Transcript March 2013 CE SOP Review

Region X SOP Review
March 2013 CE
Condell Medical Center
EMS System
Site Code: 107200E-1213
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Rev 3.12.13
1
Objectives
Upon successful completion of this CE, the EMS
provider will be able to:
1.Understands the responsibilities of the EMS provider
within the EMS System
2. Actively discuss various Region X SOP’s.
3. Understand the rationale for why a certain medication
is used and dosing schedule.
4. Understand when consultation with Medical Control
would be necessary.
2
Objectives cont’d
5. State indications for CPAP in pulmonary edema
following the Region X SOP’s.
6. Actively participate in case scenario
discussion.
7. Actively participate in review of assembling
of CPAP.
8. Successfully complete the post quiz with a
score of 80% or better.
3
EMS – Systems within Systems
• The Condell Medical Center EMS System
functions under the direction of Dr. M. Pearlman
– The CMC EMS System functions collaboratively
within Region X
• Includes HPH, North Lake County, and St. Francis
Systems
– HPH = Northshore University Health System
– North Lake County = Vista Health System
– St. Francis = Resurrection Saint Francis Hospital
• Region X oversight provided by IDPH
4
Certification vs Licensure
• Certification
– Process to grant recognition to an individual who
has met certain qualifications
• CPR, ACLS, PALS, ITLS
• Licensure
– Process of occupational regulation
– Permission granted to engage in a given trade or
profession based on the degree of competency
demonstrated
– A method to ensure public’s safety
5
Accreditation
• Process to ensure that a program meets minimal
guidelines
– Faculty, facilities, equipment, medical oversight,
clinical affiliations, financial stability
• National oversight to the process
• State of Illinois EMS Systems working on the
process of accreditation (including CMC)
– Accreditation via CoAEMSP
• Committee on Accreditation of Educational Programs for
the Emergency Medical Services Professions
6
Reciprocity
• Process by which an agency grants automatic
certification or licensure to an individual who has
comparable certification or licensure from another
agency
– To move State to State, contact the respective Department of
Public Health
– To move from one System to another, contact the Resource
Hospital for requirements
• Able to move within Region X departments based on
mutual respect for reciprocity and use of standardized
SOP’s
7
Scope of Practice
• Range of duties and skills paramedics and other
levels of EMS are allowed and expected to
perform
– Example: Your scope of practice allows you to
assess patients, bandage wounds, splint injuries, start
IV’s, and intubate (based on level of EMS provider)
• You must always function within your scope of
practice
– When performing as an ED tech, must function in
that role and NOT perform EMS skills not
approved for the tech job
8
Standard of Care
• The degree of care, skill, and judgment that
would be expected under like or similar
circumstances by a similarly trained, reasonable
paramedic in the same community
– Judged by how a prudent, similarly trained EMS
professional in your area would perform
• Example: If you have VF on the monitor, the
patient would be defibrillated, receive CPR, and
supportive therapies including medication.
