CCEMT-P Notes - Fall 2010

Written & Illustrated by: John A. Watson V, CCEMT-P, NC Level I EMS Instructor, Training Officer, MEDICCCEMT-P Notes Day #1 Concepts & Components

Ideal Critical Care Team composition variation of Medic, RN, RT, MD Standard of care An agreed upon level of excellence Transport protocols and procedures must be clearly written in advance Critical Care medicine is a totally separate subset from pre-hospital EMS History of Ambulance transports: Paramedic Inception Miami Fire Department (1970) First Air Transport Prussian Siege (1870) Hot Air Balloons First Helicopters Korean Conflict (1950) Modes of Transport: Mobile (0-50 miles) Rotor Wing (10-150 miles) Fixed Wing (150 miles or more)

Medical Legal

* www.pwwemslaw.com * CCEMT-P scope of practice - governed by civil laws (statutes), rules & regulations in each state Appropriate Care: Duty, Breach, Damages, Proximate Cause When patient info can be released Continuation of care, law requires it, billing, subpoena Pertinent transfer info Reason for transfer, MD to MD contact required PTA, treatment of patient, treatment and orders within your scope of practice, report: CC, S/S, Assessment, H&P, Plan of Care EMTALA (Emergency Medical Treatment & Active Labor Act) Requirements: Medical Records, S/S, Diagnosis, Test Results, Written Consent, MD verification that risks of transport outweigh the benefits Review Case Law for ExamNG/ OG/ Ostomies-Rectal Considerations- Small amount of blood on stool Hemorrhoids Small amount of blood in stool Lower GI Hemorrhage Melena (digested blood) Upper GI Hemorrhage Decubitus Ulcers: Decubiti Stage I redness not removed by elimination of pressure Decubiti Stage II lesions involving excoriation Decubiti Stage III full thickness skin loss Decubiti Stage IV ulcers with invasion of fascia, connective tissue, muscle or bone

-Ostomies-

Stoma opening in the abdominal wall where the end of the colon is brought to the skin surface

Indications: Bowel Injury/ Disease Bladder Injury/ Disease Decompression Stool Diversion Most common ostomy - Colostomy Diversion of urine from the bladder Urostomy Ureterostomies located on the patients flank

-Renal Assessment & Urinary Catheters-

Indications: Incontinence Sedated/ Paralyzed Patients Inability to void Collection of Specimen Nephrolithiasis (Kidney Stones) - Types: Calcium, Struvite, Uric Acid, Cystine Urinary Tract Infections More common in females, E. Coli in 80% of patients Normal Urine Output: 30+ ccs per hour Order of Assessment: Visualization, Auscultation, Palpation, Percussion-Nasogastric, Orogastric & Feeding Tubes- Gastric Tube contraindications esophageal varices, head injury or facial trauma (NG Tube) NG/OG Indications: Eternal Feeding, Medication Administration, Gastric Lavage & Decompression Measure NG/ OG tube from tip of nose to earlobe to xiphoid process Percutaneous Endoscopic Gastrostomy/ Jejunostomy (PEG/ PEJ) tube Feeding Tube

CCEMT-P Notes Day #2Therapeutic Hypothermia (Not to be tested on) Less than 5% of cardiac arrest patients will be resuscitated With successful resuscitation, hypothermia should be initiated within 15 minutes History of Therapeutic Hypothermia (1814) Invasion of Russia (1930) Germany experimented in prison camps (1970-1990) Benefits proven, skeptics still prevailed (2001-2002) Widely studied & benefits clearly demonstrated Why cool? Help save brain tissue When to cool? Immediately after return of spontaneous circulation Who to cool? At least 16 years old How to cool? Preferably Cool IV Saline Goal is to drop core temperature to 93 degrees Hypothermia reduces metabolic demand by 50% Patient can develop metabolic alkalosis with cooling. DO NOT hyperventilate!

