Transcript Advanced Paramedic Skills

Advanced Paramedic Skills
Introduction to Symptom Relief
Quickie Overview
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ACR Documentation of DMA’s
Standing Orders
Review of Symptomatology
Medications
– Epinephrine
– Ventolin
– Glucagon
 Blood Sugar Determination
Remember these drugs??
 Ventolin - ???
 Epinephrine???
 Glucagon
 50% Dextrose in Water (D50W)
Autonomic Drugs
 Which are….
 Here is the mental stretching …..!!
How autonomic drugs work
 ANS transmits nerve impulses from the CNS to
the effector organs over efferent neurons
(preganglionic or postganglionic)
 Effector organs are the heart, smooth muscle and
exocrine glands.
 Neurotransmitter at effector organ determines type
of neuron
norepinephrine or epinephrine=adrenergic (sympathetic)
acethylcholine = cholinergic (parasympathetic)
Receptors
 If receptor responds to
NOREPI
ACH
EPI
acethylcholine
= muscarinic or
nicotinic
 If receptor responds to
norephinephrine or
epinephrine
= adrenergic
muscarinic
nicotinic
adrenergic
Sympathetic
Parasympathetic
Preganglionic
Acetylcholine
Preganglionic
Acetylcholine
Nicotinic receptor
Postganglionic
Norepinephrine
Nicotinic receptor
Postganglionic
Acetylcholine
Adrenergic receptor
Muscarinic receptor
Epinephrine
 Adrenergic Agonist
 Sympathomimetic
What is Anaphylaxis?
 Your text definition:
– An unusual or exaggerated allergic reaction to a
foreign protein or other allergen, resulting in a
systemic response of the body
 Causes:
– Environmental –such as..
– Medications –such as…
– Food-such as….
– Preservatives, Dyes, Blood products etc
Signs and Symptoms of
Anaphylaxis
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-
Drug Profile
 naturally occurring catecholamine that is produced in the
body and released by the adrenal gland
 Epinephrine can be considered the emergency hormone
and norepinephrine is mainly the transmitter hormone
 stimulates adrenergic neurons to bring about the various
effects on the body
Epinephrine
Pharmacokinetics
 Both Alpha and Beta-receptors are stimulated by
epinephrine.
 Epinephrine is a “direct acting” adrenergic agonist (see
explanation under Dopamine).
 It is metabolized primarily by MAO (monoamine oxidase)
and COMT (chol-o-methyltransferase).
Pharmacokinetics of Epi
Cardiovascular Effects
  SVR
 B/P
 Electrical activity in the heart
 cerebral and coronary blood
flow
 strength of myocardial
contraction
 MVO2
 automaticity
Receptor Response to Epi
Alpha Receptor
Vasoconstriction
Iris Dilatation
Intestinal relaxation
Intestinal sphincter
contraction
Pilomotor contration
Bladder sphincter
contraction
Beta Receptor
Vasodilatation (B2)
Cardioacceleration (B1)
Increased myocardial strength (B1)
Intestinal relaxation (B2)
Uterus relaxation (B2)
Bronchodilatation (B2)
Calorigenesis (B2)
Glycogenolysis (B2)
Lipolysis(B2)
Bladder wall relaxation(B2)
Therapeutic Uses
 Most widely used drug in cardiac arrest
setting
 refractory asthma
 ANAPHYLAXIS
And
– severe hypotension unresponsive to
dopamine
– Epinephrine is used extensively in the
resuscitation of children (2-10mcg)
– an additive in local anaesthetic agents to
help cause vasoconstriction
Adverse Effects
 Overdose is unlikely as the
drug is quickly metabolized
 Increased HR/BP,Sweating
 increase MVO2 demands and
have to given with caution to
those patients with ischemic
heart disease
Dosage/Supplied
– Adult- For anaphylactic reactions
–
–
–
–
(1:1,000) 0.5mg IM/SC
1 mg in 1 mL (1mg/ml conc)
For Cardiac arrest 1:10,000 1mg
IV q 3-5 mins. 2mgs ETT q 3-5
mins.
For bradycardia (hypotensive)
Pediatric- For anaphylactic
reactions (1:1,000) 0.1mg/10kg
max 0.3mg
Special Prehospital Concerns
 Epinephrine can be
administered in via IV,
ETT, SC, bolus or
infusion
 P1 administer it SC
ONLY!
 ideal dose of epinephrine
 Epinephrine is light
sensitive
 do not add to alkaline
sol’ns
 For anaphylactic shock!
Medication Handling
 5 rights
 Prepare equipment
 Drawing Up epi
 Prepare the site
 Insert the needle
 Take care of site post
 Monitor patient
See pages 444-448
Intramuscular or Subcutaneous
Injection
 Sites
– Deltoids
– Vasus lateralis Side of thigh
 How to do it
– 90/45 degrees
– 19-23/25-27 gauge needle
– 1 cc syringe
Salbutamol
 Adrenergic agonist (beta-2)
 Bronchodilator
Signs and Symptoms of
Bronchoconstriction
 Examples:
––––––-
#1
Ventolin
#2
Increase in cAMP
#4
H2O follows
sodium
#3
Activates chloride channels. As
channels open Chloride ions enter.
