Transcript Region X SOP Equipment, Drugs, Skills

Region X SOP Equipment,
Drugs, Skills
October 2011 CE
Condell Medical Center
EMS System
Site Code #107200E-1211
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
1
Objectives
Upon successful completion of this module, the EMS
provider will be able to:
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Review the changes to the Region X SOP’s
Discuss the action, indications, contraindications,
dosing, and side effects of Atrovent (Ipratropium),
Etomidate, Fentanyl, and Zofran (Ondansetron)
Given equipment, demonstrate appropriate use of the
humeral site for IO insertion
Given equipment, demonstrate placement of the King
airway
Actively participate in case scenario presentations
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Complete the 10 question pre quiz
Atrovent (Ipratropium Bromide)
Actions
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Bronchodilation of bronchial smooth muscle
 Blocks action of acetycholine at
parasympathetic sites in bronchial smooth
muscle (an anticholinergic drug)
Will dry up excessive secretions
Onset 5 - 15 minutes
Duration 4 - 6 hours
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Atrovent (Ipratropium Bromide)
Indications
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Treatment of bronchospasm due to asthma,
COPD, bronchitis, emphysema
 Not used for immediate relief but for
maintenance of effects from bronchospasm
 Therefore helpful when mixed with
Albuterol
 Albuterol used for the rescue, Atrovent
for the longer effects
 If taken at home, can be repeated by
EMS upon their arrival
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Atrovent (Ipratropium Bromide)
Contraindications
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Hypersensitivity to atropine
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No age-related precautions
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Children and elderly
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Unknown if passes through to breast milk
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Peanut allergies are related to the metered dose
prescription; not the product used in Region X 5
Atrovent (Ipratropium Bromide)
Dosing
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Adult and peds
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0.5mg / 2.5 mL ampule
To be mixed with Albuterol in nebulizer cup
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First dose only; Albuterol alone after first dose
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Atrovent (Ipratropium Bromide)
Side Effects
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Coughing
Dizziness
Insomnia, restlessness
Nausea
Dry mouth
Headache
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Etomidate Actions
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Nonbarbiturate hypnotic, sedative
Short acting drug to produce rapid anesthesia
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Minimal cardiovascular effects
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Onset 1 - 2 minutes
Duration generally 3 - 5 minutes
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Etomidate Indications
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Sedation to relieve apprehension or impair
memory during intubation
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Effects may be increased when combined with
other central nervous system (CNS)
depressants
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Etomidate
Contraindications
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Hypersensitivity to Etomidate
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Labor and delivery
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Insufficient data to support its use
Contact Medical Control for clarification
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Etomidate
Dosing
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Adult and peds
 0.3 mg/kg slow IVP/IO
 Give over 30-60 seconds
 Maximum dose 20 mg
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Too rapid an injection may result in hypotension
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Typical 150 pound person meets the max of 20mg
Treat with fluid challenge
0.3 mg is an average dose
Dosing charts for adults and peds available in SOP’s 11
Etomidate Side Effects
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Nausea and vomiting
Dysrhythmias
Breathing difficulties
Hypotension – treat with fluids
Hypertension
Transient involuntary muscle movement
Myoclonic activity (coughing, hiccups)
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Appears as muscle twitching especially if given too rapidly
 Usually resolves spontaneously, does not interfere with
ability to finish securing the airway
Pain at injection site
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Less when larger, more proximal sites used
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Fentanyl Actions
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Opioid analgesic
Alters pain reception
Increases pain threshold
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Also known as
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Duragesic
Onset 7-8 minutes
Duration ½ - 1 hour
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Fentanyl Indications
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Sedation
Pain relief
Adjunct to general or regional anesthesia
In cardioversion, Versed (midazolam) used for
the initial sedation and as an amnesic
Fentanyl used for any pain/discomfort
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Fentanyl Contraindications
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Increased intracranial pressure (ICP)
Severe hepatic (liver) or renal impairment
Severe respiratory depression
Cautious use in bradycardia
Readily crosses the placenta
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May prolong labor if given in first stage of labor or
before cervical dilation of 4-5 cm
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Fentanyl Dosing
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Adult and peds
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0.5 mcg/kg slow IVP/IN/IO
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May repeat 0.5 mcg/kg slow IVP/IN/IO in 5
minutes
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Administer over 1-2 minutes
 IN route must be a rapid delivery to create a mist
Too rapid administration increases risk of skeletal and
thoracic muscle rigidity resulting in larygo and broncho
spasms and apnea
IN route must be delivered rapidly to create a mist