X-Ray Interpretation

If you see upper rib fractures, always assume c-spine injury Diaphragm is dome-shaped with clear costophrenic angles (inferior bilaterally) Inferior Ventricular Width is approximately 1/3 to1/2 the chest width Air = Black Fresh blood & water = Opaque White Tissue = Dense White ET Tube - should be 2cm above the carina Consolidation Infection, fluid, inflammatory exudate Atelectasis No ventilation to the lobe beyond obstruction (leads to pneumonia) Order of Chest X-Ray assessment: A Airway (midline?) B Bone Structures (visible?) {asymmetry, fractures, lesions, curvature of spine} C Cardiac (size?) D Diaphragm (clear costophrenic angles?) E Event (Chronic or Acute?) 5 Steps to X-Ray Interpretation:1. Assess lung expansion2. Assess pleura3. Look for infiltrates4. Look at the mediastinum5. Assess the abdomen Infiltrate = Pneumonia Thumb print/ Thumb sign = epiglottitis Steeple Sign = Croup Increased prominence in pulmonary vasculature, cardiomegaly = heart failure Diaphragm Right side is always higher 'White out consolidation or fluid filled alveoli Fluffy Pneumonia or ARDS Cor = size of the heart CT Scan assessment & findings: The X Look for symmetry in the film Black spots Infarct or old blood White spots Acute blood Ventriloquist Are the ventricles compressed or too large? Breaks Are there any fractures? Masses Are they new or old?

Multi-System Organ Failure Clinical Setup of MSOF (Multi-System Organ Failure) MSOF: A group of conditions which results in varied physiological dysfunction of more than two organs: Sepsis, ARDS, DIC

Sepsis/ Septic Shock Infection with failure of at least one organ Misdistribution of blood (under-perfused & over-perfused areas) Caused by Microorganism invasion (aerobes, anaerobes, fungi, viruses) Bacteremia Microorganisms/ toxins in the blood Etiology: Gram (-) Endotoxin (E. Coli) {Released when bacterium broken} Gram (+) Exotoxin History: DM HTN CHF COPD Cirrhosis HIV CX Pregnancy Signs & Symptoms: Tachycardia Fever/ Hypothermia Tachypnea Hypo-perfusion Management: Fluid Therapy (preferably colloids) 20 ml/kg Vasopressors & (+) Inotropes Antibiotics Corticosteroids ARDS (Acute Respiratory Distress Syndrome) relative pulmonary failure, characterized by hypoxemia with shunting, dyspnea and onset of bilateral diffuse pulmonary infiltrates on x-ray Usually develops within 24 - 48 hours of the insult Etiology: MSOF Insult to the lung Pneumonia Chest Trauma Burns Near Drowning Pancreatitis Signs & Symptoms: Dyspnea, Rapid & Shallow Respirations Accessory muscle use Cyanotic or mottled skin, not improving with O2 Management High FiO2, ABGs, Ventilation, CPAP c PEEP, fluid administration End Result - Decreased compliance, decreased gas exchange, hypoxemia

DIC (Disseminated Intravascular Coagulation) Causation Factor Any causes of disequilibria in the balance of clotting versus lysis History: Recent Pregnancy Multi-System Trauma Cancer Infection Signs & Symptoms: Bleeding from odd sites: Gums, Nail Beds, Eyes, IV Puncture Sites Thrombocytopenia Decrease of clotting factors Acute Renal Failure Acute Hepatic Failure Management: Treat underlying cause Treat loss of blood & constituents Heparin Therapy as required

Shock Definition: Cells become hypoxic because of inadequate perfusion of the tissues. 4 Categories of shock:1. Hypovolemic (Loss of volume) Burns, Hemorrhage, Gastroenteritis, Spleen Rupture2. Cardiogenic (Loss of pump) Acute/ Chronic Cardiac Patients, TB Patients, Trauma Patients3. Distributive (Loss of competency of vasculature) Septic, Neurogenic, Anaphylactic4. Obstructive (Loss of pathway) Airway Obstruction, Cardiac Tamponade, Tension Pneumothorax Stages of shock:1. Compensatory 2. Progressive3. Irreversible Cellular Effects of Shock: Decreased ATP production Excess Lactic Acid Production Mitochondrial Death Cellular Edema Deterioration of the sodium-potassium pump Crystalloids are administered @ a 3:1 ratio Blood products are administered @ a 1:1 ratio

CCEMT-P Notes Day #3Blood Administration Hematocrit The percentage, by volume, of RBCs in a whole blood sample. Symptoms of Anemia: Pallor, weakness, vertigo, dizziness

