Dosing is 40 mg IVP/IO
If patient is on Lasix, they are
sensitized to it
Use the larger dose of 80 mg IVP/IO
Lasix (furosemide) cont’d
May
cause headache, dizziness,
hypovolemia, nausea
Patient may experience temporary hearing
loss and ringing in the ears with repeated
doses given rapid IVP/IO over a period of
time
Morphine
Narcotic analgesic (opioid)
Reduces anxiety
Creates a euphoric feeling
Depresses the central nervous system (CNS)
• Reduces pain sensation
Dilates venous blood vessels
• Decreases blood return to the heart (pre-load)
Useful in ACS, pulmonary edema, pain
Potentiates versed during conscious sedation
Helps versed to be more effective
Morphine cont’d
Dosing
2 mg given slow IVP (over 2 minutes)
May repeat every 2-3 minutes
Maximum total dose is 10 mg
Side
effects
Hypotension
Respiratory depression
Bradycardia
Altered level of consciousness
Morphine cont’d
Opioids
cause pupils to constrict
Use cautiously when other depressant
drugs have been taken
Includes alcohol
Reversal
agent is Narcan
Adult dosing 2 mg IVP
• May repeat every 5 minutes; max total 10 mg
Pediatric dosing < 20kg – 0.1 mg/kg
IVP/IO/IM
• Max total dose is 2mg
• > 20kg – 2 mg IVP/IO/IM
Narcan
Narcotic antagonist with an onset within
2 minutes
May cause withdrawal symptoms including
seizures
Adult dose – 2 mg IN/IVP/IO
Repeated every 5 minutes as needed up to 10 mg
Pediatric dose up to 15 years weight based
<20 kg (44#) – 0.1 mg/kg IVP/IO/IM
>20 kg (44# - typically a 4-6 year old) –
2 mg IVP/IO/IM
Narcan cont’d
Side
effects are rare. Watch for
hypotension, nausea, vomiting, blurred
vision, opiate withdrawal (including
seizures)
Goal is to reverse severe respiratory
depression; NOT to have an awake &
talking patient
Duration of Narcan may be shorter than
drug it is trying to counteract
Watch for return of symptoms
Alternate Medication Delivery MAD
Mucosal
atomization device
Tool to deliver medications via nasal route
Medication atomized into tiny particles
Nasal mucosa highly vascular
• Immediate absorption into bloodstream
• Onset of action within 3-5 minutes
• Peak onset 15-20 minutes
Using Nasal Route - MAD
Unable
to establish IV access
Medication administration indicated
Nasal mucosa intact and
clear of blood and mucus
MAD
Luer
tip can be connected to variety of sizes
of syringe
White wedge fits firmly into nostril
Fine mist spray covers a large surface area
Medication adheres to nasal mucosa
versus running down the throat
Each nostril can tolerate up to 1 ml volume
Narcan packaged 2mg/2ml – will need to deliver
1 ml in each nostril
Attaching MAD Tip to Syringe
Nasal cavity suctioned as needed to clear
blood or secretions
• Clear nasal passages enhance absorption
of medication
Medication delivered in divided doses
• Maximum of 1 ml per nares
Inserting MAD Nasal
Patient’s head controlled with
one hand
Need to prevent movement
•
MAD gently but firmly placed
into one nostril
• Aimed upward and toward
ear on same side
Syringe briskly compressed
to deliver the drug as an
atomized mist into nares
Dispensing Mist
Must briskly compress
syringe to convert liquid
drug to a fine atomized
mist
Mist results in broader
mucosal coverage;
better chance of
absorption into the
blood stream than
drops that can run
straight back into the
throat.
MAD
Region
X have implemented the MAD
beginning with Narcan
“IN” documented for route of
administration
Will have the potential in the future to
add further medication using the MAD
Cricothyrotomy, QuickTrach
Indications
Assisted ventilations required and all other
means have failed to secure an airway
Contraindications
Transected trachea
Less invasive maneuver will be effective
Note:
In ED, staff will need to assist the
MD with this device – do you know how?
Equipment
BVM
QuickTrach kit
>77 pounds use 4 mm kit
22 – 77 pounds use 2 mm kit
< 22 pounds use needle cricothyrotomy
Skin prep material
Where is your airway kit kept in the
ED?
QuickTrach Kit
Contents
Needle
with syringe
Cannula with wings
for strap attachment
Extension tubing
Velcro strap
QuickTrach cont’d
Procedure (RN to assist MD)
Assemble equipment
Patient supine, neck hyperextended if no trauma
Locate cricothyroid membrane and cleanse site
• Soft spot palpated just below Adam’s apple
• Or, start at notch, run fingers up toward head
First ridge of bone palpated is cricoid
cartilage
Membrane is just above this bony
cartilage
Procedure cont’d
Anchor and stretch skin slightly
Puncture cricothyroid membrane at 900 angle
Aspirate syringe as needle enters trachea to confirm
placement
• Ability to freely aspirate air
Change angle of needle to 600 towards feet
Advance device until stopper is flush with skin
Remove stopper
• Stopper will be snug; avoid motion of needle
Slide plastic cannula forward until snug against skin as
you remove needle and syringe
• Advance cannula as you remove needle like starting
an IV
Procedure cont’d
Hold cannula snuggly
• Patient may reflexively cough and could
dislodge cannula
Attach flexible connecting tube to cannula
proximal end
Begin to bag/ventilate the patient immediately
• Once every 6-8 seconds for all patients
Confirm placement
• Auscultation lung sounds
• Adequate chest rise
Finish securing cannula with neck strap
Case Study #1
Your
patient called 911 after dropping her
tea cup and being unable to move her
right side
Conscious, cooperative, speech slurred
VS: 175/110; P – 98; R – 18; pupils
cataract
Initial care started (IV – O2 – monitor)
What is your impression?
