Transcript The Medical Patient - Chronic Renal Disease

The Medical Patient
The Renal System;
Hypertensive Emergencies
Condell Medical Center
EMS System
ECRN Packet
Module IV 2008 CE
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Objectives
• Upon successful completion of this module, the
ECRN should be able to:
– List the components and function of the
urinary system
– State signs and symptoms of chronic kidney
disease
– Define hemodialysis
– Identify the differences between AV fistulas
and AV shunts & implications in the field
– Apply the Renal SOP’s given a scenario
– List the steps in performing an abdominal
assessment
– Describe the physical assessment of the
patient with flank pain
– Describe the management of the patient with
flank pain
– Define the criteria for a hypertensive emergency
– List the signs and symptoms of hypertensive
emergencies
– Describe the rationale for treatment using Lasix
and Nitroglycerin for hypertensive emergencies
– Describe the proper technique to obtain a blood
pressure
– Describe the components of a neurological
assessment
– Successfully calculate the GCS given the
findings of the patient assessment
– Identify proper method of pupillary assessment
– Identify the preparation of an Amiodarone IVPB
set-up in the field per Region X SOP’s
– Identify and appropriately state interventions
for a variety of EKG rhythms
– Identify ST elevation on a 12 lead EKG
– Successfully complete the 10 question quiz
with a score of 80% or better
Urinary System
• Contains 4 major structures
– Kidneys
• Vital organs
• Located in upper abdomen;
retroperitoneal area
• 1 behind the spleen; 1 behind the liver
– Ureters
– Urinary bladder
– Urethra
Function of the Urinary System
• Major functions
– Maintains blood volume via proper balance of
water, electrolytes, and pH
– Retains key compounds (ie: glucose) and
eliminates wastes (ie: urea)
– Monitors and maintains arterial blood
pressure (in addition to other mechanisms)
– Regulates erythrocyte (RBC) development
Urinary Bladder
• Storage receptacle for the production of
urine until it is convenient or necessary to
void
• Fully distended can hold 500 ml of urine
– The more distended the bladder, the
more vulnerable to blunt trauma
• After urination, the bladder contains about
10 ml of fluid
Chronic Kidney Disease
• Can be from a specific kidney disease or as a
complication from other conditions
– Diabetes
#1 reason in USA for need for kidney
transplant
– Hypertension
– Kidney inflammation (glomerulonephritis)
– Inflammation of blood vessels (vasculitis)
– Polycystic kidney disease
Chronic Kidney Disease
• Diseased or injured kidneys
– Blood flow through the renal system decreases
– Inflammatory changes occur in the glomeruli
• A group of capillaries where blood is filtered
into a nephron (structure that produces urine)
– Capillary walls thicken decreasing permeability
– Glomerular filtration rate (GFR) is reduced
• Volume of blood filtered per day thru
glomeruli
Symptoms of Chronic Kidney Disease
• Most common symptoms
–
–
–
–
–
–
–
–
–
Swelling, usually of lower extremities
Fatigue
Weight loss, loss of appetite
Nausea and/or vomiting
Change in urination
• Reduction in volume or frequency
Change in sleep patterns
Headache
Itching – high levels of phosphorus in system; dry skin
Difficulties with memory or concentration
Complications of Chronic Kidney
Disease
• Hypertension
– May be a leading cause but can also develop
in the early stages as a complication
• Anemia
– Decreased production of red blood cells
• Bone disease
– Disorders of calcium and phosphorus
• Malnutrition
• Altered functional status and well-being
Dialysis
• Dialysis is required when the kidneys fail
and a transplant is not performed
• Peritoneal dialysis uses a catheter thru the
abdominal wall to filter the blood
Hemodialysis
• Hemodialysis is a procedure in which a
machine filters harmful waste and excess
salt and fluid from your body
• Access points are created to be functional
within weeks and to last several to many
years
