May 2016 CMC EMS CE Behavioral Emergencies, Bariatric Patients, Autism, VAD’s, and Life Vest Prepared by:Deborah Semenek RN, EMT-P Mark Dzwonkiewicz FP-C, LI Elizabeth Peaslee RN 1

Objectives  Upon successful completion of this module, the EMS provider will be able to: 1. Examine the differences in behavioral health diagnoses. 2. Review how to interact, de-escalate and treat patients with psychiatric disease. 3. Examine differences in patient care approaches when caring for the bariatric patient. 4. Review the patient population utilizing a VAD to support heart function. 5. Review care and transportation issues related to the patient with a VAD. 6. Review and discuss the use and care of a patient with a Life Vest. 7. Discover alterations in patient care in the environment of the patient with autism. 8. Actively participate in review of selected Region X SOP’s related to the topic presented. 9. Actively participate in case scenario discussion. 10. Successfully complete the post quiz with a score of 80% or better. 2

Behavioral Emergencies Behavior- a persons observable conduct and activity Behavioral Emergency- A situation in which the patient’s behavior becomes unusual, bizarre, threatening and/or dangerous that another person takes notice. Factors that may indicate behavioral emergency…. Core life function disruption Eating, sleeping, etc. Threat to ones self or others Deviation from societal norms 3

Pathophysiology Up to 20% of the population has some form of mental health problems Most are cared for in outpatient centers Common reason for EMS involvement is due to medication noncompliance 4

Causes of Behavioral Emergencies Biological Results from disease process Tumors or infections Structural changes Abuse of drugs and alcohol Never assume a patient with AMS has a psychological condition until all possible medical conditions or substance abuses are ruled out. 5

Psychosocial Related to personality style, unresolved conflicts or crisis management methods Examples…. Traumatic childhood event Development of peer pressure Dysfunctional families Lack of parental support Abusive parents 6

Sociocultural Related to patients actions and interactions with society Effect patient social space, social isolation or otherwise impact patient socialization Relationships, support system, social habits, social skills and values Caused by profound events Rape, assault, witness to victimization of others, death of a loved one, acts of violence 7

AMS SOP Consider Etiology (Diabetes, drug overdose, Poisoning, stroke, Alcohol related) Adult Routine Medical Care Immobilize C-spine as indicated Obtain blood glucose and record If <60 administer Dextrose 50% 50 mL IVP/IO -or- Glucagon 1 mg IM/IN 8

AMS SOP cont. If patient not alert/decreased respiration/ suspected narcotic overdose Narcan 2mg IN/IVP/IO every 5 minutes as needed to max dose of 10mg Attempt to ID substance involved Bring any containers found to hospital, so long as they aren’t a safety risk Consider restraints prior to administration of Narcan 9

Remember Etiology  A- Acidosis, Alcohol  E- Epilepsey  I- Infection  O- Overdose  U- Uremia  T- Trauma, Tumor  I- Insulin  P- Psychosis  S- Stroke 10

Arrive on Scene Scene safety and BSI Call law enforcement, if necessary Begin verbal report with the patient Determine and document if patient is a threat to themselves or others Examine the environment for potential threats If suicidal, patient can not be left alone. At least one EMS provider should remain with the patient. 11

Verbal De-escalation Attempt with all patients Should be first method to attempt to calm aggressive patient Safest because it requires no physical contact Be honest and straight-forward with a friendly tone Avoid direct eye contact or invading patient’s personal space which may increase stress and anxiety Can diffuse a situation and prevent further escalation and/or the need for physical restraints 12

Restraints Last resort Two types- locked and soft Suggested to have 5 people for safest application Make every attempt to avoid injury to patient Never transport patient in prone position Document: Reason for restraint, type and location of restraint, time of restraints Assess distal SMV’s 13

Consider Medical Etiology Hypoxia Substance Abuse/Overdose Excited Delirium/Hyperthermia Neurologic Disease (CVA, Intracerebral Bleed, etc.) Metabolic Problems (Hypoglycemia) Continue routine medical care for adult or pediatric patient 14

Medications Needed Contact medical control for pediatric patients In patient with severe anxiety or agitation: Versed 2mg IN May repeat every 2 minutes until desired results to max of 10mg If additional medication needed: Valium 5 mg IVP over 2 minutes, may repeat up to 10mg or Valium 10mg IM 15

