1 Integration of Revised Region X SOP’s February 2012 CE Condell Medical Center EMS System Site...

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Integration of Revised Integration of Revised Region X SOP’sRegion X SOP’s

February 2012 CEFebruary 2012 CECondell Medical Center Condell Medical Center

EMS SystemEMS SystemSite Code: 107200E -1212Site Code: 107200E -1212

Prepared by: Sharon Hopkins, RN, BSN, EMT-PPrepared by: Sharon Hopkins, RN, BSN, EMT-PRev 2.29.12Rev 2.29.12

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ObjectivesObjectives

Upon successful completion of this module, the Upon successful completion of this module, the EMS provider will be able to:EMS provider will be able to:

1. Identify treatment protocols per current 1. Identify treatment protocols per current Region X SOP’s.Region X SOP’s.

2. Explain rationale for treatment based on 2. Explain rationale for treatment based on assessment of the patient.assessment of the patient.

3. 3. Given a variety of scenarios, utilize the Given a variety of scenarios, utilize the SOP’s to determine treatment indicated for SOP’s to determine treatment indicated for the patient.the patient.

4. Given a variety of EKG rhythms, identify 4. Given a variety of EKG rhythms, identify the rhythm and discuss treatment.the rhythm and discuss treatment.

5. Successfully complete the post quiz with a 5. Successfully complete the post quiz with a score of 80% or better.score of 80% or better.

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Region X SOP’sRegion X SOP’s

Region X SOP’s went into effect Region X SOP’s went into effect February 1, 2012February 1, 2012

This CE module will incorporate This CE module will incorporate reinforcing the SOP’s by working in small reinforcing the SOP’s by working in small groupsgroups

A scenario will be presentedA scenario will be presented Work as a small group using the SOP’s as Work as a small group using the SOP’s as

a reference to determine appropriate a reference to determine appropriate treatmenttreatment

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Case Scenario #1Case Scenario #1

EMS is called to the scene for a 87 year-EMS is called to the scene for a 87 year-old male who “fell”old male who “fell”

The patient is unconscious and The patient is unconscious and “bystander” CPR is being performed“bystander” CPR is being performed Patient didn’t “fall”; was helped to the groundPatient didn’t “fall”; was helped to the ground

EMS arrives on the scene, the scene is EMS arrives on the scene, the scene is safesafe

EMS approaches the patient who is lying EMS approaches the patient who is lying on the ground, not movingon the ground, not moving

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Upon arrival EMS needs to reassess the patient Upon arrival EMS needs to reassess the patient for evidence of breathing and presence of a for evidence of breathing and presence of a pulsepulse

There is no pulse, continue CPRThere is no pulse, continue CPR What equipment will be required?What equipment will be required?

First piece of equipment to attach is the First piece of equipment to attach is the monitormonitor Identifying the rhythm drives care to be Identifying the rhythm drives care to be

delivereddelivered Need vascular accessNeed vascular access Anticipate additional methods to further Anticipate additional methods to further

secure the airway beyond BVMsecure the airway beyond BVM

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Point of discussion…Point of discussion…

How do you perform 1 and 2 man CPR on How do you perform 1 and 2 man CPR on an adult?an adult? 30:2 ratio compression to ventilations30:2 ratio compression to ventilations Compressions at a rate of at least 100/ minuteCompressions at a rate of at least 100/ minute Once advanced airway placed, ventilate once Once advanced airway placed, ventilate once

every 6-8 secondsevery 6-8 seconds How often do you switch CPR compressors?How often do you switch CPR compressors?

Every 2 minutes (after 5 cycles)Every 2 minutes (after 5 cycles) Getting tired, you get sloppy, technique suffersGetting tired, you get sloppy, technique suffers

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What is the rhythm (NO PULSE!!!)?What is the rhythm (NO PULSE!!!)?

PEA PEA What interventions are required?What interventions are required?

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CPRCPR Searching for causes (H’s and T’s)Searching for causes (H’s and T’s) Begin fluid challenge if breath sounds are Begin fluid challenge if breath sounds are

clearclear Epinephrine 1:10,000 1 mg IVP/IOEpinephrine 1:10,000 1 mg IVP/IO

May repeat every 3-5 minutesMay repeat every 3-5 minutes

If return of spontaneous circulation, follow If return of spontaneous circulation, follow ROSC Hypothermia InductionROSC Hypothermia Induction

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What methods are used to secure an What methods are used to secure an airway?airway? Positioning – easiest, quickest, least attemptedPositioning – easiest, quickest, least attempted BVMBVM

May need oro/nasopharyngeal supportMay need oro/nasopharyngeal support Endotracheal tube (ETT)Endotracheal tube (ETT)