9
On-line Medical Direction
• Orders given directly to a prehospital provider by radio or
telephone
– Function may be delegated to the ECRN
• Registered nurse who has completed a specialized course
– Approved to monitor telecommunications from and give
voice orders to EMS personnel under the authority of
the EMS Medical Director following System protocols
– As a nurse, the ECRN can only give orders as stated in
the SOP’s
• Additional orders must come from a physician as a
nurse cannot give medical orders without direction
10
Off-line Medical Direction
• Medical policies, procedures, and practices
established in advance of a call
• Includes pre and post call oversight and activity
on:
– Training and education
– Auditing, peer review, and other quality assurance
processes
– Conflict resolution
– Choice of equipment used
– Clinical protocols - SOP’s policies, and procedures
11
Emergency Medical Dispatch
• EMD
– A method to assign and direct emergency medical
care following pre-arrival directions
– Direction oversight provided by the Medical
Director
– Involvement of the EMS System personnel
– Includes annual training and education
12
Initial Education
• Course material presented following National
EMS Education Instructional Guidelines
published by US DOT
• Minimum content established
– EMS Systems may add to the minimum guidelines
• Uses 3 learning domains
Cognitive – facts, information, knowledge
Affective – assign emotions, values, attitudes
Psychomotor – hands-on skills learned in a lab or
clinical setting
13
Continuing Education
• Used to keep EMS personnel current
• Medicine is a dynamic process – always changing
• Process can be offered in a variety of mediums
–
–
–
–
Lectures
Observation vs active participation
Return demonstration of skills
Review/critique of activity
14
Evidence-Based Medicine
• The practice of following current best scientific
evidence when making decisions regarding the
care of patients
• Clinical evidence used to replace invalid
previously accepted treatments and procedures
with new ones that are more appropriate
– i.e.: Sodium bicarbonate is no longer automatically
administered to every arrested patient
– CPR rate of compressions is now at least 100 per
minute
15
System Operating Protocols
• Also referred to as Standing Orders
• Purpose
– Provide preauthorized policies and procedures to be
followed based on the patient assessment
• Allows for swift initiation of appropriate
interventions
• EMS provider needs to apply critical thinking
skills based on assessment, observation,
education, and training
16
SOP’s
• EMS cannot blindly follow the SOP’s in exact
detail – need critical thinking skills
• It is the EMS provider’s responsibility to know
when the SOP is followed as printed and when
deviation is appropriate
– i.e.: NTG is not given blindly to every patient with
chest pain
The blood pressure must be evaluated
A 12 lead EKG needs to be obtained observing for ST
elevation in the inferior leads II, III, aVF
EMS must screen for use of Viagra type medications
17
“Contacting Medical Control”
• Certain situations are listed in the SOP’s when
Medical Control is contacted
• For example:
Whenever the EMS provider is unsure of which way
to proceed on the call
For consideration of additional medication orders
To provide advanced notification to facilitate rapid
patient intervention (i.e.: patients with ST elevation
on 12 lead EKG’s and patients with suspected acute
stroke)
To terminate/withdraw resuscitative efforts
18
Scenario Review
• Review the following case presentations
• They are provided as a means to stimulate
discussion
– Determine your general impression
• This drives your choice of SOP to follow
–
–
–
–
Discuss which SOP is appropriate
Discuss the questions posed
Use critical thinking skills
Determine any opportunities for improvement
noted
19
Scenario #1
• Called to the scene for a 55 year-old male who
passed out
• Upon arrival patient lying on kitchen floor
unresponsive, apneic and pulseless (0-0-0)
• History of lung cancer and an old stroke
• Wife states patient hasn’t taken meds for past
week
• Patient in terminal stages of cancer
• What would you do?
20
Scenario #1
• Do you start CPR or withhold it?
– You need to ask if the patient has a valid DNR
• The wife states they have a DNR but it was to
be signed by the doctor at their visit later that
week
• In this patient’s terminal condition, do you start
or withhold CPR?
– Without a valid DNR and in absence of obvious
irreversible death like lividity or rigor mortis CPR
must be started (SOP page 87)
21
Scenario #1
• CPR is initiated
– 30:2 one and two man CPR for adults
– Compressions are 2 inches deep delivered at a rate
of at least 100 compressions per minute
• What’s the first piece of equipment that should
be used on a full arrest after CPR initiated?
– Get the monitor on the patient
– The rhythm drives the treatment decision
22
Scenario #1
• The monitor shows:
• What’s the rhythm?
– Asystole
• What treatment is administered and why?
23
Scenario #1
• Treatment for asystole
– CPR
• To provide artificial circulation/perfusion
• Keep interruptions to compressions under 10
seconds
– Establish IV/IO access
• Airway already covered under CPR; need access
established to administer medications
– Search for treatable causes
• The H’s and T’s
24
Scenario #1 – For Asystole
• NO defibrillation!!!
– Defibrillation results in asystole
• Allows opportunity for the dominant pacemaker site (SA
node) to take over with an organized rhythm
• NO pulse checks at the 10 second pause in CPR!!!
– Pulse checks are to be performed ONLY when the
rhythm viewed is one that should produce a pulse
• i.e.: VT or any organized rhythm
• In asystole and VF, would unnecessarily waste too much
time feeling for a pulse
25
Scenario #1 – Why Epinephrine?
