Care of the Burn Child
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Transcript Care of the Burn Child
Formulating a Pre-hospital
General Impression
July 2010 CE
Condell Medical Center EMS System
Prepared by: FF/PMD Michael Mounts
Lake Forest Fire Department
Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P
Objectives
Upon successful completion of this module, the
EMS provider will be able to:
Review critical thinking concepts.
Identify a patient with a medical emergency.
Identify a patient with a cardiac emergency.
Identify a patient with a CVA.
Identify a patient with traumatic injuries.
Identify a pediatric patient with a medical
emergency.
Objectives cont.
Identify a geriatric patient with a medical
emergency.
Review documentation components for
discussed conditions.
Demonstrate treatment during patient
scenario.
Demonstrate use of cardiac equipment.
Demonstrate use of bandaging techniques.
Critical Thinking Review (June CE)
EMS personnel must be knowledgeable in
the specific components, stages, and
sequences associated with the critical
thinking process.
Concept formation
Data interpretation
Application of principle
Evaluation
Reflection on action
Concept Formation
Multiple elements gathered to form a
general impression
The “what” of the patient story
Scene assessment
Chief complaint
Pt history & affect
Initial assessment
Physical exam
Diagnostic test
Data Interpretation
Information gathering
“Working phase” of patient care
Quality of interpretation depends on
knowledge of A & P and experience
Obtaining a complete “picture”
Success greatly affected by attitude and
patient interaction
Application of Principle
Patient care after impression and working
diagnosis/general impression
Treatments & Interventions
Based on SOP or Medical Control
Evaluation
Ongoing assessment
Effectiveness of interventions
Revision of impression
Review of protocol or orders
Revision of treatments and/or interventions
Reflection on Action
After the event or incident
Critique
Provides EMS with avenue to add or
modify experience related to future calls
Thinking Under Pressure
Mental checklist
Stop and think
Scan the situation
Decide and act
Maintain clear and concise control
Regularly and continually evaluate the patient
Not reassessment… think constant
assessment!
Thinking Under Pressure cont.
Plenty of information can be ascertained in a
very short amount of time
Once on scene, you start assessing long
before you are told anything
Utilize all of your senses during size-up
The following video slide illustrates this point…
Check volume level please
Click anywhere on video picture to play…
Thinking Under Pressure cont.
In about 8 seconds, he was able to get basic
visual info on 5 people
Oh and 4 rolls of paper, too
Practice and experience will help you hone
these skills
Always Remember…
Initial Assessment
Airway/c-spine immobilization
Breathing
Circulation
Deficit/disability
If cardiac complaint think “D” for
defibrillation and apply cardiac
monitor
Don’t forget ABC’s !!!
Patient Scenarios
Time to put ideas to work
Step by step verbal and practical application of
skills
Have crews review the following cases as if
they were on the call
Use as much equipment as possible to care for
the patient
Use the time to discuss your department’s
particular equipment (ie: monitor) and how it
works including trouble shooting
Scenario #1
Called for checkup of 45 year-old male that
was driving erratically. Police have pt. sitting
on roadside. Pt. is alert and oriented x2 and
has slight ETOH odor. Pt stated had 2 beers a
couple hours ago during a buffet dinner.
Impression?
Scenario #1 cont.
Vitals:
History:
BP: 158/86, P-76, R- 24, SpO2 97%, Wt 130 kg
HTN (hypertension), Asthma, gastric bypass
Pt. states he feels nauseous and has to
“pee real bad again”
Same impression?
What else do you want to know?
Scenario #1 cont.
Blood sugar is 376
Possible new onset, or worsening, of diabetes
Large food intake
Polyuria (excessive urination)
Nausea
Rapid respirations
Acetone odor
Scenario #1 Summary
Some signs are very similar to intoxication
Not always “just another drunk guy”
Hyperglycemic Protocol (pg. 28)
If glucose reading >200
Fluid challenges - 200ml
Hyperglycemia
So, why are fluids necessary?