• Usual access point is the forearm
Fistulas and Shunts
• Arteriovenous (AV) fistula
– Most common type of access
– Fistula created internally by sewing an artery
to a vein forming a small opening between the
two
– Pressure from the arterial flow eventually
enlarges and strengthens the vein
– May take 6 weeks to heal but can last for
years
• Arteriovenous (AV) graft
– Access is similar to a fistula
– A synthetic tube is used to surgically
connect the artery to the vein
– AV grafts often heal within 2-3 weeks
– With proper care, can last several years
– Higher likelihood of forming clots or
becoming infected than an AV fistula
Renal Dialysis
Hemodialysis
• Most people treated with hemodialysis 3
times a week
– Each session lasts approximately 3-5 hours
• Some patients, at some dialysis centers,
may choose daily dialysis
– Usually performed 6 days per week for 2 –
21/2 hours each session
– Patients often report improved B/P and quality
of life with the more frequent dialysis
Continuous Ambulatory Peritoneal
Dialysis
• CAPD is a self-care treatment where the
patient instills dialysate fluid into the
peritoneal (abdominal) cavity through a
surgically implanted catheter through the
abdominal wall
• The dialysate stays in the abdominal
cavity a prescribed period of time and then
is drained out
CAPD Instructions
• EMS will not disconnect the CAPD bags
from the catheter
– If the patient is transported, transport is with
the drainage bag remaining below the level of
the patient’s waist
• EMS will not infuse any fluids or
medications directly into the catheter
– This IS NOT an alternate IV site
Region X Renal Protocol
Care of Patients with Grafts or Shunts
• Do NOT take B/P on arm with active fistula or
graft
• Do NOT start IV on arm with active fistula or
graft
• If site is bleeding, apply direct pressure
• In case of arrest and no extremity IV access,
consider external jugular or IO site
EMS access of fistula or graft is only after contact
with Medical Control who will give directions
Care of The Renal Patient
• Best to err on the side of conservative
treatment
– Monitor and support the ABC’s
– High flow O2 is appropriate to maximize
respiratory efficiency
– Monitor fluid administration carefully
– Monitor cardiac rhythm for disturbances
– Home caregivers will be a great resource of
information for the equipment used
Abdominal Pain Assessment
• Chief complaint
– The sign or symptoms that prompted the
patient to call for or seek help
– Use an open – ended question to determine
the reason for the patient seeking help
• “Why are you here today?” or
• “What seems to be the problem?”
– During the interview the chief complaint
generally becomes more specific
OPQRST Assessment Mnemonic
O – onset of the problem
– Did problem start suddenly or gradually?
– What was patient doing at the time?
P – provocation/palliation
– What makes the symptoms worse? Better?
Q – quality
– In the patient’s own words how do they
describe their pain (ie: crushing, tearing,
sharp, dull?)
R – region/radiation
– Where is the symptom?
– Does it move?
– If the patient uses one finger or isolates to
one spot, the pain is considered localized
– If the pain is described using both hands or
indicating a larger area, the pain is diffuse
– Is there referred pain (pain felt in a body area
away from the source)?
S – severity
– Intensity of pain or discomfort
– 0 – 10 scale
• “0” is no pain; “10” is the worse pain in your life
– Can the patient be distracted?
– Do they lie still or are they writhing about?
T – time
– When did the symptoms begin?
Associated symptoms
– Are other symptoms present that are
commonly linked to certain diseases that can
help rule in or out your diagnosis?
Pertinent negatives
– Are any likely associated symptoms absent?
– Absence of symptoms can be information as
helpful as presence of other symptoms
Assessment Pitfalls in the Chronic
Renal Patient
• The challenge to the medical professional
is to separate the acute complaint from the
chronic condition
– What is new today that changes your status?
