Summer EmergenciesPacemakersQuick Trach

APRIL 2015 CECONDELL MEDICAL CENTER

EMS SYSTEMSITE CODE: 107200E-1215

Prepared by: Sharon Hopkins, RN, BSN

Revised 4.16.151

Objectives

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

1. Distinguish the difference between heat cramps, heat exhaustion, and heatstroke.2. List the steps of assessment for the patient involved in water emergencies.3. Analyze signs and symptoms to determine the level of allergic reaction a patient is experiencing.4. Actively participate in review of selected Region X SOP’s as related to the topics presented.

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Objectives cont’d

5. Review pacemaker rhythms. 6. Actively participate in case scenario discussion. 7. Actively participate at the paramedic level in return demonstration of insertion of the Quick Trach. 8. Actively participate in ventilating a manikin at

the appropriate ventilation rate for the situation. 9. Successfully complete the post quiz with a score of

80% or better.

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Thermoregulation

The ability to maintain or regulate a steady body temperature despite changes to the environmentHypothalamus at base of brain regulates temperature

You can lose or gain heat from and within the body itself

You can lose or gain heat by contact with the external environment

The body’s core/normal temperature of deep tissues is normally 370C or 98.60F

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Converting Temperatures

0F = 9/5 0C + 32

0C = 5/9 (0F – 32)

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Thermal Gradient

The difference in temperature between the environment (also called the ambient temperature) and the body

Heat flows from the warmer environment (higher temp) to the cooler environment (lower temp)

Wind and relative humidity (percent of water vapor in the air) affect heat gain and loss

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Process of Transferring Heat

ConductionDirect contact of one surface with another

ConvectionHeat loss to air currents passing over the bodyHeat must be conducted and exposed to the air before being

carried away by convection Radiation

Heat loss via infrared raysExposed body could lose 60% of total body heat in

environment with normal room temperature

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Transfer of Heat cont’d

EvaporationChange of a liquid to a vaporWater or sweat evaporates from skinHeat loss is great via evaporation of fluids

from the lungs Normal water loss from the skin and lungs is

approximately 600 ml per day

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Transfer of Heat cont’d

RespirationCombines the mechanics of convection,

radiation, and evaporationAccounts for a large proportion of heat loss

Heat transfers from body to inspired air via convection and radiation

Evaporation process in lungs humidifies inspired air

During expiration, humidified air released to the environment creating on-going heat loss

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Measuring Body Temperatures By touch – get a sense of cool, warm, hot Oral – normal 98.60F (370C) Rectal – 0.5 – 10F higher than oral Tympanic – 0.5 – 10F higher than oral Axillary – 0.5 – 10F lower than oral Core – area where most major organs are located

In the field tympanic (ear) or rectal In the hospital bladder, heart with use of

special catheters/measuring tools

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Homeostasis

Process of maintaining constant suitable conditions Body functions within small ranges of “normal” Hypothalamus at base of brain responsible for

temperature regulation (i.e.: the “thermostat”) Body constantly compensating to maintain “normal”

Core and peripheral temperaturesOxygen levelsEnergy supplies

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Homeostasis of Core Temperature

Body continually adjusting metabolic rateThe rate in which the body consumes energy

to maintain function required at the timeEnergy production = heat production

Temperature controlled by dilating or constricting blood vesselsDilation of blood vessels – flushed skinConstriction of blood vessels – pale skin

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Temperature Control

To decrease the body temperature Blood vessels dilate to expose more vessel surface space

to the skin Excess heat carried from core to the periphery close to the

skin; heat dissipates from skin to environment

To increase body temperature Blood vessels constrict to shunt warm blood away from

superficial veins near skin and back into deeper veins near the core

Shivering increases the metabolic rate and generates heat

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Risk Factors Impacting Environmental Illness Age

Especially very young and elderly

Poor general health Fatigue Predisposing medical conditions (i.e.: Diabetes – damages

autonomic nervous system & interferes with thermoregulatory input)

Certain meds – prescription and OTC Level of acclimatization – adjustment to the environment

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Factors Influencing Impact of Environmental Challenges

Length of exposure Intensity of exposure Environmental factors

Humidity – influences evaporation rateWind – influences convection

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Heat Emergencies - Hyperthermia

