Transcript 7. Actively participate in review of selected

Altered Mental Status
Aging Process
FEBRUARY 2015 CE
CONDELL MEDICAL CENTER
EMS SYSTEM
SITE CODE: 107200E-1215
Prepared by: Sharon Hopkins, RN, BSN
Rev 2.13.15
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Objectives
Upon successful completion of this module, the EMS provider
will be able to:
1. Given a variety of signs or symptoms, be able to distinguish presence
of neurological problems.
2. Predict which patients may be presenting with a stroke based on
chief complaint and signs and symptoms.
3. Prioritize transport for patients presenting with a variety of
neurological emergencies.
4. Discuss the normal aging process.
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Objectives cont’d
5. Determine physical and psychological clues that would suggest
elder abuse or neglect.
6. Successfully return demonstrate a field neurological assessment.
7. Actively participate in review of selected Region X SOP’s as
related to the topic presented.
8. Actively participate in case scenario discussion.
9. Actively participate in successful insertion of an IO needle
into a manikin.
10. Review responsibilities of the preceptor role.
11. Successfully complete the post quiz with a score of 80% or
better.
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The Nervous System
• Body’s principle control system
• Regulation primarily through electrical impulses transmitted thru
nerves
• 2 main divisions
• Central nervous system – brain and spinal cord
• Peripheral nervous system (PNS) – with 2 major subdivisions
• Somatic NS – voluntary functions
• Autonomic NS – involuntary functions – 2 divisions
• Sympathetic (SNS) and parasympathetic nervous systems (PNS)
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Central &
Peripheral
Nervous
System
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Defining Neurological Problems –
Central Nervous System (CNS) Disorders
• Key sign is an altered level of consciousness
• Loss of ability to respond to stimuli and  awareness of environment
• Two mechanisms produce mental status changes
Structural lesions
• Destruction or encroachment on substance of brain (i.e.: tumor,
trauma/bleeding, degenerative diseases, parasites)
Toxic-metabolic states
• Presence of circulating toxins or metabolites or absence of
necessary metabolites (i.e.: oxygen, glucose, thiamine (Vit B1))
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Defining Neurological Problems cont’d
• Peripheral nervous system disorders
• Malfunction or damage of peripheral nerves results in peripheral
neuropathy
• Single or multiple nerves can be affected
• Single nerves usually from local conditions (i.e.: trauma, infection,
compression (i.e.: carpal tunnel))
• Multiple nerve damage characterized by demyelination or
degeneration of peripheral nerves
•Myelin is protective sheath surrounding nerves
•Destruction of myelin leads to sensory, motor or mixed deficits
(i.e.: diabetic neuropathy, Guillain-Barre syndrome)
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Myelin Sheathing
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Central Nervous System Disorders
• Four general categories of common causes
Drugs
• Depressants, hallucinogens, narcotics
Cardiovascular insults
• Arrest, stroke, shock, dysrhythmias, hypertensive encephalopathy
Respiratory insults
• COPD, toxic gas, hypoxia
Infections
• AIDS, encephalitis, meningitis, parasites
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Examples Neurological Disease/Problems
• ALS – Lou Gehrig’s Disease
• Alzheimer’s disease
• Bell’s palsy
• Guillain Barre syndrome
• Huntington’s disease
• Multiple sclerosis
• Muscular dystrophy
• Parkinson’s disease
• Polio
• Seizures
• Spina Bifida
• Stroke
• Tumor
• Trigeminal neuralgia
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General Impression
• NOT the role of EMS to diagnose the specific
neurological disease present
• Important to note that SOMETHING neurological is
happening!
• Obtain adequate history – pertinent past and present
• Perform detailed assessment and reassessment
• Includes neurological assessment
• Watching for trending
• Knowing what to do with the trend – action & reporting to MC
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General Impression cont’d
• Form a general impression when first meeting the patient
• General impression revised as more information is gathered
• General impression guides the responder in choice of intervention
• Obtain information from a variety of sources
• Scene size up
• Evaluation of surroundings
• Evidence of toxic exposure or trauma
• Clues to the patient’s condition
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Clues to Patient Conditions
General Appearance…
Speech…
Skin…
Posture/gait…
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Clues - General Appearance
Determine patient’s normal or baseline
• Is patient conscious?