Patient becomes dehydrated
Large glucose molecule “stuck” in
vascular space
• Glucose drags fluid out of cells to
dilute the high solute concentration
• “Where glucose goes so does water”
• Cells become dehydrated
• urination to rid body of excess
glucose eliminates excess fluid
Hyperglycemia
Signs and symptoms of dehydration
Warm and dry skin; dry mouth
Tachycardia & weakness
Hypotension (fluid level down!)
Restless (unconscious with high levels)
Fruity breath - build up of ketone byproducts from alternative fat metabolism
(fat used for energy instead of glucose)
Deep, rapid respirations (blowing off
excess acid by-products)
Region X SOP –
Hyperglycemia/Ketoacidosis
Blood glucose determinant >200 and
warm, flushed skin and
deep, rapid respirations
IV fluid challenges 200 ml
May repeat IV fluid challenge
200 ml x 2
Transport
DKA and Hyperkalemia
Patient in DKA prone to hyperkalemia due to shift
in potassium from inside cell to vascular space
Potassium critical for normal function of muscles,
heart, & nerves
Major electrolytes for transmission of electrical
signals throughout the nervous system of the body
Increased levels result in abnormal heart rhythms,
slowing of the heart rate, weakening of the pulse,
and suppression of all cardiac activity
EKG Effects of
Hyperkalemia:
Tall peaked T
waves
Documentation Keys
Results of blood glucose levels taken
Amounts of fluid administered (in ml)
Cardiac monitor interpretation
Mounted 6 second strip
Copies with EMS “pink” and ED chart
Scenario #2
Called for a 56 year old female that
fell during a syncopal episode. Pt
states she has had similar events in
the past, but this one is different.
She denies any alcohol intake and
has eaten normally. She also states
that she feels slightly out of breath.
Impression?
Scenario #2 cont.
Vitals:
History:
BP: 116/68, P-70, R-12, SpO2 96%, Wt 65 kg
Diabetes (diet controlled), runs every day
Pt. states she can be “a klutz”
Same impression?
What else do you want to know?
Scenario #2 cont.
Pt. states she is starting to feel a little dizzy
Would you do ECG monitoring?
What rhythm is this?
• Normal sinus rhythm
Scenario #2 cont.
Would you obtain a 12-lead?
If so…
What’s going on?
ST elevation V1 –V4 (anterior-septal wall)
12-Lead EKG Format/Pattern
Lead I
Lateral wall
aVR
not evaluated
V1
Septum
V4
Anterior wall
Lead II
Inferior
wall
aVL
Lateral wall
V2
Septum
V5
Lateral wall
Lead III
Inferior
wall
aVF
Inferior wall
V3
Anterior
V6
Lateral wall
Most Frequent Complications
Related to MI Locations
Lateral wall – I, aVL, V5, V6
Heart block
Inferior wall – II, III, aVF
Hypotension (hold that NTG – call Medical
Control for permission to administer)
Septal wall – V1 – V2
Heart block
Anterior wall – V3 – V4 (The “widowmaker”)
Lethal dysrhythmias, cardiogenic shock
Scenario #2 Summary
Remember
categories for vague
cardiac symptoms
Females
Long standing diabetics
Elderly
Watch out for the “triple threat”
This patient only contained the first two
ACS
Protocol (pg. 12)
I.V., Monitor (12-lead), O2, ASA, Nitro
Region X SOP - ACS
Stable – alert, warm & dry, B/P >100
Aspirin 325 mg
Withhold if reliable and taken within past 24
hours
If consistently takes aspirin and takes 1
baby per day, contact Medical Control for
guidance
• May not add additional doses
– Drug level is already established
Region X SOP – ACS cont
Nitroglycerin
For pain control and to reduce the workload
of the heart
Screen for use of Viagra type drugs within
past 24 hours
May repeat a dose in 5 minutes
After 2 doses, consider advancing to
Morphine
• Medical Control may have you continue
to alternate Nitro with Morphine
Region X SOP – ACS cont
Morphine
Used as pain reliever
Also dilates blood vessels decreasing
blood flow volume returning to the heart
Watch for hypotension
2 mg IVP slowly over 2 minutes
May repeat every 2 minutes up to a
total dose of 10 mg
Documentation Keys
Full assessment following OPQRST process
Onset, provocation/palliation, quality,
radiation, severity, time
Obtain and record B/P before administering
Nitroglycerin
When obtaining a 12 lead EKG, document
findings related to ST elevation
If present, state in which leads viewed
Scenario #3
Called for a 5 year-old with trouble breathing
in a school lunchroom.
