Transcript June/July 2014 CE - Advocate Health Care

Electrical Therapies
Case Scenarios
JUNE/JULY 2014 CE
CONDELL MEDICAL CENTER EMS SYSTEM
IDPH SITE CODE: 107200E-1214
SHARON HOPKINS RN, BSN, EMT-P
REV 6.15.14
1
Objectives

2
Upon successful completion of this module, the EMS
provider will be able to:
1. Actively participate in case scenario discussion.
2. Actively participate in review of a variety of EKG rhythms and 12
lead EKG’s.
3. Actively participate in review of selected Region X SOP’s.
4. Describe the intervention or treatment plan for the case presented
following Region X SOP guidelines.
Objectives cont’d
3
5. Actively participate in using your department
monitor/defibrillators to review the process of pacing,
synchronized cardioversion and defibrillation skills.
6. Review safety procedures observed when using electrical therapies.
7. Review CPR guidelines per the American Heart Association (AHA) 2010
Guidelines.
8. Review responsibilities of the preceptor role.
9. Successfully complete the post quiz with a score of 80% or better.
Electrical Therapies for Patient Care

Usually used when the patient is unstable and
immediate therapies are required

Measuring patient stability = assessing perfusion
 Evaluate
level of consciousness
 Brain
function VERY sensitive to level of oxygen perfused
as well as glucose
 Reacts
 Evaluate
 Falls
quickly when O2 and glucose supplies drop
blood pressure
when all levels of compensation are exhausted
4
Transcutaneous Pacing (TCP)

Electrical pacing of heart through the skin

Beneficial in symptomatic bradycardia
 Sinus
bradycardia
 High-degree
 Second
 Third
 Atrial
 Any
heart block
degree Type II (Classical)
degree – complete
fibrillation with slow ventricular response
other bradycardic rhythm causes symptoms
5
TCP

6
Symptomatic bradycardia
 Patient’s
symptoms related to poor perfusion to
vital organs
 Patient
evaluated on THEIR response to their level
of perfusion; not just on the heart rate number
 Example
 Conditioned
athletes normally maintain
excellent perfusion with a heart rate in the 40’s
TCP
7

Monitoring electrodes placed in usual fashion

TCP pad placement
 Anterior
chest pad (-) placed in apical area
 Posterior
pad (+) placed in mid-upper back area
 Between
 Bone
spine and scapula
is poor conductor of electricity so avoid
placement over a bone
TCP Settings
8

Rate: 80 / minute

Sensitivity: Auto / demand

Output: mA started at 0 and turned up until capture noted
with lowest energy level
 Capture
spike

Evaluate
perfusion

LOC

B/P
evident with wide QRS complex following a pacer
Pain Management For TCP
9

TCP use is painful/uncomfortable for the patient

Administer Valium as a benzodiazepine to relax the patient
2
mg IVP/IO over 2 minutes
 May

repeat every 2 minutes as needed to a max of 10 mg
To manage pain, administer Fentanyl, an opioid
1
mcg/kg IVP/IO/IN
 May
repeat same dose in 5 minutes as needed to max 200 mcg
total dose

Watch for respiratory depression in both categories of meds
Synchronized Cardioversion

A controlled form of defibrillation with delivery of
lower energy settings

Used when the patient still has an organized rhythm
and a pulse

Electrical discharge delivered during R wave of
QRS
 Current
delivered on downslope of T wave (relative
refractory period) could cause the rhythm to
deteriorate into ventricular fibrillation (VF)
10
Stable vs. Unstable Tachycardia

In tachycardia, the ventricles contract so fast
they are unable to properly fill to capacity

Contract out smaller stroke volumes than normal

Leads to overall decrease in cardiac output

For stability:
 Check
level of consciousness - first indicator to
change
 Check
B/P - last indicator to change
11
Synchronized Cardioversion Indications 12

Unstable SVT

Unstable rapid atrial flutter /fibrillation (narrow complex
tachycardia)

