EMS REGION VIII SOPs 2014 UPDATESJuly 2014

2014 Updates

Effective August 1, 2014 SOP books will be distributed by each

System

SOP Changes

SOP Page Number References

Anywhere an SOP is referenced, the SOP is noted in BOLD type and the page number is also included

Easier to locate SOPs that refer to another other SOPs

Terminology: Standard Precautions

“Standard precautions” has replaced the old wording “body substance isolation” (BSI) and “universal blood and body secretions”

Fentanyl Dosing for Adults

Fentanyl dosing is changed and is now consistent for adults (< 65 YO) regardless of SOP 2012 SOPs did not allow for a repeat

dose of fentanyl for the adult suspected cardiac patient with chest pain

2014 SOPs allow for a repeat dose of fentanyl

Must have a systolic BP > 100 mmHg

Fentanyl Dosing for Adults

The initial fentanyl dose remains the same for all adult patients < 65 year olds 1mcg/kg SLOW IV/IM, max 100 mcg

Addition of one repeat dose 0.5 mcg/kg SLOW IV/IM after 5 min, max

50 mcg

Fentanyl Dosing > 65 Years Old

New dosing for patients > 65 years old Slower renal clearance of drugs More likely to experience adverse effects

of opiates (even at lower doses) Initial and repeat dosages are the

same, regardless of SOP Must have a systolic BP > 100 mmHg

0.5 mcg/kg SLOW IV/IM, max dose 50 mcg Repeat dose 0.25 mcg/kg SLOW IV/IM,

max dose 25 mcg

Adverse Effects of Fentanyl

AMS, respiratory depression (particularly if >65 YO)

Stupor Delirium Somnolence Dysphoria Chest wall-rigidity

Muscle rigidity (involving the respiratory musculature including the glottis)

Seizures Difficulty or inability to ventilate the patient

Adverse Effects of Fentanyl

Hypotension Bradycardia Nausea/vomiting Constipation Arrhythmias (rarely) Hypersensitivity side effects including

anaphylaxis have been reported on rare instances

Pediatric Fentanyl Dosing

Dosing for pediatrics has NOT changed 1 mcg/kg SLOW IV/IM, max dose 100 mcg Remember: most pediatric dosages don’t

exceed the adult dose! Obtain accurate weight from

parents/caregivers No repeat dose, but can call Medical

Control to request additional dosing as appropriate

NO IO route for fentanyl administration in peds If the patient requires an IO, stabilizing the

patient takes priority to giving pain medication.

Fentanyl Administration

Administering fentanyl too quickly can cause chest wall rigidity

IV administration should be over 1-2 minutes

If using a saline lock, push the fentanyl over 1-2 minutes, then push the saline flush over 1- 2 minutes as well

Fluid Bolus

In all SOPs, the phrase “Fluid Challenge” has been replaced with “Fluid Bolus” Administering a large amount of IV fluid

in a relatively short period of time is a fluid bolus.

Remember to reassess your patient after administration of each bolus Vital signs, including pulse characteristics Lung sounds (crackles) Change in condition

Pleural Decompression

“Pleural decompression” has replaced “needle decompression” throughout the SOPs

General Patient Assessment

Page 2 Initial Assessment, Breathing Addition of “assess lung sounds”

A reminder that auscultation of lung sounds should occur in the primary assessment stage of patient care

Zofran (ondansetron)

Page 4 Adult Initial Medical Care

Zofran (ondansetron) may now be administered 4 mg tab ODT or 4 mg slow IV x1 dose.

Patients must be actively vomiting and/or nauseous prior to administration

Onset of action of IV Zofran (ondansetron) is twice as fast as ODT

Administer over 1-2 minutes IV (no less than 30 seconds)

Zofran (ondansetron)

Not approved for prophylactic administration (prevention) of nausea or vomiting

Can only be given IV or ODT once – NOT both.

ODT: patient should allow tablet to dissolve on their tongue for rapid absorption into the bloodstream Do not have patient chew or swallow

whole tablet

Initiation of ALS Care

Page 6 Abnormal vital signs respiratory rate

upper limit is changed from 28 to 30 breaths/minute Consistent with other portions of SOPs

Adult Suspected Cardiac Patient With Chest Pain

Page 11 Removed if “pain unrelieved by NTG”,

administer fentanyl After administering nitroglycerin

(NitroStat) x 2 (ALS), administer fentanyl to achieve the goal of pain relief

The goal is to alleviate all pain in the adult suspected cardiac patient with chest pain, as long as the patient remains stable

Adult Suspected Cardiac Patient With Chest Pain

Page 11

Adult Pulmonary Edema(Due to Heart Failure)

Page 21 Lasix has been removed from SOP

Dose was not adequate for the purpose of diuresis that was needed for respiratory distress secondary to pulmonary edema

