4SOP Page Number References Anywhere an SOP is referenced, the SOP is noted in BOLD type and the page number is also includedEasier to locate SOPs that refer to another other SOPs
5Terminology: Standard Precautions “Standard precautions” has replaced the old wording “body substance isolation” (BSI) and “universal blood and body secretions”
6Fentanyl Dosing for Adults Fentanyl dosing is changed and is now consistent for adults (< 65 YO) regardless of SOP2012 SOPs did not allow for a repeat dose of fentanyl for the adult suspected cardiac patient with chest pain2014 SOPs allow for a repeat dose of fentanylMust have a systolic BP > 100 mmHgPreviously, there was one dosing for adult patients with chest pain (suspected cardiac origin) that did not permit a repeat dose and another for patients with musculoskeletal pain that allowed a repeat dose. This is now consistent for all adult pain, allowing for a potential repeat dose. (see dosing details in following slides).Reminder: Providers should be reassessing vital signs in between and prior to medication administration.Note: This applies to adults < 65 years of age. For those 65 years of age or older, new dosages have been added to the SOPs
7Fentanyl Dosing for Adults The initial fentanyl dose remains the same for all adult patients < 65 year olds1mcg/kg SLOW IV/IM, max 100 mcgAddition of one repeat dose0.5 mcg/kg SLOW IV/IM after 5 min, max 50 mcg
8Fentanyl Dosing > 65 Years Old New dosing for patients > 65 years oldSlower renal clearance of drugsMore likely to experience adverse effects of opiates (even at lower doses)Initial and repeat dosages are the same, regardless of SOPMust have a systolic BP > 100 mmHg0.5 mcg/kg SLOW IV/IM, max dose 50 mcgRepeat dose 0.25 mcg/kg SLOW IV/IM, max dose 25 mcgReminder: Providers always have the option of contacting Medical Control with specific requests that are not in the SOPs. If providers feel the fentanyl dosing is not providing adequate pain relief and the patient remains stable, a request can be made to Medical Control.
9Adverse Effects of Fentanyl AMS, respiratory depression(particularly if >65 YO)StuporDeliriumSomnolenceDysphoriaChest wall-rigidityMuscle rigidity (involving the respiratory musculature including the glottis)SeizuresDifficulty or inability to ventilate the patientMuscle rigidity (involving the respiratory musculature including the glottis) may also occur and further aggravate the respiratory depression associated with fentanyl therapy.Cases of seizures have occasionally been reported, but some investigators have suggested that the seizure-like events reported may have been episodes of fentanyl induced-rigidity.Both may have been related to cases of administering fentanyl too quickly; it is advised to administer fentanyl SLOWLY over 1-2 minutes IV.With chest wall rigidity you may experience difficulty or be unable to ventilate the patient. The treatment is to administer paralytic medication to paralyze the chest muscles until the fentanyl wears off. In the field without paralytics, continue making efforts to ventilate the patient by bagging. Do not perform a cricothyroidotomy, as this will not improve ventilation. Remember: this is not an airway problem, but a problem with chest wall compliance (movement) that inhibits exchange of gases (oxygen and carbon dioxide) in the lungs.
10Adverse Effects of Fentanyl HypotensionBradycardiaNausea/vomitingConstipationArrhythmias (rarely)Hypersensitivity side effects including anaphylaxis have been reported on rare instancesClosely monitor the patient for adverse changes, especially in mental status and vital signs. Provide supplemental support per appropriate SOP if condition changes or deteriorates.
11Pediatric Fentanyl Dosing Dosing for pediatrics has NOT changed1 mcg/kg SLOW IV/IM, max dose 100 mcgRemember: most pediatric dosages don’t exceed the adult dose!Obtain accurate weight from parents/caregiversNo repeat dose, but can call Medical Control to request additional dosing as appropriateNO IO route for fentanyl administration in pedsIf the patient requires an IO, stabilizing the patient takes priority to giving pain medication.Broselow tapes and other length-based resuscitation tapes are intended for use with pediatric resuscitations. The best method for obtaining a weight on a pediatric patient is to ask the parent or caregiver what their most recent weight was from their healthcare provider (such as physician) and when that measurement was obtained. Contact medical control if unsure as to the appropriate dose.Pediatric weights should be documented and relayed to Medical Control in kilograms. Since pediatric medications are based on kilograms, this is the standard. 1 lb. = 2.2 kgAs always, if the SOP does not allow for additional medications that you think are necessary, contact medical control with your request for physician consideration.
12Fentanyl Administration Administering fentanyl too quickly can cause chest wall rigidityIV administration should be over 1-2 minutesIf using a saline lock, push the fentanyl over 1-2 minutes, then push the saline flush over minutes as well
13Fluid BolusIn 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 bolusVital signs, including pulse characteristicsLung sounds (crackles)Change in conditionFluid bolus correctly describes the procedure intended in the SOPs. Administering a large amount of IV fluid in a short period of time (5-10 minutes) is a fluid bolus.Remind providers that each fluid bolus administration requires reassessment, including new crackles in lung fields indicating fluid overload. Caution providers when administering fluid boluses to patients with pre-existing heart conditions (heart failure) and pulmonary conditions. Patients with heart failure should also be assessed for edema in their dependent extremities (lower legs and ankles). Pitting edema is present when an indentation persists after release of pressure to an area of the soft tissue.
14Pleural Decompression “Pleural decompression” has replaced “needle decompression” throughout the SOPsReview with providers that pleural decompression is listed in NEMSIS as “respiratory: chest decompression” in the procedures section.LUMC has changed this so it now lists pleural decompression.Review the System-approved location and alternative site location for pleural decompression and the correct procedure, including a brief review of anatomy to avoid complications (compromising an artery or nerve).