• If not, do they respond to voice (3*), pain (2*) or not at all (1*)?
• Is patient alert?
• To what degree?
• Is patient confused?
• Pleasantly confused or using inappropriate words?
• Can the patient sit upright?
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* - reflects GCS score
Clues - Patient Speech
Determine patient’s normal or baseline
• Can the patient speak?
• Is the speech clear and coherent with appropriate content to the
situation?
• Does the patient speak in full sentences?
• Remember to document if unable to speak in full sentences (i.e.: “2-3
word sentences”) especially when related to complaints of difficulty
breathing
• Is the speech slurred?
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Clues - Patient's Skin
Determine patient’s normal or baseline
• What is the color – pink, pale, cyanotic?
• What is the temperature - warm, hot, cool?
• Is the patient dry, diaphoretic or clammy?
• Is facial drooping present?
• If yes, to which side?
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Clues - Patient’s Posture/Gait
Determine patient’s normal or baseline
• Is the patient able to maintain an upright position?
• If the patient is leaning, to which side?
• If you observe the patient walking, do they have a steady gait or
do they stagger?
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AVPU and GCS
• AVPU determines mental status
A – alert and aware of surroundings
V – responds to verbal stimuli
P – responds to painful or tactile stimuli
U – unresponsive
• Glasgow Coma Scale – GCS
Used to monitor a patient’s condition
Used as a predictor of morbidity and mortality
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Assessing Cerebral Function Via
Emotional Status
• Look for changes from normal or baseline
• Mood –affect natural or irritable, anxious, apathetic, depressed, manic,
happy?
• Thought – logical, appropriate, scattered?
• Perception –appropriate interactions and perception of environment?
• Judgment – logical, using reasonable and sound judgment?
• Memory and attention –short and long term memory intact? Able to pay
attention and maintain conversations?
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Patient Assessment & Monitoring
• Need to know patient’s baseline to best make sense of any
changes noted
• Changes from “normal” must be investigated
• Respiratory center is in the brain
• Must carefully monitor respiratory patterns if evident problem in
central nervous system (CNS)
• Remember focus of primary assessment
• Determine any life threatening condition and address it
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Nervous System Evaluation
• Evaluation of sensoriomotor status, motor system status, and
cranial nerves
• Sensoriomotor status - assessment of sensation and motor function
• Can you feel this? Can you move that?
• Motor system status
• Assessment of tone, strength, flexion/extension, coordination, balance
• Many motor functions not tested by EMS in the field
• Cranial nerves
• 12 pairs extend from lower surface of brain
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12 Pairs Cranial Nerves
• Originate from base of brain
• Provide sensory and motor innervation mostly to head and face
• Each pair can carry sensory, motor,
or both types of fibers
• Limited assessment performed in
the field
• Usually test CN III – pupillary response
Details of 12 cranial nerves in handout
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Acute Stroke – A Neurological Insult
• Injury or death of brain tissue
• Usually due to interruption of cerebral blood flow
• Oxygen deprivation causes damage to affected tissue
• 2 categories – occlusive and hemorrhagic
• Early recognition and rapid transport can improve patient
outcome
• High risk history – atherosclerosis, heart disease, hypertension
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Acute Occlusive Stroke
