Ems region viii SOPs 2014 Updates Changes in SOPs are referenced in this document bolded in RED. July 2014

2014 Updates Effective August 1, 2014 SOP books will be distributed by each System Contact your System for details.

SOP Changes

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

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

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 Previously, 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

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

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 Reminder: 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.

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 Muscle 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.

Adverse Effects of Fentanyl Hypotension Bradycardia Nausea/vomiting Constipation Arrhythmias (rarely) Hypersensitivity side effects including anaphylaxis have been reported on rare instances Closely monitor the patient for adverse changes, especially in mental status and vital signs. Provide supplemental support per appropriate SOP if condition changes or deteriorates.

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. 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 kg As always, if the SOP does not allow for additional medications that you think are necessary, contact medical control with your request for physician consideration.

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

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 Fluid 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.

Pleural Decompression “Pleural decompression” has replaced “needle decompression” throughout the SOPs Review 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).

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

Zofran (ondansetron) Adult Initial Medical Care 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)

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 Zofran 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)

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

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 Persisting 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 mmHg Contraindications ST-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 hours Contact medical control if patient is taking Brilinta (ticagrelor) due to possible decrease in efficacy of aspirin administration during a suspected myocardial infarction

Adult Suspected Cardiac Patient With Chest Pain Page 11 Review the SOP (page 11) and focus on the new dosing for fentanyl administration.

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

Adult Pulmonary Edema (Due to Heart Failure) Page 21 Review the SOP. Make sure providers understand the criteria of stable vs. unstable patients. Definite normotension (systolic BP > 100 mmHg). Supplemental High FiO2 Oxygen 12-15 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.

Adult Pulmonary Edema (Due to Heart Failure) Page 21 Review 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 understand Instructions, talking about inappropriate things or conversation not about current situation Signs 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 shock Review erectile dysfunction and pulmonary anti-hypertensive drug names for recognition. These are possible contraindications to administering nitroglycerin. Contact Medical Control prior to administration.

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 Reinforce the need for patient to be stable by being Normotensive or Hypertensive, alert and oriented

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

Adult Pulmonary Edema (Due to Heart Failure) Page 21 CPAP administration Initial setting is 5 cmH2O Maximum pressure is 10 cmH2O Discontinue if change in mental status change in patient condition (e.g. ↓blood pressure) ↑anxiety/unable to tolerate mask nausea/vomiting occur Reinforce the need for patient to be stable by being Normotensive or Hypertensive, alert and oriented Initial 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 8.5-10cmH2O at a setting of 12-14lpm. Do not exceed 25cmH2O.

Adult Drug Assisted Intubation - Etomidate (Amidate) 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” Page 24 Adequate, bilateral and symmetrical chest wall expansion should be assessed for as another means of confirmation of correct ET tube placement.

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 Due to vaccination trends, epiglottitis is becoming more prevalent in adults instead of just children.

Adult Diabetic/Glucose Emergencies Page 29 Added dextrose 10% dosing in the event of a severe drug shortage System-specific procedure for details Shortages of Dextrose 50% and utilization of the alternative Dextrose 10% will be determined by the System. Refer to System-specific policy/procedure.

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 transient response ….patient responds but then relapses back to initial state of depressed respirations and decreased mental status In 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.

Adult Syncope/Near Syncope Page 30 Review changes in ALS: Unstable section of SOP to Narcan (naloxone) dosing.

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 Review 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.

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

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 transient response ….patient responds but then relapses back to initial state of depressed respirations and decreased mental status Generic names were added in for the “Club” drugs.→ easier identification with more names

Adult Toxicologic Emergencies Page 35 Added generic drug names to “Club Drugs” transient response ….patient responds but then relapses back to initial state of depressed respirations and decreased mental status Generic names were added in for the “Club” drugs.→ easier identification with more names

Adult Cold Emergencies Page 42 Fentanyl doses are now the same for adult patients < 65 YO and those > 65 YO across all SOPs

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 Treat any/all suspected pelvic fractures and pelvic instability as a fracture in the prehospital setting

Adult Chest Injuries Sucking Chest Wound/Open Pneumothorax 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

Adult Ophthalmic Emergencies Page 60 Fentanyl doses are now the same for adult patients < 65 YO and those > 65 YO across all SOPs

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) Review indications and contraindications for administration of tetracaine

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 IO use of fentanyl, even in burns, is NOT approved for pediatrics.

Adult Burn Injuries Determining TBSA burned Rule of Nines 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!

Parkland Formula Adult Burn Injuries 4 mL x BSA(%) x weight (kg) Page 61 Parkland Formula Volume of Normal Saline: 4 mL x BSA(%) x weight (kg) Parkland Formula for fluid replacement 4ml x pt weight in kg x % BSA burned = amount of fluid to be delivered over the next 24 hour period ½ given in first 8 hours post time of injury Determine the amount to be given in the first 8 hours and divide by eight = amount of fluids to administer per hour 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)

Adult Burn Injuries Keep patient NPO 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

Adult Musculoskeletal Injuries Pages 64-65 Fentanyl doses are now the same for adult patients < 65 YO and those > 65 YO across all SOPs

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 Contact phone numbers for the State reporting lines have been updated.

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 Contact phone numbers for the State reporting lines have been updated.