Unstable ventricular tachycardia (VT) or wide complex
tachycardia

Peds probable SVT with poor perfusion after no response
to meds

Peds possible VT with poor perfusion

Peds probable SVT or VT with adequate perfusion and
after no response to meds
Synchronized Cardioversion
Sedation


The conscious patient should be sedated if at all possible!
 This
is a painful procedure
 But,
do not delay procedure to sedate
Sedation with benzodiazepine
 Versed
 Max

13
2 mg IVP/IO every 2 minutes titrated
10 mg total dose
Pain control with Fentanyl 1 mcg/kg
 Repeated
in 5 minutes; max total dose 200 mcg
Set Up For Synchronized
Cardioversion

Activate synchronizer mode button

Watch for flagging of the R wave

Look and call “all clear”

Hold oxygen source away from the patient

Press and hold discharge buttons until machine
discharges on next R wave
 Will

be momentary delay
Assess the monitor and patient
14
Flagging the R Wave
15
Precautions with Cardioversion

Patients in atrial fibrillation >480 not on anticoagulants
have increased risk of blood clot formation in quivering
atria

Cardioversion causes the atria to contract and could
break off a clot increasing risk for stroke

Avoid cardioversion if at all possible on atrial fibrillation
patient until detailed and further evaluation can be
completed (if possible)
16
Defibrillation

Non-synchronized delivery of energy during any
part of the cardiac cycle

Cells depolarized allowing them to repolarize
uniformly

Electrical therapy causes the heart to contract
simultaneously
 The
goal is to allow the SA node (dominant
pacemaker) to take over the electrical control of
the heart
17
Defibrillation Back Ground

Most defibrillator units are biphasic

This waveform allows use of less energy
 Less
energy = less myocardial/tissue damage

Current moves in one direction and then travels
back in the opposite direction

Need to know YOUR respective manufacturer’s
recommendation for energy settings
 Suggestion:
place a label next to screen with YOUR
setting recommendations
18
Increasing Success Rate for
Defibrillation

19
Time from onset of VF – sooner the better
 Perform
CPR ONLY until the defibrillator is set up and
ready to go

Pad placement
1
to right of upper sternum below clavicle
1
to left of left nipple anterior axillary line over apex of
heart
 Do

not place over pacemaker or internal defibrillator
Confirm pads are secured tightly to chest wall with no
air gaps
Set Up For Defibrillation

Perform CPR while setting up machine and
placing pads

Hold CPR to analyze rhythm

Confirm VF or pulseless VT

Charge unit as recommended by manufacturer
 May
perform CPR just until unit is charged

Look and call “all clear”

Hold oxygen source away from patient

Depress defib buttons

Resume CPR for 2 minutes
20
Shockable Rhythms
21
Pulseless VT
Polymorphic VT
Course VF
Results post
defibrillation
Now check
for a pulse
Summary Electrical Therapies

Know YOUR particular brand monitor/defibrillator

Know how to operate YOUR equipment

Check equipment every shift for adequate
stocking of supplies

Know how to trouble shoot YOUR equipment

Acknowledge when YOUR equipment requires
regular monitoring electrodes to be placed IN
ADDITION to defib/pacing/cardioversion pads
22
Obtaining and Transmitting 12 Lead
EKG’s

Review placement of electrodes for obtaining
12 lead EKG’s

Review YOUR equipment process for transmitting
to the hospital

Remember to state in report YOUR interpretation
for presence/absence of ST elevation

THEN read word for word the print-out
interpretation
23
Electrode Placement for 12 Lead EKG’s
24
For every person, each precordial lead placed in
the same relative position

V1 - 4th intercostal space, R of sternum

V2 - 4th intercostal space, L of sternum

V4 - 5th intercostal space, midclavicular

V3 - between V2 and V4, on 5th rib

V5 - 5th intercostal space, anterior axillary line

V6 - 5th intercostal space, mid-axillary line
25
Precordial
Lead
Placement
Case Scenario Discussions

Read the cases presented

Discuss what your general impression is

Determine appropriate interventions based on
the most current Region X SOP’s dated “IDPH
Approved April 10, 2014”
 Pocket
Region
 Full
sized protocols being printed by the
size copies forwarded to the Medical Officer
for department distribution
26
Case Scenario #1