• 85% of incidence of strokes
• Caused by blockage of cerebral artery with clot or foreign matter
• Embolic stroke from material that travels from a remote site
• Thrombotic stroke is buildup on plague in vessel that blocks flow of
blood
• Ischemia due to inadequate blood supply leads to infarction with
death of tissue
• As tissue dies, it swells causing further damage
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Acute Hemorrhagic Stroke
• 15% of incidence of strokes
• Caused by rupture of a vessel
• Bleeds with in the brain – intracerebral
• Can bleed in space around outer surface of brain – subarachnoid
• Often from congenital blood vessel abnormality
• Weakened vessels (aneurysms) or collection of abnormal blood
vessels (AV malformations)
• Common in hypertensive patient
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Thrombotic/Embolic Stroke vs Hemorrhage
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Heightened Suspicion of Stroke
• Facial drooping
• Arm drift
• Unilateral weakness (hemiparesis)
• Unilateral paralysis (hemiplegia)
• Dysphasia (difficulty speaking)
• Aphasia ( inability to speak)
• Confusion and agitation
• Headache
• Dizziness
• Visual disturbances
• Unilateral numbness or tingling (paresthesia)
• Inability to recognize by touch
• Gait disturbances
• Incontinence
• Coma
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High Index of Suspicion
• NOT everyone presents with one of the classic 3 signs of stroke
Facial droop
Arm drift
Speech not clear
• Pay attention to the odd complaints
• I can’t get out of bed – determine “why”
• My legs don’t seem to work – determine “why”
• Something is “just not right” – consider if it is cardiac or neurological
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Predisposing Factors Contributing to Stroke
• Hypertension – especially poorly controlled
• Diabetes
• Abnormal lipid levels – high cholesterol
• Oral contraceptive use
• Sickle cell disease
• Cardiac arrhythmia – notably atrial fibrillation
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Transport of Patients With Acute Stroke
• Transport expedited to closest appropriate hospital
• All hospitals in Lake County are designated Primary Stroke Centers
• Have internal process to assemble their “stroke team” for patient care
• Prepared to quickly obtain a CAT scan
• Used to rule out hemorrhagic bleed
• Minimize scene time
• If there is a delay in transport, make sure it is time well spent
• IV’s attempted only if process will not delay transport
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Minimum Assessment All Potential Strokes
• Establishing last known normal time
• This is not necessarily the time patient was found!
• Cincinnati Stroke Scale
• Obtaining capillary blood glucose level
• Perform a finger stick versus obtaining from an IV site
• Complete a baseline field neurological assessment
• GCS
• Pupils
• Sensory and motor response
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Field Neurological Assessment
• Establish level of consciousness – AVPU scale
• Compare to patient’s normal baseline if possible
• Obtain GCS – watching for trends
• Always give highest score possible
• Vital signs – watching for trends
• Head insult - B/P;  pulse rate; irregular respirations
• Shock - B/P;  pulse rate
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Field Neuro cont’d
• Pupillary reflex – 3rd cranial nerve
• Abnormal pupillary response points to same side of head injury
• Sensory and motor
• What can patient feel? What can patient move?
• Abnormal motor and sensory response reflects opposite side of head
injury
• Blood glucose level
• Obtained on all patients with altered level of consciousness and
potential stroke
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What About These Pupils???