Condition involving unusually high body core temperatures

Usually involves a transfer of heat from the external environmentCould include excessive heat production within the

body Could occur with use/abuse of certain medications

Malignant hyperthermia is a severe response to use of certain anesthetics

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Eliminating Excessive Heat

Body’s attempt to eliminate excessive heat: Diaphoresis – due to sweating mechanism

Evaporation process to reduce the temperature

Increased skin temperature to touch – due to vasodilation Moves more blood volume to the skin surface to

induce radiation, conduction, convection

Flushing due to vasodilation process

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Heat Cramps / Muscle Cramps

Caused by overexertion and dehydration in high temperature situations

Sweating is a response to lower the body temperatureSodium (salt) is transported to the skinWater follows sodiumWater on skin surface cools body via evaporation

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Heat Cramps cont’d

Loss of electrolytes due to sweatingCan cause intermittent skeletal muscle

crampingExtremitiesAbdominal muscles

Patient generally remains alert and complains of weakness

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Heat Cramp Signs and Symptoms

Dizziness Syncope/near-syncope Stable vital signs Body temperature normal or slightly

elevated Skin moist and warm

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Treatment Heat Cramps

Consider what is making the patient symptomatic

Aim your therapy at the source of the problemRemove from the offending environmentRemove clothing as necessary to facilitate coolingPatient education goals

Cooling techniquesAppropriate hydration guidelines

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Heat Exhaustion

An acute reaction to

heat exposureThe most common heat emergencyPatient can lose 1-2 L of fluid per hour

Loses sodium and waterDehydration and electrolyte loss from sweating often account for the signs and symptoms noted

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Heat Exhaustion – Body Responses

General vasodilationPooling of blood volume mimics a decrease in

blood volumeLeads to a decrease in cardiac output

History of exposure to a heated environment helps with the diagnosis

If treatment is not instituted, the patient may progress to heat stroke

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Signs and Symptoms Heat Exhaustion Increased body temperature (>37.80C / 1000F) or Cool and clammy with heavy perspiration Rapid and shallow respirations Weak pulse Diarrhea Muscle cramps Weakness May have loss of consciousness

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Forming Your General Impression

History and assessment very importantNeed clues to determine a working diagnosis to know which

treatment plan to institute In the presence of the following CNS signs &/or symptoms

consider interventions for heat stroke Headache Anxiety Paresthesia - pins and needles sensation Impaired judgment Psychosis

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Treatment Heat Exhaustion

Move to a cooler environment Remove as much clothing as possible, as indicated Begin to fan the patient - air currents (convection) Keep patient supine IV fluid challenge

Adult: 200 ml increments; titrated with frequent reassessmentsNote: adult formula also calculated at 20 ml/kg

Peds: 20ml/kg; repeat to max of 60 ml/kg; titrated

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Heatstroke

True environmental emergency Hypothalamic temperature regulation lost Hyperthermia leads to cell death and damage

to brain, liver, kidneys Indications of heat stroke

Central nervous system imbalanceBody temperature usually >1050F (40.60C)Absence of sweating

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Heatstroke – Hot & Dry or Hot & Wet?

Sweating stops usually from destruction of sweat glands or due to dysfunction from sensory overload

Patient may still be covered with sweat though from earlier exertion (i.e.: marathoner, construction worker)

Classic heatstroke – hot, red, dry skinExertional heatstroke– hot, moist skin

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Classic vs Exertional Heatstroke

Predisposing factors for classic heatstroke Age Diabetes Other medical conditions

Predisposing factors for exertional heatstroke Generally person in good health Excessive ambient temperature with excessive

exertion with prolonged exposure and poor acclimation

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Exertional Heatstroke – Big ProblemsSevere metabolic acidosis

From excessive lactic acid accumulationLactic acid develops as by-product during

anaerobic metabolismHyperkalemia – excessive potassium

moved from the cell into the bloodstreamReleased from injured cells or created due

to renal failure (poor clearing capability) or development of metabolic acidosis

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Signs and Symptoms Heatstroke

Hot skin that is dry or moist Very high core temperature Deep respirations (blowing off acids) that become shallow, rapid

and later slow Rapid, full pulse initially then slow Hypotension with low or absent diastolic Confusion or disorientation or unconsciousness CNS impairment – headache, anxiety, impaired judgment,

paresthesia, psychosis Possible seizures

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Treatment Heat Stroke Move patient to cool environment Remove unnecessary clothing Fluid challenge