• Many patients with chronic renal disease
have unstable baselines to start with
– Fluid and electrolyte imbalance
– EKG disturbances
Physical Assessment - Abdomen
• Boundaries run from xiphoid process to
symphysis pubis
• A full bladder will distort assessment and
increase discomfort for the patient
• To relax the abdominal wall or to ease
pain, a pillow placed under the knees
would be helpful
• Start by asking the patient where it hurts
– Examine painful areas last
• Warm your hands and stethoscope
– If hands are cold, palpate over clothing
until hands warm up
• Monitor facial expressions for pain or
discomfort
– Validate the facial expression
• Often the patient may scrunch their
face in anticipation of pain
• Assessment techniques to use
– Inspection, auscultation, percussion,
lastly palpation
Abdominal Assessment Techniques
 Inspection
– A visual review looking for abnormalities
– Always performed first for all assessments
 Auscultation
– Move the stethoscope in a circle
approximately 2 inches from the umbilicus
listening for bowel sounds
• Normal bowel sounds gurgle approximately
every 5-15 seconds
Percussion
– Not often performed in the field
– Helps determine size and location of
organs
– Determines gas, solid, and fluid filled
areas
– Tympany heard over most of abdomen
– Dullness percussed over spleen and
liver
Palpation
– Palpate painful areas last
– To increase comfort to patient, have
them take slow, deep breaths thru open
mouth
– Flexing knees relaxes abdominal wall
– Abdominal pain on light palpation
indicates peritoneal irritation or
inflammation
– Voluntary guarding – patient anticipates
pain or is not relaxed
– Involuntary guarding – peritoneal
inflammation (lining of abdominal cavity)
Region X SOP - Abdominal Pain
Stable Patient
• Routine medical care
• Watch the patient for vomiting
• Stable patient
– Patient alert
– Skin warm and dry
– Systolic B/P > 100 mmHg
• Contact Medical Control for pain
management (Region X carries Morphine)
Region X SOP - Abdominal Pain
Unstable Patient
• Routine medical care
• Watch the patient for vomiting
• Unstable patient
– Altered mental status
– Systolic B/P < 100 mmHg
• Establish IV; x2 if possible
– Fluid challenge in 200 ml increments
• Carefully monitor breath sounds
• 20 ml/kg in pediatric patient (max 3 challenges)
• Contact Medical control for pain management
Flank Pain
• Where’s the flank?
– The area of the back below the ribs and
above the hip bones
• What organs lie in the flank areas?
– The kidneys
• What is a common reason for flank pain?
– Renal calculi (aka kidney stones)
Kidney Stones
• The formation of crystals in the kidney’s
collection system
• Hospitalization common for pain control
and fluid hydration
• Additional inpatient treatment may be
necessary
– Lithotripsy – sound waves used to break apart
larger stones into smaller ones that can be
passed during urination
Kidney Stones
• More common in males
• Suggestion of hereditary patterns
• Risk factors include immobility and certain
medications (anesthetics, opiates,
psychotropic drugs)
• Stones can form in metabolic disorders (ie:
gout)
– Production of excessive uric acid and calcium
Stones From Calcium Salts
• The most common type of stone
– 75 – 85% of all stones
• Calcium stones 2 – 3 times more
common in men
• Average age of onset 20 – 30 years
• Familial indication
• History of one stone and patient likely
to form another one within 2 – 3 years
Struvite Stones
• Represent 10 – 15% of all stones
• Formation associated with chronic urinary
tract infection or frequent bladder
catheterization
– Patients with spinal cord injuries
– Patients with spina bifida
• More common in women (due to their
higher incidence of UTI’s)
Uric Acid Stones
• The least common of all stones
• Form more often in men
• Tend to occur with family histories so most
likely a hereditary component
• Half of patients with uric acid stones have
gout
Patient Assessment
• Chief complaint almost always severe pain
– Kidney stones considered to be the most
painful medical condition
• Pain started vague, dull, poorly localized
(visceral pain) in one flank
• Within 30 – 60 minutes pain is extremely
sharp, remains in the flank and radiates
downward and anteriorly to the groin
Physical Exam
•
•
•
•
Agitated, restless, uncomfortable patient
B/P and heart rate elevated with the pain
Skin typically pale, cool, clammy
Patient may not be able to lie still for
abdominal examination
• Observed urine sample may have gross
hematuria or may be evident only in lab
analysis
Management
• Position of comfort
• Be prepared for vomiting (due to pain)
• IV fluids for volume replacement and as a
drug route, and to promote urine formation
and movement through the system to flush
through the stone
• Analgesia for pain – limited amounts used
in the field often have minimal effect, if at all
Region X SOP - Flank Pain
• SOP treatment same as abdominal pain
• EMS must call Medical Control to obtain
pain medication orders (Region X EMS
Morphine 2 mg slow IVP; repeated every 2
minutes to a maximum of 10 mg)
• Be patient’s advocate for pain control
– Kidney stones are considered the most painful
human condition (just ask someone who has
had one!)