Could be normal or point to injury
left side of brain
• Could indicate exposure to
narcotics or response to light
• Could indicate exposure to
stimulants or response in
darkened room
• Cataracts
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The Aging Process – Not For Sissies
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The Aging Process
• Survival rates are up; life expectancy increasing
• Birth rates are down
• Healthcare providers need to be prepared for an increase in
numbers of the aging population
• EMS calls are very stressful on the elderly
• Elderly often equate illness with death
• Often don’t report changes in health – viewed/considered as normal
process of aging
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Understanding Problems of the Aged
• Poverty and loneliness prevalent
• Social support system declines especially if living alone
• Disease and disability often linked to unhealthy and unsafe
behaviors
• Independence is important concept
• Functional impairment affects self sufficiency
• Tight finances and limited mobility become issues
Decrease in adequacy of nutrition
Safety issues
Under adherence of medication (reduce doses to save money)
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On Aging
• Aged susceptible to same disease as the young but maintenance,
defenses, repair processes are weaker
• Progressive loss of function with aging body
• Increases likelihood of malfunction
• Vital organs lose ability to compensate in times of need
• Aged often have more than 1 disease/illness present
• Average of 6 medical disorders co-exist in elderly
• Disease in 1 organ often leads to deterioration in another system
• Presence of co-morbidities/other disease causes vague complaints or
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non-specific complaints not linked to any one disorder
Think About This…
• Being “old” does not automatically mean you have dementia
• Having dementia doesn’t mean you are old
• “Loosing your keys” doesn’t mean you have Alzheimer’s
• Not knowing what keys are or what to do with them may indicate Alzheimer’s
• 5.2 million Americans have Alzheimer’s
• 200,000 are under 65 years of age
• 6th leading cause of death in the USA
• Women 3:1 over men
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Road Blocks to Medication Compliance
• Limited income
• Memory loss
• Limited mobility
• Sensory impairment (hearing, sight, understanding directions)
• Multiple or complicated drug therapies
• Fear of toxicity
• Childproof containers (especially with arthritis)
• Duration of drug therapy (longer the therapy, the less compliance)
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Tactics to Increase Medication Compliance
• Improving patient-physician communication
• Acknowledging/accepting that a disease or illness is serious
• Drug calendars or reminder cards
• Compliance counseling
• Easy to open packaging
• Multiple compartment pillboxes
• Transportation services to pharmacy
• Clear, simple directions written in large type
• Ability to read
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Problems Related to Lack of Mobility
in the Elderly
• Poor nutrition
• Difficulty with elimination
• Poor skin integrity
• Greater predisposition for falls
• Loss if independence and or confidence
• Depression from “feeling old”
• Isolation and lack of social networks
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Contributory Factors to
Communication Difficulties
• Sensory changes related to aging
• Impaired vision or blindness
• Impaired or loss of hearing
• Altered sense of taste or smell
• Lower sensitivity to pain and touch
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Impaired Vision
Nearsightedness
Color blindness –44
what number do you see?
Macular degeneration
Common Complaints of the Elderly
• Fatigue and weakness
• Dizziness – vertigo – near-syncope
• Falls
• Headache
• Insomnia
• Dysphagia – difficulty swallowing
• Loss of appetite
• Inability to void – constipation - diarrhea
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Impact On Forming General Impression
• Living situation
• Level of acuity
• Network of social support
• Level of independence
• Medical history
• Sleep patterns
• Elderly often vague; consider their complaints as trivial
• Often complain of 1 thing which is not the main problem
•
Healthcare worker often has to “dig” to find the real story
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Patient Assessment in the Elderly
• Obstacles
• “Normal vitals” are not normal in the elderly
• Pneumonia for example
• Fever often absent
• Chest pain and cough less pronounced
• Etiology (cause) often due to aspiration versus infection
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Mechanism of Injury - Falls
• Fall related injuries leading cause of accidental death in elderly
• Intrinsic falls – related to the patient
• History of falls, dizziness, weakness, impaired vision, altered gait,
CNS problems, decrease mental alertness, certain medications
• Extrinsic falls – related to the environment
• Slippery floors, no handrails, loose throw rugs
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Spinal Injuries In The Elderly
• Degenerative changes occur in the spine as a person ages
• Increases risk of spinal fractures with even minor forces
• Odontoid fracture (C2) especially common in elderly
• Mechanism of injury in elderly are low impact falls especially
falling and striking chin - look for abrasions!