Most secure method to protect the airwayMost secure method to protect the airway King airwayKing airway

If 2 failed attempts with ETT or difficult airwayIf 2 failed attempts with ETT or difficult airway CombitubeCombitube

Limited situationsLimited situations

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SOP’s utilized - PEASOP’s utilized - PEAEmergency Cardiac Care, Universal Adult Emergency Cardiac Care, Universal Adult

(pg 6) (pg 6) Pulseless Electrical Activity, Adult (pg 10)Pulseless Electrical Activity, Adult (pg 10)Ref: CPR Guidelines (pg 85)Ref: CPR Guidelines (pg 85)Skill: Intraosseous Infusion, Adult (pg 78)Skill: Intraosseous Infusion, Adult (pg 78)Ref: ROSC Hypothermia Induction (pg 88)Ref: ROSC Hypothermia Induction (pg 88)

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EMS is called to the scene of a private EMS is called to the scene of a private residence for a 25 year-old female with residence for a 25 year-old female with abdominal painabdominal pain

Upon arrival the patient is lying on the Upon arrival the patient is lying on the couch appearing uncomfortable, pale, with couch appearing uncomfortable, pale, with shallow breathingshallow breathing

Patient is hugging a bucket and has the Patient is hugging a bucket and has the dry heavesdry heaves

Patient weighs 160 poundsPatient weighs 160 pounds

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What information is important to obtain during What information is important to obtain during assessment for any patient with abdominal pain?assessment for any patient with abdominal pain? O – onset – what were they doing?O – onset – what were they doing? P – what provokes/palliates it (makes it better)?P – what provokes/palliates it (makes it better)? Q – what is the quality in their own words?Q – what is the quality in their own words? R – does it radiate? If yes, where?R – does it radiate? If yes, where? S – how severe on a scale of 0 10?S – how severe on a scale of 0 10? T- what time did is start?T- what time did is start?

Have you inspected the site and have you Have you inspected the site and have you palpated the abdomen?palpated the abdomen?

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What information is important to obtain for a What information is important to obtain for a female with complaints of abdominal pain?female with complaints of abdominal pain? Ask about the potential for pregnancyAsk about the potential for pregnancy

When was the last menstrual period (LMP)?When was the last menstrual period (LMP)?Need to consider an ectopic pregnancyNeed to consider an ectopic pregnancy

Patient may not even be aware she is Patient may not even be aware she is pregnantpregnant

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Case Scenario #2Case Scenario #2 What care is to be provided to this patient What care is to be provided to this patient

after obtaining the history of illness and after obtaining the history of illness and SAMPLE?SAMPLE? Pain scale with reassessmentPain scale with reassessment If SpO2 >94% does not need oxygenIf SpO2 >94% does not need oxygen EKG monitor (not indicated)EKG monitor (not indicated)

Careful - some “abdominal problems” may be Careful - some “abdominal problems” may be cardiac issues masking as abdominalcardiac issues masking as abdominal

IV access for medication administrationIV access for medication administration Fentanyl 0.5 mcg/kg IVP/IN/IO for painFentanyl 0.5 mcg/kg IVP/IN/IO for pain Zofran 4 mg IVP over 30 seconds for nauseaZofran 4 mg IVP over 30 seconds for nausea

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If the patient weight falls in between on the If the patient weight falls in between on the SOP scale, what dose is followed?SOP scale, what dose is followed? Safer to go to the lesser amountSafer to go to the lesser amount

Can always give more medications but can’t get it Can always give more medications but can’t get it back if already deliveredback if already delivered

Can always do the math calculation for a Can always do the math calculation for a precise amountprecise amount

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How fast can these medications be given?How fast can these medications be given? Fentanyl over 2 minutesFentanyl over 2 minutes Zofran over 30 secondsZofran over 30 seconds

What side effects may occur?What side effects may occur? Fentanyl may cause respiratory depression Fentanyl may cause respiratory depression

and muscle rigidity if given fastand muscle rigidity if given fast Zofran may cause involuntary movements; Zofran may cause involuntary movements;

often see drowsiness especially in children; often see drowsiness especially in children; side effects are rareside effects are rare

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If respiratory depression occurs with If respiratory depression occurs with Fentanyl, what action is needed?Fentanyl, what action is needed? Can use Narcan as a reversal agentCan use Narcan as a reversal agent

Fentanyl is a synthetic narcoticFentanyl is a synthetic narcotic Prepare to ventilate (bag) the patient Prepare to ventilate (bag) the patient

one breath every 5-6 secondsone breath every 5-6 seconds

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SOP’s Utilized – Abdominal PainSOP’s Utilized – Abdominal Pain Routine Medical Care, Adult (pg 5)Routine Medical Care, Adult (pg 5) Pain Management, Adult (pg 34)Pain Management, Adult (pg 34) Nausea Management, Adult (pg 34)Nausea Management, Adult (pg 34) Ref: CPR Guidelines (pg 85)Ref: CPR Guidelines (pg 85)

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EMS responds to a call for a 83 year-old EMS responds to a call for a 83 year-old female who fell. On arrival, the patient is female who fell. On arrival, the patient is found to be lying on her side and states “I found to be lying on her side and states “I can’t move my legs.” can’t move my legs.”