Sodium is drawn in to maintain ionic
balance.
Drug Profile
 beta agonists are thought to work is
by increasing the intracellular
concentrations of cAMP
 causes epithelial chloride channels
to open
 As the chloride ions move they
draw sodium ions along with them.
The  in sodium ions create a
gradient to draw water along with
them. This  in water acts to
lubricate the mucous
Therapeutic Uses
 Ventolin is used to treat bronchospasm
brought about from a number of factors.
 Intrinsic vs Extrinsic Asthma, COPD
 The fact that Ventolin is predominantly a
beta 2 receptor stimulator, the effects on
the beta 1 receptors of the heart are
minimal.
Adverse Effects
• nervousness
• tremors
• agitation
• dizziness
• palpitations
• headache
• tachycardia
• nausea.
•allergic reactions include angioedema,
urticaria, bronchospasm, hypotension, rash
•Overdosage may cause tachycardia, cardiac
arrhythmias, hypertension, hypokalemia and
in extreme cases, sudden death
Dosage -Adult and Pediatric
Dose: Salbutamol via Nebulizer:
< 25 kg – 2.5 mg
>=25 kg – 5.0 mg
Salbutamol via MDI
< 25 1 puffs followed by 4 breaths –repeat 6 times
>=25 1 puffs followed by 4 breaths –repeat 8 times
 Remember to allow MDI to recharge (30secs)
Special PreHospital Concerns
 administered by MDI
(metered dose inhaler) or
by nebulizer mask driven
by oxygen or air.
 Aerochamber is better
 To test how full an MDI
container is -see figure
How to administer Ventolin
 Things to remember:
Drug Profile
 Pancreatic Hormone
 Insulin Antagonist
 Hyperglycemic Agent
Signs and Symptoms of
Hypoglycemia
 Review:
Therapeutic Uses
•naturally occurring hormone which is produced in
the alpha cells of the islets of Langerhans in the
pancreas
•Glucagon works in opposition to insulin as it is
secreted when blood glucose concentrations
decrease
•increase the blood glucose concentration by
causing glycogenolysis in the liver (the
conversion of glycogen to glucose) as well as
increasing gluconeogenesis (the production of
‘new’ glucose in the liver from amino acids).
Used for symptomatic hypoglycemia (if unable/or not
certified to establish IV access for dextrose administration).
FYI As Antidote- beta blocker overdose (sinus bradycardia,
hypotension, AV block as well as widening of the QRS
complex, peaked T waves and ST changes)
IV Glucagon reverse these by enhancing
myocardial contractility, heart rate and AV conduction.
Special Prehospital Concerns
 BG First ( <4.0 mmol)
 Dose- given 1 mg SC
 Contraindications
– Pheochromocytoma
 0.5 mg for peds
 in large amounts
(phenol in sol’n) can
get toxic
Dextrose 50%
 Carbohydrate (Caloric Supplement)
Drug Profile
 simple sugar substance that the body can
rapidly metabolize while in hypoglycemic
states.
 It is a hypertonic solution that can produce
Ch2OH
O
OH
H
H
OH
H
OH
H
OH
high (intravascular) osmotic pressures,
resulting in a transient rise in intravascular
volume
 excreted in the kidneys it results in an
increased excretion of water from the body
and to a lesser degree sodium and chloride
 50ml pre load contains 25 grams of
dextrose
Therapeutic Uses/Adverse Effects
Therapeutic Uses
Acute hypoglycemia
Hyperkalemia
(helps K+ to shift
intracellularly) and to
prevent hypoglycemia
as pt receives insulin
Adverse Effects
 Hyperglycemia
 severe burning in
the vein
 tissue necrosis if
extravagation
 with CVA, worsens
condition due to
hypertonicity
Special Prehospital Concerns
 Take BS first
 large vein
 flush after admin
 watch for aggressive
behavior-hold arm
 pediatrics (25% sol’n)
 Thiamine first for
ETOH and
malnutrition
Blood Glucose Determination
 Glucometers
– How they work
 Preparation of the patient
– Consent
– Anticipate patient changes
 Prepare the glucometer
 Take the blood sugar
 Record the reading
Glucometer-Ascentia Contour
 No coding
 15 sec
 Touch blood to
Strip
 See handout
Blood Glucose Determination
 Lab work
 Heres where you get to try it on each other
Readings for You! -bledsoe
 Review Diabetes and S&S –pg 1381-1388
 Review Anaphylaxis S& S –pgs 1394-1404
 Review bronchoconstriction- pages1181-
1184
 Read Pharmacology section 414-425 and
434-448
Name a few things that could be confused
with hypoglycemia! What would they
present like??