Whole Blood Complete blood, unadulterated except for anticoagulants. Cross-Match Necessary Indications: Hypovolemic shock Acute hemorrhage Exchange transfusion Surgery Obstetrics Packed Red Blood Cells (PRBCs) - Contains all characteristics of Whole Blood, minus plasma. Indications: Anemia CHF Surgery Fresh Frozen Plasma (FFP) Contains clotting factors For low PT/ PTT Must be infused within 24 hours of being thawed Indications: Active bleeding Hemophilia Thrombocytopenia Type & Screen - Indications: Blood Loss Anemia Surgical Work-Up Procedure: Phlebotomy Spin & Separate Test for antibodies

Cross Matching Indications: Specific blood for specific patient

(O) Universal donor (AB) Universal Recipient

Both

RH Factor Rh Positive Possess D Antigen Rh Negative Possess no D antigen Rh Negative patients may develop D Antigen Blood Administration - Equipment needed: Physicians order Blood Type & Matched Large Bore Venous Access Filtered Administration Set Isotonic NS Thermometer Transfusion Procedure:1. Flush tubing with NS2. Inspect Blood3. Cover administration with blood4. Connect Blood Tubing5. Piggyback IV line of NS6. Slowly start transfusion7. Monitor for adverse reactions8. Have at least two IV Sites Transfusion Rate Procedure: Initial Rate of 1 ml/min Evaluate for hemolytic reaction Monitor vitals every 15 minutes After 30 minutes adjust flow rate Evaluate for hemolytic reaction Monitor vitals every 30 minutes Transfusion Reaction: Fever Hives, Itching or skin symptoms Swelling or soreness @ IV site Tachycardia Respiratory Distress Hypotension Anaphylaxis Nausea/ Vomiting Blood in Urine Treatment of Transfusion Reaction:1. STOP the Transfusion!2. Maintain IV access with Isotonic NS3. Save the remaining blood product4. Administer Oxygen PRN Treatments continued: Medications: Benadryl Epinephrine Tylenol LasixPediatrics General Pediatric Assessment: Identify baseline findings Systems Assessment Vital Signs Toe to Head Assessment Pediatric History: Activity Level Feeding/ Fluid Pattern Perinatal history if under 1 year old Transport Considerations: Double check fluid rates and medications Secure Lines & Tubes SBP is = (90) + (2X Age in years) Rewarm Children @ no more than 1 Degree Celsius/ HourDialysis

Function of the Kidneys: Control bodys Water Balance Regulation of Blood Pressure (Renin-angiotensin) Electrolyte Balance (Na+, Ca2+, K+, etc) Excretion of Metabolic Wastes (Urea, creatinine) Acid/ Base Balance Regulation of Red Blood Cell Production (erythropoietin) Production of Vitamin D

Indications for Dialysis: Traumatic renal Insufficiency, End-Stage Renal Disease Dialysis Transport Complications: Bleeding Infection Infiltration Abdominal Pain Signs of electrolyte & chemical Imbalances Hyper/ Hypoglycemia Sodium/ Potassium imbalances Hemodialysis: Vascular Access through either a fistula or arteriovenous shunt Peritoneal Dialysis: Introduction of Dialysate solution into the abdominal cavity with a catheter Accessing an Arteriovenous shunt: Need to know these steps!1. 2. 3. 4. 5. 6.