Lasix was sometimes administered prior to nitroglycerin (not consistent with SOP) Nitroglycerin dilates coronary AND

pulmonary vasculature, leading to relief of respiratory symptoms

Adult Pulmonary Edema(Due to Heart Failure)

Page 21

Adult Pulmonary Edema(Due to Heart Failure)

Page 21

Adult Pulmonary Edema(Due to Heart Failure)

Page 21 CPAP is positive pressure

Increases intrathoracic pressure Decreases venous return to the heart Decreases cardiac output Decreases blood pressure

Patient MUST be stable prior to administration

Adult Pulmonary Edema(Due to Heart Failure)

Page 21 CPAP absolute contraindications Respiratory arrest Agonal respirations Unconscious Shock with cardiac insufficiency Pneumothorax Penetrating chest trauma Persistent nausea and vomiting Facial anomalies/stroke/facial

trauma

Adult Pulmonary Edema(Due to Heart Failure)

Page 21 CPAP administration Initial setting is 5 cmH2O Maximum pressure is 10 cmH2O Discontinue if

change in mental status change in patient condition (e.g. ↓blood

pressure) ↑anxiety/unable to tolerate mask nausea/vomiting occur

Adult Drug Assisted Intubation - Etomidate (Amidate)

Page 24 Sellick’s maneuver has been removed

Not performed consistently Has not been proven to be effective by

evidence based medicine After passing the tube, verify

placement Added “adequate chest expansion

bilaterally and symmetrically”

Adult Partial (Upper) Airway Obstruction/Epiglottitis

Page 27 ALS/ Unstable

Added “severely diminished or absent breath sounds”

If a patient doesn’t look well, consider that absence of adventitious lung sounds means that little-to-no air is being moved in the lungs instead of “clear” lung sounds, indicating normal pulmonary exchange of gases

Adult Diabetic/Glucose Emergencies

Page 29 Added dextrose 10% dosing in the

event of a severe drug shortage System-specific procedure for details

Adult Syncope/Near Syncope

Page 30 Change in Narcan (naloxone) dose

Narcan (naloxone) 1 mg IV/IN Repeat dose 0.5 mg IV/IN PRN every 2

minutes up to a max dose of 2 mg if transient response observed

Administration indicated if decreased sensorium and pinpoint pupils, depressed respirations, and possible history of narcotic/synthetic narcotic ingestion

Don’t forget! Obtain 12-Lead ECG to rule out cardiac origins

Adult Syncope/Near Syncope

Page 30

Adult Stroke

Page 32 Now includes obtaining and documenting

Last Known Well time Requirement for hospital stroke center criteria

Time Last Known Well Ask the family for the specific time Relay that time to Medical Control Give that time to the emergency nurse in

report Document the time in your run report

Section 7 criteria opening sentence reworded but the content is the same

Adult Acute Abdominal Pain

Page 33 Fentanyl doses are now the same for adult

patients < 65 YO and those > 65 YO across all SOPs

Addition of Zofran (ondansetron) IV

Adult Toxicologic Emergencies

Page 34 Narcan (naloxone) 1 mg IV/IN Repeat 0.5 mg IV/IN PRN every 2 minutes up

to a max dose of 2 mg if transient response observed Focus on getting patient breathing but not

causing withdrawal

Adult Toxicologic Emergencies

Page 35 Added generic drug names to “Club

Drugs”

Adult Cold Emergencies

Page 42 Fentanyl doses are now the same for

adult patients < 65 YO and those > 65 YO across all SOPs

Adult Initial Trauma Care

Page 53 “Pelvic fracture” was changed to “pelvic instability”

Treat any/all suspected pelvic fractures and pelvic instability as a fracture in prehospital setting

Adult Chest Injuries

Page 58 Sucking Chest Wound/Open

Pneumothorax “Apply occlusive chest dressing” Removed “to create a flutter valve”

Three sided or occlusive dressing does not create a flutter valve

If a tension pneumothorax develops with occlusive dressing, temporarily remove the dressing to allow air to escape

Adult Ophthalmic Emergencies

Page 60 Fentanyl doses are now the same for

adult patients < 65 YO and those > 65 YO across all SOPs

Adult Ophthalmic Emergencies

Page 60 Tetracaine

Instill 0.5% tetracaine 1 drop in each affected eye

May repeat until pain relief achieved Use for Chemical/splash burn

Irrigate the eye first Use for suspected corneal abrasion

Patch affected eye after tetracaine instilled

Do not use for penetrating injury/ruptured globe (no tetracaine, no irrigation)

Adult Burn Injuries

Page 61 The IO route for fentanyl is approved

in this SOP. Both adults under and over 65 years old can get fentanyl via IO

Adult Burn Injuries

Page 61 Determining TBSA burned Rule of Nines

Include all second, third and fourth degree burns

First degree burns are not included The Palmar method

Estimated1% TBSA The patient’s palm, not yours!