Patient is conscious and alertPatient is conscious and alert Pain in her hip and thigh is 10/10 if she Pain in her hip and thigh is 10/10 if she

tries to movetries to move Patient weighs 180 poundsPatient weighs 180 pounds

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What question is important to ask for any call What question is important to ask for any call involving a patient who has fallen?involving a patient who has fallen? WHYWHY did the patient fall? did the patient fall?

Syncope/dizziness?Syncope/dizziness? Think medical problem (ie: cardiac, Think medical problem (ie: cardiac,

CVA) along with traumaCVA) along with traumaTripped?Tripped?

Think traumaThink trauma Document Document WHYWHY the patient fell and include in the patient fell and include in

the verbal reportthe verbal report Consider need for c-spine immobilizationConsider need for c-spine immobilization

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Case Scenario #3Case Scenario #3 VS: 136/80; P – 60; R – 16; SpOVS: 136/80; P – 60; R – 16; SpO22 98% 98% What needs to be included in an orthopedic What needs to be included in an orthopedic

assessment?assessment? MOI (mechanism of injury)MOI (mechanism of injury) Consider additional injuries (ie: C-spine)Consider additional injuries (ie: C-spine) Appearance – Any deformity? Change in color?Appearance – Any deformity? Change in color? Distal CMS/PMS/SMV before/after splintingDistal CMS/PMS/SMV before/after splinting

All abbreviations in SOP dictionaryAll abbreviations in SOP dictionaryPain scalePain scaleReassessment/response to Reassessment/response to

treatment/interventionstreatment/interventions

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How is pain addressed?How is pain addressed? RICERICE

Rest, ice, compress, elevateRest, ice, compress, elevate Fentanyl 0.5 mcg/kg IVP/IN/IOFentanyl 0.5 mcg/kg IVP/IN/IO

May repeat same dose in 5 minutesMay repeat same dose in 5 minutes Question…Question…

Are you likely to see cardiovascular changes Are you likely to see cardiovascular changes (ie: drop in B/P) with Fentanyl?(ie: drop in B/P) with Fentanyl?Cardiovascular changes are NOT seenCardiovascular changes are NOT seen

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SOP’s Utilized – Orthopedic CallSOP’s Utilized – Orthopedic Call Routine Medical Care, Adult (pg 5)Routine Medical Care, Adult (pg 5) Pain Management, Adult (pg 34)Pain Management, Adult (pg 34) Region X Field Triage Criteria (pg 30)Region X Field Triage Criteria (pg 30) Routine Trauma Care, Adult (pg 29)Routine Trauma Care, Adult (pg 29)

Document methods used to assess the patient Document methods used to assess the patient and if determined no need for spinal and if determined no need for spinal immobilization/spinal motion restriction, include immobilization/spinal motion restriction, include that documentationthat documentation

Remember to consider distracting injuriesRemember to consider distracting injuries

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EMS is called for a 2 year-old male who is EMS is called for a 2 year-old male who is having a seizurehaving a seizure

Dispatch reports child is unconscious and Dispatch reports child is unconscious and breathingbreathing

On arrival, child found lying limp in On arrival, child found lying limp in mother’s armsmother’s arms

Pale, respirations even, moaning, droolingPale, respirations even, moaning, drooling VS: P – 148; R 12; skin warm; withdraws VS: P – 148; R 12; skin warm; withdraws

to pain & eyelids flutterto pain & eyelids flutter

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Parents state patient had been relatively Parents state patient had been relatively healthy with a “bit of a runny nose” last few healthy with a “bit of a runny nose” last few days but “not that sick”days but “not that sick”

Patient was put down for a napPatient was put down for a nap Parents heard thrashing and found patient Parents heard thrashing and found patient

with seizure activity with seizure activity

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What is the patient’s GCS?What is the patient’s GCS? E – 2 (flutter to pain)E – 2 (flutter to pain) V – 2 (moaning/incomprehensible words/sounds)V – 2 (moaning/incomprehensible words/sounds) M – 4 (withdraws)M – 4 (withdraws) Total 8Total 8