Petition Legal documentation to transport patient to the hospital from the scene with or without patient consent Assist keeping patient in hospital throughout evaluation Family members, police, EMS or bystanders can complete petition Petition does not guarantee a patient will be committed 16

Behavioral Emergency Notes All region X hospitals can accept any psych patient Transport all medication or substance bottles safely with patient Remember mentally ill patients are more aware of their surroundings than they appear, so be caerful what is said around them 17

Cognitive Disorders Organic causes such as brain injury or disease Caused by physical or chemical injuries Delirium Dementia 18

Delirium Rapid onset of widespread disorganized thoughts (hours or days) Symptoms: Inattention, memory impairment, disorientation and general clouding of the mind Causes: Medical conditions, intoxication or withdrawal Confusion is a hallmark sign 19

Dementia Develops over months and is usually irreversible Several possible medical etiology Alzheimer’s, vascular problems, AIDS, head trauma, Parkinson’s and substance abuse Involves… Memory, cognitive, and pervasive impairments Be supportive 20

Schizophrenia Effects an estimated 1% of the U.S. population Hallmark sign is a significant change in behavior and loss of contact with reality May live in their “own world” Symptoms: Hallucinations, delusions, and depression Symptoms will cause social or occupational dysfunction Usually diagnosed in early adulthood 21

Anxiety Disorders Characterized by dominating apprehension and fear Affects approximately 2-4% of the population Uneasiness, discomfort, nervousness and restlessness Panic disorder, phobia, and post-traumatic stress syndrome 22

Panic Attack Recurrent, extreme periods of anxiety resulting in great emotional distress Acute in nature and unprovoked Usually peaks in 10 minutes and dissipates in 1 hour May present cardiac or respiratory in nature, so EMS must rule out both possibilities Symptoms: Palpitations, sweating, trembling, shortness of breath, chest pain or discomfort, nausea, dizziness, loss of control, fear of dying, numbness or tingling sensation and/or chills or hot flashes Management: Supportive care 23

Phobias A fear that becomes excessive and interferes with functioning The fear is considered intense and irrational Exposure to fear will induce anxiety or panic attack Manage patients by being supportive 24

Post-Traumatic Stress A reaction to an extreme, usually life-threatening stressor Natural disaster, victimization (rape, etc.), and emotionally taxing situations Will avoid similar situations Recurrent intrusive thoughts Depression Sleep disturbances Nightmares Manage patient with respect, empathy, and support 25

Mood Disorders Pervasive and sustained emotion that colors a person’s perception of the world Depression Bipolar Disorder 26

Depression Profound sadness or feeling of melancholy Most prevalent psychiatric condition Major depressive disorder Depression that is prolonged or severe Symptoms: Depressed most of the day Decreased interest in pleasure Weight loss Insomnia or hypersomnia Lack of concentration Thoughts of death 27

Bipolar Disorders One or more manic episodes with or without subsequent or alternating periods of depression Begins suddenly and escalates rapidly over a few days Develops in adolescence or early adulthood Symptoms: Increased self-esteem Less need for sleep More talking or pressure to keep talking Flight of ideas Distractibility Increased goal-directed activity Delusional thoughts 28

Substance Disorders Substance abuse is a common disorder EMS should rule out as a possibility when a patient is experiencing psychiatric or behavioral symptoms May present as depression, psychosis, or delirium Serious condition Patients may present ill from addiction or withdrawal from the substance 29

Withdrawal from Alcohol Happens from abrupt discontinuation of, or after prolonged use of, or from rapid fall in blood alcohol level Symptoms can occur several hours after last drink and can last up to 5-7 days Seizures can occur within the first hours after last drink 30

Withdrawal Signs and Symptoms Tremors of the hands, tongue, and eyelids Nausea and vomiting General weakness Tachycardia Sweating Hypertension Orthostatic hypotension Anxiety, irritability or depressed mood Hallucinations Poor sleep 31

Delirium Tremens Usually develop in second or third day of withdrawal Symptoms: Decreased level of consciousness Hallucinations Misinterpretation of events Seizures Significant mortality rates Treatment with benzodiazepines can help prevent seizures 32

