Presentation is loading. Please wait.

Presentation is loading. Please wait.

EMS REGION VIII SOPs 2014 UPDATES July 2014. 2014 Updates  Effective August 1, 2014  SOP books will be distributed by each System.

Similar presentations


Presentation on theme: "EMS REGION VIII SOPs 2014 UPDATES July 2014. 2014 Updates  Effective August 1, 2014  SOP books will be distributed by each System."— Presentation transcript:

1 EMS REGION VIII SOPs 2014 UPDATES July 2014

2 2014 Updates  Effective August 1, 2014  SOP books will be distributed by each System

3 SOP Changes

4 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

5 Terminology: Standard Precautions  “Standard precautions” has replaced the old wording “body substance isolation” (BSI) and “universal blood and body secretions”

6 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

7 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

8 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

9 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

10 Adverse Effects of Fentanyl  Hypotension  Bradycardia  Nausea/vomiting  Constipation  Arrhythmias (rarely)  Hypersensitivity side effects including anaphylaxis have been reported on rare instances

11 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.

12 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

13 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

14 Pleural Decompression  “Pleural decompression” has replaced “needle decompression” throughout the SOPs

15 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

16 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)

17 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

18 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

19 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

20 Adult Suspected Cardiac Patient With Chest Pain Page 11

21 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

22 Adult Pulmonary Edema (Due to Heart Failure) Page 21

23 Adult Pulmonary Edema (Due to Heart Failure) Page 21

24 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

25 Adult Pulmonary Edema (Due to Heart Failure) Page 21  CPAP a bsolute contraindications Respiratory arrest Agonal respirations Unconscious Shock with cardiac insufficiency Pneumothorax Penetrating chest trauma Persistent nausea and vomiting Facial anomalies/stroke/facial trauma

26 Adult Pulmonary Edema (Due to Heart Failure) Page 21  CPAP administration  Initial setting is 5 cmH 2 O  Maximum pressure is 10 cmH 2 O  Discontinue if change in mental status change in patient condition (e.g. ↓ blood pressure) ↑ anxiety/unable to tolerate mask nausea/vomiting occur

27 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”

28 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

29 Adult Diabetic/Glucose Emergencies Page 29  Added dextrose 10% dosing in the event of a severe drug shortage  System-specific procedure for details

30 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

31 Adult Syncope/Near Syncope Page 30

32 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

33 Adult Acute Abdominal Pain Page 33  Fentanyl doses are now the same for adult patients 65 YO across all SOPs  Addition of Zofran (ondansetron) IV

34 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

35 Adult Toxicologic Emergencies Page 35  Added generic drug names to “Club Drugs”

36 Adult Cold Emergencies Page 42  Fentanyl doses are now the same for adult patients 65 YO across all SOPs

37 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

38 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

39 Adult Ophthalmic Emergencies Page 60  Fentanyl doses are now the same for adult patients 65 YO across all SOPs

40 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)

41 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

42 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!

43 Adult Burn Injuries Page 61 Parkland Formula Volume 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 hours Divide by 8 to determine hourly rate (mL/hr)

44 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

45 Adult Musculoskeletal Injuries Pages  Fentanyl doses are now the same for adult patients 65 YO across all SOPs

46 Suspected Abuse or Neglect Domestic, 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

47 Suspected Abuse or Neglect Domestic, 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

48 Emergency Childbirth Phase III: Care of the Newborn Page 72  Updated to reflect current neonatal resuscitation national standards  Epinephrine (adrenaline) 1:10, 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

49 Emergency Childbirth Phase III: Care of the Newborn Page 72

50 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

51 Pediatric Initial Medical Care Page 75

52 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

53 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

54 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

55 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

56 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?