• A vasopressor category medication
– Stimulates vasoconstriction
• When the hose gets smaller, pressure goes up
• First category of drug to give to all arrested patients
• 1st dose 1:10,000 1 mg IVP/IO
– 1 mg repeated every 3-5 minutes
• Epinephrine has a relatively short half life
• Did you know – Epinephrine can add strain to the
heart by increasing the work load – a negative effect
you take with the good
– This is why there is cautious use in setting of a patient with
cardiac history (think 1:1000 strength for allergic reaction)
26
Scenario #1 – Look for the Causes
• H’s
– Hypovolemia
• Listen for clear breath sounds
• Then administer fluid challenges
– Hypoxia
• Administer supplemental oxygen via BVM
– Acidosis (Hydrogen ion) from retained carbon dioxide
• Ventilate / breath for patient to rid body of retained CO2
– Hypothermia
• Cannot be cold and dead; must be warmed up
– Hyper/hypokalemia
• Consider potassium problem if on renal dialysis or extremely high
blood sugar levels and in DKA
27
Scenario #1 Additional Causes
• T’s
– Toxins
• Consider the young child exposed to others drug sources
– Tamponade, cardiac
• Difficult to look for signs and symptoms in arrest
• Any history?
– Tension pneumothorax
• What’s the history?
• Having trouble ventilating patient?
• Is there equal rise and fall of chest?
– Thrombosis – coronary or pulmonary
• What’s the history?
28
Withdrawing Resuscitative Efforts
• You have arrived on the scene
– The patient was an unwitnessed arrest and found to
be in asystole and remains in asystole
• These are generally not considered potentially viable
patients
– Or perhaps, as in scenario #1, the family does not
wish to have resuscitative measures started but does
not have a valid DNR in possession
Have you considered contacting Medical
Control for withdrawing resuscitative
efforts???
29
Withdrawing Resuscitative Efforts
Once started, you need to consult Medical Control to
terminate resuscitation efforts
• Medical Control to be contacted while
continuing care
• Report events of the call including duration of
cardiac arrest and treatments rendered
30
Withdrawing Resuscitative Efforts
• Reaffirm all of the following
Patient is normothermic adult
Patient experienced an unwitnessed arrest
Airway is secured and IV/IO placement confirmed
Patient remains in asystole
and
No response to al least 20 minutes of ALS care
31
Withdrawing Resuscitative Efforts
• If the physician orders termination of efforts, note
time or withdrawal of efforts and physician name on
run report
• Notify Coroner or Medical Examiner
• Scene can be turned over to police
• Appropriate communication, support and comfort
should be offered to the family
– What are your department resources to help with
this?
32
Scenario #1 Documentation
• Points to cover
– Condition of patient when found
– Supporting documentation available or lacking
(i.e.: valid DNR)
– If assisting ventilation, what rate and what method?
– If invasive equipment used
• What size (i.e.: airway, IV)?
• Confirmation of appropriate insertion (i.e.: airway)?
– If withdrawing resuscitation efforts, what time and
physician’s name giving the order
– If scene turned over then document to who
– Notification of coroner if applicable
33
Scenario #2
• EMS was called to the scene for a patient that
has been stabbed
• How would EMS approach this scene?
– Scene safety important - Is the scene safe?
– What is your policy for coordinating with the police?
• Can you determine field triage criteria for
trauma yet?
– Need to know anatomical location of stab wound
and stability of vital signs if in a non-vital area
34
Scenario #2
• Patient is 35 year-old female stabbed in left upper
quadrant
• Wound appeared “superficial” and ½ inch wide
• VS: B/P 132/72; P – 108; R – 24; SpO2 96%
awake/alert/cooperative; GCS 15 (4/5/6)
• Weapon no longer impaled in wound
• Bleeding minimal; controlled with 4x4
• Patient report called to hospital as a “category II
trauma”
– Is this a category II trauma patient?
35
Scenario #2 – EMS Perspective
• EMS felt they could “see” the depth of the wound
– As wound determined by EMS to be superficial, EMS
downgraded category of the trauma
• Can EMS determine the depth of a wound in the field?
– No, the physician would need to probe wound – may be
bedside or wait until patient in surgery
• What organ lies in the left upper quadrant that may
have been involved?