Adult 200 ml increments (formula 20 ml/kg)Peds 20ml/kg to a max of 60 ml/kg

Rapid cooling proceduresDouse towels or sheets with water and place over patientFan body – increases air current flow (convection)Cold packs to lateral chest wall, groin, axilla, neck, temples, behind

knees

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Shivering

Shivering raises body core temperatureCan occur in the setting of too rapid of a cooling process

To stop shiveringAdult: Valium 5 mg IVP/IO over 2 minutes

Can repeat same dose in 2 minutes titrated to the max

Peds: Valium 0.2 mg/kg over 2 minutesCan repeat same dose in 15 minutes titrated to the max

Total maximum is 10 mg for the adultTotal max for peds is 5 mg (<5 years old) and 10mg (>5

y/o)

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Water Emergencies

DrowningRespiratory impairment from submersion or immersion in

a liquid Outcome

Mortality – deathMorbidity – developing a medical problemNo morbidity – no problem

A leading cause of death in children Most drownings occur in freshwater – the swimming pool

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Sequence of Events of Drowning

Submersion Struggle with attempt at breath holding Instinctive inspiratory and swallowing efforts made

Water enters mouth, posterior oropharynx, and stomach

Apnea causes rise in retained CO2 levels; decrease in O2

Hypoxia stimulates trigger to gasp Acidosis is developing Reflexive laryngospasm and bronchospasm occur

Minimizes amount of water actually measured in lungs

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Sequence cont’d

Reflex swallowing continuesGastric distension, for vomiting and aspiration

Hypotension, bradycardia then death occur Water enters lungs (before laryngospasm or after

laryngeal relaxation) Water in airways blocks gas exchange in alveoli Even small amount of water washes away

surfactantAtelectasis develops (alveolar collapse)

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Surfactant

A thin film substance in alveoli that keeps them open

Decreases pressure needed for subsequent inflation

Without adequate levels of surfactant, alveoli collapseBlood shunted past collapsed alveoli and is not

oxygenated before it is perfused throughout the body 37

Drowning

Outcome determined by degree of anoxia Goal of therapy directed at reversing anoxia Prehospital interventions and treatment is

the same regardless of the source of the drowning –

freshwater versus saltwater

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Factors Affecting Survival

Cleanliness of water source Length of time submerged Age of victim General health status of victim

Positive influence on outcome – immediate recognition of the drowning and initiation of immediate CPR

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Treatment Near Drowning

Routine medical care Spinal precautions Consider CPAP in the adult if indicated If stable (awake, alert, warm and dry, B/P

>90 in adult, then transport

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Treatment Near Drowning cont’d

Anticipate need for ventilation support Anticipate vomitus and laryngospasms

Suction available for vomitus Positive pressure ventilations (i.e.: BVM) for

laryngospasmsMany drowning victims may have foaming present

Focus on oxygenation and ventilation more than on suctioning

Protect the patient from heat lossRemove wet clothing, cover body as much as

possible

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Treatment Unstable Near DrowningAltered Mental Status; B/P <90

Secure airway Assess for hypothermia

If normothermic, treat dysrhythmias per protocol If hypothermic, also follow hypothermic protocol

Assist ventilations as indicated BVM – 1 breath every 5 – 6 seconds

1 breath every 3-5 seconds infant and child to 8

Advanced airway1 breath ever 6 -8 seconds

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Immune System Responsible for fighting infection The principle system involved in allergic reactions

Goal- rid body of offending foreign material (antigen) Components found in blood, bone marrow, and lymphatic

system Additional systems affected in immune response

CardiovascularRespiratoryNervousGastrointestinal

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Immune Response

To destroy or inactivate pathogens, abnormal cells, or foreign molecules

Activation of cascade of events triggered by exposure to foreign substance – an antigen

Immune system directs attack on foreign substance to deactivate or destroy offending agent

There is a chemical attack of antibodies on the invading agent or antigen

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Immune Response cont’d

Primary response Initial (first time) exposure to an antigenAntibodies developed to respond at

subsequent exposures Secondary response

Release of antibodies, upon recognition of the antigen, to facilitate removal of offending antigen

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Histamine

Potent chemical Principle chemical released in allergic reaction Goal of histamine release