CCEMT-P Notes Day #4Neurological Assessment Cranial Nerve I & II are the only nerves that do not cross Ipsilateral Same side affected Ansicoria Unequal Pupils Nystagmus Shaky eye movement Major Components of Neurological Exam: External Assessment Level of Consciousness Eyes, Pupil Size/ Reaction Motor Response Vital Sign Changes Localization of Pain: Patient crosses the midline to localize centralized pain (+) Babinski Reflex Cerebellar Reflex Cranial Nerves: I Olfactory: Smell II Optic: Vision III Oculomotor: Ocular movement, Pupil Reaction IV Trochlear: Ocular Movement, Pupil Contraction V Trigeminal: Chewing VI Abducens: Ocular movement VII Facial: Cheek & Jaw (expressions) VIII Acoustic: (Auditory): Hearing & Balance IX Glossopharyngeal: Taste, Visceral Sensation, Gland Secretions X Vagal: Speech, Swallowing, Uvula movement XI Accessory: Speech, Swallowing, Movements of Head & Shoulders XII Hypoglossal: Swallowing, Tongue Movements 3 4 6 make your eyes do tricks! CN III Me CN IV Floor CN VI Sticks (lateral) Neurogenic Shock Vital Signs: Bradycardia Hypertension Hyperventilation Transport Considerations? Maintain Airway Proper Positioning of ET Tube Hemodynamic Stability Physicians Orders Equipment Requirements Spinal Injured Patient:Key: Green CervicalBlue ThoracicPurple LumbarOrange Sacral Proprioception: The ability to discern where you are in space. (Spinal cord patients lose that ability) Poikilothermia: Loss of thermal regulation, patient will assume ambient temperature Spinal Shock: Profound disruption of the spinal cord Bradycardia Hypotension Flaccid paralysis Sensory loss below the level of injury Loss of bowel & bladder function Loss of temperature control Priapism Orthostatic Hypotension: Result in a loss of peripheral resistance Autonomic Dysreflexia: An exaggerated sympathetic response which results in uncontrolled hypertension Serious Hypertensive Emergency Patients with injury @ T-6 and aboveIntracranial Pressure & ICP Monitoring Intracranial Pressure: Pressure exerted by brain tissue, blood and CSF in a closed cavity (Monroe-Kellie) 80% - Brain Mass 10% - Blood Volume 10% - CSF (Cerebral Spinal Fluid) Reasons for increased ICP: Cerebral Edema, Hydrocephalus, Trauma, Tumor, Abscesses, Stroke, Bleeding/ Clots/ Bruises Cerebral edema develops and peaks in 3 5 days Autoregulation: Metabolic Autoregulation buildup of metabolic byproducts (CO2), Triggers Vasodilation Decompensation: The point when Autoregulation has failed Cushings Response: Compensatory Ischemic Response Cushings Triad: Bradycardia (Compression on Brain Stem) Hypertension (Rise in systemic Blood Pressure) Widening Pulse Pressure (Drop in diastolic BP, Rise in systolic BP) MAP = [(2 X Diastolic + Systolic) / 3] Cerebral Perfusion Pressure (CPP): Constant pressure assuring blood flow (02 & glucose) to brain MAP ICP = CPP Goal: CPP > 60 < 50 Mild Cerebral Ischemia < 40 Cerebral blood flow down 25% < 30 Irreversible Cerebral Ischemia If MAP = ICP (BRAIN DEATH) Herniation: Displacement of the brain from one compartment to another

Places Herniation Occur:a) Cingulateb) Uncalc) Central (Transtentorial)d) Externale) Tonsillar (Cerebellar)

Factors that will Increase ICP: Positional Changes Coughing (Valsalva Maneuvers) Body Temperature Drainage of Interventricular Cannula Medications Environmental Considerations Strategies for Decreasing ICP: Fentanyl, Morphine (Analgesia) Versed, Ativan (Benzodiazepine Sedation) Propofol (Sedation) Ventilation (Hyperventilation when herniated) Diuretics (Draw off excess fluid [Osmotic or Loop]) Paralytics (Eliminate Pain Response) Fluids 3% NaCl (Pull off fluid excess) Vasopressors (Maintain MAP) Potassium ([Hypokalemic] Because of Loop Diuretics) Insulin (Combat release of cortisol) Methylprednisolone (Spinal Cord Injuries) Compliance Change in volume divided by the change in pressure CSF Drainage: If IVC (Interventricular Cannula) in place, open & close Over-drainage = herniation Under-drainage = hydrocephalus Level IVC @ the ear Intracranial Pressure Waveforms: Normal ICP between 0 -15 mmHg Severe rise in ICP caused by a small increase in volume, looks like: A Vertical inflection Point

Aeromedical Physiology Boyles Law At a constant temperature, the volume of gas varies inversely with the pressure As you go up, air will expand *** More than 15% Pneumothorax Put in a chest tube Fill ETT with fluid Daltons Law - In a mixture of gases, the total pressure is equal to the sum of the partial pressures of each gas O2 Availability decreases with altitude Altitude increase, decreases barometric pressure *** Patient will require increased oxygen delivery at higher altitudes Place patient in LLR Trendelenburg (Durants Position) if suspected Air Embolus/ Bends Eight Stressors of Flight:1. Hypoxia2. Barometric Pressure 3. Temperature Changes 4. Decreased Humidity 5. Noise 6. Vibration 7. Fatigue 8. G-Forces Hypoxia: Hypoxic Hypoxia Deficiency in alveolar O2 exchange Hypemic Hypoxia Deficiency in the O2 carrying capability of blood Signs & Symptoms: Objective: Dyspnea, Tachypnea Tachycardia, Bradycardia, Arrhythmias Hypertension, Hypotension Slouching, Euphoria, Belligerence Confusion, Restlessness, Unconsciousness Subjective: Personality & Judgment Changes Hot & Cold Flashes Head Ache, Blurred Vision, Dizziness, Tunnel Vision Nausea Confusion, Stupor, Insomnia, Anger, Euphoria Numbness Inability to rationalize sight, taste, sound or pain Time of Useful Consciousness: Below 18,000 ft. (30 minutes) 25,000 ft. (3 5 minutes) 30,000 ft. (90 seconds) Greater than 40,000 ft. (< 15 seconds) Contributing Factors to Crew-Member Fatigue: Drugs Exhaustion Alcohol Tobacco Hypoglycemia