15General Patient Assessment Page 2Initial Assessment, BreathingAddition of “assess lung sounds”A reminder that auscultation of lung sounds should occur in the primary assessment stage of patient care
16Zofran (ondansetron) Adult Initial Medical Care Page 4Adult Initial Medical CareZofran (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 administrationOnset of action of IV Zofran (ondansetron) is twice as fast as ODTAdminister over 1-2 minutes IV (no less than 30 seconds)
17Zofran (ondansetron)Not approved for prophylactic administration (prevention) of nausea or vomitingCan only be given IV or ODT once – NOT both.ODT: patient should allow tablet to dissolve on their tongue for rapid absorption into the bloodstreamDo not have patient chew or swallow whole tabletZofran can only be given IV or ODT once – NOT both.If the patient throws up their Zofran (ondansetron) ODT and you physically see the Zofran (ondansetron) in the emesis, you can contact Medical Control to ask for direction. You cannot automatically administer IV Zofran (ondansetron)
18Initiation of ALS CarePage 6Abnormal vital signs respiratory rate upper limit is changed from 28 to 30 breaths/minuteConsistent with other portions of SOPs
19Adult Suspected Cardiac Patient With Chest Pain Page 11Removed if “pain unrelieved by NTG”, administer fentanylAfter administering nitroglycerin (NitroStat) x 2 (ALS), administer fentanyl to achieve the goal of pain reliefThe goal is to alleviate all pain in the adult suspected cardiac patient with chest pain, as long as the patient remains stablePersisting chest pain or chest discomfort indicates persisting myocardial oxygen deprivation. The goal is to relieve all pain as long as the patient remains stable.Must have a systolic BP > 100 mmHgContraindicationsST-elevation in Leads II, III, aVF (inferior wall infarction which could result in severely decreased cardiac output if nitroglycerin is administered)Use of erectile dysfunction drugs within past 36 hoursContact medical control if patient is taking Brilinta (ticagrelor) due to possible decrease in efficacy of aspirin administration during a suspected myocardial infarction
20Adult Suspected Cardiac Patient With Chest Pain Page 11Review the SOP (page 11) and focus on the new dosing for fentanyl administration.
21Adult Pulmonary Edema (Due to Heart Failure) Page 21Lasix has been removed from SOPDose was not adequate for the purpose of diuresis that was needed for respiratory distress secondary to pulmonary edemaLasix was sometimes administered prior to nitroglycerin (not consistent with SOP)Nitroglycerin dilates coronary AND pulmonary vasculature, leading to relief of respiratory symptoms
22Adult Pulmonary Edema (Due to Heart Failure) Page 21Review the SOP. Make sure providers understand the criteria of stable vs. unstable patients. Definite normotension (systolic BP > 100 mmHg).Supplemental High FiO2 Oxygen LPM non rebreather mask.For patients who are candidates for CPAP, they must be 1) STABLE (administering CPAP to a patient who is unstable, including altered mental status and insufficient respiratory control can result in a deterioration in the patient’s condition), 2) normotensive or hypertensive (systolic BP > 100 mmHg) and 3) meet at least TWO of the CPAP Inclusion Criteria. If patient is qualified to receive nitroglycerin (no contraindications), administer prior to initiating CPAP if possible. Don’t forget that nitroglycerin can be repeated every 5 minutes if the blood pressure remains > 100 mmHg and patient’s condition warrants it.
23Adult Pulmonary Edema (Due to Heart Failure) Page 21Review the definition of unstable. Administering CPAP to an unstable patient can worsen the patient’s condition.Altered mental status: unconscious, unresponsive is more obvious; disoriented/confused to person/place/time, unable to follow commands or understandInstructions, talking about inappropriate things or conversation not about current situationSigns of hypoperfusion: altered mental status, pale/cool/clammy/diaphoretic skin, decreased or absent peripheral pulses, weak central pulses, hypotension, unable to obtain SpO2 due to poor peripheral circulation, peripheral cyanosis, central cyanosis, signs of shockReview erectile dysfunction and pulmonary anti-hypertensive drug names for recognition. These are possible contraindications to administering nitroglycerin. Contact Medical Control prior to administration.
24Adult Pulmonary Edema (Due to Heart Failure) Page 21CPAP is positive pressureIncreases intrathoracic pressureDecreases venous return to the heartDecreases cardiac outputDecreases blood pressurePatient MUST be stable prior to administrationReinforce the need for patient to be stable by being Normotensive or Hypertensive, alert and oriented
25Adult Pulmonary Edema (Due to Heart Failure) Page 21CPAP absolute contraindicationsRespiratory arrestAgonal respirationsUnconsciousShock with cardiac insufficiencyPneumothoraxPenetrating chest traumaPersistent nausea and vomitingFacial anomalies/stroke/facial trauma
26Adult Pulmonary Edema (Due to Heart Failure) Page 21CPAP administrationInitial setting is 5 cmH2OMaximum pressure is 10 cmH2ODiscontinue ifchange in mental statuschange in patient condition (e.g. ↓blood pressure)↑anxiety/unable to tolerate masknausea/vomiting occurReinforce the need for patient to be stable by being Normotensive or Hypertensive, alert and orientedInitial setting is 5 cmH2O. Slowly increase pressure until patient has relief, cannot tolerate higher pressure or maximum pressure of 10 cmH2O is reached.Review when to discontinue CPAP.Flowsafe CPAP masks will provide approximately cmH2O at a setting of 12-14lpm. Do not exceed 25cmH2O.
27Adult Drug Assisted Intubation - Etomidate (Amidate) Sellick’s maneuver has been removedNot performed consistentlyHas not been proven to be effective by evidence based medicineAfter passing the tube, verify placementAdded “adequate chest expansion bilaterally and symmetrically”Page 24Adequate, bilateral and symmetrical chest wall expansion should be assessed for as another means of confirmation of correct ET tube placement.
28Adult Partial (Upper) Airway Obstruction/Epiglottitis Page 27ALS/ UnstableAdded “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 gasesDue to vaccination trends, epiglottitis is becoming more prevalent in adults instead of just children.
29Adult Diabetic/Glucose Emergencies Page 29Added dextrose 10% dosing in the event of a severe drug shortageSystem-specific procedure for detailsShortages of Dextrose 50% and utilization of the alternative Dextrose 10% will be determined by the System. Refer to System-specific policy/procedure.