Hypertensive Emergency
• A life-threatening crisis with an acute
elevation of the blood pressure
– Systolic B/P > 230 mmHg
– Diastolic B/P > 120 mmHg
• Usually seen in patients with untreated or
poorly controlled hypertension
Hypertensive Emergency
• Signs and symptoms
– Epistaxis – nosebleed
• The nasal tissue is very thin and prone
to bleed
– Headache
• “The worst headache in my life” often
indicates a subarachnoid bleed
– Visual disturbances (ie: blurred, blindness)
– Restlessness
– Confusion
– Nausea and vomiting
– Neurologicial changes
• Altered mental status to seizures to coma
• Complications
– Hypertensive encephalopathy
• Severe headache, vomiting, visual
changes, paralysis, seizures, stupor, coma
– Ischemic (clot) or hemorrhagic (bleed) stroke
Assessment
• Chief complaint is often headache
• Additional accompanying complaints
– Nausea and/or vomiting
– Blurred vision
– Shortness of breath
– Epistaxis (nosebleed)
– Vertigo (dizziness)
– Level of consciousness may be normal, altered,
or patient may be unconscious
Assessment
• Findings
– Skin may be pale, flushed, or normal
– Skin may be warm or cool; moist or dry
– If hypertensive encephalopathy is
present, it may cause left ventricular
failure
• Patient will be in pulmonary edema
– Lung sounds clear unless in pulmonary
edema
– Pulse often strong and bounding
Region X SOP - Hypertensive
Emergency
• Routine Medical Care
• Obtain and record the B/P in both arms
• Monitor & record vital signs and neuro
status every 5 minutes
• Lasix 40 mg IVP (venodilator & diuretic)
– 80mg if already on Lasix at home
• Contact Medical control for further orders
– Possible Nitroglycerin order as venodilator
Treating Hypertensive
Emergencies
• Initial goal
– To achieve a progressive, controlled
reduction in the blood pressure to
minimize risks of hypoperfusion in the
vascular beds in cerebral, coronary, and
renal blood flow
– Goal is not to reduce the blood pressure
to “normal” levels as fast as possible
Why Give Lasix?
• Lasix is a venodilator and a diuretic
• By dilating blood vessels, blood pressure
can be decreased
• Venodilator effect noticed before evidence
of diuretic effects are seen
• Decreasing fluid volume is another method
to reduce the blood pressure by reducing
the volume to be pumped
Why Give Nitroglycerin
• Primarily a venodilator
– Will dilate the diameter of blood vessels
– Decreases blood pressure
– Especially useful in the patient with coronary
ischemia
– Still need to screen for use of Viagra or Viagra
type drugs in the past 24-36 hours
Obtaining
A Blood
Pressure
Blood Pressure Measurement
• Poor technique can result in inaccurate
values
• Patient’s arm should be supported at the
same height level as the heart
• The cuff bladder should fit snugly around
the arm
• The lower edge of the cuff should be
placed 1 inch above the brachial artery
• The bladder should be centered over the
brachial artery
• The bell end of the stethoscope will
produce better sounds
• The diaphragm is easier to place and hold
with one hand
• The cuff and tubing should not be touching
clothes which can give false sounds
• After the cuff is pumped up, the air should
be released slowly
– Air released too fast may cause an inaccurate
measurement to be read
– Cracked tubing causes air to leak too fast
Obese Site & B/P Cuff
• Wrap the blood pressure cuff around the
forearm
• Center the bladder over the radial artery
• Place the stethoscope over the radial
artery
• Obtain and document the blood pressure
in the usual manner (ie: 120/80)
Blood Pressure by Palpation
• Rough estimation of the systolic value
• Palpate for the loss of the radial or
brachial pulse and continue to inflate the
cuff an additional 30 points
• Slowly release the air and when the pulse
is first felt, this is the recorded systolic B/P
• Document the reading as “100/palpation”
Rough Estimate of Blood Pressure
By Pulse Point Palpation
• A rough guideline; accuracy is debatable
• If the radial pulse is palpated, the B/P is
said to be roughly 80 mmHg
• If the femoral pulse is palpated, the B/P is
said to be roughly 70 mmHg
• If only the carotid (central) pulse is felt, the
B/P is said to be roughly 60 mmHg
A “Neuro” Assessment
• Level of consciousness
– A – alert (means awake but not necessarily
oriented; spontaneous eye opening; responds
to voice but can be confused; and has motor
function )
– V – responds to verbal command no matter
how slight and type of response
– P – responds to pain or tactile stimuli only
– U – unresponsive with no eye, voice, or motor
response at all to voice, pain, or touch
Neuro Exam Continued
• 2 preferred questions to determine level of
consciousness
– “What month is this?”
