Winnipeg Fire Paramedic

ServiceSpring 2014 Medical Continuing Education

Field Session

Objectives

Provide opportunity for questions

Demonstrate, practice with new

equipment

◦ Zoll X Series

◦ Nexiva and Clear Link

Case-based review of:

◦ Cardiac Emergencies

◦ Bleeding and Shock

New Equipment

Nexiva IV Catheter

New Equipment

CLearLink Solution Set

Nexiva IV Catheter

Septum

Stabilization

platform

Clamp

Q Syte Luer PortsExtension tubing

BD Q-Syte Split Septum

Smooth surface is

easily cleaned prior to

access

No crevices or

gaps around the

surface to harbor

bacteria

Clear housing

allows visual

assessment of

fluid path

Simple fluid path

design reduces

places for microbes to

grow

Simple Luer Lock System – eliminates multiple pieces

Posiflush

White cap

Flushing/Admin: Use Direct

Approach

ClearLink Solution Set

Luer ports – residual 0.03cc of air

Flush line – age considerations

Disinfect site prior to access

No need to “pinch line” due to back

check valve

Flush with 1ml of saline after

medication administration

Preparing Solution Set

6 month – Adult: remove air from

back check valve and Y luer ports by

inverting and tapping to flush out

bubbles

0 – 6 month: remove air from back

check valve by inverting and tapping

to flush out bubbles. Disinfect each (3)

Y luer port and withdraw air using a 10

cc syringe until saline enters syringe.

Preparing Solution Set

Back Check Valve

“Y”Luer Port

Luer Port

Direct Luer Access

Push and twist

Questions?

Case 1

04:30 call for a 58 year old female, unresponsive, but breathing

Patient’s husband called 911, wife had complained of chest discomfort/nausea then collapsed on way to bathroom

On arrival: you find the patient lying on the floor, now responding

Assessment Approach

What would you like to know?

What are your assessment priorities?

What are some differential diagnoses?

Initial Findings Vital Signs

AVPU: patient

responds to loud

voice/painful

stimulation

A: airway is patent

B: mildly

tachypnea

C: Weak, slow

radial pulses

No evidence of

trauma

Palpated pulse: 38

Spo2: not reading

RR: 26

BP: 106/68

Temp: 36.8

Further History

HPI:◦ Woke to chest

pain/nausea

◦ Collapsed on way to bathroom

◦ Assisted onto floor by husband

◦ Regained consciousness once supine, but now confused

PMHx:◦ HTN

◦ Thyroid

◦ Arthritis

◦ Positive family cardiac history

◦ Hyperlipidemia: diet controlled

Meds:◦ Metoprolol

◦ Levothroid

◦ Arthrotec

What else?

What is the rhythm?

Detailed Exam

CNS: Alert to pain/strong voice,

improves when supine, confused to

events

CVS: C/O non-specific chest

discomfort, ECG Third Degree block,

weak peripheral pulses, skin pale,

cool, diaphoretic

RESP: A/E clear=bilat, difficulty

obtaining sats

GI/GU: C/O nausea prior to collapse

MS/S: No evidence of trauma

Treatment

ABC’s

Oxygen

Establish IV

Nitrates?

◦ Nitro patch? When do you administer?

12 Lead?

STEMI?

Transport

Slightly Different Situation

What if this patient’s BP was 88/60? How would this change your treatment?

Nitrates? 12 lead/ look for STEMI? Atropine 0.5 - 1.0 mg IV◦ Responsive? Repeat q 3 to max of 0.04

mg/kg

Not responsive to Atropine? Establish TCP◦ Fentanyl?

◦ Midazolam?

Transport◦ Destination?

12 Lead Contest

Ten 12-Lead ECG’s for your

consideration

Equal number of positive for STEMI

and negative for STEMI

All are actual 12 Leads transmitted by

WFPS

Are you up for it?

Example 1

Example 1

Example 2

Example 2

ZOLL says positive for STEMI?!