Excited Delirium Can be caused by drug intoxication, psychotic illness or both Symptoms: Abnormal pain tolerance, tachycardia, sweating, agitation, skin that feels hot, non-compliance with police, lack of tiring, unusual strength, inappropriate clothing Difficult to diagnose Be aware of the patient who becomes suddenly tranquil after frenzied activity because this is usually followed by cardiac collapse and death Always consider if a patient needs to be restrained Allowing a patient to struggle against restraints increases risk of death 33

Bariatric Patient Most common reason EMS is toned out is for undifferentiated abdominal pain Always assure scene safety and BSI 34

Assess Patient Airway Assess for patency Morbidly obese patients have excessive skin and adipose tissue around their cheeks, lower jaw, and thorax which can place extra pressure on the tongue and airway Increased oxygen consumption Increased carbon dioxide production Excess metabolic activity 35

Assessing Breathing Decreased lung capacity from decreased chest wall compliance and increased abdominal cavity contents Makes bariatric patients at risk for hypoxemia and hypercarbia Gives patients less respiratory reserve Prepare for rapid decline Breath sounds may be difficult to hear due to increased amount of adipose tissue 36

Ventilation Complications If patient has no c-spine injury, place the patient supine and use blankets to place under head, neck and shoulders to place in a “ramp position” Utilize oral and nasal airways Don’t overestimate lung volume due to patient size When possible use two person technique with a jaw thrust for BVM ventilation If intubation needed…. Prepare for difficult attempt in patients with sleep apnea Sedatives given can completely occlude airway with tongue Use capnography for tube confirmation due to difficulty in auscultation related to increased adipose tissue 37

Ramp Position 38

Assessing Circulation Increased stress on the heart Increased cardiac output even at rest due to the need for extra tissue profusion Increased basal heart rate ECG may be less reliable due to the distance of the electrodes to the heart Increased prevalence of heart disease in a younger demographic If the need for immobilization arises, use caution so the collar is not so tight it restricts blood flow to major vessels in the neck 39

Obtaining History Per normal protocol, like with any patient Signs and symptoms of complaint Allergies Medications Past medical history Prepare for increased number of medical conditions DM, HTN, hyperlipidemia, increased vascular disease, stroke, cardiac disease, CHF, peripheral edema, and ulcerations of the skin 40

Bariatric Surgery To include gastric bypass, Lap-Band and gastric sleeve can result in early and late complications Early- within the first month s/p surgery Think DVT, PE, wound infection, sepsis or GI bleed Late- after the first month s/p surgery Think strictures, hernia or hardware complications Gastric bypass has increased incident of ulcers Lap-Band has increased hardware malfunctions 41

Bariatric Surgery Gastric BypassLap-Band 42

Abdominal Assessment Exam will be complicated by loss of anatomical landmarks Palpation of deep structures will be limited due to amount of adipose tissue Increased adipose tissue also limits Cullen’s and Grey Turnner’s signs 43

Autism Neurological disorder typically appearing in the first three years of life Affects the area of brain function responsible for development of communication and social interaction 1 in 110 children, more males than females No known cause or cure No obvious physical markers 44

Autism Low-functioning Difficulty with basic life skills Usually a caregiver is with the patient at all times High-functioning Live semi- or fully-independent lives Affects sensory responses Manage environment safely May not react well to change while en-route May have “fight or flight” when approached Decrease as much stimulation as possible 45

Autism Signs and Symptoms Non-verbal or limited speech Avoid eye contact Prefer to be alone Difficulty expressing needs Difficulty interacting with others Avoids touch Sustained unusual repetitive actions Laugh or giggle inappropriately Trouble with correct speech volume 46

Common Reasons for 911 Patient or caregiver action may be misinterpreted as assault Unusual behavior in the community setting Escalating behavior Rocking, pacing, grunting, noisemaking, running into walls, head banging, or hiding Dangerous wandering May not respond to the calling of their name May not want to seek help 47

Scene Safety Make sure patient is unarmed and at a safe distance Patient’s body language my show you what is stressing them out May suddenly invade your personal space To move patient, you may need to quickly wrap them with a blanket with their arms at their sides EMS must always stay with patient 48