49 y/o male got arm caught in
machine at work

Large open wound noted to left
forearm

Large amount of blood loss
evident

Make-shift tourniquet applied by
co-workers
27
Case Scenario #1

What are the steps in controlling bleeding?
 Direct
pressure with gloved hand
 Direct
pressure with gauze
 Elevation
not found to have any advantage or
disadvantage
 Pressure
points usually not effective
 Operator
 EMS
error – not enough pressure applied
tourniquet placed if bleeding not controlled
28
Case Scenario #1

What are the steps for CAT application?
 Place
as far distally as possible at least
2 inches proximal to wound on bare skin
 Tighten
windlass until bleeding stops; pulse
no longer palpable
 Monitor
for further bleeding
 Consider
 Lower
pain management
leg injuries may require tourniquet
placement on thigh vs calf
29
Case Scenario #1
 Would
you remove tourniquet applied by
by-standers?
 Case
by case decision
 Most
tourniquets in this situation have been
inappropriately applied and with improper
technique
 EMS
would remove the tourniquet to evaluate
the site and then treat based on EMS
assessment
30
Case Scenario #1- Identify the
Rhythm
Sinus tachycardia

Regular R to R intervals; rate 130

P waves rounded, upright

PR interval 0.12 – 0.20 seconds
31
Case Scenario #1

What would you do for pain control with stable vital signs?
 Administer
 May
Fentanyl 1 mcg/kg IVP/IN/IO
repeat same dose in 5 minutes
 Maximum

32
total dose 200 mcg
What side effects should you watch for with Fentanyl?
 Fentanyl
is an opioid so watch for respiratory depression
 Reversible
with Narcan – narcotic antagonist
 Cardiovascular
effects (i.e.: drop in blood pressure) not a problem
with Fentanyl like it may be with Morphine
Case Scenario #1

33
When would the QuikClot dressing be used?
 Failure
to control bleeding after application of tourniquet
 Bleeding
not controlled with direct pressure to nonextremity areas

Should the initial dressings remain in place?
 No;
QuikClot needs to be placed directly over the wound
to be effective

Is direct pressure still required with Quikclot?
 Yes
for 2-3 minutes or until bleeding stops
 Do
not peek at the wound which disturbs the clot
Case Scenario #1 Follow-up

To OR on day of admission
 Large
soft tissue injury with numerous small metallic foreign
bodies
 Non-displaced
 OR
fracture ulnar styloid
for exploration and repair of wound

Initially unable to extend wrist but able to move 3rd,
4th, 5th digits slightly

3 days later reports electrical shooting pain to left
mid forearm

4 days later discharged home; some movement of
fingers
34
Case Scenario #2

72 year-old patient presents with palpitations
and indigestion for several hours

VS: B/P138/88; P – 84; R – 18; SpO2 98%

Vague on their history but takes meds but
doesn’t know what for

General impression?
 Worse
case scenario – cardiac
 Other
considerations – “ill”
35
What’s Your Interpretation?
Ventricular paced rhythm
36
Case Scenario #2

37
False ST elevation
 Paced
 Left
rhythms
bundle branch block (LBBB)

There is an appearance of ST elevation but NOT in the
presence of an acute myocardial infarction process

Patient evaluated and treated in field based on signs
and symptoms

Bit more challenging for everyone to assess for
presence of acute process
Is ST Elevation Present In This EKG?
38
ST elevation II, III, aVF
Hold NTG and morphine until consulted with Medical Control
What About This EKG?
39
Left bundle branch block
EKG Interpretation

Looks like ST elevation in chest leads V 1 – V4

Actually, this is left bundle branch block (LBBB) that also
can give appearance of ST elevation that does not
indicate an acute process

Remember the hints for determining a LBBB pattern
 Widened
 Possibly
 Think
QRS
notched QRS (rabbit ears)
of a car’s turn signal
 If
wide QRS predominately negative in V1, consider left
bundle branch block
 If
wide QRS predominately positive in V1 consider right
bundle branch block
40
Case Scenario #3