– Major organ is spleen
• Remember: It may be hard to determine if there is
isolated abdominal or chest wound or combination
36
Review:
Patient Categorization for Trauma
• Category I trauma
– Based on patient being unstable and/or anatomical
injuries with highest risk to life and/or limb
• Category II trauma
– Based on mechanism of injury
• Significant transfer of energy where the risk for
injury is high but the patient is stable at this point
in time
– Patient deserves frequent reassessment and
close observation should they become a
Category I trauma patient
37
Review – Trauma Category I
• Criteria for Category I level trauma
– Unstable vital signs
– GCS <13 with blunt head injury
• Attempt to eliminate Category I trauma activation
on the person with an altered level of consciousness
due to high alcohol levels – not trauma
– Anatomical injuries
• Penetration to head, neck, torso, groin
EMS does not explore the depth in the field
These are high risk areas if penetration due to
presence of organs or vessels
38
Category I Trauma cont’d
• Anatomy of Injury cont’d
– Combination trauma with burns >20%
– 2 or more proximal long bone fractures
– 2 or more body regions with potential of life/limb
threat
– Unstable pelvis
• Potential for large amounts of hidden blood loss
– Flail chest
• Chest wall unstable or with deformity’
• High risk for respiratory inadequacy
39
Category I Trauma cont’d
• Anatomy of Injury cont’d
– Limb paralysis &/or sensory deficits above the wrist
or ankle
– Open or depressed skull fracture
– Amputation proximal to wrist or ankle
40
Review: Category II Trauma
• Mechanism of injury
– Partial or complete ejection
– Death in same passenger compartment
– Motorcycle crash >20 mph or with separation of
rider form bike
– Rollover (unrestrained)
– Falls >20 feet (Peds > x3 body length)
– Pedestrian thrown or run over
– Auto vs pedestrian/bicyclist with > 5 mph impact
41
Category II Trauma cont’d
– Extrication > 20 minutes
– High speed MVC
• Speed > 40 mph
• Intrusion > 12 inches
• Major deformity > 20 inches
• Co-morbid Factors (increases the risks)
–
–
–
–
Age <5 without car/booster seat
Bleeding disorders or on anticoagulants
Pregnancy > 20 weeks
Renal disease requiring dialysis
42
Review: Transport Destinations
• Category I trauma patient
Highest level trauma center within 25 minute
transport time
• Category II trauma patient
Closest trauma center
• Traumatic arrest
Closest trauma center
• No airway
Closest comprehensive ED (includes free standing
facilities)
43
Scenario #2
• Is spleen a hollow or solid organ?
– Solid
• What is the danger of injury to a solid organs?
– Injured organ has the potential for blood loss
• What is the danger of injury to a hollow organs?
– Contents would spill and contaminate the
peritoneum or surrounding area
44
Abdominal
Contents
• Ribs
overlie
the spleen
• Damage
to ribs
could
cause
damage
to spleen
45
Retroperitoneal
Organs
46
Defining Location in Abdomen
• The abdominal area is defined by the quadrants
and related to the patient's right or left
47
Reporting and Documenting Chest
Injuries
• There are NO quadrants in the chest
– “Quadrants” is a term for describing the location of
the abdominal assessment
• Describe locations in the chest wall related to:
Clavicular line
Nipple line
Axilla reference – anterior, mid, posterior axillary
Intercostal spacing
48
Scenario #3
• Called to the scene for a 74 y/o male with
weakness; unable to get out of bed
• Weakness started “Thursday”
• Hx: AMI 2 years ago, pacemaker 1 year ago
• Meds: Metoprolol, Plavix, Levothyroxine,
Losartan, ASA
• GCS: 4/5/6 (total 15)
• What are you thinking as a general impression?
49
Scenario #3
• Weakness, dizziness, wooziness, can’t get out of
bed, don’t feel right
– Consider an abnormal presentation of a stroke
– At minimum perform the Cincinnati Stroke Scale
and document results
• Consider that this could also be the presentation
of an acute MI
– Obtain a 12 lead EKG
• If the level of consciousness is altered, obtain a
glucose level
50
Scenario #3
• Cincinnati Stroke Scale
Check facial dropping
Check arm drift
Check speech pattern
• Documenting results as “abnormal” is too vague
– Which component was not normal?