Max total dose is 200 mcg adult and pediatrics
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Fentanyl Side Effects
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Mixing with benzodiazepines may increase risk of
hypotension and respiratory depression
 Narcan an effective reversal agent
 BVM should be available when medications that
can cause respiratory depressant are being
administered
Nausea, vomiting, diarrhea, constipation
 Less nausea noted than with use of Morphine
Dry mouth
Abdominal pain
Orthostatic hypotension
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Zofran (Ondansetron)
Actions
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Antinausea, antiemetic
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Half-life 3 – 6 hours
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Zofran (Ondansetron)
Indications
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Prevention/treatment of nausea and/or
vomiting
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Zofran (Ondansetron)
Contraindications
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Hypersensitivity to the medication
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Caution:
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A 9/15/11 FDA Medwatch Safety Alert issued for
patients with long QT syndrome
 May develop tachydysrhythmia (i.e.; Torsades)
 Watch for dysrhythmias
 Patient may complain of a racing feeling
 Palpate the pulse and compare with the
initial assessment
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Zofran (Ondansetron)
Dosing
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Adult 4 mg IVP/IO over 30 seconds
Peds <40 kg 0.1 mg/kg IVP/IO over 30
seconds
Peds >40 kg 4 mg IVP/IO over 30 seconds
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May repeat once after 10 minutes
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Zofran (Ondansetron)
Side Effects
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Anxiety
Dizziness
Drowsiness – especially noted in children
Headache
Fatigue
Constipation, diarrhea
Hypoxia
Urinary retention
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The King Airway
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Alternate airway device
 Supraglottic, supralaryngeal, extraglottic,
oropharyngeal
 Back up for failed or difficult intubation
attempts in the field
 Provides a ventilatory device
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King Airway
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A dual lumen supraglottic
airway
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2 cuffs inflated with a single
valve
Device sits in the larynx above
the vocal cords
Distal cuff seals esophagus
Proximal cuff seals oropharynx
 Throat at the back of the mouth
Balloons
inflated
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King Airway Contraindications
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Persons less than 4 feet tall
Presence of a gag reflex
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Check for presence of a blink reflex
 Stroke eye lashes looking for eye movement
 Tap space between eyes at bridge of nose to
check for blink reflex
Known esophageal disease
Caustic ingestion
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Sizing
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Choose color-coded size based on patient height
 4-5' tall – size 3 – yellow
 Think “3-4-5”
 5-6' tall – size 4 – red
 Think “4-5-6”
 >6' tall – size 5 – purple
 Think “5-6”
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Procedure
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Pre-oxygenate patient via BVM
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May need to insert an oropharyngeal airway
(OPA) or nasopharyngeal airway (NPA)
Pre-oxygenate for 3 minutes
Prepare to remove airway adjunct just prior to
insertion of King airway
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Procedure cont’d
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Assemble and check equipment
 King airway
 Syringe
 Water-soluble lubricant
 BVM
 Stethoscope
 Device/tape to secure tube
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Procedure cont’d
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Lubricate back side of tip of King airway
 Avoid lubricant in ventilation ports
With non-dominate hand, hold mouth open
and apply chin lift
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Must use a chin lift to facilitate passing the device
 In the presence of trauma, manual control of the
c-spine needs to be simultaneously performed
Hold King airway at connector with dominant
hand
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Procedure cont’d
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Using lateral approach, introduce tip into
patient’s mouth
Blue orientation line should be touching corner
of mouth
Advance tip behind base of tongue while
rotating tube to midline
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Blue orientation line faces chin of patient
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Procedure cont’d
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Without excessive force, advance tube until
base of colored connector is aligned with
patient's teeth or gums
 Tube must be inserted all the way in, cuffs
inflated, and then withdrawn into correct
position
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Procedure cont’d
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Inflate pilot balloon with appropriate volume
of air
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Inflate using the minimum volume of air posted
Ranges printed on side of tube as reference
 Size 3 (yellow) – 45 - 60 mL
 Size 4 (red) – 60 – 80 mL
 Size 5 (purple) – 70 -90 mL
Remove syringe while holding down plunger
to avoid pulling air out of cuffs
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Procedure cont’d
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While bagging, gently and simultaneously
withdraw King airway until breath sounds are
auscultated and ventilation is easier
Adjust cuff inflation if necessary if air leak is
heard
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Procedure cont’d
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Confirm device placement
 5 point auscultation
 Negative epigastric sounds
 Bilateral breath sounds
 Equal rise and fall of chest
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ETCO2 yellow or capnography 35-40 mm Hg
Apply cervical collar to assist in maintaining
tube position
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Nice to Know!