Immediate care necessaryImmediate care necessary BVMBVM

12 breaths/minute NOT normal for a 2 year-old12 breaths/minute NOT normal for a 2 year-old Normal respiratory rate for 2 year-old – 20-30 breaths/minNormal respiratory rate for 2 year-old – 20-30 breaths/min Deliver 1 breath every 3-5 seconds Deliver 1 breath every 3-5 seconds

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What interventions are necessary if patient What interventions are necessary if patient begins to have a seizure that does not begins to have a seizure that does not stop relatively quickly?stop relatively quickly? Versed 0.1mg/kg IN/IVP/IOVersed 0.1mg/kg IN/IVP/IO

Titrated to control seizureTitrated to control seizure Max 10mgMax 10mg May be repeated if seizure activity May be repeated if seizure activity

continues/reoccurscontinues/reoccurs

Evaluate glucose levelEvaluate glucose level Blood glucose level 94Blood glucose level 94

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Do all patients with an altered level of Do all patients with an altered level of consciousness need to have a glucose level consciousness need to have a glucose level checked?checked? YES!!! YES!!!

What’s most likely causing this child’s seizures?What’s most likely causing this child’s seizures? FebrileFebrile Poisons/chemical exposure/accidental Poisons/chemical exposure/accidental

overdoseoverdose Head injuryHead injury TumorTumor

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SOP’s UtilizedSOP’s Utilized Routine Medical/Trauma Care, Pediatric Routine Medical/Trauma Care, Pediatric

(pg 43)(pg 43) Altered Mental Status, Pediatric (pg 55)Altered Mental Status, Pediatric (pg 55) Seizures, Pediatric (pg 56)Seizures, Pediatric (pg 56) Febrile Seizures (pg 56)Febrile Seizures (pg 56) Ref: CPR Guidelines (pg 85)Ref: CPR Guidelines (pg 85) Ref: Vital Signs, Pediatric Normal (pg 93)Ref: Vital Signs, Pediatric Normal (pg 93)

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EMS is called to the scene for a 57 year-EMS is called to the scene for a 57 year-old female feeling “ill”old female feeling “ill”

Patient is lying on the couch awake but Patient is lying on the couch awake but sleepily answering questionssleepily answering questions

Pale, diaphoretic, feels lightheaded when Pale, diaphoretic, feels lightheaded when sitting upsitting up

Hx: diabetic, hypertension, old CVAHx: diabetic, hypertension, old CVA

VS: B/P 86/56; P – 42; R – 20; SpOVS: B/P 86/56; P – 42; R – 20; SpO2 2 99%99%

Weight – 200 poundsWeight – 200 pounds

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What’s the rhythm?What’s the rhythm?

Sinus bradycardiaSinus bradycardia

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What indicators are present if the patient is What indicators are present if the patient is unstable due to the bradycardia?unstable due to the bradycardia? Stable and unstable patients can BOTH beStable and unstable patients can BOTH be

Pale, diaphoretic, feel lightheadedPale, diaphoretic, feel lightheaded If unstableIf unstable

Altered level of consciousnessAltered level of consciousness First indicator to changeFirst indicator to change

Hypotension is presentHypotension is present Last indicator to change after Last indicator to change after

compensation is exhaustedcompensation is exhausted

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What care is being provided to the What care is being provided to the patient?patient? IV accessIV access Monitor – Sinus bradycardiaMonitor – Sinus bradycardia Atropine 0.5 mg rapid IVP/IOAtropine 0.5 mg rapid IVP/IO Prepare for transcutaneous pacingPrepare for transcutaneous pacing

If Atropine ineffective, administer Valium 2 mg If Atropine ineffective, administer Valium 2 mg IVP/IO over 2 minutes (reduce anxiety)IVP/IO over 2 minutes (reduce anxiety)

Begin pacingBegin pacing Manage pain with Fentanyl 0.5 mcg/kg IVP/IN/IOManage pain with Fentanyl 0.5 mcg/kg IVP/IN/IO

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Is oxygen indicated?Is oxygen indicated? No respiratory distressNo respiratory distress SpOSpO22 >94% >94%

But…But… LightheadedLightheaded Decreased perfusionDecreased perfusion

Could be argument for applying per nasal Could be argument for applying per nasal cannula and argument for withholdingcannula and argument for withholding A clinical decision based on assessmentA clinical decision based on assessment If in doubt, contact Medical ControlIf in doubt, contact Medical Control

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Point of discussion:Point of discussion:

Where are the pads placed for the TCP?Where are the pads placed for the TCP? Anterior (-) chest pad in apical areaAnterior (-) chest pad in apical area Posterior (+) pad placed in mid upper back Posterior (+) pad placed in mid upper back

between spine and scapulabetween spine and scapula If the TCP was applied, what are the If the TCP was applied, what are the

settings?settings? Rate 80/minuteRate 80/minute Sensitivity to “auto”Sensitivity to “auto” mA – start at 0 and increase until capturemA – start at 0 and increase until capture

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Application of pacing padsApplication of pacing pads Anterior/anterior Anterior/anterior

OrOr Anterior/posteriorAnterior/posterior

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Why are both Valium and Fentanyl being Why are both Valium and Fentanyl being used if the TCP is applied and activated?used if the TCP is applied and activated? Valium takes the edge off, relaxes the patientValium takes the edge off, relaxes the patient

Longer acting than Versed, so less repeat Longer acting than Versed, so less repeat doses may be neededdoses may be needed

Fentanyl issued for pain controlFentanyl issued for pain controlGetting electrical current sent thru the body Getting electrical current sent thru the body

80 times per minute80 times per minute

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SOP’s utilized – Adult Bradycardia & AV SOP’s utilized – Adult Bradycardia & AV BlocksBlocksAdult Routine Medical Care (pg 5)Adult Routine Medical Care (pg 5)Universal Adult Emergency Cardiac Care Universal Adult Emergency Cardiac Care

(pg 6) (pg 6) Bradycardia and AV Block, Adult (pg 12)Bradycardia and AV Block, Adult (pg 12)Pain Management, Adult (pg 34)Pain Management, Adult (pg 34)Skill: Transcutaneous Pacing (pg 76)Skill: Transcutaneous Pacing (pg 76)

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You are called to the scene for a 43 year-You are called to the scene for a 43 year-old patient with a “racing heart”old patient with a “racing heart”

Patient is anxious, slightly agitatedPatient is anxious, slightly agitated States has been under a great deal of States has been under a great deal of

stress, little sleep, taking Red Bull drinksstress, little sleep, taking Red Bull drinks Warm and dry, lung sounds clearWarm and dry, lung sounds clear VS: B/P 126/78; P – 170; R – 20; VS: B/P 126/78; P – 170; R – 20;

SpOSpO22 97% 97%

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What is the patient’s rhythm?What is the patient’s rhythm?

SVTSVT

4141


Is the patient stable or unstable?Is the patient stable or unstable? What do you assess?What do you assess?

What makes someone unstable?What makes someone unstable? First change is altered level of consciousnessFirst change is altered level of consciousness Last change is hypotensionLast change is hypotension

When can the valsalva maneuver be When can the valsalva maneuver be performed?performed? Stable SVTStable SVT Stable rapid a fib/flutter (narrow complex)Stable rapid a fib/flutter (narrow complex)

4242

Point of discussion…Point of discussion… How does the “valsalva maneuver” work?How does the “valsalva maneuver” work?

Breath holding against a closed glottis Breath holding against a closed glottis increases intrathoracic pressureincreases intrathoracic pressure Venous return decreasesVenous return decreases Cardiac output falls (CO = HR x stroke volume)Cardiac output falls (CO = HR x stroke volume) B/P fallsB/P falls

Initially heart rate increases to compensateInitially heart rate increases to compensate When the breath is let out, sudden rise in When the breath is let out, sudden rise in

blood flow increases pressuresblood flow increases pressures The parasympathetic system is triggered with a The parasympathetic system is triggered with a

vagal response and the heart rate decreasesvagal response and the heart rate decreases Valsalva maneuver held for 10 secondsValsalva maneuver held for 10 seconds

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Treatment stable SVTTreatment stable SVT ValsalvaValsalva

Bear down for 10 secondsBear down for 10 seconds Adenosine 6 mg rapid IVP followed Adenosine 6 mg rapid IVP followed

immediately with 20 ml normal saline flushimmediately with 20 ml normal saline flush If no response in 2 minutesIf no response in 2 minutes

Adenosine 12 mg rapid IVP followed immediately Adenosine 12 mg rapid IVP followed immediately with 20 ml normal saline flushwith 20 ml normal saline flush

If no response in 2 minutesIf no response in 2 minutes Verapamil 5 mg SLOW IVP over 2 minutesVerapamil 5 mg SLOW IVP over 2 minutes If no response in 15 minutes and B/P If no response in 15 minutes and B/P >>90, repeat 90, repeat

VerapamilVerapamil

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What does the patient often complain What does the patient often complain about while receiving Adenosine?about while receiving Adenosine? Hot, flushed feeling in the neckHot, flushed feeling in the neck Feeling of chest pressureFeeling of chest pressure Feeling of not catching your breathFeeling of not catching your breath

