medical i refresher lecture aaron j. katz, aemt-p, cic
TRANSCRIPT
Medical I Refresher Lecture
Aaron J. Katz, AEMT-P, CICwww.es26medic.net
Pharmacology
The study of drugs Sources, characteristics and effects
Always refer to drugs as medications
EMTs can deliver some medications and can assist the patient in delivering some other medications
Meds EMTs can deliver
Oxygen Oral Glucose Activated Charcoal Epinephrine injectors (“EpiPen”) Aspirin
Meds that EMTs can assist
Prescribed inhalers Nitroglycerin
Drug Names
Chemical Generic
E.g. Ibuprofin, Nitroglycerin Trade
E.g. Advil, Nitrostat
Important terms Action
The therapeutic effect that a drug is expected to have on the body
Indications Signs/Symptoms/Conditions for which a particular
medication should be used Contraindications
Signs/Symptoms/Conditions or patient for which a particular medication should NOT be used
Side effects Any actions of a medication other than the desired
ones
Drug Administration
Before administering any drug, know the “four rights” Right patient Right medication Right dose Right “route”
Medication Routes Intravenous (“IV”) Oral (“PO”) Sublingual (“SL”) Intramuscular (“IM”) Intraosseous (“IO”) Subcutaneous (“SC”) Transcutaneous Inhalation Rectal (“PR”)
References
PDR USP Merck Manual The Pill Book
Not an “official” guide, but a very good source
ePocrates
Survey of commonly used drugs
Anti-hypertensives
Accupril Cozaar Isoptin (Verapamil)
Lotensin Monopril Norvasc
Lopressor (Metoprolol)
Toprol XL Tenormin (Atenalol)
Vasotec Zestril Calan (verapamil)
Prinivil
Diuretics
Lasix (Furosemide) Bumex Diazide HCTZ Hydrodiuril
Combination HTN, diuretics
Zestoretic Prinzide Vasaretic
Potassium supplements
K-Dur K-Tab Slo-K
Cholesterol Lowering
Lipitor Mevacor Lopid Pravachol Zocor Crestor
Antianginals
Procardia XL (Nifedipine)
Nitrostat (nitroglycerin)
Cardizem (Diltiazam)
Isordil (Isosorbide Dinitrate)
Inderal (propranalol) Imdur (Isosorbide Mononitrate)
Capoten Corgard
Oral Anti-hyperglycemics
Diabeta (Glyburide) Diabenase
Glucotrol (Glipizide) Glucophage
Glynase (Glyburide) Micronase (Glyburide)
AvandiaAvandia
Injected Anti-hyperglycemics
Humulin Humalog Lente Lantus And many others
Anti-epilepsy
Dilantin Phenobarbitol Depakote Tegratol Nerontin
Some cardiac meds
Lanoxin Digoxin
Coumadin Warfarin
Many of the anti-hypertensives and anti-anginals are used for cardiac conditions
Assorted respiratory inhalers Atrovent Combivent/Duoneb Alupent Proventil, Ventolin (Albuterol) Intal Serevant Beclovent Advair Azmacort Aerobid
Respiratory Emergencies
Review of airway anatomy
Nose/Mouth Oropharynx/Nasopharynx Epiglottis Trachea Cricoid cartilage Larynx/vocal cords
Review of airway anatomy-2
Bronchi Bronchioles Lungs Alveoli Diaphragm
Physiology
Inspiration Expiration
Signs of normal breathing
Normal rate & depth Regular pattern of
inhaling/exhaling “Good” breath sounds bilaterally Regular rise and fall of the chest –
bilaterally “Some” movement of the abdomen
Signs of abnormal breathing
RR<8 or RR>24 Excessive respiratory muscle
usage Pale or cyanotic skin Cool, diaphoretic (“clammy”) skin Shallow or irregular respiration Pursed lips
Signs of abnormal breathing
Pursed lips Nasal flaring Tripod positioning Tachycardia Altered mental status (“AMS”)
Agitated sleepy Look for the yawn!