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“…no inadvertent tracheal intubation,
which would lead to complete obstruction
of the airway occurred.
Genzwuerker H et al. The Laryngeal Tube: A New Adjunct for Airway
Management. Prehosp Emerg Care 2000; 4(2): 168-72.
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King Airway Insertion Tips
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Use a chin lift and lateral approach
 Facilitates placement of distal tip around
posterior pharynx and under base of tongue
Keep tip and tube midline
 If advanced laterally, tip may enter a blind
pouch (pyriform fossa) and bounce back
during inflation
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King Airway Insertion Tips
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Insertion depth MUST be adjusted to
maximize ventilation
 Best insertion depth is to place colored
adapter at teeth or gum line, inflate cuffs
and withdraw until ventilations adequate
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Documentation King Airway
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Size King airway used
Confirmation method
Rate of ventilations provided
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One breath every 6 seconds
 Works for patients with or without a pulse
 Works for the patient receiving CPR
Can write the word “King” in space next to
“ET” and finish documentation in notes
section
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EZ IO
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The alternative IV access method
Rapid placement
Rapid entry into the bloodstream
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Consider if patient NEEDS IV access or do
YOU just want IV access?
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Remember in the patient with a stroke
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Minimize IV sticks – they’ll be receiving
fibrinolytics that will affect clotting time
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Highlights on EZ IO Needles
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Avoid prejudicing decisions of needle size to patient
population
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Needles referred to by their length
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No longer referring to “pink=peds”, “adult” and “bariatric”
needles
15mm (pink), 25mm (blue), and 45mm (yellow)
 Half of peds needs a 15mm needle and half need 25mm
Determine needle length needed by palpating over the site
Let the drill pull itself in, don’t push the needle in
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Stop drilling when loss of resistance is felt
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EZ IO Needles
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Note the black
identifying line
mark on each
needle
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Need to keep at
least one black
line visible once
needle touches
bone and prior to
drilling
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EZ IO Needle Sizing
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Insert needle tip into
site until resistance
is felt
 The needle tip is
touching bone
If at least one black
mark is still visible,
there is enough
needle length
remaining to secure
into the site
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EZ IO 45 mm Yellow Needle
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Used for obesity over the landmark site
 Some patients may be large in select areas
of their body but not in their extremities
 Think of the patient with
COPD
 Palpation and clinical
judgment used
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EZ IO 45mm Needle
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Recommended for the humeral site in all patients
over 40 kg (88 pounds)
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A back-up site alternative to the tibial site
Humerus a relatively softer bone
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Not a weight bearing bone
Longer needle provides more stability in the bone
Aim needle in slightly inferior (downward) direction
 Imagine the tip moving toward the arm socket or toward
an imagined space between the heart and the spine
Immobilize the arm after IO insertion to avoid dislodging
needle
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Palpating the Humeral Head
G = greater tuberosity
L = lesser tuberosity
M = metaphysis
Target site is the
greater tuberosity
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Humeral IO Insertion Site
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Adduct patient's arm over their abdomen
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Push your thumb into humerus about mid-shaft,
palpate up the humerus until you feel the bone bow
out
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In supine patient, elbow pulled back, resting on the
bed/backboard,/ground makes this site more prominent
This is the surgical neck
Continue to palpate up about 1 finger width (1 cm)
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This will be the center of the greater tubercle of the
humerus
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Humeral IO Insertion Site
Alternate identification of site:
 Hit your palm on anterior portion of the
shoulder
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You feel a golf ball sized bone in the natural
indentation of your palm
This is the greater tubercle which is just anterior to
midline
To find midline, square up the shoulder and
visualize where the middle is
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Humeral IO Insertion Site
Alternate identification of site:
 Gently lift arm straight up via the elbow
 Keep arm and elbow next to body
 Lift up like trying to touch the shoulder to
patient's ear
 Proximal humerus very pronounced and
easy to identify
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Humeral IO Site
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As a non-weight bearing bone, humerus softer
than tibia