Adult Burn Injuries

Page 61 Parkland FormulaVolume of Normal Saline:

4 mL x BSA(%) x weight (kg)

Give half of solution in

first 8 hours

Give other half of solution in

next 16 hoursDivide by 8 to

determinehourly rate (mL/hr)

Adult Burn Injuries

Page 61 Keep patient NPO Keep accurate intake and output records

Report accurate I&O volumes to receiving nurse

Intraosseous route is approved for this SOP to administer fluids and medication IO can be placed through burned tissue if

there are no other options for IV/IO placement

Adult Musculoskeletal Injuries

Pages 64-65

Fentanyl doses are now the same for adult patients < 65 YO and those > 65 YO across all SOPs

Suspected Abuse or NeglectDomestic, Sexual, Elder

Page 67 The reporting phone numbers have

been changed by the State and updated in SOPs

EMS providers are mandated to report suspected abuse Giving report to ED staff does not meet

as the mandated reporting legal requirements for EMS providers

Individual providers must make reports to the appropriate agency

Document case number, worker name, and include in narrative if able to obtain

Suspected Abuse or NeglectDomestic, Sexual, Elder

Page 67 Documenting suspected

neglect/abuse No accusations Objective facts only History as given by patient (if able) and

family/caregiver Document physical environment if

pertinent Exact (pertinent) statements in quotes Relevant physical findings

Emergency ChildbirthPhase III: Care of the Newborn

Page 72 Updated to reflect current neonatal

resuscitation national standards Epinephrine (adrenaline) 1:10,000

0.1 mL/kg IV/IO q 3-5 minutes If unsuccessful, 0.5 ml/kg ET Repeat every 3-5 minutes as long as heart

rate < 60 beats per minute with CPR

DO NOT follow ET dose with flush Ventilate the patient to assist dose

distribution Beware of mL/kg versus mg/kg….

these doses are mL/kg

Emergency ChildbirthPhase III: Care of the Newborn

Page 72

Pediatric Initial Medical Care

Page 75 Zofran (ondansetron) doses are written by weight AND age > 1 YO AND > 40 kg

4 mg ODT or 4 mg slow IV x1 dose only > 1 YO AND < 40 kg

0.1 mg/kg slow IV x1 dose only No oral dose for < 40 kg

IV administration over 1-2 minutes

Pediatric Initial Medical Care

Page 75

Pediatric Drug Assisted Intubation - Versed (Midazolam)

Page 81 Sellick’s maneuver has been removed

Not performed consistently Has not been proven to be effective by

evidence based medicine After passing the tube, verify

placement Added “adequate chest expansion

bilaterally and symmetrically” Focus for peds patients is on BLS

maneuvers as appropriate

Pediatric Altered Mental Status

Page 88 Added definition of Newborn (< 24

hours old) versus Neonate (1-28 days old) under glucose doses

Narcan (naloxone) can now be given IM (in addition to IV/IO/IN) Narcan (naloxone) IM route approved for

peds only

Pediatric Altered Mental Status

Page 88 Narcan (naloxone) doses changed,

now dosed by weight or age Respiratory compromise in pediatric

patients is more likely to be due to OD or accidental ingestion, therefore different dose than adults

Pediatric Altered Mental Status

Page 88 Special Considerations

Added dextrose 10% dosing in the event of a severe drug shortage (> 8 YO)

System-specific procedure for details

Pediatric Altered Mental Status

Page 88 To administer dextrose 12.5%, providers

need to mix their own 12.5% concentration

How do you mix D12.5?

Pediatric Toxicologic Emergencies

Page 92 Added generic drug names to “Club

Drugs”

Pediatric Burns

Page 102 Pediatric fentanyl dosing for has NOT

changed Fentanyl 1 mcg/kg SLOW IV/IM, max dose

100 mcg Peds doses rarely exceed adult doses

No repeat dose but can call Medical Control to request additional dosing

The IO route for fentanyl is not approved in the pediatric SOPs

If the patient requires an IO, stabilizing the patient takes priority to giving pain medication

Drug Appendix

Adenocard (adenosine)

Page 112 Administer Adenocard (adenosine)

immediately followed by rapid IV flush, then elevate the extremity Half life is 6 seconds Proximal vein (AC or upper arm) 10-20 mL NS flush

Obtain 12-lead ECG during attempted cardioversion if possible

Additional adverse reaction added Drug is a respiratory stimulant and can

exacerbate asthma

Adenocard (adenosine)

Page 112 Additional contraindications for

Adenocard (adenosine) Atrial fib/flutter with underlying Wolff

Parkinson White (WPW) syndrome Symptomatic bradycardia except those

with functioning pacemakers

Wolff Parkinson White (WPW) Syndrome

Page 112 Classic ECG features

Shortened PR interval Slurring and slow rise of the initial upstroke

of the QRS complex (delta wave) Widened QRS complex (total duration

>0.12 seconds) ST segment–T wave changes, generally

directed opposite the major delta wave and QRS complex

Wolff Parkinson White (WPW) Syndrome

Page 112 During tachycardic episodes, may be

Cool, diaphoretic, and hypotensive Crackles in the lungs from pulmonary

vascular congestion

Amiodarone (Cordarone)