Interaction Use direct and short phrases Avoid figurative expression Allow for delayed responses, your interview will take longer Talk calmly and softly Become familiar with patient communication style (ask caregiver) Model calm body language Model behavior you want your patient to display Patient may repeat your words or phrases, body language or emotional state 49

De-escalation If patient is unarmed and has geographic containment, allow patient time to self de- escalate Seek information and help from parent or caregiver about techniques that help the patient Don’t attempt to stop repetitive behaviors Remain alert for the possibility of outbursts 50

Restraints May still have to restrain patient after all other options have been exhausted If absolutely necessary, approach the patient from the side After restrained, turn patient on their side to allow normal breathing Monitor patient to prevent further trauma Continue to communicate, de-escalate and use calming techniques with the patient 51

Suicide in Autism Common especially among high-functioning autistics They miss social cues Lack the ability and experience to deal with school Become emotional wrecks by middle school, putting them at high risk for suicide 52

EMS Tips Allow for delayed response Difficulty adapting to change Take everything literally Person may not show any signs of pain Evaluate for pain with a thorough secondary exam Avoid touching Explain all medical procedures, they will be more likely to allow it Metal, plastic, or other objects of different temperatures can feel like pinpricks to patient 53

EMS Tips (con’t) Equipment should fit snugly Allow patient to bring security item Remember ambos are loud. Reduce as much secondary noise as possible including air blowing on the patient May flee due to sensory overload Constant patience and reassurance Behaviors will challenge your training and instincts Be aware of associated medical conditions 54

VAD’s  Ventricular Assist Device  Treatment for advanced heart failure  Surgical process to implant  Assists heart function by circulating the blood  A continuous flow pump  Increases patient energy level 55

Indications Patient in class 3 or 4 heart failure while at rest or in cardiogenic shock Short term Patient on transplant list but very sick Long term Not a transplant candidate Bridge to Recovery Treating cardiogenic shock Unable to come off heart-lung machine s/p surgery 56

Usual Demographics  years old  Multiple medical problems  Death is primarily from non-VAD related causes  Without transplant survival rate is about 4-5 years 57

Living with the VAD May return to daily activities with few limitations Patients look normal and healthy They have increased energy No travel restrictions Must avoid contact sports and water activities 58

Risks To Patient Bleeding All VAD patients are on prophylactic anticoagulants which increase a patients risk for bleeding Infection Direct access portal of entry to heart Stoke Device malfunction Death 59

VAD Function  Inflow portion surgically connected to apex of left ventricle  Outflow portion surgically connected to ascending aorta  Right side of heart can still function normally 60

Components of VAD  Surgically implanted in body with communication to the outside of the body  Pump  Inside body and delivers blood to aorta  Take over the work of left ventricle  Driveline  Inside and outside of body  Communicates with the pump  Don’t cut or disconnect, pump will stop 61

Components (con’t) System Controller Outside of the body Computer that controls all functions of the VAD “Brain” Batteries Outside the body External power source Last 4-12 hours Can press battery button to determine the charge level AC/wall power NEVER remove both power sources at the same time 62

Care of the Driveline A wire that exists the body High risk for infection Always stays covered with a sterile dressing Direct portal to the heart DO NOT remove the dressing DO NOT pull or tug on the driveline DO NOT disconnect from battery pack 63

Back Up Equipment  All patients have a travel bag  This bag contains:  Extra system controller  Extra set of charged batteries  AC/ wall plug  Cell phone with appropriate phone numbers  MUST come with the patient for transport 64

VAD Readings Flow Amount of blood flowing through the pump Measured in L/min AKA: cardiac output Speed A set number Shows how fast the pump is running PI Volume in left ventricle Power Amount of energy in WATTS to maintain speed Like an extra set of vitals 65

Patient Assessment Pulses may or may not be present Differs from patient to patient Use a stethoscope over lower part of heart to listen for the “hmmm” sound of the VAD working May only obtain blood pressure if patient has pulses If no pulses, a Doppler is needed to assess pressure Pulse ox may be unreliable 66

Patient Assessment Neurologic Increased risk for stroke due to anticoagulation Glucose levels are unaffected Skin parameters stay the same VAD doesn’t affect ECG Electrical activity continues in the heart with or without capture PEA 67