• Mechanism in younger aged population are high impact MVC
• Neck pain is common without spinal cord injury
• Treatment can range from surgery to immobilization in halo
vest or collar
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Halo brace
Assessment of Potential Spinal Injuries
• Palpate neck feeling for pain or step off
• Test strength in all extremities
• Test sensation in all extremities
• Test ability to shrug shoulders
• Document results; continue reassessments
• Assume presence of injury until x-ray confirmation obtained
• Based on mechanism of injury (MOI), elderly deserve spinal motion
restriction/immobilization until proven otherwise
• Remember – minimum MOI can relate to significant injury
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Backboard Use In Elderly
• Consider anatomical positioning of the
patient
• Kyphosis (abnormal curvature of spine;
hump) often present
• Patient will need extra padding to fill in
the gaps
• Laying on a backboard can increase the
risk of skin breakdown
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Ethical Considerations When
Caring For the Elderly
• May question the patient’s capacity to live on own
• May question decisional capacity to give consent
• Faced with Advanced Directives
• Trying to honor the patient’s wishes
• Hesitant caregivers should raise suspicion of abuse
• Increased rate of depression and suicide noted in elderly
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Resources of Community Support
• Catholic Charities – 1-847-782-4000 (M-F - 0830-1630)
• Private, not-for-profit social service agency
• Can evaluate the living conditions
• Service Directory available online www.catholiccharities.net
• United Way Human Services Resource Guide
• Guide book to provide information about a broad range of available
services
•
The old “red book” of resources
• Guide book available online www.LIVEUNITEDlakecounty.org.
• Online searchable database at www.FindHelpLakeCounty.org
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Preserving The Health Status of the Elderly
• Disease/illness
• Encourage routine screenings
• Keep up to date with immunizations
•
•
Tetanus booster, annual flu
Consider one time pneumococcal (for pneumonia) and shingles vaccine
• Pharmacological
• Regularly review all medications including over the counter (OTC)
• Focus on potential interactions and side effects
• Average elderly person takes 4.5 medications per day
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Health Status cont’d
• Dental care
• Encourage regular checkups and dental hygiene
• Important for nutrition and well-being
• Mental/emotional health
• Observe for depression, disrupted sleep patterns,
psychosocial stress
• Check effectiveness of support networks
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Protecting Our Elders
• Elder abuse
• Any physical injury, sexual abuse or mental injury inflicted on
a person age 60 or older other than by accidental means
• Elder neglect
• A failure to provide adequate medical or personal care or
maintenance, which failure results in physical or mental injury
to a person or in the deterioration of a person’s physical or
mental condition
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Elder Abuse and Neglect
• Primary presentation – unexplained trauma
• Average abused patient over 80 years old
• Patient usually has multiple medical problems
• Senile dementia often present
57
Profile Elder Abuser
• May be a family member or healthcare worker in nursing home
and other health care facilities
• No socioeconomic descriptions
• Usually older person no longer totally independent
• Abuser experiencing extra stress
• Typical to be sleep deprived, experiencing marital discord,
financial problems, and work-related problems
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Signs of Physical Elder Abuse
• Bruises
• Described by color which indicates age of the injury; do not
use words “new” or “old” to describe
• Broken bones
• Burns abrasions
• Pressure marks
• Odd explanations of the injury (“she ran into a wall”)
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Signs of Elder Neglect
• Dirty clothes
• Soiled diapers
• Bedsores
• Unusual weight loss
• Unusually messy home –
• Especially if a change from previous conditions
• Lack of medical aids
• Eye glasses, hearing aids, cane, walker
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Signs of Verbal or Emotional Abuse
• Withdrawal, apathy
• Unusual behavior such as rocking, hitting
• Nervous, fearful behavior, especially around caregiver
• Strained or tense relationship between caregiver and elder
• Caregiver snapping or yelling at the elder
• Forced isolation by family member or caregiver
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Signs of Sexual Abuse in Elderly
• Bruises around breasts and/or genital areas
• Evidence of venereal disease
• Vaginal or rectal bleeding
• Difficulty walking or standing
• Depressed or withdrawn behavior
• Flirtation or touchiness by caregiver
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Signs of Financial Abuse in Elderly
• Unpaid bills
• Money disappearing and unaccounted for
• Caregiver taking money for purchase that doesn’t arrive
• Unusual purchases person wouldn’t normally make
• Increased use of credit cards
• More frequent withdrawals of cash
• Adding someone new to bank accounts or credit cards
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Mandatory Reporting
• EMS personnel are mandatory reporters of suspected
elder abuse or neglect
• Abuse Hot Line 866-800-1409
• Accurately, objectively, and completely document any
physical findings on the patient care run report
• Relay findings to the ED staff
• Also mandatory reporters
• Document who you have notified
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Case Scenario Group Discussion
• Review the following case studies
• Determine your general impression after analyzing data obtained
• Discuss the details of your assessment of the patient
• Interpret the results of the assessment
• Determine the appropriate interventions based on
Region X SOP’s
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Case Scenario #1
• 91 y/o F found at 10am by “son” with mumbling speech
• History: hypertension, lung cancer, on hospice
• Also found to have right sided weakness
• Eyes open; does not seem to track movement in room
• What is your general impression at this point???