32 year-old patient presents with 2 hours of
dyspnea with increasing wheezing and
increasing difficulty breathing

Patient in tripod position

Pale, slightly damp, VERY anxious

B/P 138/84; P – 98; R 32; SpO2 95%

Bilateral inspiratory and expiratory wheezing

What is your general impression?
41
Case Scenario #3

Impression – Acute asthma
 Confirmed

with history
Would you administer oxygen?
 Yes
– presence of respiratory difficulty even
though pulse ox is over 94%

What interventions need to be provided to help
this patient?
 Supplemental
oxygen
 Bronchodilators
42
Case Scenario #3
Treatment Based on Region X SOP’s
43

Adult Routine Medical Care

Albuterol 2.5 mg/3ml mixed with Atrovent 0.5 mg/2.5 ml
neb treatment
 Needs
O2 flow rate of 6 lpm to generate a mist

If no improvement, repeat above medications

If no improvement, administer Albuterol alone as a neb
treatment

For severe distress, contact Medical Control to consider
Epinephrine 1:1000 at 0.3 mg IM
Case Scenario #3
 When
is a repeat of the Duoneb of Albuterol
and Atrovent automatic in the Region X
SOP’s?

Adult and child asthma

Adult and child allergic reactions with wheezing

Croup
44
Case Scenario #3
 What
45
are the benefits of Albuterol and Atrovent?
 Albuterol is a bronchodilator
Acts
mostly on receptors in the lungs (Beta 2)
Minimal
effects on receptors in the heart (Beta 1)
but may cause an increase in heart rate
 Atrovent
is an anticholinergic that acts as a
bronchodilator
 Combination
therapy increases the dilating
effects in the bronchioles
Case Scenario #3
 Describe
wheezing and how you assess for it
 Wheezes
are continuous high-pitched musical
sounds similar to a whistle
 Air
is moving through partially obstructed airways
 First
appear at end of exhalation
Important
to not move your stethoscope to the
next site too prematurely
Wheezes
heard during inspiration and exhalation
indicate a worsening condition
46
Case Scenario #4
47

EMS is called for a 32 y/o patient with altered level of
consciousness

VS: B/P 100/56; P – 72; R – 12; SpO2 98%; GCS 11 (3, 3, 5)

History: Diabetes (blood sugar 32)

What is your impression?
 Diabetic

reaction – hypoglycemia – insulin shock
What is your treatment goal?
 Raise
the blood sugar level
Case Scenario #4
 How
do you raise the blood sugar level in the
field???
 If
IV access, administer Dextrose
Strength
based on age (D50%; D25%, D12.5%)
The
younger/more immature the IV site, the
weaker the concentration
 If
no IV access, Glucagon 1 mg IM/IN
 Oral
glucose gel (Glutose) 15 grams
48
Case Scenario #4
 Oral
Glutose gel – 15 grams
 Useful
in the patient who is able to tolerate oral
preparations, has an intact gag reflex and is able
to protect their own airway
 Available
for the patient in the above condition
with no access to food or fluids that would
otherwise be used to raise the blood sugar level
49
Case Scenario #4

50
Can this patient sign a release / refusal for transportation?
 Yes,
if certain conditions are met
 Patient
must be awake, alert, oriented
 Patient
must be able to understand risks and benefits
 Patient’s
blood sugar must be documented as being over 60

Document your discussion with the patient

Document your advice for transport

Document follow-up – personal physician; to call 911 if any
further problems

Document D/C of IV if applicable
Case Scenario #5
 42
51
y/o Spanish speaking male found at a job site
 Unclear
mechanism of injury with machinery
 Upon
EMS arrival male on steel conveyor belt
being held in sitting position by co-workers
 Obvious
facial trauma with possible broken jaw,
missing teeth, bleeding from mouth
 Able
to move toes and wiggle fingers
Case Scenario #5
 Patient
denied head, neck, back pain by
nodding head
 Assisted
 Mouth
to cot
suctioned as needed
 Fentanyl
 Patient
 How
1 mcg/kg given for pain
is 230 pounds
much Fentanyl is indicated?
104
mcg / 2.08 ml
52
Case Scenario #5