• Cannot trend for changes if specific results not
communicated (i.e.: documented)
51
Scenario #3- Cincinnati Stroke Scale
• Appropriate documentation of results
– Is there a right/left droop or no droop?
– Is there right/left arm drift or no arm drift?
– Is speech clear or not clear?
52
Scenario #3 - Documentation
• How many days ago was “Thursday”?
– Need to state number of days ago the incident
occurred or use the calendar date in documentation
• Especially in the event of a stroke, need specific
time of onset documented
– Most patients must be treated within a 3 hour time
frame from time of last known normal
• A few select cases may be extended to 4.5 hours from
time last known normal
• Need to document glucose level especially if
abnormal level of consciousness
53
Scenario #3
• Care for the patient with possible acute stroke?
– Follow Routine Adult Medical Care
• Don’t delay transport to initiate an IV
– Can IV be initiated while performing other scene
care?
– Can IV be initiated while enroute?
– IF sites do not look hopeful, should you forgo
attempts in the field and what for arrival in the ED?
• O2 if indicated
• SpO2 <94%
• Signs of respiratory distress present
54
Scenario #3
• If this patient began having a seizure, what
would you do?
– Versed 2 mg IN/IVP/IO
• Every 2 minutes titrated to control seizure activity
• Maximum up to 10 mg
• If seizure activity continues or recurs
– Repeat Versed 2 mg IN/IVP/IO
• Every 2 minutes titrated to control seizure activity
• Total maximum an additional 10 mg
55
Scenario #3
• Why is Versed used for seizure activity???
– A Benzodiazepine
• Amnesic, sedative, seizure activity
– Relatively fast acting (onset 1-3 minutes)
– Relatively short duration (20-30 minutes)
– Can be administered via nasal route in absence of IV
access
Cautious use in volume depleted patient
Can cause respiratory depression and hypotension
• Assist ventilation if necessary
• Monitor blood pressure
56
Scenario #3
• How do you care for a patient with active seizure
activity???
– Protect airway
• Place them on their side if no trauma suspected
• Consider use of suction
– Limited to 10 seconds at a time
– If long term seizure need to support respirations
• Use BVM at a rate of one breath every 5-6 seconds
– If patient intubated, ventilations delivered once
every 6-8 seconds
57
Scenario #4
• 82 year-old patient calls due to sudden onset
difficulty breathing
• Found sitting upright in recliner
• Talking in 2-3 word sentences
• Diaphoretic
• Appears in obvious respiratory distress
What’s your impression???
58
Scenario #4
• Impression
– Sounds like pulmonary edema until proven
otherwise
Consider age, medical history, list of medications used
– Could be acute MI from being in pulmonary edema
or acute MI causing the pulmonary edema
• What information is necessary in the assessment
to help drive treatment/intervention choices?
– Lung sounds
– Vital signs
– Rhythm strip and 12 lead EKG
59
How Does Fluid Accumulate?
• Left ventricle fails as forward pump
– Pulmonary venous pressures rise
– Fluid is forced from capillaries into interstitial
(tissue) spaces between capillaries and alveoli
• In pulmonary edema, fluid eventually fills alveoli
– Decreased space available for oxygen exchange
Hypoxia develops
– Carbon dioxide cannot be exchanged & builds up
and hypercarbia develops
60
Pulmonary Edema
• In pulmonary edema, the body becomes a
hypoxic, acidotic environment
– Many body functions not efficient or unable to
function in this environment
– Many medications and interventions less effective, if
at all, in hypoxic, acidotic environments
– With excess carbon dioxide (hypercarbia), patient
develops CNS depression
• Respiratory drive and ventilation rate can slow
61
Scenario #4 – Signs and Symptoms
Pulmonary Edema
• Sudden onset dyspnea
• Signs of respiratory distress
–
–
–
–
–
–
Unable to speak in full sentences
Use of accessory muscles
Increased respiratory rate (tachypnea)
Crackles beginning at both bases
Rhonchi- fluid in larger airways
Wheezes as protective mechanism
• Bronchioles constrict to minimize fluid moving into lungs
– Coughing
– Cyanosis in late stages
• JVD may be present
62
Scenario #4
• What is the treatment for pulmonary edema???