• Hopefully, stroke is a consideration
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Case Scenario #1
• VS: 184/98; P – 88 irregular; R – 18; SpO2 96%
• Blood glucose 157
• Eyes open; mumbling
• R side does not move, L arm randomly swatting at the air
What is the rhythm??? Rhythm: Atrial fibrillation
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Risk to patient with this? Acute stroke
Case Scenario #1
• Impression???
• Acute stroke
• Assessment (the minimum related to “stroke”)
and action
• Cincinnati Stroke Scale
• Blood glucose
• Report to receiving hospital
• Expedited transport
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Case Scenario #1 – Points to Emphasize
• Clarify last known normal versus when found
• Important distinction to determine if patient is in window of opportunity
for intervention with fibrinolytic (TPA)
• Verify who the bystanders are – don’t assume relationships
• The “son” was the nephew (who did have power of attorney)
• Cincinnati Stroke Scale in Image Trend “box” marked as abnormal
• MUST document in narrative which components are abnormal
• Reassessment/trending less valuable without accurate data
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Case Scenario #1 – Follow-up
• Code Neuro activated by pre-hospital report
• CT scan “negative”
• Indicates no active bleed; evidence of acute stroke takes time
to develop (hours to days if at all – depending on size and location) to
see effects on CT repeated later
• Need bedside assessment to determine if symptoms related
to acute stroke and then decide on intervention
• Supportive care provided
• Due to failing health and extensive status of cancer, family
elected no aggressive intervention
70
Case Scenario #2
• 46 y/o M is noted stumbling around a public area; halting speech
• EMS summoned by concerned by-stander
• VS: 130/70; P – 138; R – 26; SpO2 96%
• What do you think is going on???
• Could be lots of issues (think AEIOU – TIPS as a starting point)
• By the way, patient history includes ALS
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Case Scenario #2
• What is ALS (Lou Gehrig’s Disease)?
• A progressive, degenerative neurological disease causing
rapid decline of voluntary muscles
• Weakness, loss of motor control, difficulty speaking, cramping
• Eventual weakness of diaphragm leads to respiratory
insufficiency
• Patients must be on ventilators at this stage
• Poor prognosis – most die within 3-5 years of diagnosis
• Cause of death usually a pulmonary infection
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Case Scenario #2 - Assessment
• Eyes open
• Patient oriented and conversant, just halting speech
pattern
• Extremities all move to command but in jerky manner
• GCS?
• 4, 5, 6 for total of 15
What’s the rhythm? Sinus tachycardia
73
Case Scenario #2
• So, why are you at the scene?
• Eventually discover patient is short of breath and that is new
• RR was 26 and SpO2 was 96%
• Would you apply O2?
• Yes, due to respiratory complaint
• Remember: ALS is a disease that eventually affects the
respiratory system and causes respiratory malfunction (weakens
the diaphragm)
74
Case Scenario #2
• What was rhythm interpretation?
• Sinus tachycardia
• Would you give Adenosine?
• NO!!! Find the causes of ST and treat them, not the rhythm
• Document that cardiac monitor applied
• Must also interpret the rhythm strip
• Present rhythm strip to ED staff to place on the patient's hospital
medical record (and 12 lead EKG’s, too)
75
Case Scenario #3
• 51 y/o F with sudden onset headache, dizziness, nausea
• Witnessed by husband who then called 911
• Found sitting in chair leaning to the right side
• Mental status deteriorated from time of initial call
• Eyes open but not tracking movement
• Non-verbal
• Right arm hanging limp by side
• Does not follow command
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Case Scenario #3
• VS: 190/110; P – 66; R – 18; SpO2 97%
• GCS – How would you score the motor response?