Question
 Would
you have immobilized this patient with
significant trauma to the face, unclear the exact
mechanism of injury?
This

patient was not immobilized
What were some “red flags” for securing
immobilization?
 Non-English
 Unclear
speaking (medic interpreter was on call)
mechanism of injury
 Significant
trauma evident to face
53
Case Scenario #5
 When
is immobilization indicated?
 Evidence
clavicles
 Known
of injuries above the level of the
or questionable mechanism of injury
 Unable
to clear with spinal immobilization
protocol
Mechanism
of injury, signs or symptoms,
patient reliability
54
Case Scenario #5
 Clearance
Patient
of cervical spine
awake and fully cooperative
Neck
free of pain, swelling, hematoma,
pain to palpation, no bony abnormality
No
distracting injures
Full
range of motion by patient is pain free
Never
passively (movement performed by
another person) attempt to move the head
55
Case Scenario #5

Patient struck in face with piece of machinery

Distracting injuries present
 This
patient had jaw fracture
 Significant

bleeding from mouth
Patient not reliable – arguable
 Non-English
 Helpful
speaking
that one of the paramedics on the scene
was Spanish speaking
56
Case Scenario #5

How would you immobilize a patient that cannot
tolerate traditional cervical collar?

Head blocks on backboard

Towel rolls taped into place

Manual control

Any creative method that gets the job done

Document unique actions taken and be descriptive

Document CMS before and after splinting
 Circulation,
movement, sensation
57
Case Scenario #5

58
Immobilization on backboard
 Patient
had significant bleeding from oral/facial injuries

If immobilized flat on backboard could have compromised
airway

What would you have done?
 Critical
thinking skills needed here as well as past experience
could have helped
 Would
need to elevate backboard
 Consider
transport with backboard tilted to avoid
compromising airway
 Utilize
suction
 Limited
to 10 seconds per attempt
Case Scenario #5 Follow-up

Patient diagnosed with C2-C3 subluxation
 Ligament
injury of 2 adjoining spinal bones that
have abnormally separated causing instability
 OR
for cervical fusion; cervical collar worn post
surgery to be worn 3 – 6 weeks
 Central

Open fracture mandible
 Jaw

cord syndrome
wired in OR
Left vertebral artery dissection
 Treated
with aspirin – anticoagulant
59
Case Scenario #5 Follow-up
continued

Central Cord Syndrome

An incomplete spinal cord injury
 Middle
area of cervical spine affected
 Impairment
of arms and hands more than legs
 More
motor loss than sensory loss
 More
upper extremity than lower extremity loss
 More
distal than proximal muscle weakness
 Usually
due to hyperextension mechanism
60
Case Scenario #5 Central Cord cont’d 61

No cure; some people recover near normal
function

Improvement noted first in legs, then bladder,
then arms
 Hand
function recovers last if at all
Case Scenario #5 – Cord Syndromes

62
Named based on location of injury in relation to the spinal cord

Central Cord Syndrome

Anterior Cord Syndrome
 Spares
 Loss
upper extremities and touch
of motor, pain, temperature sensation
 Preserves
light touch, vibratory sensation, proprioception
(awareness of position of ones body)

Brown Sequard Syndrome
 Ipsilateral
(same side) motor & proprioceptive loss, light
touch, motor
 Contralateral
(opposite side) loss to pain and temperature
Case Scenario #5

Patient discharged to RIC (Chicago) 9 days post injury

Bilateral lower extremities 5/5 (normal strength and
movement

Right upper extremity – 2/5


Remains weaker but with improvement
Left upper extremities

Grip 3-4/5

Left elbow flexion 3-4/5

Numbness shoulder to fingers

Time will tell what function/sensation returns
63
Case Scenario #5 – Lesson Learned
Assume spinal injury til
proven otherwise in blunt
trauma
 Note:
As swelling progresses, signs and
symptoms can intensify and worsen
64
Case Scenario #6