Just warn your patient they may feel weird Just warn your patient they may feel weird for just a few minutesfor just a few minutes Have them inform you if they feel weirdHave them inform you if they feel weird

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What do you remember about Verapamil?What do you remember about Verapamil? Inhibits movement of calcium movementInhibits movement of calcium movement Will decrease the heart rate, contractility, and Will decrease the heart rate, contractility, and

conductionconduction Causes vasodilationCauses vasodilation Onset 1-2 minutes; duration 10-20 minutesOnset 1-2 minutes; duration 10-20 minutes Avoid use in any bradycardia and history of Avoid use in any bradycardia and history of

WPWWPW Watch for hypotension and bradycardiaWatch for hypotension and bradycardia

4646

Point of discussion…Point of discussion… What’s WPW (Wolff-Parkinson-White)?What’s WPW (Wolff-Parkinson-White)?

Occurs in approximately 3/1000 personsOccurs in approximately 3/1000 persons Abnormal conduction from atria to ventriclesAbnormal conduction from atria to ventricles

AV node is bypassedAV node is bypassed Characterized by short PR interval (<0.12 Characterized by short PR interval (<0.12

seconds), long QRS, slurred upstroke of QRS seconds), long QRS, slurred upstroke of QRS (delta wave)(delta wave) EKG observation made when heart rate normalEKG observation made when heart rate normal

Patient typically asymptomatic until Patient typically asymptomatic until tachydysrhythmias occurtachydysrhythmias occur Symptomatic due to increased heart rateSymptomatic due to increased heart rate

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Wolff Parkinson WhiteWolff Parkinson White If rapid atrial fib with history of WPW, contact If rapid atrial fib with history of WPW, contact

Medical ControlMedical Control Amiodarone or cardioversion most likely to be Amiodarone or cardioversion most likely to be

orderedordered Adenosine and Verapamil to be avoidedAdenosine and Verapamil to be avoided

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SOP’s utilized – Adult SVTSOP’s utilized – Adult SVTAdult Routine Medical Care (pg 5)Adult Routine Medical Care (pg 5)Universal Adult Emergency Cardiac Care Universal Adult Emergency Cardiac Care

(pg 6) (pg 6) Supraventricular Tachycardia, Adult (pg 15)Supraventricular Tachycardia, Adult (pg 15)

4949


EMS is called to the scene for a 69 year-EMS is called to the scene for a 69 year-old patient who is “sick”old patient who is “sick”

Spouse states patient had not been acting Spouse states patient had not been acting right the past hour right the past hour

Upon arrival, EMS notices patient Upon arrival, EMS notices patient slouched in a chair with mumbling speechslouched in a chair with mumbling speech

Denies chest pain or SOBDenies chest pain or SOB

VS: B/P 120/60; P – 92; R – 18; SpOVS: B/P 120/60; P – 92; R – 18; SpO2 2 97%97%

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Point of discussion…Point of discussion… Are you thinking stroke?Are you thinking stroke? What assessments are necessary?What assessments are necessary?

Blood glucose levelBlood glucose level Cincinnati stroke scaleCincinnati stroke scale

Facial droopFacial droopArm driftArm driftSpeechSpeech

Noting time of onsetNoting time of onsetLast known time to Last known time to

be normalbe normal

5151


What are the components of a neurological What are the components of a neurological exam in the field?exam in the field? Level of consciousness/mental stateLevel of consciousness/mental state GCSGCS Following commandsFollowing commands Motor responseMotor response Sensory responseSensory response PupilsPupils Reflexes and 12 cranial nerves not often Reflexes and 12 cranial nerves not often

tested in the fieldtested in the field

5252


Which rhythm is most often associated with Which rhythm is most often associated with predisposing a patient to the possibility of having a predisposing a patient to the possibility of having a stroke?stroke?

Atrial fibrillationAtrial fibrillation

Why?Why? Clots can form in the stagnated blood in the Clots can form in the stagnated blood in the

atriaatria If one breaks lose, can lodge in the lungs or If one breaks lose, can lodge in the lungs or

brainbrain

5353


How else may a stroke patient present?How else may a stroke patient present? Abnormal feeling, vague complaint that might Abnormal feeling, vague complaint that might

not point to any specific disease processnot point to any specific disease process Weak, woozy, worriedWeak, woozy, worried Motor abnormalityMotor abnormality

GEC had a young patient who “couldn’t use their GEC had a young patient who “couldn’t use their left hand to text”left hand to text”

Patient complaint “I can’t get out of bed”Patient complaint “I can’t get out of bed”

HeadacheHeadache

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SOP’s utilized – Adult SVTSOP’s utilized – Adult SVTAdult Routine Medical Care (pg 5)Adult Routine Medical Care (pg 5)Universal Adult Emergency Cardiac Care Universal Adult Emergency Cardiac Care