30Adult Syncope/Near Syncope Page 30Change in Narcan (naloxone) doseNarcan (naloxone) 1 mg IV/INRepeat dose 0.5 mg IV/IN PRN every 2 minutes up to a max dose of 2 mg if transient response observedAdministration indicated if decreased sensorium and pinpoint pupils, depressed respirations, and possible history of narcotic/synthetic narcotic ingestionDon’t forget! Obtain 12-Lead ECG to rule out cardiac originstransient response ….patient responds but then relapses back to initial state of depressed respirations and decreased mental statusIn this SOP, Narcan (naloxone) is indicated by decreasing sensorium and pinpoint pupils, depressed respirations, and possible history of narcotic/synthetic narcotic ingestion. Narcan should not be given for general Syncope with no suspicion of narcotic ingestion.Per the Adult Initial Medical Care, a 12 lead should be obtained in any situation that could be cardiac-related. Syncope is often caused by a sudden decrease in blood pressure due to severely reduced cardiac output which can be secondary to a cardiac arrhythmia.
31Adult Syncope/Near Syncope Page 30Review changes in ALS: Unstable section of SOP to Narcan (naloxone) dosing.
32Adult StrokePage 32Now includes obtaining and documenting Last Known Well timeRequirement for hospital stroke center criteriaTime Last Known WellAsk the family for the specific timeRelay that time to Medical ControlGive that time to the emergency nurse in reportDocument the time in your run reportSection 7 criteria opening sentence reworded but the content is the sameReview importance of Last Known Well time. Time sensitive for thrombolytics and interventional radiology, so time Last Known Well becomes critical. The sooner prehospital providers can identify the precise time the patient was last known well and relay that information to Medical Control and the receiving hospital, the quicker the hospital stroke team can be activated and be prepared for the appropriate treatment.If last time seen was last night and now it is morning, that places the patient outside the window for thrombolytics and interventional radiology. There must be a defined time last seen. If bystanders are unable to provide a precise time, try to obtain a specific window in which the symptoms could have began.
33Adult Acute Abdominal Pain Page 33Fentanyl doses are now the same for adult patients < 65 YO and those > 65 YO across all SOPsAddition of Zofran (ondansetron) IV
34Adult Toxicologic Emergencies Page 34Narcan (naloxone) 1 mg IV/INRepeat 0.5 mg IV/IN PRN every 2 minutes up to a max dose of 2 mg if transient response observedFocus on getting patient breathing but not causing withdrawaltransient response ….patient responds but then relapses back to initial state of depressed respirations and decreased mental statusGeneric names were added in for the “Club” drugs.→ easier identification with more names
35Adult Toxicologic Emergencies Page 35Added generic drug names to “Club Drugs”transient response ….patient responds but then relapses back to initial state of depressed respirations and decreased mental statusGeneric names were added in for the “Club” drugs.→ easier identification with more names
36Adult Cold Emergencies Page 42Fentanyl doses are now the same for adult patients < 65 YO and those > 65 YO across all SOPs
37Adult 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 settingTreat any/all suspected pelvic fractures and pelvic instability as a fracture in the prehospital setting
38Adult Chest Injuries Sucking Chest Wound/Open Pneumothorax Page 58Sucking Chest Wound/Open Pneumothorax“Apply occlusive chest dressing”Removed “to create a flutter valve”Three sided or occlusive dressing does not create a flutter valveIf a tension pneumothorax develops with occlusive dressing, temporarily remove the dressing to allow air to escape
39Adult Ophthalmic Emergencies Page 60Fentanyl doses are now the same for adult patients < 65 YO and those > 65 YO across all SOPs
40Adult Ophthalmic Emergencies Page 60TetracaineInstill 0.5% tetracaine 1 drop in each affected eyeMay repeat until pain relief achievedUse for Chemical/splash burnIrrigate the eye firstUse for suspected corneal abrasionPatch affected eye after tetracaine instilledDo not use for penetrating injury/ruptured globe (no tetracaine, no irrigation)Review indications and contraindications for administration of tetracaine
41Adult Burn InjuriesPage 61The IO route for fentanyl is approved in this SOP. Both adults under and over 65 years old can get fentanyl via IOIO use of fentanyl, even in burns, is NOT approved for pediatrics.
42Adult Burn Injuries Determining TBSA burned Rule of Nines Page 61Determining TBSA burnedRule of NinesInclude all second, third and fourth degree burnsFirst degree burns are not includedThe Palmar methodEstimated1% TBSAThe patient’s palm, not yours!
43Parkland Formula Adult Burn Injuries 4 mL x BSA(%) x weight (kg) Page 61Parkland FormulaVolume of Normal Saline:4 mL x BSA(%) x weight (kg)Parkland Formula for fluid replacement4ml x pt weight in kg x % BSA burned = amount of fluid to be delivered over the next 24 hour period½ given in first 8 hours post time of injuryDetermine the amount to be given in the first 8 hours and divide by eight = amount of fluids to administer per hourGive half of solution infirst 8 hoursGive other half of solution innext 16 hoursDivide by 8 to determinehourly rate (mL/hr)
44Adult Burn Injuries Keep patient NPO Page 61Keep patient NPOKeep accurate intake and output recordsReport accurate I&O volumes to receiving nurseIntraosseous route is approved for this SOP to administer fluids and medicationIO can be placed through burned tissue if there are no other options for IV/IO placement
45Adult Musculoskeletal Injuries Pages 64-65Fentanyl doses are now the same for adult patients < 65 YO and those > 65 YO across all SOPs
46Suspected Abuse or Neglect Domestic, Sexual, Elder Page 67The reporting phone numbers have been changed by the State and updated in SOPsEMS providers are mandated to report suspected abuseGiving report to ED staff does not meet as the mandated reporting legal requirements for EMS providersIndividual providers must make reports to the appropriate agencyDocument case number, worker name, and include in narrative if able to obtainContact phone numbers for the State reporting lines have been updated.
47Suspected Abuse or Neglect Domestic, Sexual, Elder Page 67Documenting suspected neglect/abuseNo accusationsObjective facts onlyHistory as given by patient (if able) and family/caregiverDocument physical environment if pertinentExact (pertinent) statements in quotesRelevant physical findingsContact phone numbers for the State reporting lines have been updated.