CCEMT-P Notes Day #5Hemodynamics

Preload Ventricular filling during diastole Afterload Resistance against which the heart contracts Determines the amount of volume the heart can pump Contractility Cardiac performance independent of preload or afterload Factors that decrease contractility: Anoxia, Acidosis Medications (Beta Blockers, etc.) CHF, MI Vagal Maneuvers Factors that increase contractility: Sympathetic Nerve Impulses Natural Catecholamines Positive Chronotropes Ejection Fraction Percent of blood the ventricle actually pumps out Normal EF is 55% 75% Mean Arterial Pressure Average of Blood Pressure 2 X Diastolic + Systolic / 3 = MAP Cardiac Output Amount of blood flow in LPM (CO) = HR X SV / 1000 Decrease in CO: Decreased preload, diuresis, arrhythmias, MI, increased afterload, SVR Increase in CO: Fever, Pain, Inotropic Pharmacology Stroke Volume Amount of blood that is ejected in one contraction SV = (CO) /(HR) X 1000 Normal SV is 60 100 ml Systemic Vascular Resistance (SVR) Resistance to the Left Ventricle created by arterial contraction/ dilation SVR = 80 X (MAP RAP) / CO Normal SVR is 800 1200 dynes/sec/cm squared Increase in SVR in due to vasoconstriction Decrease in SVR due to vasodilation Pulmonary Vascular Resistance (PVR) - Resistance to the Right Ventricle created by pulmonary artery contraction/ dilation Normal PVR is 40 100 dynes/sec/cm squaredHemodynamic Monitoring Types: Arterial MAP (Mean Arterial Pressure) Venous CVP (Central Venous Pressure) Pulmonary PAP, PCWP (Pulmonary Artery Pressure, Pulmonary-Capillary Wedge Pressure) Phlebostatic Axis 4th Intercostal Mid-Axillary To zero a hemodynamic monitor, open it to air Waveforms Types:

Atrial Waveforms Ventricular Waveforms Pulmonary Artery Waveforms Arterial Waveforms

Dicrotic Notch An increase in Aortic Pressure that signals the start of diastole

Central Venous Monitoring Evaluates net volume and Right Atrial Pressure (RAP) Normal CVP or RAP is 2 -6 cm H2O Increased CVP = Hypervolemia Decreased CVP = Hypovolemia Pulmonary Artery Catheter (Swan-Ganz Catheter) Measures: Right Atrial Pressure (RAP) Pulmonary Artery Pressure (PA) Pulmonary Artery Capillary Wedge Pressure (PCWP)

Complications: No waveform: Transducer is not open to the catheter Dampened Waveform: Improper monitor calibration Clot or air bubble in catheter Aspirate, NEVER irrigate first Blood in the transducer Continuous PCWP Wedge Waveform: /.Catheter Migration Have the patient cough No PCWP Wedge Waveform: Incorrect position of the catheter Insufficient air in the balloon Balloon Rupture Swan-Ganz Catheter Diagram:

Laboratory Data Interpretation Sensitivity Test will be positive in the presence of disease Specificity Test will be negative in the absence of disease K+ will read high in hemolyzed blood drawn Complete Blood Count (CBC) - Hematocrit (HCT) 45 Volume of blood occupied by erythrocytes Normal HCT is 40% -50% (male), and 35% - 45% (female) Decreased HCT: Anemia, Hemodilution Increased HCT: Polycythemia, Hemoconcentration Hemoglobin (HGB) 15 Oxygen Carrying Protein Normal HGB is 14 -18g/dl (male), and 12 -16g/dl (female) Increase in HGB: Polycythemia, COPD, CHF, Altitude sickness Decrease in HGB: Anemia, Hyperthyroidism, Live Cirrhosis, Hemorrhage Red Blood Cells (RBC) 5 Diagnose Anemia & Indication of good Hydration Normal RBC is 4.5 6.0 Increase RBC: Similar for HCT, HGB Decrease RBC: Similar for HCT, HBG Differential Blood Count (DBC) White Blood Cells (WBC) White corpuscles in blood (host defenses) Normal WBC is 5,000 10,000 cells/mcl Infant white counts are higher Decreased WBC: Influenza, Measles, Rubella, Hepatitis, AIDS, Rubella, Typhoid Increased WBC: Infection, Leukemia, Trauma, MI Measures the percentage of different types of WBCs: Neutrophils: 2500 8000/mm cubed Basophils: 25 100/ mm cubed Eosinophils: 50 55--/mm cubed Lymphocytes: 1000 4000/ mm cubed Monocytes: 100 700/mm cubed

LEFT SHIFT Early type of active bacterial infection

Platelet Count (Thrombocytes) Cell important for coagulation and hemostasis Normal Platelet Count is 150,000 400,000 mcl Decreased Platelets: Leukemia, Splenic Injury, Bone Marrow Disease Increased Platelets: Hemorrhage, Anemia (Iron Deficiency), Surgery, Splenectomy, Trauma

Blood Chemistry Looks for Electrolyte & Metabolic Balances/ Abnormalities Basic Metabolic Panel (BMP) Glucose Chief source of energy in the blood Normal Glucose Value is 70 -110mg/dl Increase Glucose: DM, Cushings, Pancreatitis, Hyperthyroidism Decrease Glucose: Addisons, Hypothyroidism, Bacterial Sepsis

Blood Urea Nitrogen (BUN) Metabolic byproduct from the breakdown of blood, muscle and protein Normal BUN is 8 20 mg/dl Increase in BUN (Azotemia): Kidney Disease, CHF, Gastrointestinal Hemorrhage Decrease in BUN: Excessive Hydration/ Fluids, Pregnancy

Creatinine Waste product of protein metabolism found in urine Normal Creatinine is 0.5 1.2 mg/dl BUN/ Creatinine Ratio is normally 10:1 or less. Greater than 10:1 is an indicator of renal failure Sodium Electrolyte: Alkali Metal Normal Sodium is 135 145 mEq/l Decreased Sodium: Diarrhea, Vomiting, Diabetic Acidosis Increased Sodium: Cushings, Diabetes Insipidus Potassium Electrolyte: Alkali Element Normal Potassium is 3.5 5 mEq/l Decrease in Potassium (Hypokalemic): V-Fib Increase in Potassium (Hyperkalemic): Asystole Sine Wave --------------------------------------------------------- Creatine Phosphokinase (CPK) Enzyme broken down in muscles Increased CPK: Rabdomyolysis, Hypokalemia, Hypothyroidism, Trauma, Damaged Cardiac Muscle, Cerebrovascular Disease, Electrical Burns Troponin I & T Requires myocardial necrosis for release Early Rise 4 12 hours Peak in 12 -24 hours B-Type Natriuretic Peptide (BNP) Release from the ventricles in response to stretch from extra volume Normal BNP is 20% BSA 2 Large Bore IVs Lactated Ringers for 1st 24 hours Fluid Resuscitation for 1st 24 hours Do Not delay transport to gain IV access5. Foley Catheter to monitor hourly I/O6. NG/OG tube7. Prevent HypothermiaRapid Sequence Induction & Difficult Airways Indication questions for RSI: Can the patient maintain their airway? Can the patient protect this airway? Is the patient appropriately ventilated? Is the patient appropriately oxygenating? Is the patients condition likely to deteriorate? Is the scene appropriate? (Safety, moving the patient while apneic) Indication: Where respiratory arrest is imminent Trixmus A clenched jaw Glottic Opening in Child: Level of C-3/ C-4 (Age 7) Level of C-1 (Infant) RSI Contraindications: Burns or Crush Injuries over 5 days old Hyperkalemia Malignant Hyperthermia Rare - 1:15,000 patients Neuromuscular Disorders The 7 Ps:1. Preparation Assess the Risk Difficult to: BVM, Laryngoscopy, Intubate, Cricothyrotomy Prepare the equipment Monitor the Patient2. Pre-Oxygenation For At Least 2 Minutes @ 100%3. Premedication Lidocaine for Increased ICP (1.5 mg/kg) Atropine to prevent Bradycardia (0.5 mg) Correct Hypoxia First! Fentanyl as an Analgesic (3 Mcg/Kg) 100X more powerful than MS May cause chest wall rigidity Sedatives [Benzodiazepine] Midazolam for sedation (0.1 mg/kg) Causes Hypotension & Bradycardia [Barbiturate] Thiopental for Head Injury Sedation (3-4 mg/kg) NO Asthmatics! [Nonbarbiturate-analgesic-hypnotic] Etomidate for sedation (0.3 mg/kg) Little to no side effects [Dissociative-anesthetic-analgesic] Ketamine for sedation (1-2 mg/kg) PCP derivative [Sedative-Hypnotic] Propofol for sedation or anesthesia Initiate @ (5 Mcg/kg/min) Increase @ (5 10 Mcg/kg/min) Titrate every 5 10 minutes Max dose @ (50 Mcg/kg/min)4. Paralyze [Depolarizing Nerve Agent] Succinylcholine for Paralysis (1 1.5 mg/kg)