(pg 6) (pg 6) Stroke/Brain Attack (pg 24)Stroke/Brain Attack (pg 24)

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EMS is called for a 64 year-old male complaining of left sided chest pain Pain is rated 7/10 and does not radiate Started while he was taking out the garbage Is feeling short of breath Complains of nausea; denies vomiting Patient is pale and diaphoretic Hx of diabetes and hypertension VS: B/P 120/78; P – 62; R- 22; SpO2 98%

5656


What care is appropriate to initiate?What care is appropriate to initiate? 12 lead EKG as soon as possible upon 12 lead EKG as soon as possible upon

contact with patientcontact with patient Interpretation drives rest of treatment!Interpretation drives rest of treatment!

Aspirin 324 mg chewedAspirin 324 mg chewed Chewing hastens absorptionChewing hastens absorption Can be held if patient very reliable & took AspirinCan be held if patient very reliable & took Aspirin

Notify Medical Control and document why Notify Medical Control and document why Aspirin was heldAspirin was held

No harm if an extra dose is given to patient; No harm if an extra dose is given to patient; more harmful if not administeredmore harmful if not administered

5757

Case Scenario #8Case Scenario #8 Is there ST elevation?Is there ST elevation?

5858

Case Scenario #8Case Scenario #8 ST elevation noted V5, V6, I, II, aVF with ST elevation noted V5, V6, I, II, aVF with

reciprocal changes (ST depression) V1-3reciprocal changes (ST depression) V1-3

5959

Case Scenario #8Case Scenario #8 What influence does the location of ST What influence does the location of ST

elevation have on administration of elevation have on administration of medications that cause venodilation?medications that cause venodilation? Inferior wall MI’s (II, III, aVF) can involve the Inferior wall MI’s (II, III, aVF) can involve the

right ventricleright ventricle Right ventricle may lose capability to pump Right ventricle may lose capability to pump

blood to the lungsblood to the lungs Venous return exceeds right atrium output and Venous return exceeds right atrium output and

blood accumulates in the right ventricleblood accumulates in the right ventricle Patient may present with hypotension, JVD, and Patient may present with hypotension, JVD, and

clear lung soundsclear lung sounds

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Hallmarks of right ventricular infarctionHallmarks of right ventricular infarction JVD as blood backs up into the right ventricleJVD as blood backs up into the right ventricle Hypotension from a decreased blood volume Hypotension from a decreased blood volume

moving to the lungs and therefore returning to moving to the lungs and therefore returning to the left ventricle to be distributed to the bodythe left ventricle to be distributed to the body

Clear lung sounds – blood is NOT backing up Clear lung sounds – blood is NOT backing up from the left ventricle to the lungs from the left ventricle to the lungs Shortness of breath and pulmonary edema may Shortness of breath and pulmonary edema may

occur related to decreased perfusion with occur related to decreased perfusion with hypotension and hypoxiahypotension and hypoxia

6161


What treatment is indicated?What treatment is indicated? Patient complains of shortness of breath so Patient complains of shortness of breath so

oxygen is indicatedoxygen is indicated4L/nasal cannula would be adequate at this 4L/nasal cannula would be adequate at this

pointpoint Aspirin is appropriate for the majority of Aspirin is appropriate for the majority of

patients (ie: held for allergy)patients (ie: held for allergy) EMS held Nitroglycerin & Morphine; Medical EMS held Nitroglycerin & Morphine; Medical

Control contacted & ordered MorphineControl contacted & ordered Morphine

6262

Case Scenario #8Case Scenario #8 Morphine administered per online Medical

Control order 2 mg IVP slowly over 2 minutes Patient became hypotensive at 70/50 200 ml fluid bolus given which restored

pressure What needs to be closely monitored when

administering fluid challenges? Lung sounds watching for fluid overload

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Point of discussion… Did the morphine cause this response or

the inferior wall MI? Not known but good example of why

we must be very careful treatment with this type of MI

Patient can easily become hypotensive which can be deadly

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What are side effects of nitroglycerin?What are side effects of nitroglycerin? HypotensionHypotension HeadacheHeadache Metallic taste to mouthMetallic taste to mouth

What are side effects of Morphine?What are side effects of Morphine? HypotensionHypotension Respiratory depression (reversed with Narcan) Respiratory depression (reversed with Narcan)

and supported with BVMand supported with BVM Decreased level of consciousnessDecreased level of consciousness

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Case Scenario #8 Case Scenario #8 Cath Lab Results 100% blockage Cath Lab Results 100% blockage circumflex artery – 2 stents placedcircumflex artery – 2 stents placed