Minimize body’s exposure to the antigen Bronchoconstriction - lung exposure Increased intestinal motility - move antigen thru system Vasodilation - remove antigen from circulation Increased vascular permeability - remove antigen from

circulation

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Histamine Release – Smooth Muscle Constriction

Bronchoconstriction Minimizes amount of antigen that can enter

the respiratory tract Abdominal cramping

From increased gastric motility Diarrhea and vomiting

Attempt to move antigen quickly through the system and eliminate it from the body

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Histamine Release – Increased Capillary Permeability

Third spacing – fluids (plasma) shift from intravascular to interstitial space Trying to move offending antigen out of circulatory system Angioedema especially of head, neck, face, upper airway

Relative hypovolemia Decreased cardiac output Decreased tissue perfusion Impaired cellular function Cellular death

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Histamine Release – Peripheral Vasodilation

Decreased peripheral vascular resistance Less tone in blood vessels Less efficient circulation of blood Decreased preload – amount of blood returning to

the heart Decreased after-load – the pressure the heart must

pump against to move blood Blood pressure will drop Cardiac output drops

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Allergic Reaction Exaggerated response by immune system to foreign

substance (antigen) Repeated exposure results in much stronger immune

response Hypersensitivity

Unexpected, exaggerated reaction to an antigen Range from mild skin rashes to more severe systemic

reactions throughout many more body systems

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Anaphylaxis

Most severe allergic reaction Usually occurs when an antigen enters the circulation

Rapid and wide distribution facilitated through-out the body

Most reactions occur within seconds In a few cases there may be a delay over an hour

The more severe the reaction, the quicker the onset of signs and symptoms

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Anaphylaxis

Life-threatening emergency requiring prompt recognition and intervention

Can develop in seconds; can cause death in minutes after exposure

Develops after exposure and sets off biochemical reactions that could lead to shock and death

Most common causative agents – injected penicillin and hymenoptera (bee and wasp) stings

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Anaphylaxis – Presentation / Appearance

Flushing Rash – fine, red, diffusely spread over entire

body Itching Hives (urticaria) – wheal of red, raised bumps

across body Swelling – 3rd space fluid shift Pallor and/or cyanosis

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Anaphylaxis – Respiratory System

Respiratory difficulty with tachypneaSneezing, coughing – trying to rid offending antigenWheezing, stridor – bronchoconstriction & edemaLaryngeal edema – 3rd space fluid shiftLaryngospasm – may cause difficulty in being able to

speak BronchospasmLabored breathing; use of accessory muscles

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Anaphylaxis – Cardiovascular System

Vasodilation Increased heart rate – compensation attempt Decreased blood pressure – from capillary

leakage, peripheral vasodilation and eventual failure of compensatory mechanisms

Development of acidotic and hypoxic environment

Eventual fall in cardiac output55

Anaphylaxis – Nervous System

Dizziness Headache Change in level of consciousness Convulsions Tearing

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Anaphylaxis – Gastrointestinal System

Nausea and vomiting – to rid offending antigen

Abdominal cramping – hypermotility Diarrhea – to rid offending antigen

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Anaphylaxis – Ominous Signs

Decline in respiratory rate Following increasing edema of tissues and

initial dyspnea Bradycardia

After compensatory mechanisms have failed Drop in blood pressure

Significant 3rd space fluid shift has occurred along with peripheral vasodilation

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Allergic Reactions

Less severe immune response Gradual onset of signs and symptoms Milder signs and symptoms Normal mentation Adequate perfusion status of the patient Response could be localized to one particular

areaEx: Forearm site for localized reaction to bee sting

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Allergic Reactions

May experience mild flushing, itching, and rash Urticaria (hives) may be present May experience mild bronchoconstriction

Body still trying to minimize exposure to antigen Mild abdominal cramps and diarrhea

Body still trying to rid self of offending antigen

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Intervention of Allergic Reactions

To know the correct intervention relies on an accurate and detailed assessment

GoalsDetermine extent of immune response

Allergic reaction or anaphylaxis

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Interventions

EpinephrineVasoconstrictorBronchodilator

BenadrylAntihistamine- stop release of

histamine response Fluids

Volume expansion62

Region X SOP - Allergic Reaction Stable

Hives, itching, red skin GI distress Alert, warm and dry; systolic B/P >90mmHg

Ice pack to site Benadryl (antihistamine) 25 mg IVP slowly over 2

minutes or IMPeds Benadryl 1 mg/kg IVP to adult max of 25 mg

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Region X SOP – Allergic Reaction Stable with Airway Involvement