Page 112 Adverse effects

May also prolong the QT interval, leading to ventricular dysrhythmias

Dextrose

Page 115 In the event of drug shortages of

D50%, use D10% per System-specific procedure

Dextrose can be administered IV or IO

Etomidate (Amidate)

Page 115 Etomidate (amidate) can be

administered IV or IO

Epinephrine (adrenaline)

Page 116 Epinephrine (adrenaline) can be

administered IV or IO for anaphylaxis Differentiate between anaphylaxis and

systemic allergic reaction Neonatal doses changed

Systemic Allergic Reaction

Onset: gradual Skin: mild-to-moderate flushing, rash,

hives Respiration: mild-to-moderate

bronchoconstriction GI System: mild cramps, diarrhea Vital Signs: normal-to-slightly

abnormal (↑pulse, ↑RR)

Mental Status: normal

Anaphylaxis

Onset: sudden, typically 30-60 seconds

Skin: severe flushing, rash, hives, angioedema (swelling) of face or neck

Respiration: severe bronchoconstriction (wheezing), laryngospasm (stridor), difficulty breathing

GI System: severe cramps, diarrhea, vomiting

Vital Signs: early↑pulse/late↓,early↑RR/late↓RR, falling BP

Mental Status: anxiety, confusion/unconsciousness

Sense of impending doom

Respiratory distress

Signs of shock

Signs/Symptoms Ominous Signs

Epinephrine (adrenaline)

Page 116 Updated to reflect current neonatal

resuscitation national standards Epinephrine (adrenaline) 1: 10,000

0.1 mL/kg IV/IO q 3-5 minutes If unsuccessful, 0.5 ml/kg ET Repeat every 3-5 minutes as long as heart

rate < 60 beats per minute with CPR

DO NOT follow ET dose with flush Ventilate the patient to assist dose

distribution Beware of mL/kg versus mg/kg….

these doses are mL/kg

Fentanyl

Page 117 The IO route for fentanyl is not

approved in most SOPs, except the Adult Burn SOP If the patient requires an IO, stabilizing

the patient takes priority to giving pain medication.

Pushing IV fentanyl too quickly can cause chest wall rigidity Administration should be over 1-2

minutes If using a saline lock, push the fentanyl

over 1-2 minutes and then push the saline flush over 1-2 minutes

Fentanyl

Page 117 The dosing of fentanyl is changed and

is now consistent for adults regardless of SOP

Adult patients receiving fentanyl must have a systolic BP > 100 mmHg

The initial fentanyl dose remains the same for all adult patients < 65 years old

Now all adult patients < 65 years old, regardless of SOP, can have one repeat dose up to a maximum of 50 mcg

Fentanyl

New doses added for patients > 65 years old These patients tend to have slower renal

clearance of drugs and are more sensitive to the effects of opiates even at lower doses.

Adult patients receiving fentanyl must have a systolic BP > 100 mmHg

Initial dose of 0.5 mcg/kg (max 50 mcg) SLOW IV/IM

Repeat dose of 0.25 mcg/kg (max 25 mcg) SLOW IV/IM

Fentanyl

Page 117 Pediatric fentanyl dosing for has NOT

changed Fentanyl 1 mcg/kg SLOW IV/IM, max dose

100 mcg Peds doses rarely exceed adult doses

No repeat dose but can call Medical Control to request additional dosing

The IO route for fentanyl is not approved in the pediatric SOPs

If the patient requires an IO, stabilizing the patient takes priority to giving pain medication

Glucagon (GlucaGen)

Page 117 For Beta Blocker or Calcium Channel

Blocker overdose, may be administered IV or IO

Adult dose1 mg slow IV/IO May repeat x1

Pediatric dose 0.5 mg slow IV/IO May repeat x1

Administer in cases where suspected BB or CCB overdose is suspected and the patient has hypoperfusion with associated bradycardia

Glucose, oral

Page 117 New to drug appendix Dose

Pediatrics and adults = one tube/15 grams Onset

~10 minutes Indication

Hypoglycemia in patients with normal mental status and intact gag reflex

Contraindications Altered mental status and no gag reflex

Adverse reactions Nausea, and potential for aspiration in patients

with impaired airway reflexes

Narcan (naloxone)

Page 118 New dosing for adults

Initial dose of 1 mg IV/IN May repeat 0.5 mg IV/IN prn q 2 minutes

up to a max dose of 2 mg if transient response observed

Old wording was “as needed” Focus now is on getting patient breathing

but not causing withdrawal

Narcan (naloxone)