• Need to see the response when you apply stimuli
• When stimuli applied, patient uses left hand to grab at you
• Is it purposeful?
• Is it withdrawal?
• General impression?
• Acute stroke vs subarachnoid bleed
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Case Scenario #3 - Interventions
• Monitor vital signs
• Trend to watch for?
• Cushing’s reflex - B/P;  pulse; irregular respirations
• Closely monitor respirations
• During transport, respiratory rate drops and respirations shallow
• What is the rate to support ventilations via BVM?
• 1 breath every 5 – 6 seconds (10-12 breaths per minute)
• What is the rate for bagging via advanced airway (ETT or King)?
• 1 breath every 6 – 8 seconds (8 – 10 breaths per minute)
78
Case Scenario #3 - Interventions
• What medications are used if intubation performed?
• Lidocaine – in presence of head insult (trauma, stroke), decreases cough
reflex to minimize increase in ICP
•
•
1.5 mg/kg IVP/IO one time
No precautions if bradycardia in this setting
• Etomidate – as hypnotic to induce anesthesia
•
0.3 mg/kg IVP/IO (max 20 mg - 150# on upward get 20 mg)
• Versed – benzodiazepine for post intubation sedation
•
2 mg IVP/IO every 2 minutes to desired effect; max 20 mg
• Apply cervical collar to help maintain ETT position
79
Case Scenario #3 – Follow-up
• Pt had been diagnosed with hypertension and prescribed
multiple medications several years ago – non-compliant
• Pt had subarachnoid hemorrhage due to ruptured vessel
• Taken to OR to evacuate hematoma and reduce pressure on
brain tissue
• Pt remained comatose, ventilator dependent
• Received trach, PEG tube for feedings
• Poor prognosis – likely to remain in vegetative state
• Discharged to nursing home
80
Case Scenario #4
• 65 y/o M living in poor conditions
• History severe dementia (Alzheimer’s) now with worsening
mental decline
• Care giver is daughter – does not live with patient
• Patient in dirty PJ’s
• Moldy food found around apartment
• Feces on floor; strong smell of urine
• Multiple bruises noted in various stages of healing
• Blue/purple – green/yellow - brown
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Stages of bruising
Case Scenario #4
• General impression?
• Unable to care for self
• Elder neglect
• Intervention – transport
• Resources
• Human Services Resource Guide by United Way of Lake County
• Catholic Charities – 847-782-4000 (M – F)
• Hospital Social Worker
• Reminder – Document color of bruises; do not use words “new”
or “old”
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Skill Practice
• Review the process of inserting an IO needle
• Find the landmarks on a partner – humerus and tibia
• Insert an IO needle into a manikin
• With a partner, perform a field neurological exam on
each other
• AVPU
• Orientation
• Pupillary response
• Sensation and motor
83
Intraosseous Needle Insertion - IO
• Indications
Shock, arrest, or impending arrest
Unconscious/unresponsive or conscious patient without IV access
2 unsuccessful IV attempts or 90 seconds duration or no visible sites
• Contraindications
Extremity with acute fracture
Infection at insertion site
Previous orthopedic procedure at site (i.e.: knee replacement)
Pre-existing medical condition (i.e.: tumor, peripheral vascular disease)
Inability to locate landmarks
84
IO Equipment
• EZ IO needle – 15mm 15G; 25mm 15G; 45mm 15G
• Syringe with 0.9 NS (10ml adult >88 pounds; 5ml <88 pounds)
• Primed EZ-connect tubing
• Driver
• Material to cleanse site
• Primed IV bag
• Pressure bag
85
Primary IO Landmarks – Proximal Medial Tibia
• Leg must be straight to identify
landmarks
• Palpate lower edge of patella
• Identify site 2 finger widths below
patella (tibial tuberosity)
• Identify site 1 finger width
medially toward big toe
86
Adult Back-up IO Landmark –
Proximal Humerus (Greater Tubercle)
• Position flexed elbow tucked back & adducted; hand over navel
• Palpate prominence of greater tubercle (use heel of hand to gently
strike area feeling for prominent bone)
OR
• Palpate up humerus until groove of surgical neck is palpated; then
move up 1 cm (1 finger width) to most prominent spot
• Site is ANTERIOR to midline
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Demonstration IO Insertion
(Computer must have internet access)
• Click here to view video – humeral insertion site for IO
• Click here to view video – humeral insertion site for IO
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What’s With the Black Lines?