– To know what pathway to follow need to determine
if patient is relatively stable or is unstable
• If unstable, means:
– Unable to use standard treatment
• NTG, CPAP, Lasix, Morphine
– All have the potential to drop the blood pressure
• What does “relatively” stable mean???
– Patient will have some signs and symptoms but
perfusion is still maintained
63
Scenario #4 – Treatment of Stable
Pulmonary Edema
• Nitroglycerin
– 0.4 mg sl
– May repeat every 5 minutes to 3 doses
• Begin CPAP
• Lasix
– 40 mg IVP
– Increase to 80 mg if taken at home
• Morphine
– If B/P remains >90
– 2 mg IVP repeated every 2 minutes to 10 mg
64
Scenario #4 –
Why do we do what we do???
• Nitroglycerin
– Venodilator – reduces volume of blood returning to the heart
(preload) by vasodilating blood vessels
– Less pressure in vessels allows CPAP to move fluid from
lungs to vascular space
• CPAP
– Keep alveoli open and distended increasing surface space for
oxygen exchange
• Lasix
– Diuretic and venodilator (works relatively quickly as a
venodilator; takes longer to act as a diuretic)
• Morphine
– Reduces anxiety and acts as venodilator
65
Scenario #4 – CPAP Mask
• Applying the tight fitting mask can be
frightening
• But, patients turn around quickly once CPAP
has been started
• Patient will need to be “talked through” first few
minutes to decrease their anxiety in this situation
66
Scenario #4
• All treatment used in pulmonary edema can cause a
drop in blood pressure
– Monitor B/P carefully and frequently
– If patient develops hypotension, stop therapies and consider
administration of dopamine drip
• The patient could become hypotensive because they are
developing cardiogenic shock due to nature of their
condition
• Medications are given to support the patient until the
CPAP takes effect
– Medications are given simultaneously with CPAP treatment
67
Scenario #4 - Dopamine
• Effects in body dose dependent
– At lower doses 5-20 mcg/kg get beta influence on
the heart
• Increased contractility strength to move more blood out
of the heart
– At higher doses over 20 mcg/kg get alpha influence
in blood vessels
• Extreme vasoconstriction that is too restrictive to
promote adequate blood flow
• Start dosing at 5 mcg/kg and titrate upward to
20 mcg/kg
– Goal – B/P >90 mmHg
68
Dopamine
• Watch infusion site carefully
• If IV infiltrates, basically will “dump” a load of
drug at the site
– Will cause severe vasoconstriction to the area
– Can cause tissue sloughing over the next few days
– Will need a counteractive medication to be
administered at the hospital
• Report to hospital staff any incidence of
infiltration
• Document infiltration site if it occurs
69
Dopamine Extravasation
• Carefully monitoring can help prevent this effect
70
Scenario #4
• Important to determine WHY a patient is in
pulmonary edema in order to treat the
underlying problem
• Good rule to live by:
– Consider any patient in pulmonary edema to
be having an acute MI until proven otherwise
– Make all attempts to obtain a 12 lead EKG as
soon as possible
71
Scenario #4 – ST elevation present?
V2 – V6
72
Scenario #4
• What complications are more common for the
patient with ST elevation in the anterior/septal
and lateral chest leads???
• Lateral and septal walls (I, aVL, V1-V2, V5-V6)
– Conduction dysrhythmias most common
• Heart block – 2nd degree Type II (classical) & 3rd degree
(complete)
• Bundle branch blocks
• V 3 -4
– Known as the “widow maker” - potential for a massive area
of infarction from blockage of the large amount of
myocardium supplied by the LAD (left anterior descending
artery)
– Lethal ventricular dysrhythmias and cardiogenic shock
– Early death within a few days often from CHF
73
Reporting Results of 12 Lead EKG
• In report, give YOUR interpretation of
presence/absence of ST elevation
– If ST elevation present, in which leads?