48Emergency Childbirth Phase III: Care of the Newborn Page 72Updated to reflect current neonatal resuscitation national standardsEpinephrine (adrenaline) 1:10,0000.1 mL/kg IV/IO q 3-5 minutesIf unsuccessful, 0.5 ml/kg ETRepeat every 3-5 minutes as long as heart rate < 60 beats per minute with CPRDO NOT follow ET dose with flushVentilate the patient to assist dose distributionBeware of mL/kg versus mg/kg…. these doses are mL/kgFor endotracheal administration of medication for the neonate, draw up the exact amount of medication. Do not dilute the medication (add extra normal saline or sterile water into the syringe). Administer the medication down the endotracheal tube. DO NOT follow it with a flush of normal saline. Just bag the endotracheal tube 5 or 6 times; that will help to get the medication to the alveoli for absorption. Then return to your normal ventilation of the patient.2012 SOPs dose was 0.02 mg/kg (0.2 ml/kg)
49Emergency Childbirth Phase III: Care of the Newborn Page 72For endotracheal administration of medication for the neonate, draw up the exact amount of medication. Do not dilute the medication (add extra normal saline or sterile water into the syringe). Administer the medication down the endotracheal tube. DO NOT follow it with a flush of normal saline. Just bag the endotracheal tube 5 or 6 times; that will help to get the medication to the alveoli for absorption. Then return to your normal ventilation of the patient.2012 SOPs dose was 0.02 mg/kg (0.2 ml/kg)
50Pediatric Initial Medical Care Page 75Zofran (ondansetron) doses are written by weight AND age> 1 YO AND > 40 kg4 mg ODT or 4 mg slow IV x1 dose only> 1 YO AND < 40 kg0.1 mg/kg slow IV x1 dose onlyNo oral dose for < 40 kgIV administration over 1-2 minutesZofran can only be given IV or ODT once – NOT both.If the patient throws up their Zofran (ondansetron) ODT and you physically see the Zofran (ondansetron) in the emesis, you can contact Medical Control to ask for direction. You cannot automatically administer IV Zofran (ondansetron)
51Pediatric Initial Medical Care Page 75Zofran can only be given IV or ODT once – NOT both.If the patient throws up their Zofran (ondansetron) ODT and you physically see the Zofran (ondansetron) in the emesis, you can contact Medical Control to ask for direction. You cannot automatically administer IV Zofran (ondansetron)
52Pediatric Drug Assisted Intubation - Versed (Midazolam) Page 81Sellick’s maneuver has been removedNot performed consistentlyHas not been proven to be effective by evidence based medicineAfter passing the tube, verify placementAdded “adequate chest expansion bilaterally and symmetrically”Focus for peds patients is on BLS maneuvers as appropriate
53Pediatric Altered Mental Status Page 88Added definition of Newborn (< 24 hours old) versus Neonate (1-28 days old) under glucose dosesNarcan (naloxone) can now be given IM (in addition to IV/IO/IN)Narcan (naloxone) IM route approved for peds onlyPediatric IM dosing for Narcan is allowed due to most pediatric ingestions/overdoses are unintentional and administration of Narcan is crucial to reverse the cause.
54Pediatric Altered Mental Status Page 88Narcan (naloxone) doses changed, now dosed by weight or ageRespiratory compromise in pediatric patients is more likely to be due to OD or accidental ingestion, therefore different dose than adultsAdult altered mental status/respiratory compromise is more likely due to drug abuse.
55Pediatric Altered Mental Status Page 88Special ConsiderationsAdded dextrose 10% dosing in the event of a severe drug shortage (> 8 YO)System-specific procedure for details
56Pediatric Altered Mental Status Page 88To administer dextrose 12.5%, providers need to mix their own 12.5% concentrationHow do you mix D12.5?Discuss with providers different options for mixing D12.5How do we take D50% and make D12.5%?How do we take D25% and make D12.5%?Start with D50% syringe or vial.Remove 37.5 ml of the D50% solution.Add 37.5 ml of normal saline solution to the remaining 12.5 ml of D50%.Now you have a concentration of dextrose 12.5%.
57Pediatric Toxicologic Emergencies Page 92Added generic drug names to “Club Drugs”
58Pediatric Burns Pediatric fentanyl dosing for has NOT changed Page 102Pediatric fentanyl dosing for has NOT changedFentanyl 1 mcg/kg SLOW IV/IM, max dose 100 mcgPeds doses rarely exceed adult dosesNo repeat dose but can call Medical Control to request additional dosingThe IO route for fentanyl is not approved in the pediatric SOPsIf the patient requires an IO, stabilizing the patient takes priority to giving pain medication
60Adenocard (adenosine) Page 112Administer Adenocard (adenosine) immediately followed by rapid IV flush, then elevate the extremityHalf life is 6 secondsProximal vein (AC or upper arm)10-20 mL NS flushObtain 12-lead ECG during attempted cardioversion if possibleAdditional adverse reaction addedDrug is a respiratory stimulant and can exacerbate asthmaReview: ask questions of providers…..reminder half life is six seconds,discuss methods for rapid administration → proximal vein, rapid cc normal saline flush, then elevate extremity
61Adenocard (adenosine) Page 112Additional contraindications for Adenocard (adenosine)Atrial fib/flutter with underlying Wolff Parkinson White (WPW) syndromeSymptomatic bradycardia except those with functioning pacemakers
62Wolff Parkinson White (WPW) Syndrome Page 112Classic ECG featuresShortened PR intervalSlurring 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 complexClassic ECG features are as follows:A shortened PR intervalA slurring and slow rise of the initial upstroke of the QRS complex (delta wave)A widened QRS complex (total duration >0.12 seconds)ST segment–T wave changes, generally directed opposite the major delta wave and QRS complex
63Wolff Parkinson White (WPW) Syndrome Page 112During tachycardic episodes, may beCool, diaphoretic, and hypotensiveCrackles in the lungs from pulmonary vascular congestionWolf Parkinson White:Clinical manifestations of WPW syndrome may have their onset at any time from childhood to middle age, and they can vary in severity from mild chest discomfort or palpitations with or without syncope to severe cardiopulmonary compromise and cardiac arrest. Presentation varies by patient age.Infants may present with the following:TachypneaIrritabilityPallorIntolerance of feedingsEvidence of congestive heart failure if the episode has been untreated for several hoursA history of not behaving as usual for 1-2 daysAn intercurrent febrile illness may be presentA verbal child with WPW syndrome usually reports the following:Chest painPalpitationsBreathing difficultyOlder patients can usually describe the following:Sudden onset of a pounding heartbeatPulse that is regular and “too rapid to count”Typically, a concomitant reduction in their tolerance for activityPhysical findings include the following:Normal cardiac examination findings in the vast majority of casesDuring tachycardic episodes, the patient may be cool, diaphoretic, and hypotensiveCrackles in the lungs from pulmonary vascular congestionIn many young patients, only minimal symptoms (eg, palpitations, weakness, mild dizziness) despite exceedingly fast heart ratesClinical features of associated cardiac defects may be present, such as the following:CardiomyopathyEbstein anomalyHypertrophic cardiomyopathy (AMPK mutation)See Clinical Presentation for more detail.DiagnosisRoutine blood studies may be needed to help rule out noncardiac conditions triggering tachycardia. These may include the following:Complete blood countChemistry panel, with renal function studies and electrolytesLiver function testsThyroid panelDrug screeningThe diagnosis of WPW syndrome is typically made with formal ECG monitoring (eg, telemetry, Holter monitoring) in conjunction with clues from the history and physical examination. Although the ECG morphology varies widely, the classic ECG features are as follows:A shortened PR intervalA slurring and slow rise of the initial upstroke of the QRS complex (delta wave)A widened QRS complex (total duration >0.12 seconds)ST segment–T wave changes, generally directed opposite the major delta wave and QRS complex
64Amiodarone (Cordarone) Page 112Adverse effectsMay also prolong the QT interval, leading to ventricular dysrhythmias
65DextrosePage 115In the event of drug shortages of D50%, use D10% per System-specific procedureDextrose can be administered IV or IO
66Etomidate (Amidate) Etomidate (amidate) can be administered IV or IO Page 115Etomidate (amidate) can be administered IV or IO
67Epinephrine (adrenaline) Page 116Epinephrine (adrenaline) can be administered IV or IO for anaphylaxisDifferentiate between anaphylaxis and systemic allergic reactionNeonatal doses changedAddition of IO route.