6666


What is the circumflex artery?What is the circumflex artery? A branch of the left anterior descending artery

(which is a branch of the left main artery)

Feeds the inferior wall of the left ventricle and part of the right ventricle

Blockage produces elevation in II,III and AFV

Elevation in leads II, III, aVF can also be caused by blockage of the right coronary artery

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SOP’s utilized – Acute Coronary SyndromeSOP’s utilized – Acute Coronary SyndromeAdult Routine Medical Care (pg 5)Adult Routine Medical Care (pg 5)Universal Adult Emergency Cardiac Care (pg Universal Adult Emergency Cardiac Care (pg

6) 6) Acute Coronary Syndrome, Adult (pg 13)Acute Coronary Syndrome, Adult (pg 13)

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EKG Rhythm Strip ReviewEKG Rhythm Strip Review

Review and identify the following stripsReview and identify the following strips AnalysisAnalysis

Rhythm regular or irregular?Rhythm regular or irregular? What is the rate?What is the rate? Are there P waves, upright, uniform, followed Are there P waves, upright, uniform, followed

by a QRS?by a QRS? What is the PR interval (norm 0.12 - .20 sec)?What is the PR interval (norm 0.12 - .20 sec)? What is the QRS (norm <0.12 seconds)?What is the QRS (norm <0.12 seconds)? What is the interpretation?What is the interpretation? What does the patient look like?What does the patient look like?

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EKG Rhythm ReviewEKG Rhythm Review

Be prepared to discussBe prepared to discussWhy the rhythm could be dangerous for the Why the rhythm could be dangerous for the

patientpatientSigns and symptoms expectedSigns and symptoms expectedTreatment indicated based on signs and Treatment indicated based on signs and

symptomssymptoms

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Strip #1Strip #1

Sinus bradycardiaSinus bradycardia Treatment for bradycardia if symptomaticTreatment for bradycardia if symptomatic

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Strip #2Strip #2

Ventricular fibrillationVentricular fibrillation How do you know it’s not just a loose lead?How do you know it’s not just a loose lead?

Check the pulseCheck the pulse

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Strip #3Strip #3

Second degree type II – ClassicalSecond degree type II – Classical Treatment for bradycardia if symptomaticTreatment for bradycardia if symptomatic

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Strip #4Strip #4

Monomorphic VTMonomorphic VT Is patient stable or unstable?Is patient stable or unstable?

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Strip #5Strip #5

Atrial fibrillationAtrial fibrillation Patient at increased risk for strokesPatient at increased risk for strokes

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Strip #6Strip #6

Third degree heart block – completeThird degree heart block – complete Treatment for bradycardia if symptomaticTreatment for bradycardia if symptomatic

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Strip #7Strip #7

Torsades – a form of Polymorphic VTTorsades – a form of Polymorphic VT If pulseless, treat as VF/pulseless VTIf pulseless, treat as VF/pulseless VT

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Strip #8Strip #8

NSRNSR

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Strip #9Strip #9

PEA – is Atropine given if rate is low?PEA – is Atropine given if rate is low? No, it was not found to be helpfulNo, it was not found to be helpful

NO PULSE!

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Strip #10Strip #10

Third degree heart block – completeThird degree heart block – complete Treatment for bradycardia if symptomaticTreatment for bradycardia if symptomatic

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BibliographyBibliography

American Heart Association. 2010 Guidelines for American Heart Association. 2010 Guidelines for Cardiopulmonary Resuscitation.Cardiopulmonary Resuscitation.

Bledsoe, B., Porter, R., Cherry, R.. Essentials of Bledsoe, B., Porter, R., Cherry, R.. Essentials of Paramedic Care 2Paramedic Care 2ndnd Edition. Brady. 2011. Edition. Brady. 2011.

Campbell, J.E., International Trauma Life Support 6Campbell, J.E., International Trauma Life Support 6thth Edition. Brady. 2008Edition. Brady. 2008

Phalen, T., Aehlert, B. The 12 Lead EKG in Acute Phalen, T., Aehlert, B. The 12 Lead EKG in Acute Coronary Syndromes. 2Coronary Syndromes. 2ndnd edition. Elsevier. 2006. edition. Elsevier. 2006.

Region X SOP’s February 1, 2012; IDPH approval 1/6/12Region X SOP’s February 1, 2012; IDPH approval 1/6/12 http://www.ems1.com/print.asp?act=print&vid=397955http://www.ems1.com/print.asp?act=print&vid=397955 en.wikipedia.org/wiki/Wolff–Parkinson–White_syndromeen.wikipedia.org/wiki/Wolff–Parkinson–White_syndrome

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