• Then read word for word the print out posted
on the 12 lead EKG
– You may not think the words are important but they
may help interpret the 12 lead
• We rely more on YOUR interpretation but
putting the 2 together are important assessment
tools
74
Scenario #5
• You are called to the scene for a 66 year-old
patient in respiratory distress
• Upon arrival, patient is sitting upright
complaining of dyspnea for 30 minutes
• History: diabetes, COPD, hypertension
• VS: B/P 146/70; P – 122; R – 18; SpO2 95%
room air
• Monitor – sinus tachycardia
• Lungs – bilateral expiratory wheezes
• Glucose - 287
75
Scenario #5 – History cont’d
• Medications
–
–
–
–
Combivent
Albuterol
Insulin
Hydrochlorothiazide
• Patient has used his inhaler x2 in past 30
minutes with no relief
• Patient denied chest pain; but states has been
feeling weaker than normal
76
Scenario #5
• What is your general impression???
– Acute exacerbation of COPD?
• Would you think new onset of asthma???
- No, you do not typically suddenly develop asthma at
an older age
– Wheezing in older patients with no history of
COPD or asthma - consider CHF until proven
otherwise
• Hence the saying… Old geezers do not become
new wheezers
77
Scenario #5 - What About
Pulmonary Edema?
• Should be a consideration
– What is the history???
• Look at the list of medications taken
– What is the presentation???
• Any clues to chronic right sided heart failure or acute left
sided?
–
–
–
–
–
Pedal or dependent edema?
JVD?
Increasing shortness of breath?
Inability to lie down?
Bilateral crackles?
78
Scenario #5 – Treatment for COPD
with Wheezing
• Adult Routine Medical Care
• DuoNeb
– Albuterol 2.5 mg/3ml mixed with
– Atrovent 0.5 mg/2.5ml
– Administered with O2 flow at 6l
• When could you repeat a treatment?
– Albuterol repeated every 5 minutes as needed
• Severe distress, contact Medical Control
– Considers order for Epinephrine 1:1000 0.3 mg IM
79
Scenario #5 – Why These Meds???
• They are bronchodilators
– They work differently in the body for same end result
• Albuterol = Proventil, Ventolin
– Short acting, quick acting rescue drug
• Atrovent = ipratropium
– Not considered a “rescue” drug (ie: not fast acting)
• Muscles wrapped around airways relax easing
bronchoconstriction
• A frequent complaint after use is a feeling of
jitteriness
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Scenario #5
• Why Epinephrine with contact of Medical
Control???
– A bronchodilator
– Works quickly
– As a negative effect, can add strain to the heart
Increases heart rate and strength of contractility
Increased work load to the heart means it will
require more oxygen
Can put a strain on the heart of a patient with
cardiac history
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Scenario #5
• What are components of patient assessment?
–
–
–
–
–
General appearance
Position patient found in and best tolerated
Vital signs including room air SpO2 if possible
Breath sounds before, during, and after treatment
Ability to complete sentences or number of words
patient able to speak per breath (ie: “speaking in 2-3
word sentences”)
– Response to treatment
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Scenario #5 - Documentation
Include data from assessment
General appearance
Position patient found in and best tolerated
Vital signs including room air SpO2 if possible
Breath sounds
Ability to complete sentences or number of words
per breath (ie: “speaking in 2-3 word sentences”)
Response to treatment
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Scenario #5
• What about the glucose level of 287???
– This is elevated beyond having just eaten
• May be why patient states feeling weaker than normal
• Do not automatically treat this patient for
hyperglycemia
– Treat presenting problem first
– Do consider dual problems though
• But use critical thinking skills
– Would you feel comfortable administering fluid
challenges to the patient in respiratory distress?
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Scenario #5
• What is the rhythm strip?
Sinus tachycardia
• Why do you think they are in this rhythm?
– Working hard to breath
– Increased anxiety level
– Elevated glucose levels can cause tachycardia
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Scenario #6
• You are called to the scene at 3 am for an
unconscious male at a local restaurant
• He appears to be in his 20’s
• Friends state they are unaware of any medical
history
• Upon arrival patient has snorous respirations
and withdraws to pain
• There is no medic alert tag
• There is no sign of trauma
What is your general impression???