69Anaphylaxis Sense of impending doom Respiratory distress Signs/SymptomsOminous SignsOnset: sudden, typically secondsSkin: severe flushing, rash, hives, angioedema (swelling) of face or neckRespiration: severe bronchoconstriction (wheezing), laryngospasm (stridor), difficulty breathingGI System: severe cramps, diarrhea, vomitingVital Signs: early↑pulse/late↓, early↑RR/late↓RR, falling BPMental Status: anxiety, confusion/unconsciousnessSense of impending doomRespiratory distressSigns of shockInvolve providers in discussing signs of shock and respiratory distress: ↓RR, ↓BP, ↓pulse, respiratory distress, altered/declining mental status
70Epinephrine (adrenaline) Page 116Updated to reflect current neonatal resuscitation national standardsEpinephrine (adrenaline) 1: 10,0000.1 mL/kg IV/IO q 3-5 minutesIf unsuccessful, 0.5 ml/kg ETRepeat every 3-5 minutes as long as heart rate < 60 beats per minute with CPRDO NOT follow ET dose with flushVentilate the patient to assist dose distributionBeware of mL/kg versus mg/kg…. these doses are mL/kgFor endotracheal administration of medication for the neonate, draw up the exact amount of medication. Do not dilute the medication (add extra normal saline or sterile water into the syringe). Administer the medication down the endotracheal tube. DO NOT follow it with a flush of normal saline. Just bag the endotracheal tube 5 or 6 times; that will help to get the medication to the alveoli for absorption. Then return to your normal ventilation of the patient.
71FentanylPage 117The IO route for fentanyl is not approved in most SOPs, except the Adult Burn SOPIf the patient requires an IO, stabilizing the patient takes priority to giving pain medication.Pushing IV fentanyl too quickly can cause chest wall rigidityAdministration should be over 1-2 minutesIf using a saline lock, push the fentanyl over 1-2 minutes and then push the saline flush over 1-2 minutesMuscle rigidity (involving the respiratory musculature including the glottis) may also occur and further aggravate the respiratory depression associated withfentanyl therapyCases of seizures have occasionally been reported, but some investigators have suggested that the seizure-like events reported may have been episodes of fentanyl induced-rigidity.Both may have been related to cases of administering fentanyl too quickly; it is advised to administer fentanyl over 1-2 minutes IV.With chest wall rigidity you are unable to ventilate the patient. The treatment is to administer paralytic medication to paralyze the chest muscles until the fentanyl wears off. In the field without paralytics, continue making efforts to ventilate the patient by bagging. Do not cric, as this will not improve ventilation.
72FentanylPage 117The dosing of fentanyl is changed and is now consistent for adults regardless of SOPAdult patients receiving fentanyl must have a systolic BP > 100 mmHgThe initial fentanyl dose remains the same for all adult patients < 65 years oldNow all adult patients < 65 years old, regardless of SOP, can have one repeat dose up to a maximum of 50 mcg
73Fentanyl 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 mmHgInitial dose of 0.5 mcg/kg (max 50 mcg) SLOW IV/IMRepeat dose of 0.25 mcg/kg (max 25 mcg) SLOW IV/IM
74Fentanyl Pediatric fentanyl dosing for has NOT changed Page 117Pediatric fentanyl dosing for has NOT changedFentanyl 1 mcg/kg SLOW IV/IM, max dose 100 mcgPeds doses rarely exceed adult dosesNo repeat dose but can call Medical Control to request additional dosingThe IO route for fentanyl is not approved in the pediatric SOPsIf the patient requires an IO, stabilizing the patient takes priority to giving pain medication
75Glucagon (GlucaGen)Page 117For Beta Blocker or Calcium Channel Blocker overdose, may be administered IV or IOAdult dose1 mg slow IV/IOMay repeat x1Pediatric dose 0.5 mg slow IV/IOAdminister in cases where suspected BB or CCB overdose is suspected and the patient has hypoperfusion with associated bradycardiaChanges includes the additional route of IO.