Page 118 Narcan (naloxone) doses changed for

pediatrics, now dosed by weight or age ≤20 kg or < 5 YO

0.1 mg/kg IV/IO/IM/IN ≥20 kg or ≥ 5 YO

2 mg IV/IO/IM/IN

Can now be given IM (as well as IV/IO/IN)

Versed (midazolam)

Page 119 Added IO route as additional route to

IV

Zofran (ondansetron)

Page 119 As alternative route to ODT, adults may

now be given 4 mg Zofran (ondansetron) SLOW IV x1 dose only

Zofran can only be given IV or ODT once – NOT both

Pediatric Zofran (ondansetron) doses are by weight AND age > 1 YO AND > 40 kg

4 mg ODT or 4 mg slow IV x1 dose only > 1 YO AND < 40 kg

0.1 mg/kg slow IV x1 dose only No oral dose for < 40 kg.

IV administration over 1-2 minutes

Region VIII EMS Systems

RESPIRATORY:OXYGENATION VS VENTILATION

Objectives

SME video of the month Describe the respiratory system and the

process of breathing Recognize adequate vs inadequate

oxygenation vs ventilation in patients Understand the tools used for monitoring both

oxygenation and ventilation Discuss acute and chronic disease processes

that effect oxygenation and/or ventilation Discuss considerations for selecting the best

device for delivering oxygen and ventilations

Announcements

Region

System

SME video

Review of Respiratory SystemUpper Airway• Pharynx• Nasopharynx• Oropharynx• Larynx

• Thyroid cartilage• Glottic opening• Cricoid ring• Trachea

Review of Respiratory SystemLower Airway Trachea Bronchi and

bronchioles Alveoli Lungs

Review of Respiratory System Breathing is only one of the activities of

the respiratory system The body’s cells need continuous supply of

oxygen for the metabolic processes necessary to maintain life

The respiratory system works with the circulatory system to provide oxygen and remove waste products of metabolism (carbon dioxide)

Helps to regulate pH of the blood

Review of Respiratory System

Every 3-5 seconds, nerve impulses stimulate ventilation, which moves air through a series of passages into and out of the lungs There is an exchange of

gases between the lungs and blood, which is called external respiration

The exchange of gases between the blood and tissues is called internal respiration

Cellular respiration (metabolism) is when the cells utilize the oxygen for their specific activities

Review of Respiratory

• Breathing is primarily controlled involuntarily by autonomic nervous system

• Regulation is largely r/t maintaining normal gas exchange and blood gas levels

• Receptors in the body constantly measure the amount of oxygen (O2), carbon dioxide (CO2) and hydrogen ions (pH) to signal the brain to adjust rate and depth of respirations

Review of Respiratory

98% of O2 is carried bound to Hemoglobin (the other 2% is dissolved in blood plasma)

In summary, we breathe not only because we need O2 to survive, but to get rid of CO2, a by-product of cellular metabolism

Common Respiratory Diseases Obstructive Airway Diseases

Chronic Bronchitis Emphysema

These 2 often coexist and are then termed chronic obstructive pulmonary disease (COPD)

Asthma Status Asthmaticus is a severe prolonged

asthma exacerbation that cannot be broken with repeated doses of bronchodilators

True emergency, requires early recognition and may quickly lead to respiratory failure

Common Respiratory Diseases or Disorders

Upper Airway Infections Pneumonia

Can be viral or bacterial Adult Respiratory Distress Syndrome

(ARDS) Respiratory failure with acute lung inflammation

and diffuse alveolar-capillary injury Pulmonary Embolism (PE) Spontaneous Pneumothorax Lung Cancer

Let’s start with the patent Airway . . .

Head-tilt/chin lift Maneuver Opening the airway with repositioning

Jaw thrust without head-tilt Opening the airway if spinal injury is

suspected

Suction Remove secretions or debris

Airway Management

• Nasopharyngeal (nasal) Airway Maintain airway in a semiconscious patient

Oropharyngeal (oral) Airway Maintain airway on an unconscious patient (no gag reflex)

Airway Management Endotracheal Intubation – patient can no

longer protect airway Advantages:

Provides complete airway management Helps prevent aspiration Positive pressure ventilation can be given Control of volumes of ventilation Tracheal suctioning is possible Prevents gastric distention Provides a route for some medications (not

preferred, but worst case if no IV/IO) High concentration of oxygen can be given

Airway Management

Alternative Airways:

King Airway Advantage is ease of

use Can reduce time spent

off the chest if CPR is ongoing

Cricothyroidotomy Surgical or Needle, per

system specific procedure

Airway Management

Traits to look for in difficult to obtain airways (ANOTES): A: Awake patients (with a Glasgow Coma Scale

score greater than 3) N: Neck (short or “no neck”) O: Obese patients T: Trauma (facial, airway or requiring C-spine

stabilization) E: Emesis S: Space: limited space about the head to

manage the airway

Definition of Ventilation

The process of air movement into and out of the lungs

For ventilation to occur, the following must be intact: Patent upper airway Neuro control – brain stem Muscles of respiratory system, including

diaphragm and intercostal muscles Functional lower airway, including functional

alveoli

Inadequate Ventilation

Occurs when the body cannot: compensate for increases in O2 demands maintain normal oxygen/carbon dioxide

balance Causes:

Infection Trauma Brain stem insult Noxious or hypoxic atmosphere

Signs and Symptoms

Respiratory Distress Tachypnea Use of accessory muscles

(intercostal, suprasternal or substernal retractions)

Adventitious breath sounds Nasal flaring Tripod or position of

comfort Grunting Cyanosis

Respiratory Failure Decreased level of

consciousness Increased work of

breathing Poor air entry Decreased breath

sounds Bradycardia Apnea or respirations

less than 6 per minute

Respiratory Distress vs Failure

1. Adventitious Breath Sounds: http://

www.youtube.com/watch?v=5JA6D1Mguh0

2. Respiratory Distress or Failure? http://

www.youtube.com/watch?v=uA02h6FYSYQ

3. Respiratory Distress or Failure? http://

www.youtube.com/watch?v=0YJxz-Sxx90=

Causes of Respiratory Distress/Failure

Failure to Maintain Airway Upper Airway obstruction

Foreign body Anaphylaxis (laryngeal edema) Epiglottitis Croup Tracheal trauma

Lower Airway Obstruction Bronchospasm Inhaled objects (foreign body aspiration)

Causes of Respiratory FailureFailure to Ventilate Neuro

Opioids, sedative or anesthetic agents

Brain or spinal injuries Muscular

Steroids Myasthenia Gravis (or

other neuromuscular disorders)

Trauma Chest wall trauma such

as flail chest Pneumo-/hemothorax

Failure to Oxygenate Pulmonary

Embolism Pulmonary

Fibrosis Interstitial Lung

Disease COPD Pneumonia

Pulmonary Edema

Ventilation vs Oxygenation

It is important to remember that these terms are NOT synonymous

Adequacy of ventilation is evaluated using qualitative, external cues such as respiratory rate, chest rise and fall, compliance of a bag-valve mask

Ventilation

Many studies have shown that HCP’s tend to hyperventilate patients Both the rate and volume of assisted

ventilations are often too high Hyperventilation causes vasoconstriction

which can lead to hypoperfusion to major organs (especially the brain)

American Heart teaches that providers should administer ventilation at 10-12 breaths per minute and titrate to achieve EtCO2 of 35-40mm/Hg using continuous waveform capnography

Ventilation Capnography is a

quantitative tool that can be used to monitor ventilation adequacy r/t end tidal CO2 concentration (EtCO2)

Our medulla measures CO2 levels to adjust rate and depth of respirations

If patient is having respiratory distress, the provider should measure CO2 to determine if breaths, whether spontaneous or artificial, are adequate

Normal CO2 level 35-45mm/hgHypocapnia (CO2 < 35mm/hg)• Hyperventilation (blowing

off too much CO2)• Metabolic condition such as

diabetic ketoacidosis or kidney failure

• Hypoperfusion• Hypotension• Shock

• Hypothermia• Metabolism is slowed in

hypothermic state, so less CO2 is produced

Hypercapnia (CO2 > 45mm/hg) Ventilatory failure

(hypoventilation) Narcotic overdose Stroke that affects the

brainstem CO2 Retention

COPD Respiratory Acidosis

Chest wall injury Chest muscle weakness

Fever (hypercatabolic state)

Capnography

American Heart defines capnography as the measurement and graphic display of CO2 levels in the airway, which can be performed by infrared spectroscopy

Long the standard for monitoring intubated patients, especially in the operating room and intensive care units, capnography is now a standard tool for assessing ventilation in both intubated and non-intubated patients

Ventilation and Capnography

Our bodies “blow off” CO2, so during expiration an upstroke in the waveform is seen This creates a plateau

until the end of expiratory phase

It is at this peak level that the EtCO2 value is measured and resulted

During inspiration, CO2 is purged from the airway and alveoli, so the waveform drops down to baseline

Normal Capnogram

Field Application for Capnography

Triage Tool Help narrow a differential diagnosis of dyspnea Assist in assessing severity of asthma attack Trend CO2 retainers if patient has COPD

Monitor for relapses following therapies Such as following administration of a

bronchodilator

CPR Correlate blood delivery to the lungs (adequate

chest compressions, ventilations)

Field Application for Capnography Endotracheal or other advanced airway

placement confirmation Waveform should appear to be SQUARE

if tracheal intubation is successful

Ongoing assessment of ventilations following insertion of advanced airway Rate AND volume of assisted ventilation

Troubleshoot Abnormal Waveforms

Oxygenation Adequacy of oxygenation, such as pallor,

cyanosis or other physical findings are not as reliable as signs of ventilation (ie: chest-rise and fall, resp. rate) Pulse-oximetry is the quantitative tool

that monitors saturation of peripheral O2 (oxygenation/SpO2) This tool has its limitations:

Hypoxia follows hypoventilation, which can take 30 seconds or more for the pulse-ox to reflect

Hypovolemia, vasoconstriction, peripheral vascular disease and even nail polish can cause false readings

Oxygen Delivery Devices

Nasal Cannula – delivers 1-6L, approximately 24-44% concentration, of O2 Indications for use: treat hypoxia,

dyspnea or increased myocardial work

Contraindications: nasal trauma or blockage

Consider placing patient on 10L while intubating!