Some terms
Dyspnea Difficulty breathing Shortness of breath (SOB)
Apnea No breathing
Hypoxia Not enough oxygen
What causes us to breath Normal individuals
Excessive CO2 levels in arterial blood COPD patients
Low levels of O2 in arterial blood COPD
Chronic Obstructive Pulmonary Disease Emphysema Chronic bronchitis
Causes of dyspnea
Obstructed lower airways Due to fluid, infection, collapsed alveoli
Damaged alveoli Damaged cilia in lower airways Spasms, mucus plugs, floppy airways Obstructed blood flow to lungs Pleural space filled with air or fluid
Common respiratory disorders causing dyspnea
Airway infections Acute Pulmonary Edema (“APE”) COPD Spontaneous pneumothorax Asthma, allergies, anaphylaxis Pleural effusion Prolonged seizures FBAO Pulmonary embolism Hyperventilation syndrome Severe pain
Infections
Colds/flu Bronchitis Bronchiolitis Pneumonia Croup Epiglottitis History will often “tell the
story”
Acute pulmonary edema
Not really a respiratory problem A cardiac problem Congestive Heart Failure (“CHF”)
TBD with cardiac emergencies Severe dyspnea Pink frothy, blood-tinged sputum
COPD
Almost always caused by Long-term smoking Long term inhalation of “bad things”
Chronic bronchitis Emphysema
Chronic bronchitis
Damaged respiratory pathway cilia Excessive mucus production Can’t “cough out” effectively Very frequent
bronchitis/pneumonia
Emphysema
Loss of alveolar elasticity and shape
Air pockets Can not expel CO2
COPD
Most have elements of both diseases
Prolonged expiratory phase Most common lung sound
Expiratory wheeze Minor respiratory problemd
exacerbates COPD Patient is usually old
COPD
Altered mental state over time Due to CO2 retention
Barrel shaped chest Well developed respiratory
muscles Long term COPD may cause heart
failure
Spontaneous pneumothorax
Collapsed portion of lung due to weakness in lung tissue
No apparent cause Sudden SOB Pleuritic chest pain Common in asthmatic/COPD Common in tall thin men
Asthma/allergies Reversible spasm of bronchioles Excessive mucus production Normal inspiration Difficult expiration Expiratory wheezing – common A quiet chest is an ominous sign
Be prepared for respiratory arrest Be prepared to use BVM
Status astmaticus
An asthma attack that cannot be “broken” after repeated doses of bronchdilators
Needs aggressive airway management
Needs rapid transport Needs BVM
Pulmonary embolism Embolus: something in the circulatory system
that travels from one place to a distant place – and lodges there
Effective inspiration/expiration – BUT Vessels leading to alveoli are blocked by:
Blood clots Often following long bed rest
Air bubbles Often following open neck injuries
Bone marrow Often following a long-bone fracture
Amniotic fluid Often following an “explosive delivery”
Pulmonary embolism
Very often a dangerous complication of a “DVT” Common in pt with varicose veins
“perfusion/ventilation mismatch”
Small emboli may cause no S/S
Pulmonary embolism Common S/S
Dyspnea Pleuritic chest pain Hemoptysis Cyanosis Tachycardia Tachypnia
A large embolus may cause sudden cardiac arrest
Hyperventilation
Overbreathing – reduces CO2 level excessively
May be emotional in nature May be a sign of MANY serious
medical conditions DO NOT WITHOLD Oxygen! DO NOT HAVE THEM BREATH
INTO A BAG!