Example 3

Example 3

Example 4

Example 4

Example 5

Example 5

Example 6

Example 6

Example 7

Example 7

Example 8

Example 8

Example 9

Example 9

Example 10

Example 10

Need a Break?

Case 2 21:30 call for a 22

year old male, thrown? or jumped? from a third floor window at the McLaren Hotel to sidewalk

Police arrive on scene, report conscious male, requesting “rush”

On arrival, bystanders report approximately 5 minute period of unconsciousness

Prehospital Trauma Life

Support Recall our PHTLS approach to trauma? “Find it, manage it, move on” Search for life threatening injuries and

take immediate action: treat as you go◦ If unable to manage, transport immediately

Limited interventions on scene, do this enroute◦ Recognizing that time taken with

interventions increases time to blood, surgery, CT, etc.

Consider if interventions on scene actually harm the critical patient by increasing time to definitive care

PHTLS Algorithm

PHTLS Algorithm

Other Key PHTLS Concepts

Limited scene intervention:

◦ Control bleeds, correct life-threatening

airway/breathing/circulation concerns

◦ Assist ventilations as required

Other interventions (eg. IV and fluid

resuscitation) to occur enroute

Limited scene time/ expedited

transportation to appropriate facility

Ideally; Trauma center

Other Key PHTLS Concepts

For a critical patient:

◦ Vitals on scene?

◦ Detailed history on scene?

◦ Detailed physical exam on scene?

Back to the Patient 21:30 call for a 22

year old male, thrown? or jumped? from a third floor window at the McLaren Hotel to sidewalk

Police arrive on scene, report conscious male, requesting “rush”

On arrival, bystanders report approximately 5 minute period of unconsciousness

Assessment Approach

What would you like to know?

What are your assessment priorities?

What are some expected injuries

given the kinematics of the fall?

Scene Assessment

WPS has arrived and secured scene

Scene is safe us and everyone else

Patient is in back lane and traffic has

been blocked from entering

Appears to be only one patient

EMS unit and Fire unit arrive together

◦ No need for further resources

◦ Everyone has taken standard precautions

Walking Up

What details will you look for?

General appearance?

What Next?

AIRWAY: small amount of blood in

mouth = gurgling

Cleared with suction, now patent

Now What?

BREATHING:

◦ Expose

◦ Palpate

◦ Auscultate

Treatment?

◦ NRB sufficient for now

◦ Consideration to assisting respirations/

have BVM ready

Next?

CIRCULATION:

◦ HEMORRHAGE CONTROL:

Look for external hemorrhage

Manage these bleeds

Direct pressure

◦ PERFUSION:

Assess pulse (presence, quality, rate)

Assess skin (color, temp, moisture)

Hmm…

What do you think about your findings

so far?

On to “D”

DISABILITY:

◦ Assess GCS

◦ Assess pupils

Glasgow Coma Scale

And finally, “E”EXPOSE/ENVIRONMENT

Internal Hemorrhage

If suspected, quickly expose the

abdomen and pelvis

Palpate abdomen and pelvis

There it is! When you palpate the pelvis the patient

groans loudly and it does not feel stable

When you expose you note that the

patient’s scrotum/inner thigh area is turning

purple

Later at hospital, staff sees this:

Time to go?

Set of vitals first?

Start one IV on scene?

How do we package the patient?

Immobilization? Should we immobilize this patient?

Don’t forget the blanket!

Transport

Enroute

Reassessment Vital Signs

AVPU: patient responds to strong painful stimulation

A: airway is patent

B: ^ WOB

C: Barely palpable radial pulses

◦ Skin cool, pale, clammy

D: Pupils 4mm = sluggish

◦ GCS: E-2, V-2, M-4

Pulse: 130

Spo2: not reading

RR: 28

BP: 78/40

Temp: 36.8

Blood sugar: 5.6 mmol/l

PHTLS

Easy as:

Questions?

Thanks for your participation!