Onset happened during her meal just after gym
class.
Pt A&O x3 and in moderate to severe distress.
Teacher tells you this happens from time to
time.
Impression?
Pediatric Assessment Triangle
Assess
from the doorway
Appearance
Work of breathing
Circulation
Scenario #3 cont.
Vitals:
BP: 88/56, P-112, R-28, SpO2 91%, Wt 40 lbs
Hx:
Asthma, seasonal allergies, & some food
allergies
Patient states she traded part of a sandwich with
her friend.
Same impression?
What else do you want to know?
Scenario #3 cont.
What did she eat?
Sandwich was peanut butter & jelly
Peanut allergy?
Many kids have this now
Most know about it due to history of severe
reaction, but be prepared
Can go into anaphylaxis very quickly
Anaphylaxis
Key difference between allergic reaction
and anaphylaxis is:
HYPOTENSION
Both patients can look “bad” and both can
have wheezing
Note: Need a 1st exposure for the body to
develop antibodies to antigens to be able to
react to subsequent exposures
Scenario #3 Summary
Peds Allergic reaction (pg. 70)
Stable with airway involvement
Epi 1:1000 SQ 0.01 mg/kg
Benadryl 1 mg/kg IVP slowly
Albuterol 2.5mg/3 ml nebulized
Again, be prepared for worsening
Medications
Benadryl – antihistamine
Stops further release of histamines
Epinephrine – sympathomimetic
Stimulates vasoconstriction to support
blood pressure; bronchodilates to ease
breathing
Albuterol – bronchodilator
To ease breathing by dilating bronchioles
Documentation Keys
SpO2 room air and after oxygen initiated
Pertinent negatives
Effort of breathing
Use of accessory muscles
Positioning (ie: tripoding)
Ability to speaking full sentences
Scenario #4
You are called to the scene for an unknown
medical emergency. The scene is secure. Your
patient is a 54 year-old male who is having
trouble communicating. Patient’s speech is clear,
but responses are not to anything you are saying to
him.
Impression?
Scenario #4 cont.
Vitals:
BP: 188/96, P-76, R-12, SpO2 98%, Wt 184 lbs
Hx:
HTN, diabetic, depression, & alcoholism
Pt. appears to be “favoring” right side and still
having trouble following direction.
Same impression?
What else do you want to know?
Scenario #4 cont.
Attempt to do Cincinnati Stroke Scale Test
Mild right side arm drift noted
Determine time of onset
Treat for CVA (pg. 26)
Is comprehension problem an issue or
symptom?
Yes, positive for Receptive Aphasia
i.e. Wernicke’s Aphasia
Scenario #4 cont.
Wernicke’s Area
Controls speech comprehension
Brocca’s Area
Controls speech production
Both on left side of brain
If either of the above speech
areas are noted to be affected,
see if right sided weakness
is also present
Speech and motor problems will be
reflected on opposite sides of the
body
Cincinnati Stroke Scale or FAST
F – look for facial drooping
Have patient smile large enough to see
teeth
A – check for arm drift
Patient holds hands out in front for 10
seconds with eyes closed, palms up
S – check for slurred speech
T – teach patients to call 911 – time is
essential
Scenario #4 Summary
With someone having trouble understanding,
you may have to treat as a language barrier
Person with trouble speaking will look and act
visibly frustrated with themselves. They can
hear and comprehend the strange things they
are saying.