76Glucose, oral New to drug appendix Dose Onset Indication Page 117New to drug appendixDosePediatrics and adults = one tube/15 gramsOnset~10 minutesIndicationHypoglycemia in patients with normal mental status and intact gag reflexContraindicationsAltered mental status and no gag reflexAdverse reactionsNausea, and potential for aspiration in patients with impaired airway reflexes
77Narcan (naloxone) New dosing for adults Initial dose of 1 mg IV/IN Page 118New dosing for adultsInitial dose of 1 mg IV/INMay repeat 0.5 mg IV/IN prn q 2 minutes up to a max dose of 2 mg if transient response observedOld wording was “as needed”Focus now is on getting patient breathing but not causing withdrawaltransient response ….patient responds but then relapses back to initial state of depressed respirations and decreased mental status
78Narcan (naloxone)Page 118Narcan (naloxone) doses changed for pediatrics, now dosed by weight or age≤20 kg or < 5 YO0.1 mg/kg IV/IO/IM/IN≥20 kg or ≥ 5 YO2 mg IV/IO/IM/INCan now be given IM (as well as IV/IO/IN)
79Versed (midazolam)Page 119Added IO route as additional route to IV
80Zofran (ondansetron)Page 119As alternative route to ODT, adults may now be given 4 mg Zofran (ondansetron) SLOW IV x1 dose onlyZofran can only be given IV or ODT once – NOT bothPediatric Zofran (ondansetron) doses are by weight AND age> 1 YO AND > 40 kg4 mg ODT or 4 mg slow IV x1 dose only> 1 YO AND < 40 kg0.1 mg/kg slow IV x1 dose onlyNo oral dose for < 40 kg.IV administration over 1-2 minutes
81Respiratory: Oxygenation vs Ventilation Region VIII EMS Systems
82Objectives SME video of the month Describe the respiratory system and the process of breathingRecognize adequate vs inadequate oxygenation vs ventilation in patientsUnderstand the tools used for monitoring both oxygenation and ventilationDiscuss acute and chronic disease processes that effect oxygenation and/or ventilationDiscuss considerations for selecting the best device for delivering oxygen and ventilationsToday will be a review of cardiac SOPs, with several scenarios which will range from dispatch information (including actual recordings where available) through field treatment and include medical control communications as available. Some recordings will be simulated, or will be similar recordings obtained from public or internet sources.
85Review of Respiratory System Upper AirwayPharynxNasopharynxOropharynxLarynxThyroid cartilageGlottic openingCricoid ringTrachea
86Review of Respiratory System Lower AirwayTracheaBronchi and bronchiolesAlveoliLungs
87Review of Respiratory System Breathing is only one of the activities of the respiratory systemThe body’s cells need continuous supply of oxygen for the metabolic processes necessary to maintain lifeThe 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
88Review of Respiratory System Every 3-5 seconds, nerve impulses stimulate ventilation, which moves air through a series of passages into and out of the lungsThere is an exchange of gases between the lungs and blood, which is called external respirationThe exchange of gases between the blood and tissues is called internal respirationCellular respiration (metabolism) is when the cells utilize the oxygen for their specific activities
89Review of RespiratoryBreathing is primarily controlled involuntarily by autonomic nervous systemRegulation is largely r/t maintaining normal gas exchange and blood gas levelsReceptors 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
90Review of Respiratory98% 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
91Common Respiratory Diseases Obstructive Airway DiseasesChronic BronchitisEmphysemaThese 2 often coexist and are then termed chronic obstructive pulmonary disease (COPD)AsthmaStatus Asthmaticus is a severe prolonged asthma exacerbation that cannot be broken with repeated doses of bronchodilatorsTrue emergency, requires early recognition and may quickly lead to respiratory failure
92Common Respiratory Diseases or Disorders Upper Airway InfectionsPneumoniaCan be viral or bacterialAdult Respiratory Distress Syndrome (ARDS)Respiratory failure with acute lung inflammation and diffuse alveolar-capillary injuryPulmonary Embolism (PE)Spontaneous PneumothoraxLung Cancer
93Let’s start with the patent Airway . . . Head-tilt/chin lift ManeuverOpening the airway with repositioningJaw thrust without head-tiltOpening the airway if spinal injury is suspectedSuctionRemove secretions or debris
94Airway Management Nasopharyngeal (nasal) Airway Maintain airway in a semiconscious patientOropharyngeal (oral) AirwayMaintain airway on an unconscious patient(no gag reflex)
95Airway ManagementEndotracheal Intubation – patient can no longer protect airwayAdvantages:Provides complete airway managementHelps prevent aspirationPositive pressure ventilation can be givenControl of volumes of ventilationTracheal suctioning is possiblePrevents gastric distentionProvides a route for some medications (not preferred, but worst case if no IV/IO)High concentration of oxygen can be given
96Airway Management Alternative Airways: King Airway Cricothyroidotomy Advantage is ease of useCan reduce time spent off the chest if CPR is ongoingCricothyroidotomySurgical or Needle, per system specific procedure
97Airway ManagementTraits 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 patientsT: Trauma (facial, airway or requiring C-spine stabilization)E: EmesisS: Space: limited space about the head to manage the airway
98Definition of Ventilation The process of air movement into and out of the lungsFor ventilation to occur, the following must be intact:Patent upper airwayNeuro control – brain stemMuscles of respiratory system, including diaphragm and intercostal musclesFunctional lower airway, including functional alveoli
99Inadequate Ventilation Occurs when the body cannot:compensate for increases in O2 demandsmaintain normal oxygen/carbon dioxide balanceCauses:InfectionTraumaBrain stem insultNoxious or hypoxic atmosphere
100Signs and Symptoms Respiratory Distress Respiratory Failure TachypneaUse of accessory muscles (intercostal, suprasternal or substernal retractions)Adventitious breath soundsNasal flaringTripod or position of comfortGruntingCyanosisDecreased level of consciousnessIncreased work of breathingPoor air entryDecreased breath soundsBradycardiaApnea or respirations less than 6 per minute
101Respiratory Distress vs Failure Adventitious Breath Sounds:Respiratory Distress or Failure?1. Sounds that may accompany respiratory distress.2. Retractions in the child with probable croup, upper airway obstruction, displays respiratory distress. This could lead to failure if not treated appropriately.3. This child displaying Kussmaul respirations (often associated with acidosis, such as in DKA) is on the cusp of respiratory failure. Note the grunting, retractions (indicating increased work of breathing) and decreased level of consciousness is clear.