Oxygen Delivery Devices Non-rebreather Mask – delivers 10-15L, approximately 90% concentration, of O2

Indications for use: respiratory distress, trauma

Contraindications: CO2 retainer such as COPD exacerbation

Bag-valve Mask – delivers15L, 90%+ concentration, of O2 Indications for use: respiratory failure, support for bradypnea or apnea, positive pressure to open the airway/alveoli (this is used to admin- ister oxygen and ventilations BOTH)

Ventilation vs Oxygenation

*** REMEMBER: the provider is the best “monitor” ***

If available, combining pulse-ox and capnography are ideal for monitoring oxygenation and ventilation, as providers can detect insufficiencies early and intervene

While they are helpful tools, Pulse-oximeters and capnometers do not treat the patient, YOU DO

The provider in charge of the airway and ventilating needs be able to focus on this task only so as not to have poor outcome that hyperventilating a patient can cause

BREAK TIME

Scenario 1

EMD / BLS

EMD/BLS

• Call comes in as an 8 year old shortness of breath from the local elementary school

• EMD: What questions would you ask the caller?

• EMD: Which units would you dispatch? How many?

BLS Arrives on Scene:

General Appearance Awake, alert, anxious

Work of Breathing Dyspnea

Circulation Hot, dry, red, patchy,

swollen areas on skin of extremities and face

BLS Scenario A – patent

(“tightening”), no stridor noted at this time

B – increased effort, audible wheezes without auscultation, SpO2 92%

C – flushed, capillary refill is 2 seconds, pulse is strong and fast

Vitals: B/P 105/65, P 128, R 30, T 99.0

S - hives, itchy, throat tightening and dyspnea

A – tree nuts, no known drug allergies

M – EpiPen Jr (at home), Albuterol inhaler

P – asthma, seasonal and food allergies

L – lunch about a 20 min ago

E - ate a cookie offered to him by another student, started to feel throat closing feeling and itchy, hot skin in class right after lunch

BLS Scenario

Obtain SAMPLE history

Initial Medical Care You have already assessed for signs of

respiratory distress vs failure

Reassure patient, place in position of comfort

Should this patient receive oxygen? What would you use to deliver this? Should you assist ventilations?

BLS Scenario

Should you give this patient an auto-injection of Epinephrine (EpiPen)?

Where is the site of injection?

What if the school nurse says she cannot find his prescribed EpiPen and hands you an adult EpiPen because its all she could find?

BLS SKILL REVIEW

Epinephrine Auto-injector

BLS Skill Review

Indications for use of EpiPen EpiPen® (epinephrine) 0.3 mg and EpiPen Jr®

(epinephrine) 0.15 mg Auto-Injectors are indicated in the emergency treatment of type 1 allergic reactions, including anaphylaxis, to allergens, idiopathic and exercise-induced anaphylaxis, and in patients with a history or increased risk of anaphylactic reactions. Selection of the appropriate dosage strength is determined according to body weight.

Important Safety Information EpiPen Auto-Injectors should only be injected

into the anterolateral aspect of the thigh. DO NOT INJECT INTO BUTTOCK, OR INTRAVENOUSLY.

EpiPen for Anaphylaxis

http://www.epipen.com/How-to-Use-EpiPen

Scenario 2

BLS/ALS

BLS/ALS Scenario

Your medic unit is dispatched for 78 year old female shortness of breath

You arrive on scene where a daughter directs you to the bedroom to find the female patient sitting in high-fowler’s position with several pillows propped behind her Appearance: awake and alert with a GCS of 15 Increased work of breathing noted Skin is pale

BLS/ALS A – patent B – dyspnea, rales

audible from across the room

C – pale, cool to the touch, edema to BLE

Vitals: B/P: 194/106 P: 116 R: 28 T: 97.6

S – short of breath A – PCN M – Metoprolol, Plavix,

Norvasc, Crestor, Diovan HCT

P –cardiac stents, high cholesterol, CHF, pneumonia

L – dinner about 6 hours ago

E – over the last week she has needed to be propped up more to sleep d/t inability to breath lying flat

ALS

• Are we thinking pulmonary edema d/t heart failure?