What specific assessment should be
done?
Case Study #1 cont’d
Impression
Acute stroke
Additional assessment
Cincinnati Stroke Scale
• Facial droop
• Arm drift
• Speech
Transport decision
Is CT scan available at receiving hospital?
Case Study #2
EMS is at a local school for a patient with asthma
Assessment taken walking towards child
Sitting upright
In obvious distress
• Use of accessory muscles – neck,
intercostal
• Increased respiratory rate
• Panic on their face
Impression
• Severe acute asthma attack
Is assessment done after vital signs?
Case Study #2 cont’d
Assessment
performed
Observation / visual inspection
Initial ABC’s
• To determine presence of life threats
Breath sounds auscultated
• Bilateral wheezing heard predominately on
exhalation
Obtain vital signs
• 98/62; P – 110; R – 28 and labored; SpO2 94%
Case Study #2 cont’d
Interventions
required
IV – O2 – monitor - medication
Question
Do you need an IV established prior to
administration of medication?
• No, albuterol nebulizer should be started as
soon as possible
• Give verbal prompts to slow breathing down, to
take deeper breaths, and to eventually take and
hold a deep breath
Case Study #3
You are caring for a traumatically injured
patient
When asking them to open their eyes, you
yelled their name and their eye opened briefly
and then closed again
They are using swear words during care
provided
They are pulling off equipment and grabbing
at your hands while you provide care
What is their GCS?
Case Study #3 cont’d
Eye
opening
To verbal – 3 points
Verbal
Inappropriate words – 3 points
Motor
response
Purposeful movement – 5 points
Total
response
GCS – 11 points
Indicates moderate head injury
Case Study #4
You
are caring for a patient complaining
of dyspnea
Your patient is 62 years-old
They are sitting in the tripod position
They are using accessory muscles and
have an increased respiratory rate
With your stethoscope, you auscultate
crackling sounds heard in the bases
during exhalation
Case Study #4 cont’d
What are these breath sounds?
What do these breath sounds indicate?
Fluid in the smaller airways
• CHF, pulmonary edema, pneumonia
What medications may be indicated in the
field (per SOP) for CHF?
Crackles
Nitroglycerin – venodilator
Lasix – venodilator and diuretic
Morphine – venodilator, reduce anxiety
And of course, oxygen
Intervention to add is CPAP
Case Study #5
You
received a 7 year-old patient from a
local school with an asthma attack
Your impression is an acute asthma attack
You begin supplemental oxygen and begin
to prepare to provide interventions
Case Study #5 cont’d
If this is an asthma attack, what signs and
symptoms do you expect?
Sitting up leaning forward
Dyspnea with shortness of breath
Increased respiratory rate
Use of accessory muscles
Dry mucous membranes
Possibly audible wheezing
Bilateral wheezing heard first on exhalation
Dry, nonproductive cough
Case Study #5 cont’d
If
you cannot hear any breath sounds,
what does this mean?
The airway is so constricted that no air is
moving in or out – ominous
What
does wheezing sound like?
Whistling, musical sound that can be heard
on inhalation and exhalation
• The louder the breath sounds the more
air that is exchanging
Case Study #5 cont’d
What medication is indicated?
Albuterol 2.5 mg (in 3 ml) nebulizer
How can you help maximize the effects of the
treatment?
Calmly, quietly talk the patient through breathing
Get the patient to slow down the breathing
Get the patient to take some deeper breaths
Get the patient to inhale and hold their breath
periodically to get the drug into the lungs
Case Study #6
You
have an unresponsive male in his
twenties
The patient responds to painful stimuli
The respirations are 6 per minute and
shallow
Pupils are constricted
What is your impression?
What interventions were necessary in
the field?
Case Study #6
Impression
Narcotic overdose
Interventions
Immediately support ventilations
• Bag at a rate of once every 5-6 seconds
Protect the airway from aspiration
Administer Narcan 2 mg (via MAD if no IV)
• Administer a maximum of 1 ml per nares
if using MAD
Case Study #7
A patient
is unable to be ventilated via
BVM
What options are available?
Reposition the airway
• Consider c-spine precautions if indicated
Attempt intubation
QuickTrach if unable to intubate
Needle cricothyrotomy if unable to identify
landmarks
Case Study #7
Landmarks
for Quicktrach
Soft space just inferior/below thyroid cartilage
(Adam’s apple)
Or
Start in notch and move finger upward
• Feel first bony prominence – cricoid
cartilage
• Palpate for soft space above the cricoid
cartilage
Bibliography
Bledsoe, B., Porter, R., Cherry, R. Paramedic
Care Principles and Practices. Prentice Hall.
2009.
Campbell, J. BTLS 5th Edition. Brady. 2004.
Region X SOP, March 2007; amended January
1, 2008.
videolaryngoscopy.com/…/AdultCobaltAirway.jpg
www.wolfetory.com