102Causes of Respiratory Distress/Failure Failure to Maintain AirwayUpper Airway obstructionForeign bodyAnaphylaxis (laryngeal edema)EpiglottitisCroupTracheal traumaLower Airway ObstructionBronchospasmInhaled objects (foreign body aspiration)
103Causes of Respiratory Failure Failure to VentilateFailure to OxygenateNeuroOpioids, sedative or anesthetic agentsBrain or spinal injuriesMuscularSteroidsMyasthenia Gravis (or other neuromuscular disorders)TraumaChest wall trauma such as flail chestPneumo-/hemothoraxPulmonary EmbolismPulmonary FibrosisInterstitial Lung DiseaseCOPDPneumoniaPulmonary Edema
104Ventilation vs Oxygenation It is important to remember that these terms are NOT synonymousAdequacy of ventilation is evaluated using qualitative, external cues such as respiratory rate, chest rise and fall, compliance of a bag- valve mask
105VentilationMany studies have shown that HCP’s tend to hyperventilate patientsBoth the rate and volume of assisted ventilations are often too highHyperventilation 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
106VentilationCapnography 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 respirationsIf patient is having respiratory distress, the provider should measure CO2 to determine if breaths, whether spontaneous or artificial, are adequate
107Normal CO2 level 35-45mm/hg Ventilatory failure (hypoventilation) Hypocapnia (CO2 < 35mm/hg)Hypercapnia (CO2 > 45mm/hg)Hyperventilation (blowing off too much CO2)Metabolic condition such as diabetic ketoacidosis or kidney failureHypoperfusionHypotensionShockHypothermiaMetabolism is slowed in hypothermic state, so less CO2 is producedVentilatory failure (hypoventilation)Narcotic overdoseStroke that affects the brainstemCO2 RetentionCOPDRespiratory AcidosisChest wall injuryChest muscle weaknessFever (hypercatabolic state)
108CapnographyAmerican Heart defines capnography as the measurement and graphic display of CO2 levels in the airway, which can be performed by infrared spectroscopyLong 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
109Ventilation and Capnography Our bodies “blow off” CO2, so during expiration an upstroke in the waveform is seenThis creates a plateau until the end of expiratory phaseIt is at this peak level that the EtCO2 value is measured and resultedDuring inspiration, CO2 is purged from the airway and alveoli, so the waveform drops down to baseline
111Field Application for Capnography Triage ToolHelp narrow a differential diagnosis of dyspneaAssist in assessing severity of asthma attackTrend CO2 retainers if patient has COPDMonitor for relapses following therapiesSuch as following administration of a bronchodilatorCPRCorrelate blood delivery to the lungs (adequate chest compressions, ventilations)According to American Heart, persistent low CO2 suggests that return of spontaneous circulation is unlikely but an abrupt increase to normal CO2 value is a reasonable indicator of return of spontaneous circulation (ROSC).
112Field Application for Capnography Endotracheal or other advanced airway placement confirmationWaveform should appear to be SQUARE if tracheal intubation is successfulOngoing assessment of ventilations following insertion of advanced airwayRate AND volume of assisted ventilation
114OxygenationAdequacy 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 take30 seconds or more for the pulse-ox to reflectHypovolemia, vasoconstriction, peripheral vascular disease and even nail polish can cause false readings
115Oxygen Delivery Devices Nasal Cannula – delivers 1-6L, approximately % concentration, of O2Indications for use: treat hypoxia, dyspneaor increased myocardial workContraindications: nasal trauma or blockageConsider placing patient on 10L while intubating!
116Oxygen Delivery Devices Non-rebreather Mask – delivers 10-15L,approximately 90% concentration, of O2Indications for use: respiratory distress, traumaContraindications: CO2 retainer such as COPD exacerbationBag-valve Mask – delivers15L, 90%+ concentration, of O2Indications for use: respiratory failure, supportfor bradypnea or apnea, positive pressure toopen the airway/alveoli (this is used to admin-ister oxygen and ventilations BOTH)
117Ventilation 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 interveneWhile they are helpful tools, Pulse-oximeters and capnometers do not treat the patient, YOU DOThe 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
120EMD/BLSCall comes in as an 8 year old shortness of breath from the local elementary schoolEMD: What questions would you ask the caller?EMD: Which units would you dispatch? How many?
121BLS Arrives on Scene: General Appearance Work of Breathing Circulation Awake, alert, anxiousWork of BreathingDyspneaCirculationHot, dry, red, patchy, swollen areas on skin of extremities and face
122BLS 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 fastVitals: B/P 105/65, P 128, R 30, T 99.0S - hives, itchy, throat tightening and dyspneaA – tree nuts, no known drug allergiesM – EpiPen Jr (at home), Albuterol inhalerP – asthma, seasonal and food allergiesL – lunch about a 20 min agoE - ate a cookie offered to him by another student, started to feel throat closing feeling and itchy, hot skin in class right after lunch
123BLS Scenario Obtain SAMPLE history Initial Medical Care You have already assessed for signs of respiratory distress vs failureReassure patient, place in position of comfortShould this patient receive oxygen? What would you use to deliver this? Should you assist ventilations?Oxygen administration is appropriate, O2 saturations will determine NC vs non-rebreather. A nebulized bronchodilator would be recommended if ALS became available due to the audible wheezing.If the patient started to have more throat closing with stridorous sounds, accessory muscle use and dropping SpO2, he may needed assisted ventilations. Consider BVM or if ALS arrives, these are indications for CPAP. (Follow your system-specific procedures)
124BLS ScenarioShould 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?With symptoms such as dyspnea, wheezing, throat tightness and diffuse hives, it is recommended that the patient use EpiPen.Injection site is anterolateral aspect of the quad muscle (thigh).If an adult EpiPen is the only form of Epinephrine available, this is not weight-based dosing for a pediatric patient, therefore do not administer the injection and contact your medical control for direction.
127BLS Skill Review Indications for use of EpiPen EpiPen® (epinephrine) 0.3 mg and EpiPen Jr® (epinephrine) 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 InformationEpiPen Auto-Injectors should only be injected into the anterolateral aspect of the thigh. DO NOT INJECT INTO BUTTOCK, OR INTRAVENOUSLY.
130BLS/ALS ScenarioYour medic unit is dispatched for 78 year old female shortness of breathYou 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 herAppearance: awake and alert with a GCS of 15Increased work of breathing notedSkin is paleBLS can start IMC, but this patient warrants ALS protocols.