Epinephrine 1:1000 0.3mg SQMay repeat in 5 minutesPeds dose Epi 1:1000 0.01 mg/kg SQ (max 0.3 mg)

Benadryl 50 mg IVP slowly over 2 minutes or IMPeds dose Benadryl 1 mg/kg (max 50 mg)

If wheezingDuoneb treatment

Albuterol 2.5 mg with Atrovent 0.5mg

If no improvement repeat Duoneb treatment If no improvement, albuterol alone

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Region X SOP – Anaphylactic Shock

Altered level of consciousness Systolic B/P <90 mmHg

Secure airwayMake sure patient can ventilate/breathe and is

adequately oxygenated Goals of treatment

Open airways Support vascular status

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Adult Anaphylactic Shock Medications

Epinephrine 1:1000 0.5 mg IMCan repeat in 5 minutes

Benadryl 50 mg IVP/IO slowly over 2 minutes or IM IV/IO fluid challenge in 200 ml increments Duoneb treatment – Albuterol with Atrovent

If no improvement, administer Albuterol alone every 5 minutes

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Pediatric Anaphylactic Shock Medications

Epinephrine 1:1000 0.01 mg/kg IMMax 0.3 mg/0.3 ml per single doseMay repeat in 5 minutes

Benadryl 1 mg/kg to max of 50 mg Fluid challenge 20 ml/kg

Titrated to desired patient responseMax 60 ml/kg

Duoneb treatment – Albuterol with Atrovent If no improvement, administer Albuterol alone every 5 minutes

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Continued Deterioration AnaphylaxisContact Medical Control to considerEpinephrine 1:10,000

Adult 1:10,000 0.5 mg IVP/IOPeds 1:10,000 0.01 mg/kg IVP/IOAdminister slowly

This is adrenalineA strong cardiac stimulant!!!Have patient on the cardiac monitor

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Epi Pens

Prescribed medication for use by patients Adult dose (yellow) – 0.3 mg Peds dose (green) – 0.15 mg To activate

Cap removed Gripped firmly – keeping fingers away from tip Jabbed into outer thigh and held in place 10 seconds

Caution – needle remains exposed after activation Note: If patient’s EpiPen is ready to be used by them, don’t delay. Assist patient

in using their pen; repeated doses, if necessary, of Epinephrine will be your stock

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Pacemakers

Artificial pulse generator that delivers an electrical currentStimulates depolarization

Useful when normal pacemaker site (SA node) unreliable

How would you know a patient has one? Patient tells you See it written in the history See the bulge under the skin Medic alert tag

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Pacemaker Components

Power sourceBattery unit called pulse generator

Conducting wireElectrodes from the battery to the heart

Return wireWire that returns to the battery unit to

complete the electrical circuit71

Pacemaker Types - Temporary

Usually used in acute setting and for relatively short periods of time (i.e.: acute MI)

Pacing unit outside the bodyTranscutaneous – stimulus across the skinTransvenous – via venous vessel access

Current measured in milliamperes (mA)

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Pacemaker Type - Permanent

Long term support anticipated Wires inserted surgically into the right heart Battery implanted in fatty layer pocket

under the skin of the chest or abdominal wallMay be inferior to right or left clavicle

Usually opposite side to dominant hand

Could be abdominal placement – rarer nowadaysCould be combination with AICD

Current AICD’s also have capability to pace73

Pacemaker Sensing

Parameters set on pacemaker determine if pacing stimulus is necessary or is withheldDemand mode – pacemaker functions only

when patient’s own rate falls below a preset valuePacemaker functions on “demand”Most common type of pacemaker setting used

Fixed mode – pacemaker will fire regardless of what the intrinsic (normal) conduction system doesInfrequently seen nowadays

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Pacemaker Types - Ventricular Single-chamber pacemaker Stimulates only the ventricles See spike followed by wide QRS Most common type of pacemaker implanted

Can look like slow monomorphic VT at first glanceBut, spikes are present; history supports pacemaker

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Pacemaker Type - Atrial

Single chamber pacemaker Atria are depolarized Heart’s own conduction system used to stimulate the

ventricles See spike followed by P wave and then normal QRS

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Pacemaker Type – AV Synchronous