Using hand signals or other forms of
communication may come in handy
Region X SOP- Stroke/Brain Attack
Determine time of onset
Obtain blood glucose level
Perform Cincinnati Stroke Scale
Alert Medical control early
If rapid neurological deterioration ventilate with
BVM
Adult once every 3 seconds (20/minute)
Child once every 2 seconds (30/minute)
Infants once every 1.7 seconds (35/minute)
Documentation Keys
Time of onset of signs and/or symptoms
Results of Cincinnati Stroke Scale
Right, left or no facial droop
Right, left, or no arm drift
Clear speech or not
Notification made to receiving hospital
Scenario #5
Called for a 89 year-old female
with chest pain. Patient stated
she had pain going on for about
an hour and “just got scared”.
Pt seems very anxious and
states she does want to go to the
hospital and doesn’t want to
die.
Impression?
Scenario #5 cont.
Vitals:
BP: 186/102, P-102, R-16, SpO2 100%, Wt 55kg
Hx:
HTN, asthma, & anxiety
Pt. states her pain was a 10/10 and substernal.
Pt. also states she has a long history of heart and
lung issues.
Same impression?
What else do you want to know?
Scenario #5 cont.
ECG monitor
Lead II shows…
Sinus rhythm with junctional bigeminy
Scenario #5 cont.
12-lead – no ST elevation noted (look at sinus beats)
Scenario #5 Summary
Could be cardiac or anxiety
Treat as ACS to be safe (pg. 12)
I.V., Monitor (12-lead), O2, ASA, Nitro
Some elderly patients are very lonely and
scared to ask for help
EMS must gain and keep their trust
Don’t be quick to judge or treat as lesser illness
and/or injury
Documentation Keys
If St elevation is noted or not on 12 lead
EKG
If St elevation is noted, in which leads
Detailed assessment covering OPQRST
prompts
Onset
Provocation
Quality
Radiation
Severity
Time
Scenario #6
Your 34 year-old patient received a GSW to the
right upper abdomen. They are conscious and
alert; bleeding is minimal. Patient in moderate
amount of pain.
Impression?
Do you know you’re A & P?
Category trauma?
Scenario #6 cont.
Vitals:
BP: 90/62, P- 120, R- 28, SpO2 94%, Wt 85kg
History:
Denies any past history or medications
Pt. denies any trouble breathing, but says it hurts
when he breaths in deep. No other injuries noted.
Pt is Category I trauma
Same impression?
What else do you want to know?
Scenario #6 cont.
Make sure the scene is secured. Consider need
for spinal immobilization. During assessment,
consider thoracic injury in addition to
abdominal injury depending on the angle of
GSW.
Examine for an exit wound
Check the back and the axilla
Look for signs & symptoms of possible pneumo
Prepare for the worst – assume the patient will
deteriorate before ED arrival
Scenario #6 cont.
Repeat VS: B/P 80/; HR 140; R 32
Remains conscious and in pain
Cover the wound and watch for evisceration
Fluid resuscitation – keep B/P at low levels;
the higher the B/P the faster the patient bleeds
out
Scenario #6 cont. - Transfer Mode
Where does this pt. need to
be transported to?
Highest level Trauma
Center within 25 minutes
How should they be
transported?
Ground or Aero?
Whichever you deem
necessary in the field
Documentation Key Reminders
Remember…
If you don’t write it, it didn’t happen!
Include pertinent negatives
Make sure to use the proper abbreviations
See Condell approved list
Available from your Medical Officer
Fill out the proper doses on meds
Use ml not cc
Documentation Keys cont.
Trauma
Include results of inspection, auscultation,
palpation
Mechanism of injury
Deformity
Assessment of the general area (ie: contusions,
bleeding, swelling/distention, pain, powder
marks)
Location of entrance and exit wounds
Size of wound(s)
If distance & angle from weapon known
Remember why we’re here…
Questions?
Bibliography
Mosby’s Paramedic Textbook – Second Edition
Movie clip: “Metro”. 1997.
Various photos via BING search engine
Wikipedia – Brain photo & info
Previous Condell CE’s – some patient info and treatments