– “How old are you?”
• Obtain the Glasgow Coma Scale (GCS)
on all EMS patients
– Best eye opening (4 points)
– Best verbal response (5 points)
– Best motor response (6 points)
• Evaluate pupillary response
Performing a Pupillary Check
• Ask patient to focus
on an object (ie: tip of
your nose)
• Bring the light in from
the side and out the
same way
• Without shining in the
eyes move the
penlight into position
for the opposite side
and repeat
Neuro Exam Continued
• Vital signs
– Signs of increasing intracranial pressure
include increasing B/P and dropping heart rate
• Check muscle tone and strength
• Evaluate facial symmetry (smile)
• Evaluate clarity of speech
– The above 3 are the Cincinnati Stroke Scale
Arm drift, facial symmetry, speech
• Additionally:
– Coordination or gait and sensory
• Movement and sensation
Repeat Assessment
• If you want to see where the patient is
going, you’ve got to know where they’re
coming from
– GET A BASELINE EVALUATION
• You can anticipate something happening if
you are watching the trends
– PERFORM REPEAT ASSESSMENTS AS
OFTEN AS INDICATED
• Prevents surprises
Region X Pain Management SOP
• Routine trauma or medical care
• Continuous patient monitoring
– Respiratory status
– SaO2
– Blood pressure
• Morphine
– 2 mg slow IVP over 2 minutes
– May repeat every 2 minutes
– Maximum total 10 mg
Respiratory Depression Related to
Morphine Use
• Supportive oxygenation
– If SaO2 is falling and ventilation rates are
declining, consider supportive bagging
• Ventilation rates for supportive bagging (AHA)
–Adult 1 breath every 5 – 6 seconds
–Pediatric patients 8 and less 1 breath every
3 – 5 seconds
• Narcan (narcotic antagonist)
– 2 mg IVP if respiratory depression
Glasgow Coma Scale Exercise
• Review the following 3 patient assessment
findings
• Evaluate their GCS
• Determine the best response and score the
patients
– Best eye opening 1 - 4 points
– Best verbal response 1 – 5 points
– Best motor response 1 - 6 points
• Note: Field GCS to be obtained on all patients!
Pearls for Calculating GCS
• Eye opening
– A flicker of the eyelid is enough of a response
• Verbal response
– If you do something obnoxious or painful to
the patient and they respond with “don’t” or
other similar words to the situation, they are
confused. These are not inappropriate words
to the situation; but neither is the patient fully
alert
– Incomprehensible words are just sounds
(moans and groans)
Pearls for Calculating GCS
• Motor response
– Purposeful movement is when the patient’s brain can
still distinguish what annoys the patient – they will pull
out the IV, pull off the B/P cuff, rip at the collar, pull
and grab at your hands
– Withdrawal is a deterioration and the patient just pulls
into themselves or turns away from the annoying
source
• Peds calculation
– Use the parenthesis notes when patient is too young
to be verbal and you are unsure using the standard
interpretations
GCS Exercise #1
• You are assessing a 56 year-old patient
• The patient is unresponsive. Nothing
happens when you call the patient’s name.