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Will need to immobilize arm to prevent movement
Secure IV site to avoid inadvertent needle removal
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Lidocaine and IO IV Sites
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Lidocaine is used to “marinate” the inside of
the bone
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The area will be numbed so the infusion of fluids
will be less uncomfortable in the non-arrested
patient
Once the stylet is removed, SLOWLY inject
the Lidocaine over 1 minute
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Adult 50 mg
Peds 1 mg/kg (max 50 mg)
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Lidocaine cont’d
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Lidocaine moves out of the area and into
circulation if injected too quickly
WAIT 1 minute
Flush the line via the EZ IO connect tubing
Hook up the primed IV tubing to the EZ IO
connect tubing
Place a pressure bag over the IV bag
Begin the infusion
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Accessing the Humeral Site
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Antiseptic preparation
 Use cleanser supplied
in IV start pak
 Hold needle until
taped or otherwise
secured into place
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To play video double left click
in slide show mode
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Case Scenarios
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Put it into practice
Read the following scenarios
Determine appropriate course of action
Discuss decision making and share critical
thinking skills
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Case Scenario #1
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Your general impression is that your 54 yearold patient has suffered a stroke
Their breathing is shallow and at 4 per minute
They have no gag reflex
Discuss measures to secure the airway
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Case Scenario #1
Securing the Airway
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Reposition the airway
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Begin to support ventilations via BVM
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Head tilt / chin lift in absence of trauma
1 breath every 5-6 seconds (pulse is present)
Anticipate intubation
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Preoxygenate for 3 minutes
Prepare equipment
Prepare medications
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Case Scenario #1
Securing the Airway
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Medications
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Lidocaine 1.5 mg / kg IVP/IO
 To suppress the cough reflex to avoid an
increase in intracranial pressure in patients with
head insults
Etomidate 0.3 mg/kg IVP/IO (max 20 mg)
 As hypnotic and sedative
Versed 2 mg IVP/IO every 2 minutes to max
20 mg
 For post intubation sedation
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Case Scenario #2
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How do you size for the King airway?
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How do you place the King airway?
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How do you assess placement of the King
airway?
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Case Scenario #2 cont’d
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Sizing for the King airway
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Based on height of patient
 4 -5 feet use size 3 (remember 3 – 4 – 5)
 5 – 6 feet use size 4 (remember 4 – 5 – 6)
 Over 6 feet use size 5 (remember 5 – 6)
Colored tip of King airway indicates the size
 Size 3 – yellow
 Size 4 – red
 Size 5 - purple
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Case Scenario #2 cont’d
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Placing the King airway
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Hold mouth open with chin lift with non-dominant
hand
Insert tube with dominant hand laterally (turned to
the side) with blue line touching corner of mouth
Advance tube as you rotate tube to midline; blue
line facing the patient’s chin
Advance until the base of the colored connector is
even with the patient’s teeth or gums
Inflate the pilot balloon
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Case Scenario #2 Placement cont’d
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Pilot balloon inflation
 Size 3 range 45-60 mL
 Size 4 – range 60 – 80 mL
 Size 5 – range 70 – 90 mL
While ventilating with BVM, gently withdraw tube
until ventilation easy and chest rises
Adjust air in cuff, if necessary, to obtain seal
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Case Scenario #2 cont’d
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Assessing placement of King airway
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Observe for bilateral rise and fall of chest
Auscultate for negative epigastric sounds
Auscultate for bilateral breath sounds
Evaluate capnography
Secure tube with tape or commercial holder
Apply cervical collar to help secure tube
placement
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Case Scenario #3
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When would Zofran be necessary?
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Zofran is given for nausea
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Nausea may be a symptom of the problem
Nausea may be the result of administration of
Morphine (more common than with Fentanyl)
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Case Scenario #4
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What interventions are required during asystole
and/or PEA?
CPR – CPR – CPR
 Rotate compressors every 2 minutes during rhythm
check
Only medication will be Epinephrine 1:10,000
 Administered every 3-5 minutes
Consider and start addressing possible causes – the
H’s and T’s
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Case Scenario #4
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When do you perform a pulse check during
CPR?