Order of Paralysis:1. Eyes, face, Neck2. Extremities3. Abdomen4. Intercostals, Glottis5. Diaphragm5. Pass the Tube 6. Proof of Placement Objective Visualization Spo2 CO2 Detector Subjective Negative Epigastric Sounds Mist in the tube Positive Lung Sounds Equal Chest Rises & Fall7. Post Intubation Care [Non-Depolarizing Agent] Vecuronium (Norcuron) for paralysis (0.1 mg/kg) Duration of 20 30 minutes [Non-Depolarizing Agent] Rocuronium (Zemuron) for paralysis (1 mg/kg) Duration of 20 75 minutes

CCEMT-P Notes Day #8 Capnography Indications - Monitoring: Hypoventilation, Apnea, CO2 Waveform & Parameters of Mechanical Ventilation Cardiac Resuscitation Survivors: > 10 ETCO2 Level Normal PaCO2 = 3545 mmHg Normal ETCO2 = 3043 mmHg V/Q Mismatch Ventilation/Perfusion Mismatch Gradient between 2-5 mmHg between PaCO2 and ETCO2 Increase indicates mismatch Dead Space Air Bronchial Tree Peak Expiration (Beginning of Inspiration) - Alveolar Gas Exchange Quantitative ETCO2: Actual numeric value Qualitative ETCO2: CO2 Detectors

A Baseline B Expiratory upstroke C Expiratory Plateau------------------------------ D Inspiration Begins

Rebreathing Rise in ETCO2 Baseline (COPDers)-----------

Muscle Relaxants Curare Cleft------------------------------

Bronchospasm Shark Fin------------------------------------------------------------------

Arterial Blood Gases (ABGs) & Acid/ Base Balance Drawn from an Artery Radial, Brachial, Femoral, etc Diagnoses pH - [H+] PaCO2/ CO2 - Partial Pressure of Arterial CO2 PaO2 - Partial Pressure of 02 HCO3 Bicarbonate BE - Base Excess SaO2 Arterial Oxygen Saturation pH is a measurement of the acidity or alkalinity of the blood Normal Ranges:-------------------------------------------------------------- ACIDIC STATE Decreases: Force of Cardiac Contractions Vascular Response to Catecholamines The Effects & Actions of certain medications ALKALOTIC STATE Interferes with: Tissue Oxygenation Neurological & Muscular Function pH above 7.8 or below 6.8 will cause death Bicarbonate Buffer System Respiratory Buffer System Renal Response System R.O.M.E. Pneumonic: --------------------------------------------------------

Acidity/ Alkalinity is measured using pH

Modified Allens Test

Performing an ABG Procedure: Perform Modified Allens Test Cleanse the Area Hyper-Extend the wrist Palpate the Arterial Pulse Line the needle up to 45 Degrees and puncture (Bevel Up) Withdraw the needle, Hold pressure Invert syringe several times12-Lead Electrocardiogram-Lead Placement & Acquisition-If you have a pulse and a problem You should be doing a 12-Lead. -Bob Page- Limb Leads (Bipolar): Positive looks towards negative Einthovens Triangle---------------------------------------------------

Precordial Leads (Unipolar): V1-V6 Placement based on Anatomical landmark Placement------------------