57 Pediatric Toxicologic Emergencies Page 92  Added generic drug names to “Club Drugs”

58 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

59 Drug Appendix

60 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)  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

61 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

62 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

63 Wolff Parkinson White (WPW) Syndrome Page 112  During tachycardic episodes, may be  Cool, diaphoretic, and hypotensive  Crackles in the lungs from pulmonary vascular congestion

64 Amiodarone (Cordarone) Page 112  Adverse effects  May also prolong the QT interval, leading to ventricular dysrhythmias

65 Dextrose Page 115  In the event of drug shortages of D50%, use D10% per System-specific procedure  Dextrose can be administered IV or IO

66 Etomidate (Amidate) Page 115  Etomidate (amidate) can be administered IV or IO

67 Epinephrine (adrenaline) Page 116  Epinephrine (adrenaline) can be administered IV or IO for anaphylaxis  Differentiate between anaphylaxis and systemic allergic reaction  Neonatal doses changed

68 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

69 Anaphylaxis  Onset: sudden, typically 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/SymptomsOminous Signs

70 Epinephrine (adrenaline) Page 116  Updated to reflect current neonatal resuscitation national standards  Epinephrine (adrenaline) 1: 10, 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

71 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

72 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

73 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

74 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

75 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

76 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

77 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

78 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)

79 Versed (midazolam) Page 119  Added IO route as additional route to IV

80 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

81 Region VIII EMS Systems RESPIRATORY : OXYGENATION VS VENTILATION

82 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

83 Announcements  Region  System

84 SME video

85 Review of Respiratory System Upper Airway Pharynx Nasopharynx Oropharynx Larynx Thyroid cartilage Glottic opening Cricoid ring Trachea

86 Review of Respiratory System Lower Airway  Trachea  Bronchi and bronchioles  Alveoli  Lungs

87 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

88 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

89 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

90 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

91 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

92 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

93 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

94 Airway Management Nasopharyngeal (nasal) Airway  Maintain airway in a semiconscious patient  Oropharyngeal (oral) Airway  Maintain airway on an unconscious patient (no gag reflex)

95 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

96 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

97 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

98 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

99 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

100 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

101 Respiratory Distress vs Failure 1. Adventitious Breath Sounds:  2. Respiratory Distress or Failure?  3. Respiratory Distress or Failure? 

102 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)

103 Causes of Respiratory Failure Failure 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

104 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

105 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 breaths per minute and titrate to achieve EtCO2 of 35-40mm/Hg using continuous waveform capnography

106 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

107 Normal CO2 level 35-45mm/hg Hypocapnia (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)

108 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

109 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

110 Normal Capnogram

111 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)

112 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

113 Troubleshoot Abnormal Waveforms

114 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

115 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!

116 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)

117 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

118 BREAK TIME

119 Scenario 1 EMD / BLS

120 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?

121 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

122 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

123 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?

124 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?

125

126 BLS SKILL REVIEW Epinephrine Auto-injector

127 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.

128 EpiPen for Anaphylaxis to-Use-EpiPen

129 Scenario 2 BLS/ALS

130 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

131 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

132 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!!!

133

134 Medications of the month Albuterol

135  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

136 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

137

138 MEDICATIONS OF THE MONTH Etomidate

139  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 seconds with duration of 3-5 minutes  Indications: sedation for endotracheal intubation

140 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

141

142 Do Not Forget Your Med Checks!

143 Cardiac Rhythm of the Month

144

145 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)

146 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

147 Scenario 3 ALS

148 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

149 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:  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

150 ALS Asthma 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

151 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

152 Als skill review Continuous Positive Airway Pressure (CPAP)

153 CPAP  Prehospital indications for CPAP use :  Congestive Heart Failure  Asthma/COPD  Drowning  Carbon Monoxide Poisoning  Pulmonary Infections

154 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

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

156 Questions? Contact EMS Office


Download ppt "EMS REGION VIII SOPs 2014 UPDATES July 2014. 2014 Updates  Effective August 1, 2014  SOP books will be distributed by each System."

Similar presentations


Ads by Google