Dual-chamber pacemakerBoth atria and ventricles are stimulatedAtrial kick is restored

Atria contract and therefore squeeze more blood to the ventricles prior to each contraction

See spike followed by P wave and then spike followed by wide QRS

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Pacemaker Malfunction – Failure to Capture

Spike not followed by complex therefore no depolarization

Causes: Battery failure, displacement of lead wire, energy (mA) too low, edema/scar tissue or perforation of myocardium, electrolyte imbalance

Presentation: fatigue, bradycardia, low B/P, syncope

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Failure to Capture EMS Intervention

EMS intervention: reposition patient in case of loss of lead wire contact – turn patient onto left sideMay “float” lead wire into myocardial wall contact

Follow symptomatic bradycardia protocolAdminister Atropine 0.5 mg IVPApply and prepare to begin operation of TCP

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Pacemaker Malfunction – Failure to Sense / Competition

Pacemaker fires regardless of the patient’s own rhythm No sensing of spontaneous myocardial depolarization There is potential competition for control of the heart Danger – pacemaker spike may fall on vulnerable

downslope of T wave VF Causes

Battery failure, fracture of wire, displacement of electrode tip

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Pacemaker Malfunction – Runaway Pacemaker

Pacemaker rate too fast but continues to capture

Malfunction of impulse generatorNot as common in newer models of

pacemakers Typical pacemaker rate set around 70’s

(beats per minute)

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Pacemaker Malfunction – Battery Failure

Absence of any spikes when they would be anticipated

Can cause life-threatening situation where patient dependent on pacemaker to support a healthy heart rate

Close patient monitoring and long battery life usually avoids this problem

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Assessment of Patient

Always check the patient first Determine perfusion status / mechanical

responseEvaluate the patient’s level of consciousnessEvaluate blood pressure to determine perfusion

Presence of radial pulse indicates B/P is present

EKG strip is printable representation of electrical activity

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Assessment of Paced Rhythm

Does each spike capture?Each spike is followed by a complex

Is rate reasonable? Are spikes competing with the patient’s

rhythm? Is pacemaker functioning consistently and

reliably?

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Patient Management

If pacemaker malfunctions, treat the patient and not necessarily their rhythmDon’t treat the pacemaker

Provide a copy of the rhythm strip for documentation in the patient’s hospital medical record

It is safe to touch a patient if the TCP is in useElectrical stimuli is not transferred to you 85

Transcutaneous Pacing – Potential Complications

Coughing Skin burns Interference with sensing from patient agitation

or muscle contractions Pain Failure to recognize non-capture Tissue damage 3rd degree burns

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Documentation of TCP Use Initial and repeat EKG rhythms on patient chart Date and time pacing started

RateOutput (mA) to obtain capturePatient’s response

Intervention for comfort/pain control measuresValium 2 mg IVP/IO; repeated to max of 10mg

A benzodiazepine to take the edge off

Fentanyl 1 mcg/kg IVP/IO/IN; repeated in 5 minutes A synthetic opioid for pain control

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QuickTrach

IndicationsEmergency assisted ventilations when all other means

have failed Contraindications

Tracheal transection; other measures are successful Adult device – size 4.0 mmID if >77# (>35 kg) Peds device – 2.0 mmID if 22-77# (10-35 kg)

<22# (10 kg) – use needle cricothyrotomy procedure88

Quick Trach Procedure

Attempt to ventilate patient Assemble equipment

Quick Trach kit – appropriate sizeBVMSkin prep material4x4’s

Position patient supine, neck hyperextended if able

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Quick Trach Procedure cont’d

Locate Cricothyroid membrane Inferior to thyroid cartilage (Adam’s apple)Superior to cricoid cartilagePalpate from notch upward

1st bone is cricoid cartilageGo to space just above this bone

Cleanse site

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Quick Trach Procedure cont’d

Secure larynx laterally between thumb and forefingerAnchor and stretch skin slightly

Puncture Cricothyroid membrane at 900 angle Confirm entry of needle to trachea

Aspirate air through the syringe Change angle of insertion to 600 with tip

pointed toward feet91

Quick Trach Procedure cont’d

Advance device to level of red stopperRed stopper assures proper initial depth insertionStopper should now be snug against the skin

Remove the stopper Hold needle and syringe firmly

Slide only plastic cannula forward until hub of cannula snug against skin as you withdraw the needle