When you pinch the patient, their eyes
open, then close.
• When pinched, the patient says “don’t,
stop” and then is silent.
• When pinched, the patient pushes you
away
GCS Exercise #2
• Your patient is a 16 year-old male.
• Upon approaching, the patient’s eyes are
open and they are looking around with an
anxious look.
• They do not answer questions; they groan
if pinched.
• They do not follow commands. When
touched, the patient grabs your arm and
doesn’t let go.
GCS Exercise #3
• Your patient is an 8 month-old.
• Their eyes are closed. There is no
response to pinching.
• When pinched, the patient groans weakly.
• When pinched, the patient tries to pull
away or turn away from the evaluator.
GCS Exercise Answers
• GCS #1 total –11
– Eye opening – 2 (eyes
open to pain)
– Verbal response – 4
(appropriate words for
situation so pt confused)
– Motor response – 5
(purposeful & appropriate
to being pinched)
• GCS #2 total – 11
– Eye opening – 4
– Verbal response – 2
– Motor response - 5
• GCS #3 total – 7
– Eye opening – 1 (no
response at all)
– Verbal response – 2
(groans to pain –
incomprehensible
words)
– Motor response – 4
(withdraws to pain by
pulling away and
turning away)
Skill – In-line Albuterol
• For Albuterol to
have its
bronchodilating
effects, it must
be delivered
down into the
lungs
• If the patient
can’t inhale it
in, we have to
push it in
Normal use with corrugated
tubing connected to the T-piece
Kit connected to
oxygen and run
at 6 l/minute
(enough to
create a mist).
Nebulizer kept
upright at all
times.
Albuterol Delivered In-line
• Patient intubated
– While waiting to intubate, can “bag” the Albuterol
into the lungs via in-line set-up thru ambu mask
• ETT placement confirmed in the usual
manner
– direct visualization of vocal cords
– bilateral chest rise & fall
– 5 point auscultation (abdomen then chest)
– ETCO2 detector
• Evaluated after 6 breaths are delivered
To adapt nebulizer to in-line use:
• Mouthpiece
removed from
T-piece and
replaced with
BVM
• Connect
nebulizer to
oxygen source
• Corrugated
tubing left in
place on
Tpiece
• Clear adaptor
placed on distal
end of
corrugated
tubing
• Once intubated,
clear adaptor
connected to
ETT
Albuterol will be
effective if it gets
into the
bronchial
system, not just
into the back of
the throat.
The BVM helps
push the
Albuterol where
it will do the
most good.
EKG Review & Treatment
There is NO pulse!!!
6 second strip
The
patient
has
no pulse!
EKG Interpretation #1
•
•
•
•
•
•
PEA with a rate over 60
CPR
Secure airway
Search for causes (6 H’s; 5 T’s)
Establish IV/IO access
Epinephrine 1:10,000 1 mg IVP/IO every
3-5 minutes
– No Atropine – ventricular rate over 60
6 H’s
• Hypovolemia – fluid challenge
• Hypoxia – supplemented oxygen flow
• Hydrogen ion – acidosis – ventilate
(breathe) for the patient
• Hyper/Hypokalemia – electrolyte imbalance
• Hypothermia – warm them up
• Hypoglycemia – screen all
unconscious/altered level of consciousness
patients for glucose level
5 T’s
• Toxins – think little kids getting into the
wrong places (ie: purses, cabinets)
• Tamponade, cardiac
• Tension pneumothorax – needle
decompression
• Thrombosis, coronary
• Thrombosis, pulmonary (embolism)
• Trauma
EKG Review & Treatment
EKG Interpretation #2
• Strip A – complete heart block
• Strip B – paced rhythm
• Unstable Type II and 3rd degree heart blocks
– Patient often unstable due to slow heart rate
– Begin TCP
– Rate: 80/minute
– Sensitivity: auto/demand
– Output: lowest mA until capture
Region X Comfort Measures For
TCP
– Valium 2 mg IVP slowly over 2 minutes
– May repeat 2 mg IVP every 2 minutes
– Maximum of 10 mg
• Can touch the patient and not receive
shocks
– It’s the patient that feels the electrical
stimulation
EKG Review & Treatment
EKG Interpretation #3
• VT – wide complex, until proven otherwise, is VT
• 2 questions to ask for all tachycardias
Question #1 – Is patient stable or unstable?
