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EMS 150 Lesson A


Course Overview

• Assessment Flowchart

• Assessment Inventory

• Underlying Theme

• Circulation (Shock / Types of Shock)

• Ventilation

• Oxygenation


Lesson A Overview

• Assessment Skills

• Emergent / Immediate Interventions

• Circulation-Ventilation-Oxygenation


Flowchart

• Is this a “code” (cardiac arrest)?

• CVO assessment

• Immediate interventions?

• Focused H&P to drive a differential Dx list

• Ddx drives specific interventions / plan of care


Inventory

• All of the things you MUST consider

• Determine WHICH you will do / utilize

• Few patients need ALL of these things

• Prioritize / delegate

• Gather data / toss out noise / get information


CVO

• Major Body Processes

• Must Circulate blood

• Must Ventilate air for gas exchange

• Must Oxygenate the blood to be circulated


Circulation• Shock defined

• Obstructive Shock defined

• Hypovolemic Shock defined

• Cardiogenic Shock defined

• Distributive Shock defined

• Assessment options (pulses, skin, HR, BP)


Ventilation

• Rate of breathing

• Effort / work of breathing

• Depth of breathing (“dead spacing”)

• EtCO2 as a tool


Oxygenation

• Adequate O2 content inspired

• Intact process in alveoli for gas exchange

• Assessment challenges (SpO2 limitations)

• Lung Sounds assessment


Lab A

• Pulse oximetry

• Capnography

• ECG limb leads

• BP via auscultation, palpation, doppler, use of machine pressures

• Lung Sounds auscultation


More for Lab A

• Two-thumbs down / BVM ventilation

• Oxygen Therapy

• PEEP via BVM, CPAP, BiPap

• Nebulizer treatments


Pulse Oximetry

• Not real time—may be 1-2 minutes old

• Signal strength is key to check before you start believing the number (match to pulse)

• Requires adequate perfusion—patient with SpO2 of 60 and BP of 60 example

• Can be fooled by Carbon Monoxide (CO)


Capnography

• Real time—no delay

• Requires adequate metabolism to make CO2 at the cells

• Requires adequate circulation to bring back CO2 to the lungs

• If those two are intact, shows you ventilation data—number and waveform shape matters


HR and Breathing

• Radial pulse palpation is a great 1st step

• Touch is good (let’s you feel skin)

• Look at the patient’s breathing rate, effort and depth while holding their pulse

• Presence lets you estimate BP

• Rate and Regularity gives you data on Heart


Blood Pressure

• Size and place the cuff

• Auscultate when you can hear

• Palpate when you cannot hear but can feel a pulse

• Doppler when you cannot hear or feel a pulse

• Machines don’t forget to take it or what it was


Two-Thumbs Down

• Big muscles of your hands make the seal

• Jaw thrust at the same time

• Very important

• Takes skill—more than squeezing a bag!


BVM Ventilation• Do NOT use too much volume—hurts BP

• DO get normal chest rise

• Adult BVM holds 1500 cc!!!!!

• Looking for tidal volume of 300-500 for most adults—taller needs more

• ONLY use two hands when you need more pressure (think about why)—not volume


Oxygen Therapy

• “Normal” varies if patient has lung disease

• Target is 94-99% for those without lung disease

• Adjust your target downward for lung disease

• 90-95% may be their norm

• 5% below “normal”


O2 Tools

• Nasal cannula at 2-3 liters per minute for 2-3 minutes should raise the SpO2 by 2-3 points.

• If you need more than 2-3 points, use the NRBM.

• If the SpO2 is not rising toward “normal” with cannula as above, consider why…may be a ventilation problem??


PEEP

• Recruits all available alveoli into the game

• Reduces work of breathing—prevents atelectasis

• Conscious patients may not like the tight-fitting mask at first

• Raises intra-thoracic pressure which may reduce preload (reduce BP)


CPAP or BiPAP

• Continuous Positive Airway Pressure

• Bi-level Positive Airway Pressure


Nebulizer Tx

• Makes tiny droplets out of the medication

• Patient can hold or can be attached to a mask

• Can use with CPAP / BiPAP mask usually

• Beware of dead-spacing

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