VADs & Anticoagulation  All VAD patients are anti- coagulated  Increased risk for bleeding  Take all bleeding precautions  Coumadin/warfarin is the only medication approved for all devices 68

EMS Arrest Interventions Listen for the “hmmm” of the VAD, if you hear it, no need for compressions. VAD is circulating the blood. If no “hmmm”, begin CPR Don’t worry about dislodging equipment because if nothing is done patient has no survival chance Cardiac medications Can be given, but will have different levels of effectiveness Discuss Dopamine with medical control prior to use 90-95% of patients have ICD’s, but if need arises EMS may use their defibrillator Mast arrests are not VAD failures but some other etiology 69

Emergency Action VAD stops functioning, must be restored or patient will die Check driveline connection to controller Check power lead connection to controller Check power source Replace system controller 70

VAD Do’s and Do Not’s Do  Follow CAB’s  Listen to family  Bring all VAD equipment to the hospital  Keep patient on 2 good power sources at all times Do Not  Never disconnect driveline from controller  Never disconnect both power sources at the same time  Never expose VAD to water  Don’t open or view sterile exit site 71

EMS Tips Follow BLS protocol Make sure all connections are connected Verify power Listen to patient’s family Bring all equipment to hospital in the ambulance A DNR is not required for a VAD patient 72

Zoll Life Vest First wearable defibrillator 98% first shock efficacy rate 73

Zoll Life Vest Wearable defibrillator is a treatment option for sudden cardiac arrest Worn on the outside of the body Continuously monitors patient with dry non-adhesive electrodes If life-threatening rhythm is detected the device will alert patient prior to delivering shock to give the conscious patient a chance to turn the shock off If the patient is unconscious, the device will release a blue gel over the electrodes prior to delivering shock 74

Life Vest and EMS Standard evaluation and treatment Begin CPR if devise is not saying “Press the response button” “Electric shock possible. Do not touch patient” “Bystanders do not interfere.” May replace with external defibrillator after removing Life Vest To remove First pull battery out Then remove vest 75

Zoll Life Vest 76

Case Scenario #1 You arrive on scene for a patient who “under the weather”. They are responsive, GCS 15, warm and dry, with a capillary refill less than 2 seconds. They have a VAD device. How will the VAD influence your ability to complete the assessment of vital signs and ECG for the patient? Patient may or may not have pulses No pulses means no blood pressure The ECG with remain unaffected 77

Case Scenario #2 Your patient is suffering from severe anxiety. What medications can be administered per CMC EMS SOP’s? Versed and Valium What is the dosing parameters and route of administration of these medications? Versed 2mg IN every 2 minutes, titrate to desired effect to a max dose of 10mg Valium 5mg IVP over 2 minutes, repeat as needed to max dose of 10mg. Valium 10mg IM 78

Case Scenario #3 You are toned out for a patient who according to bystanders “passed out”. When you arrive you note a blue gel on the patient. What does this indicate? Patient is wearing a Life Vest Your patient continues unconscious. What is your next step to assist the patient? If patient is safe to touch, take off life vest by removing battery first. Wipe off blue gel from patient and apply EMS pads. CPR and ACLS medications as needed. 79

Case Scenario #4 You arrive on scene for a morbidly obese patient complaining of difficulty breathing. How would your airway assessment change for this patient? Breath sounds will be difficult to hear through extra adipose tissue Excess tissue around cheeks, lower jaw and thorax decrease airway patency Ventilation is more difficult Intubation will be very difficult or impossible due to patient anatomy 80

Case Scenario #5 You are called to the scene for a patient with autism. When dealing with an autistic patient, what should EMS consider? Allow for delayed response and avoid touching Evaluate thoroughly for pain Explain all actions ahead of time Difficulty adapting to change Constant patience and reassurance Patient may attempt to flee with sensory overload Decrease as much secondary noise as safely possible 81

Bibliography Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4 th edition. Brady Mistovich, J., Karren, K. Prehospital Emergency Care. 9 th Edition. Brady Page, B. Slap the Cap-The Role of Capnography in EMS Region X SOP’s; IDPH Approved April 10, CMC EMS System CE Module August 2015 Debbaudt, D. Autism Risk and Safety Management, Nixon, L. Universal Care of the Ventricular Assist Device (VAD) Patient, powerpoint,