131BLS/ALS A – patent B – dyspnea, rales audible from across the room S – short of breathA – PCNM – Metoprolol, Plavix, Norvasc, Crestor, Diovan HCTP –cardiac stents, high cholesterol, CHF, pneumoniaL – dinner about 6 hours agoE – over the last week she has needed to be propped up more to sleep d/t inability to breath lying flatA – patentB – dyspnea, rales audible from across the roomC – pale, cool to the touch, edema to BLEVitals:B/P: 194/106P: 116R: 28T: 97.6
132ALS Are we thinking pulmonary edema d/t heart failure? Goal is to reduce the preload and afterload on the heartadministration of nitroglycerinIf available, place the patient on continuous waveform capnographyCPAP should be considered sooner rather than laterReduces work of breathingHelps reduce preload on the heartDo we use a diuretic? NO!!!It is no longer believed that patients experiencing CHF are in volume overload, rather they have inappropriate volume distribution. This is one of the reasons Lasix has been removed from the new SOP for pulmonary edema.
135Albuterol 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 bronchodilationIndications: asthma, bronchitis with bronchospasm, COPD with wheezing, allergic reaction or anaphylaxis with wheezing
139Etomidate Brand Name: Amidate Adult Dose: 0.6 mg/kg rapid IV, NO Repeat dose and NO PEDSAction: non-barbiturate hypnotic without analgesic properties. Has minimal effects on cardiac or respiratory systems. Onset is seconds with duration of 3-5 minutesIndications: sedation for endotracheal intubation
140Etomidate Contraindications: Adverse reactions: hypersensitivity to Etomidate, only use in pregnancy if potential benefits justify the potential risk to fetusAdverse 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
145Torsades de PointesAn 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 lineAssociated 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)Antiarrhythmic drugs associated with torsade include the following:Class IA - Quinidine, disopyramide, procainamideClass III - Sotalol, amiodarone (rare), ibutilide, dofetilide, almokalantOther drug classes associated with torsade include the following:Antibiotics - Erythromycin, clarithromycin, azithromycin, levofloxacin, moxifloxacin, gatifloxacin, trimethoprim-sulfamethoxazole, clindamycin, pentamidine, chloroquineAntifungals - Ketoconazole, itraconazoleAntivirals – AmantadineAntipsychotics - Haloperidol, phenothiazines, thioridazine, trifluoperazine, sertindole, zimeldine, ziprasidoneTricyclic and tetracyclic antidepressantsAntihistamines (histamine1-receptor antagonists) - Terfenadine, astemizole, diphenhydramine, hydroxyzineCholinergic antagonists - Cisapride, organophosphates (pesticides)Diuretics - Indapamide, hydrochlorothiazide, furosemideAntihypertensives - Bepridil, lidoflazine, prenylamine, ketanserinLithiumAnticonvulsants - phenytoin, carbamazepine (possible)Oral hypoglycemicCitrate (massive blood transfusions)CocaineVasopressin (possible)Fluoxetine (possible)Conditions associated with torsade include the following:Electrolyte abnormalities - Hypokalemia, hypomagnesemia, hypocalcemiaEndocrine disorders - Hypothyroidism, hyperparathyroidism, pheochromocytoma, hyperaldosteronismCardiac conditions - Myocardial ischemia, myocardial infarction, myocarditis, bradyarrhythmia, complete atrioventricular (AV) block, takotsubo cardiomyopathyIntracranial disorders - Subarachnoid hemorrhage, thalamic hematoma, cerebrovascular accident, encephalitis, head injuryNutritional disorders - Anorexia nervosa, starvation, liquid protein diets, gastroplasty and ileojejunal bypass, celiac disease
146Torsades de Pointes Patient presentation may include: Treatment: PalpitationsDizzinessSyncopeNauseaCold sweatsShortness of breathChest painSudden Cardiac DeathTreatment:Determine if patient has a pulse and then follow the appropriate ventricular tachycardia SOPMagnesium is ultimate drug of choiceLowers the amplitude of early afterdepolarization (EAD) by decreasing the influx of calcium
148ALS ScenarioYour medic unit is dispatched for the 44 year old female shortness of breathUpon arrival, you find the patient in a tripod position, having difficulty getting more than a word or 2 outAppearance: awake, alert, anxiousWork of Breathing: increased effortCirculation: pale, diaphoretic
149ALSS – cough, dyspneaA – environmental, no drug allergiesM –Xopenex, Xyzal, ChantixP – asthma with intubation in the past, allergies, smokerL – dinner last nightE – URI symptoms x2 days, labored breathing is new onset today and she tried 2 nebs prior to your arrivalA – patentB –intercostal and substernal retractions, diffuse wheezesC –strong peripheral pulses, cap refill 2 secondsVitals:B/P:168/94P: 130R: 40T: 100.4
150Airways affected by asthma ALSAsthma ExacerbationAirways affected by asthmaPossible Status AsthmaticusNeed to correct the hypoxemia caused by narrowing and blocked airwaysFollow ADULT ACUTE ASTHMA SOPSlap the Cap (monitor waveform capnography for trends with treatments – note the “shark fin” appearance in bronchospasmConsider that this patient has already self-administered nebulized bronchodilators x2 prior to your arrival on scene. Chances are she may need more support than another neb treatment.
151ALS Consider CPAP early to: Decrease work of breathing, reducing fatigueRecruit alveoli and improved oxygenationSplint larger airways, reducing airway collapse and mucous pluggingFollow your system’s specific policy/procedure for use of CPAP in asthma/COPD.
153CPAP Prehospital indications for CPAP use: Congestive Heart Failure Asthma/COPDDrowningCarbon Monoxide PoisoningPulmonary InfectionsFollow System specific policies for use of CPAP in these conditions.
154CPAP Contraindications: Cardiogenic Shock Patient is hypotensive and CPAP increases intrathoracic pressures, thereby lowering venous blood return to the right side of the heartAltered Mental Status or unconsciousFacial Trauma, anomalies or stroke with facial droopPneumothorax or penetrating chest traumaPersistent nausea/vomitingAgonal respirations/respiratory arrest
155CPAPAdditional Education from Bob Spoula – Edward Hospital Respiratory Therapy Educator (CPAP PowerPoint)