• Make best determination for needle size
• Short pink 15mm – for the very young; bone palpable just under skin
• Medium blue 25mm – for the majority of patients and in proximal tibial
site
• Long yellow 45mm – for the obese in proximal tibial site and for humeral
sites
• Insert needle into site until it stops – contact made with bone
• Look to verify at least one black line is visible
• Verifies enough needle left to insert into site
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Confirming IO Placement
• Felt “pop” upon insertion
• Needle stands up on own
• Able to aspirate blood or bone marrow
• May or may not be able to aspirate blood or bone marrow
• First attempt to aspirate should be prior to flushing
• Aspiration can be done at any time during infusion process
• Needle flushes easily without evidence of infiltration
• IV fluid flows once pressure bag placed around IV
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Controlling Pain Due to Fluid Infusion
• Insertion of IO needle not that uncomfortable
• Infusion of fluids is what could cause discomfort (non-expandable space)
• Watch for pain response from patient
• Verbal complaints, agitation, attempting to grab at IO needle (purposeful
movement), pulling affected extremity away (withdrawal)
• Administer Lidocaine 50 / 60 / 60
• Adult 50 mg over 60 seconds, wait 60 seconds then start infusion
• For pediatric patient administer 1mg/kg over 60 seconds, wait 60 seconds
• Slower instillation and waiting the time allows the medication to stay in the
area and to work
• Your dentist doesn’t inject and then start to drill right away!!!
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Documentation
• Document site used
• Document size needle used
• Printed on cap of needle holder
• Remember to place wrist band on patient
• Preferably same side as insertion site
• Patients to be banded for all attempts, failed and successful
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What is a Preceptor???
• A skilled practioner that will guide and teach those less skilled
Instructor / teacher
Tutor
Counsel
• Supports the growth and development of others
• Works with a novice to help them grow toward the expert level
• Provides direction aimed at specific performances
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Art of Precepting
• Not everyone will fall into the official role of “preceptor”
• But everyone can behave as a preceptor
• Positive attitude, sound knowledge of theory and skills, desire to learn
and desire to teach and guide others
• An effective preceptor can provide appropriate and effective critiques
• Timely – i.e.: immediately
• Respectful – not in punitive manner
• Pointing out what was good and what are opportunities for
improvement
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Final steps of this CE…
• Grab a partner and perform a field neurological exam on each
other
AVPU
GCS
Pupillary response
Sensory and motor
• Grab a partner and identify the tibial and humeral sites for IO
insertion
• Each paramedic needs to insert an IO needle
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Bibliography
 Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th
edition. Brady. 2013.
 Campbell, J., International Trauma Life Support for Emergency Care
Providers. 7th Edition. Pearson. 2012.
 Region X SOP’s; IDPH Approved January 6, 2012.
• Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady.
2010.
• http://www.helpguide.org/articles/abuse/elder-abuse-andneglect.htm#reporting
• http://www.eldercare.gov/Eldercare.NET/Public/Index.aspx
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Bibliography cont’d
• www.FindHelpLakeCounty.org
• http://www.alz.org/alzheimers_disease_facts_and_figures.asp#prevalence
• http://www.cdc.gov/Features/ElderAbuse/
• http://www.aoa.gov (Public Services of US Administration on Aging)
• http://www.jems.com/article/intraosseus/using-humerus-bone-io-access
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