Hyperventilation Patient may describe:
Numbness/tingling in hands/feet Spasms in hands and feet Called “carpal-pedal” syndrome
If all medical causes have been ruled out IN THE HOSPITAL, the condition is called “Hyperventilation Syndrome”
Treating the dyspneic patient Calm approach! Call for ALS EARLY! Position of comfort
Almost always sitting upright NEVER lie them down
Especially an APE patient High concentration oxygen
Even for COPD patients NRB – if rate & depth are adequate BVM – if not
Treating the dyspneic patient
Monitor V/S – especially resp rate Look for signs of sleepiness
Yawning Slowing RR – especially in COPD pt. pt is becoming too tired to breathe Respiratory failure Breathe for them BVM
Treating the dyspneic patient The “counting test” SAMPLE HISTORY OPQRST – medical assessment Q’s
Onset Provocation/Palliation Quality (of any pain) Radiation Severity Time
Interventions Also, help them with prescribed inhalers
Cardiac Emergencies
Mechanical structure Atria Ventricles One way valves Pulmonary arteries Pulmonary veins Aorta Coronary arteries
Provide O2 and nutrients to the heart muscle
Myocardium – the heart muscle
Electrical structure
SA Node The “dominant pacemaker”
Internodal pathways AV Node Bundle of HIS Bundle branches Purkinje Fibers/Network
Cardiovascular abnormalities Atherosclerosis
Cholesterol/calcium deposit buildup Arteriosclerosis
Hardening of the arteries Ischemia
Temporary interruption of O2 to tissues Infarction
Death of tissue after “a period of uncorrected ischemia”
Risk factors
Controllable Uncontrollable
Angina pectoris
Chest pain Supply of O2 does not meet hearts
requirement Partial blockage Spasm? (“Prinzmetal’s Angina”)
Angina -- triggers
Exercise Emotion Fear Cold Large meal elimination
Angina -- presentation
Crushing/squeezing pain in midchest, under sternum (“substernal”)
Radiation to jaw, arms, midback Nausea Dyspnea Diaphoresis Rarely lasts more than 15 minutes
Angina-promptly relieved by
Rest Oxygen Nitroglycerine
Dilates blood vessels Increases blood flow to heart
muscle
Acute myocardial infarction
“AMI”, “MI”, “Heart attack” May have same S/S as angina, but Longer in duration Often not relieved with rest, O2, nitro May be onset at rest with no
“triggers” Treat angina as AMI
Complications of AMI Sudden death
40% never “make it” to the hospital Arrhythmias
Most frequent cause of death in early hours following AMI
Congestive Heart Failure (“CHF”) Cardiogenic shock
At least 40% of the heart is infarcted
Sad facts
Unfortunately, the left ventricle is the portion of the heart most often infarcted
The left ventricle is the highest powered portion of the heart
Pumping power of the heart may be severely reduced
Classical S/S of AMI All, some or none of the following: Sudden onset of weakness, nausea,
sweating Crushing chest pain – does not change
with breathing Pain radiating to jaw, arms, neck Sudden arrhythmias causing syncopy Acute Pulmonary Edema Cardiac Arrest
Classical S/S of AMI -- 2 Vital signs -- commonly:
Pulse: increased, irregular BP: Usually normal; dropping in cardiogenic
shock RR: Usually normal, elevated in APE
Feeling of doom Looks frightened Denial Diabetics and the elderly
Congestive Heart Failure
Pathophysiology Right sided CHF Left sided CHF
Right sided CHF Dependent edema
Pedal edema, sacral edema Enlarged liver JVD Due to back-pressure from damaged right
ventricle Chronic condition
People often live with it for years Controlled by:
Medication (Lasix, Digitalis) Salt free diet
Left sided CHF “APE” Fluid in the lungs due to back pressure from
damaged left ventricle Patient feels like they are drowning Acute condition Frequent recurrences Often results in death Controlled by:
Medication (Lasix, Bumex, Digitalis) Salt free diet
Often a result of long-standing HTN
APE Calls
Most of them are due to either: Poor diet control
They eat too much sodium filled foods Poor compliance with medications
Lasix is a diuretic Annoying side effects
Cardiogenic Shock
Heart muscle is so damaged that it can no longer pump enough to meet bodily demands
Very high mortality rates Even with the best treatment
S/S of shock immediately after or within hours or days of AMI
Treating the patient with “CP” Calm reassuring approach Cardiac arrest – CPR/AED High-con Oxygen
NRB or BVM PRN Aspirin 162mg PO Call for ALS EARLY!
For any cardiac/respiratory problem Position of comfort
Usually sitting upright (dyspniac patient) NEVER let an APE pt lie down!
Treating the patient with “CP” Focused history
OPQRST – and in addition Previous MI history Previous “heart problems” Family history / risk factors
Monitor vital signs Other interventions
Assist pt with prescribed nitro – SL If systolic BP > 120