EMS called for 25 y/o with complaint of nausea
for past 8 hours
 Only
 VS:
vomited x1 – small amount of liquid
B/P 120/78; P – 86; R – 16; SpO2 99%
 Skin
warm and dry; negative for tenting
 Mouth
moist
 Negative
 No
pertinent history
known allergies
 Meds
– daily multivitamin
65
Case Scenario #6
 What
medication is used to treat nausea
per Region X SOP’s?
 Zofran
 What
4
dose and routes can be used?
mg IVP; 4 mg po (oral)
 May
repeat in 10 minutes to total max 8 mg
for adults and pediatrics >40 kg (88 pounds)
Peds
<40 kg – Zofran 0.1 mg/kg IVP
66
Case Scenario #6
 When
67
can Zofran ODT be given?
 Patients
over 40 kg (88 pounds)
 Oral
disintegrating tablet (ODT) used when goal is
to relieve nausea and patient not suspected of
needing IV fluid
 To
document ODT source of Zofran
 “Time”
given, “Zofran ODT”, “4 mg”, (route) “po”
Case Scenario #6
 Indication
IV fluids may be required
 Repeated
episodes of vomiting especially
larger volumes
 Evidence
of dehydration
Tenting
Dry
mucous membranes
Warm,
hot/dry skin
Sunken
eyes
68
Case Scenario #6
 How
do you administer Zofran ODT?
 Peel
open foil packet
Do
not push pill thru foil – pill may crumble
 Place
tablet on patient’s tongue
 Inform
patient tablet will dissolve
Dissolves
quickly – before patient can even
consider thinking of swallowing pill
69
AHA CPR Guidelines
Infant – Child - Adult
 Compression
 Ratio
rate at least 100 / minute
compression to ventilations
 30:2
-1 & 2 man adult CPR
 30:2
– 1 man infant & child
 15:2
– 2 man infant & child
 Switch
rescuers every 2 minutes or 5 cycles
 Resume
CPR compressions immediately
following defibrillation attempts
70
Aha CPR Guidelines cont’d
 Compression
 Infant
depth
– 1 ½ inches
 Child
- about 2 inches
 Adult
– at least 2 inches
 Once
intubated – asynchronous compressions
to ventilations
 Ventilate
1 breath every 6 – 8 seconds
(document 8-10 breaths delivered per minute)
71
Preceptor Role
 Be
nice
 Be
kind
 We
all started as students and “newbies”
 Invest
the time now to get “a good
product” in the long run
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Hands-on Skills
 Field
73
trip to the ambulance
 Review
Know
YOUR equipment
how to set YOUR equipment up
Defibrillation
Synchronized
cardioversion
Transcutaneous
Transmitting
pacing (TCP)
12 lead EKG’s to hospital
Safety Precautions & Electrical Therapy
 If
BVM out and oxygen flowing to it, do not
leave on cot next to patient when not being
used
 Sheets/clothing
could become oxygen enriched
 Several
in-hospital cases of spark from defibrillation
causing a fire
 Hold
BVM off to the side during discharge of
electrical therapies
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More Safety Tips
 If
patient intubated, remove BVM from
proximal end of ET tube during discharge
of electrical therapy
 Just
letting go of BVM puts excessive weight
on the ETT
 Could
inadvertently dislodge tube during
discharge of electrical therapy
 Remember
to call AND look “all clear”
prior to discharging electrical energy
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Bibliography

Bledsoe, B., Porter, R., Cherry, R. Paramedic Care
Principles & Practices, 4th edition. Brady. 2013.

Mistovich, J., Karren, K. Prehospital Emergency
Care 9th Edition. Brady. 2010.

Region X SOP’s; IDPH Approved April 10, 2014.

http://www.merckmanuals.com/professional/ne
urologic_disorders/spinal_cord_disorders/overvie
w_of_spinal_cord_disorders.html

http://lifeinthefastlane.com/ecglibrary/basics/left-bundle-branch-block/
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