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Scenario #6
• Considerations high on the list
Intoxicated
Drug overdose
Diabetic with insulin shock
Post ictal from seizure activity
• What assessments need to be completed?
– Vital signs
– Blood glucose level
– Assessment of pupillary response
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Scenario #6
• VS: B/P 110/70; P – 90; R 14; SpO2 96%
• Glucose 23
• Pupils equal and reactive; midrange size
• So now what do you think???
– Diabetic reaction most likely
• So what do you need to do???
– Establish IV access and administer Dextrose
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Scenario #6
• In the absence of IV access, what should you
do?
– Use critical thinking skills
• How urgent is the need for Dextrose?
– If patient is awake, can give food/drink orally
– Can give glucagon IM/IN
• Might be effective if there are any sugar
stores left in the body
– If patient is actively seizing due to low sugar
levels, then IO needle may be indicated to get
vascular access to give treatment
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CPAP Skill
• Review the following slides on the use of CPAP
• Review the equipment in your department
– Where are the components?
– How do you put the parts together?
– How do you document the use of CPAP?
• Note: If brand of equipment changes in the
future, the principles will remain the same
– In-services and guidelines would be distributed prior
to switching to new equipment
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CPAP
• Equipment
– Tight fitting mask with tubing
– Generator
– Oxygen source
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O2 Supply with CPAP
• The higher the setting, the faster oxygen is used
• D sized tank – 30 minutes*
– Typical size portable tank on patient cot
• H sized tank – 508 minutes* (8+ hours)
– Typical large tank kept in locker on rig
• E sized tank – 50 minutes*
– Typical size used in hospitals on patient transports
• M sized tank – 253 minutes* (approx 4+ hours)
* Based on 50 psi output & approx 30% FiO2
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CPAP
• Background
– Proven effective with acute CHF
– If applied early enough can prevent need for
intubation and mechanical ventilation of
patient
• Intubation increases mortality rates
– CPAP maintains a constant pressure within
the airway throughout the respiratory cycle
• PEEP only applies pressure during
expiration
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How Does CPAP Work?
• Some sources state CPAP forces excess fluid out
of alveoli back into pulmonary capillaries
• Some sources describe the expansion of the
alveoli giving more space to allow for
oxygen/carbon dioxide exchange
CPAP decreases the work of breathing
CPAP buys time for other therapies (ie: meds) to
work
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How CPAP Works
• Think of 2 balloons
• One deflated and with fluid (i.e.: an alveoli)
• One distended with air and same amount of
fluid (i.e.: alveoli under CPAP pressure)
• Distended balloon (i.e.: alveoli) has more surface
space available for oxygen exchange
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CPAP
CPAP expands the surface area of the collapsed
alveoli allowing more surface area to be in
contact with capillaries for gas exchange
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Hazards of CPAP
• Risk of barotrauma (ie: pneumothorax or
pneumomediastinum) if pressures are excessive
exceed 10 cm H2O)
• Increased pressure in chest cavity could reduce
ventricular filling
(ie:
– Could worsen cardiac output including a drop in blood
pressure
• Patients need to be constantly monitored and you may
have to discontinue CPAP based on patient response
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Contraindications CPAP
• Acute altered mental status
• Vomiting
• Systolic B/P <90
– Remember: All medications and devices
used to treat pulmonary edema could
cause a drop in B/P
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Adding to CPAP Set-up
• Supplemental O2
– Attach O2 tubing to red port on front of mask
– Titrate up to 15 L/minute
• Aerosol medication
– Cut corrugated tubing at first smooth part closest to
mask
– Place T connector between tubing
– Keep aerosol container upright to prevent spillage
of liquid medication
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Providing CPAP Treatment
• Remember:
– Need to set this up quickly before the patient
deteriorates
– Patient will need coaching to “hang in there”
until the treatment starts reversing their
symptoms
• Response is usually quick – within minutes
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Bibliography
• Administrative Code, Emergency Medical
Services and Trauma Center Code, Part 515.
• Bledsoe, B., Porter, R., Cherry, R. Paramedic
Care Principles & Practices, 4th edition. Brady.
2013.
• Region X SOP’s; IDPH Approved January 6,
2012.
• http://www.jems.com/article/patientcare/many-benefits-cpap
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