• Evaluate LOC and B/P
–If you are not perfusing, you cannot
maintain an adequate level of
consciousness or blood pressure
• If unstable, prepare for immediate
cardioversion
– If stable, ask question #2
2nd Question To Ask if Stable
Tachycardia
Question #2 – Is complex (QRS) narrow or wide?
• Narrow - think SVT
–Adenosine is drug of choice
• Wide - think VT
–EMS choice between Amiodarone or Lidocaine
–Mixing the antidysrhythmics makes the heart
more irritable so use only one
–EMS to let the ED know which drug therapy
was started so ED can continue same drug
• If stable VT
– Antidysrhythmic treatment Region X SOP
• Amiodarone 150 mg diluted in 100 ml D5W IVPB
–Amiodarone 150 mg added to 100 ml D5W IV
bag and gently agitated to mix; bag labeled
(drug, amount, time added)
–Mini-drip tubing primed; piggyback into the
primary IV line
–Drip run over 10 minutes (rapid drip rate just
below wide open)
• OR Lidocaine 0.75 mg/kg IVP x1
– Contact Medical Control for repeat & further orders
EKG Review & Treatment
EKG Interpretation #4
• Sinus bradycardia
• If symptomatic/unstable (poor cardiac output with
altered mental status and B/P <100)
– Atropine 0.5 mg rapid IVP
• “When they’re alive give them 0.5”
– May repeat every 3-5 minutes to a max of 3 mg
– If several doses Atropine ineffective, begin TCP
– If TCP ineffective, treat per Cardiogenic Shock
• IV fluid challenge in 200 ml increments,
Dopamine drip
Where’s ST elevation?
>1mm (>2mm septal leads)
12 Lead Interpretation #1
• ST elevation in exercise #1
– V1 – V3
• 12 lead obtained in field
– EMS to evaluate the 12 lead looking for
patterns of ST elevation
• I, aVL, V5, V6
• II, III, aVF
• Any contiguous V leads
– EMS to call in what they see & fax the 12 lead
Where’s the ST elevation?
>1mm or >2mm in septal leads
12 Lead Interpretation #2
• ST elevation in exercise #2
– V2 – V5
• 12 lead obtained in field
– EMS to evaluate the 12 lead looking for
patterns of ST elevation
• I, aVL, V5, V6
• II, III, aVF
• Any contiguous V leads
– EMS to call in what they see & fax the 12 lead
Where’s the ST elevation?
>1mm or >2mm in septal leads
12 Lead Interpretation #3
• ST elevation in exercise #3
– II, III, aVF
• 12 lead obtained in field
– EMS to evaluate the 12 lead looking for
patterns of ST elevation
• I, aVL, V5, V6
• II, III, aVF
• Any contiguous V leads
– EMS to call in what they see & fax the 12 lead
Bibliography
• Bledsoe, Porter, Cherry. Paramedic Care; Principles &
Practices. 3rd Edition. Brady. 2009.
• Burrows-Hudson, S. Chronic Kidney Disease. AJN. Feb
2005. Vol 105, No2.
• http://en.wikipedia.org/wiki/Blood_pressure
• http://en.wikipedia.org/wiki/AVPU
• www.hospital-equipment.co.uk/images/taking-bl
• www.mayoclinic.com/health/hemodialysis/DA00078
• www.neuroexam.com/
• www.strokestrategyseo.ca/pdf_docs/neurological%20assess
ment
• www.vascularweb.org/patients/NorthPoint/Dialysis_Access.
html