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Pulse checks are only performed when the
presenting rhythm is one that should generate a
pulse
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If no pulse up to 10 seconds, resume CPR
NO pulse check when observing VF or asystole on
the monitor
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Case Scenario #5
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What are the H’s to consider during
resuscitation?
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Hypovolemia – give fluids 20mL/kg – reassess as
you are passing every 200 mL
Hypoxia – add supplemental oxygen
Acidosis – properly ventilate to blow off CO2
Hyper/hypokalemia – consider the history
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Patient on dialysis? Patient with hyperglycemia?
Hypothermia – are they warm or cold?
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Case Scenario #6
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What are the T’s to consider during
resuscitation?
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Toxins – is there a possibility of drug exposure?
Tamponade – what is the history?
Tension pneumothorax – what is the history? what
are the breath sounds like? How easy is it to bag
the patient?
Thrombosis – coronary or pulmonary – what is the
history?
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Case Scenario #7
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Why is Etomidate useful in the prehospital
setting?
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Used as a short acting hypnotic (amnesic) and
to sedate the patient
It acts quickly with a short duration (3-5
minutes)
Used to facilitate intubation on the nonarrested patient
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Case Scenario #8
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How do I find the humeral IO site?
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Adduct patient's arm over their abdomen resting
elbow back on the surface supporting the patient
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Hit your palm on anterior portion of the shoulder
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Push your thumb into humerus about mid-shaft, palpate
up the humerus until you feel the bone bow out
Continue to palpate up about 1 finger width (1 cm)
You feel a golf ball sized bone in the natural indentation
of your palm
Gently lift arm straight up via the elbow
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Case Scenario #9
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Your patient is in VF
You have started CPR until the defibrillator is ready
A shock is delivered and you immediately resume
CPR; compressors switching every 2 minutes
What drugs are used during the VF code?
 Epinephrine 1 mg IVP/IOevery 3-5 minutes
alternated with
 Amiodarone 300 mg IVP/IO (repeated once in 3-5
minutes at 150 mg IVP/IO)
 Peds Amiodarone 5 mg/kg IVP/IO
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Drug Matching
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What drug makes the IV infusion more
tolerable via an IO site?
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Lidocaine 50 mg IO (peds 1 mg/kg – max 50 mg)
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Instill over 60 seconds to bathe the area
Let the medication sit for 60 seconds and then flush the
line
What drug is short acting for pain control and
does not negatively impact blood pressure?
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Fentanyl
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Drug Matching
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What medication blunts a bradycardic
response to intubation in the pediatric
population?
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Atropine 0.2 mg/kg IVP/IO
What medication is the antidysrhythmic of
choice in the patient experiencing VF or
pulseless VT?
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Amiodarone 300 mg IVP/IO first dose; then 150
mg IVP/IO in 3 -5 minutes for adults
 Peds 5 mg/kg IVP/IO
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Drug Matching
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Which Benzodiazepine is useful for the patient
with an active seizure but no IV access yet?
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Versed which can be given via IN
Why is Atrovent added to the first dose of
Albuterol?
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Atrovent reverses bronchospasms and is longer
lasting than Albuterol
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Monomorphic VT
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Ventricular complexes having the same shape
and amplitude from beat to beat
Complexes are generally wide (over 0.12
seconds)
Complexes can be stacked like blocks
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Polymorphic VT
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Ventricular complexes that vary in shape and
amplitude from beat to beat
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When occurring in the presence of a long QT,
referred to as torsades de points
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Bibliography
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Hodgson, B., Kizior, R. Saunders Nursing Drug Handbook
2009. Elsevier. 2009.
centegra.org/emergency-medical-services/ems-news/
www.co.bonner.id.us/EMS/BonnerCountyEMSTrainingDivisi
on.htm
dailymed.nlm.nih.gov/…/drugInfo.cfm?id=18810
www.ems/.com/.../video/449861-Vidacare-EZ-IO/
emsstaff.bincombecounty.org/inhousetraining/ez_io_Update/i
mg/Pro
emsstaff.buncombecounty.org/…/kinglt_info.asp
www.medclip.com/index.php?page=videos&c=21
http://www.westyadkinvfd.com/KingLTDInserviceGuide.pdf
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Region X SOP’s November 1, 2011