• Goal is to reduce the preload and afterload on the heart• administration of nitroglycerin

• If available, place the patient on continuous waveform capnography

• CPAP should be considered sooner rather than later• Reduces work of breathing• Helps reduce preload on the heart

• Do we use a diuretic? NO!!!

Medications of the month

Albuterol

Albuterol

Brand Names: Proventil, Ventolin

Adult/Pediatric Dose: 2.5mg of 0.83% solution (3ml) via nebulizer (6LPM O2 supply) until mist stops (usu 5-15 min)

Action: binds and stimulate Beta 2 receptors, resulting in bronchial smooth muscle relaxation and bronchodilation

Indications: asthma, bronchitis with bronchospasm, COPD with wheezing, allergic reaction or anaphylaxis with wheezing

Albuterol

Contraindications: angioedema, hypersensitivity to albuterol,

caution in lactating women, cardiovascular disease history

Adverse Reactions: hyperglycemia, hypokalemia, palpitations,

tachydysrhythmias, anxiety, tremors, nausea/vomiting, throat irritation, dry mouth, HTN, insomnia, headache, paradoxical bronchospasm

MEDICATIONS OF THE MONTHEtomidate

Etomidate

Brand Name: Amidate

Adult Dose: 0.6 mg/kg rapid IV, NO Repeat dose and NO PEDS

Action: non-barbiturate hypnotic without analgesic properties. Has minimal effects on cardiac or respiratory systems. Onset is 10-20 seconds with duration of 3-5 minutes

Indications: sedation for endotracheal intubation

Etomidate

Contraindications: hypersensitivity to Etomidate, only use in

pregnancy if potential benefits justify the potential risk to fetus

Adverse reactions: hypotension, respiratory depression,

injection site pain, temporary involuntary muscle movements, frequent nausea and vomiting, hyper-/hypoventilation, short duration apnea, hiccups, laryngospasm, snoring, tachypnea, HTN, dysrhythmias

Do Not Forget Your Med Checks!

Cardiac Rhythm of the Month

Torsades de Pointes An uncommon and distinctive form of

polymorphic ventricular tachycardia (VT) characterized by a gradual change in the amplitude and twisting of the QRS complexes around the isoelectric line

Associated with prolonged QT intervals, which can be congenital or acquired (such as drug therapy induced or other body system disorders)

Tends to occur in bursts that are not sustained but can recur and may degenerate into ventricular fibrillation (VF)

Torsades de Pointes

Patient presentation may include: Palpitations Dizziness Syncope Nausea Cold sweats Shortness of breath Chest pain Sudden Cardiac

Death

Treatment: Determine if patient

has a pulse and then follow the appropriate ventricular tachycardia SOP

Magnesium is ultimate drug of choice Lowers the amplitude

of early afterdepolarization (EAD) by decreasing the influx of calcium

Scenario 3

ALS

ALS Scenario

Your medic unit is dispatched for the 44 year old female shortness of breath

Upon arrival, you find the patient in a tripod position, having difficulty getting more than a word or 2 out Appearance: awake, alert, anxious Work of Breathing: increased effort Circulation: pale, diaphoretic

ALS

A – patent B –intercostal and

substernal retractions, diffuse wheezes

C –strong peripheral pulses, cap refill 2 seconds

Vitals: B/P:168/94 P: 130 R: 40 T: 100.4

S – cough, dyspnea A – environmental, no

drug allergies M –Xopenex, Xyzal,

Chantix P – asthma with

intubation in the past, allergies, smoker

L – dinner last night E – URI symptoms x2

days, labored breathing is new onset today and she tried 2 nebs prior to your arrival

ALSAsthma Exacerbation Possible Status

Asthmaticus Need to correct the

hypoxemia caused by narrowing and blocked airways

Follow ADULT ACUTE ASTHMA SOP

Slap the Cap (monitor waveform capnography for trends with treatments – note the “shark fin” appearance in bronchospasm

Airways affected by asthma

ALS

Consider CPAP early to:

Decrease work of breathing, reducing fatigue

Recruit alveoli and improved oxygenation

Splint larger airways, reducing airway collapse and mucous plugging

Als skill review

Continuous Positive Airway Pressure (CPAP)

CPAP Prehospital indications for CPAP

use: Congestive Heart Failure Asthma/COPD Drowning Carbon Monoxide Poisoning Pulmonary Infections

CPAP

Contraindications: Cardiogenic Shock

Patient is hypotensive and CPAP increases intrathoracic pressures, thereby lowering venous blood return to the right side of the heart

Altered Mental Status or unconscious Facial Trauma, anomalies or stroke with facial

droop Pneumothorax or penetrating chest trauma Persistent nausea/vomiting Agonal respirations/respiratory arrest

CPAP

Additional Education from Bob Spoula – Edward Hospital Respiratory Therapy Educator (CPAP PowerPoint)

Questions? Contact EMS Office

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