-12-Lead Analysis- Q/T Interval should be 1/3 the R/R Interval R Wave Progression------------------------------------------------

Axis Deviation:

-Determining Axis & Hemiblocks- Normal Axis - downward & to the left

Ventricles out of sync: RSR Prime-------------------------------------------------------------- Incomplete BBB: QRS Duration between 110-119 ms

LBBB Negative deflection in V1---------------------------------------

RBBB Positive deflection in V1----------------

-The 15-Lead ECG- 12-Lead Misses 50% of AMIs 23 out of 100 MIs could be missed for not doing this 15-Lead ECG increases sensitivity by 23% V4R------------------------------------------------------------------------ Up to 50% of Inferior MIs have RightVentricular Involvement

Posterior (V8 & V9)-------------------------------------------------

CCEMT-P Notes Day #9 Fetal Heart Monitoring & Obstetrics Physical Assessment: Confirm PMI (Point of maximum Impulse)

Leopolds Maneuver-------

Clonus Test - Shaking Foot Post Pedal Flexion No Response - 0 Less than normal - 1+ Normal - 2+ More than normal - 3+ Brisk - 4+ Sustained (Seizure) - 5+ Station---------------------------------------------------------------------------

Effacement:

Gravita Term babies Premies Abortions Live Births Multiple Births

-Emergencies- Emergency Childbirth: Rarely Needed in the field Support Perineum Keep baby lower than perineum Clamp, cut & tie cord Warm baby & APGAR Baby to Moms chest Record time & place Start Pitocin @ 250 ml/hr (40 Units/1000 ml NaCl)

Types of Breech Presentation:-----------------------------------------

Post-Partum Hemorrhage: 4 Ts: Tone 70% Inability to contract Uterus Leads in increased bleeding Trauma 20% Tearing away of placenta Ruptured Placenta Tissue 10% Expelled fetal product Can cause increased bleeding Thrombin 10% Bleeding disorder of Mom

3rd Trimester Bleeding - Irregular, No contractions Heavy Bleeding

Prolapsed Cord - Ruptured Membrane Presenting part occluding cord (Babies blood flow)

PROM - (Premature Rupture off Membranes) Rupture prior to 37 weeks gestation

Pre Eclampsia Hypertension >140/90 Proteinuria 1+ or >300 mg/24 hours Generalized Edema Must have ALL 3 to have Pre Eclampsia Foley to measure I&O

Eclampsia Seizures -Fetal Monitoring Rhythms- Deceleration: Early deceleration is GOOD! Late deceleration is BAD! Variability: V-Fib is good!

CCEMT-P Notes Day #10Ventilators

Types of Ventilation: Pressure Cycled Ventilation: Inspiration ends at a preset airway pressure VT is variable Patient is unconscious or sedated Volume/ Time Cycled Ventilation: Most popular and easily applied Essential parameter to control is volume delivery Tidal Volume (VT) & Minute Volume (VE) are predictable Modes of Ventilation: Control Machine is fully responsible for patients respiratory drive Assist/ Control Machine will breathe when patient wants to take a breath Synchronized Intermittent Mandatory Ventilation (SIMV) Patient cannot take machine breath, but can still spontaneously breathe Continuous Positive Airway Pressure (CPAP) VT & flow rate are completely patient controlled Pressure Control No minute volume guaranteed Pressure Support IPAP, BIPAP Terminology: (FiO2) Fraction of Inspired Air (VT) Tidal Volume Amount of gas moved in one normal breath About 500 ml or 10-15 ml/Kg (VD) Dead space Remaining gas in upper airways that does not participate in alveolar gas exchange (f) Frequency Breaths per Minute (VE) Minute Ventilation (VT) X (f) Flow Rate Inspiratory Time I time (LPM) X Flow Rate = (VT) I:E Ratio Normally 1:2 Airway Pressure Actual (PAW) Real time airway pressure Mean (MAP) Average of one completed ventilatory cycle Peak Highest pressure of one completed ventilatory cycle

Compliance Resistance of the lungs to a positive pressure breath Increased Compliance Lungs are more receptive to a ventilator Decreased Compliance (Positive End Expiratory Pressure) PEEP Positive pressure allows alveoli to stay open Clinical Guidelines: (VT) 10-15 ml/kg (f) 10-20 breaths per minute FiO2 ABG (PO2) or SpO2 Flow Rate 30-60 lpm (I:E ratio) PIP