Note: Similar maneuver when starting an IV and advancing the catheter as you retract the stylet

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Quick Trach Procedure cont’d

Distal end of flexible tubing attached to Quick Trach hub BVM attached to proximal end of flexible tubing

Helpful to have flexible tubing already attached to BVM

Immediately begin to ventilate with 100% O2

Use pre-attached strap to secure deviceMake sure device is snug against skin

Device can easily be coughed out

Helpful to have one end of strap already attached to device prior to insertion

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Quick Trach Use

Confirm placement by auscultation and observation of chest rise

Continuously monitor airway and lung sounds to ensure proper placement

Monitor for over expansion of chest wallMay need to detach BVM to allow for passive

exhalation to allow deflation of lungs Note general improvement in patient’s overall

condition94

Case Scenario Discussion

Review presentation of patient Determine your general impression Determine your treatment choice

Use your SOP booklets as a resource Discuss reassessment steps Discuss documentation highlights related to

the patient situation

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Case Scenario #1

Patient works on a road crew Complains of feeling lightheaded and dizzy VS: 148/88; P – 90; R – 20; warm and sweaty History: hypertension, high cholesterol,

diabetes

General impression? Interventions?

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Case Scenario #1 General impression

Heat emergency (exhaustion)Consider diabetic problem (blood sugar 72)Consider other medical problems

InterventionRemember to consider other causes of feeling lightheaded and

dizzyCool – remove from heat, remove extra clothingFluids – 200 ml fluid bolus increments

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Case Scenario #2

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Person training for a marathon found collapsed on a trail; unknown length of timeTemperature outside 940 and 85% relative humidity

Unknown medical history Patient moans when touched Hot and moist VS: 86/62; P – 110; R – 28 and labored

General impression? Interventions?

Case Scenario #2

General impressionHeat strokeAcute medical problem – acute MI, brain insultTrauma

InterventionsBegin to cool – wet towels, fanning, air conditioning

IV – O2 - monitor

IV fluids – 200 ml incremental fluid challenges

Remember to consider other causes of altered level of consciousness

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Case Scenario #3

Your adult patient was drinking from a can of soda and was stung by a bee that was in the can

Has swollen lips Complains of itchy throat and a feeling of swelling in

the throat VS: 110/70; P – 98; R – 22; SpO2 97%

General impression? Interventions?

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Case Scenario #3

General impressionAllergic reaction with airway involvement

InterventionsConsider IV – O2 - monitor

Epinephrine 1:1000 0.3 mg SQMay repeat every 5 minutes

Benadryl 50 mg slow IVP or IM If wheezing, Duoneb ( may repeat)

101

Case Scenario #4

Adult patient ate a dip and 15 minutes later complains of abdominal cramping, diarrhea, all over itching

You can hear audible wheezingConfirmed bilateral wheezing – breath sounds barely

audible VS: B/P 88/60; P – 116; R – 22

General impression? Interventions?

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Case Scenario #4

General impressionAnaphylactic shock

Interventions IV – O2 – monitor

Epinephrine 1:1000 0.5 mg IM (may repeat every 5 minutes)

Benadryl 50 mg IVP/IO or IMFluid challenge – 200 ml incrementsDuo neb (may repeat Albuterol neb if needed)

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Case Scenario #5

Your 78 year old patient complains of pounding in their chest and generally not feeling well

Pulse is irregular, skin warm and moist VS: B/P 92/50; P – 40; R – 18; SpO2 97%

Hx: Hypertension, gout, CABG, pacemaker, high cholesterol

General impression? Interventions?

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Case Scenario #5

General impressionConsider cardiac problem

InterventionApply cardiac monitorConsider obtaining 12 lead EKG, if possible, on

cardiac calls

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Case Scenario #5

Impression – Pacemaker with failure to capture Intervention

Turn patient onto their left sideMay “float” catheter into position

Support perfusionConsider Atropine dosePrepare for application TCPConsider need for Dopamine drip to support blood pressure

Increases strength of cardiac contractions

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Bibliography

Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady. 2013.

Region X SOP’s; IDPH Approved April 10, 2014.

Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady. 2010.

http://www.scientificamerican.com/article/why-does-lactic-acid-buil/

http://www.icufaqs.org/Pacemakers.doc http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html http://www.cdc.gov/norovirus/preventing-infection.html

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