Emergency Childbirth Phase III: Care of the Newborn Page 72 Updated to reflect current neonatal resuscitation national standards Epinephrine (adrenaline) 1:10,000 0.1 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 For 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)

Emergency Childbirth Phase III: Care of the Newborn Page 72 For 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)

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 Zofran 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)

Pediatric Initial Medical Care Page 75 Zofran 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)

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

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 Pediatric IM dosing for Narcan is allowed due to most pediatric ingestions/overdoses are unintentional and administration of Narcan is crucial to reverse the cause.

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 Adult altered mental status/respiratory compromise is more likely due to drug abuse.

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

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? Discuss with providers different options for mixing D12.5 How 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%.

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

Pediatric Burns Pediatric fentanyl dosing for has NOT changed 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

Drug Appendix

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) 10-20 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 Review: ask questions of providers…..reminder half life is six seconds, discuss methods for rapid administration → proximal vein, rapid 10-20 cc normal saline flush, then elevate extremity

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

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 Classic ECG features are as follows: A shortened PR interval A 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

Wolff Parkinson White (WPW) Syndrome Page 112 During tachycardic episodes, may be Cool, diaphoretic, and hypotensive Crackles in the lungs from pulmonary vascular congestion Wolf 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: Tachypnea Irritability Pallor Intolerance of feedings Evidence of congestive heart failure if the episode has been untreated for several hours A history of not behaving as usual for 1-2 days An intercurrent febrile illness may be present A verbal child with WPW syndrome usually reports the following: Chest pain Palpitations Breathing difficulty Older patients can usually describe the following: Sudden onset of a pounding heartbeat Pulse that is regular and “too rapid to count” Typically, a concomitant reduction in their tolerance for activity Physical findings include the following: Normal cardiac examination findings in the vast majority of cases During tachycardic episodes, the patient may be cool, diaphoretic, and hypotensive Crackles in the lungs from pulmonary vascular congestion In many young patients, only minimal symptoms (eg, palpitations, weakness, mild dizziness) despite exceedingly fast heart rates Clinical features of associated cardiac defects may be present, such as the following: Cardiomyopathy Ebstein anomaly Hypertrophic cardiomyopathy (AMPK mutation)[2] See Clinical Presentation for more detail. Diagnosis Routine blood studies may be needed to help rule out noncardiac conditions triggering tachycardia. These may include the following: Complete blood count Chemistry panel, with renal function studies and electrolytes Liver function tests Thyroid panel Drug screening The 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 interval A 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

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

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

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

Epinephrine (adrenaline) Page 116 Epinephrine (adrenaline) can be administered IV or IO for anaphylaxis Differentiate between anaphylaxis and systemic allergic reaction Neonatal doses changed Addition of IO route.

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

Anaphylaxis Sense of impending doom Respiratory distress Signs/Symptoms Ominous Signs Onset: sudden, typically 30-60 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 Involve providers in discussing signs of shock and respiratory distress: ↓RR, ↓BP, ↓pulse, respiratory distress, altered/declining mental status

Epinephrine (adrenaline) Page 116 Updated to reflect current neonatal resuscitation national standards Epinephrine (adrenaline) 1: 10,000 0.1 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 For 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.

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 Muscle 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 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.

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

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

Fentanyl Pediatric fentanyl dosing for has NOT changed 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

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 Administer in cases where suspected BB or CCB overdose is suspected and the patient has hypoperfusion with associated bradycardia Changes includes the additional route of IO.

Glucose, oral New to drug appendix Dose Onset Indication 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

Narcan (naloxone) New dosing for adults Initial dose of 1 mg IV/IN 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 transient response ….patient responds but then relapses back to initial state of depressed respirations and decreased mental status

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)

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

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

Respiratory: Oxygenation vs Ventilation Region VIII EMS Systems

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 Today 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.

Announcements Region System

SME video

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

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

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

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

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

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

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

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

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

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

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

Airway Management Alternative Airways: King Airway Cricothyroidotomy Advantage is ease of use Can reduce time spent off the chest if CPR is ongoing Cricothyroidotomy Surgical or Needle, per system specific procedure

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

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

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

Signs and Symptoms Respiratory Distress Respiratory Failure Tachypnea Use of accessory muscles (intercostal, suprasternal or substernal retractions) Adventitious breath sounds Nasal flaring Tripod or position of comfort Grunting Cyanosis Decreased level of consciousness Increased work of breathing Poor air entry Decreased breath sounds Bradycardia Apnea or respirations less than 6 per minute

Respiratory Distress vs Failure Adventitious Breath Sounds: http://www.youtube.com/watch?v=5JA6D1Mguh0 Respiratory Distress or Failure? http://www.youtube.com/watch?v=uA02h6FYSYQ http://www.youtube.com/watch?v=0YJxz-Sxx90= 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.

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)

Causes of Respiratory Failure Failure to Ventilate Failure to Oxygenate 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 Pulmonary Embolism Pulmonary Fibrosis Interstitial Lung Disease COPD Pneumonia Pulmonary Edema

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

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 10-12 breaths per minute and titrate to achieve EtCO2 of 35-40mm/Hg using continuous waveform capnography

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

Normal 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 failure Hypoperfusion Hypotension Shock Hypothermia Metabolism is slowed in hypothermic state, so less CO2 is produced Ventilatory failure (hypoventilation) Narcotic overdose Stroke that affects the brainstem CO2 Retention COPD Respiratory Acidosis Chest wall injury Chest muscle weakness Fever (hypercatabolic state)

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

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

Normal Capnogram

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) 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).

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

Troubleshoot Abnormal Waveforms

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

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!

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)

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

Break Time

Scenario 1 EMD / BLS

EMD/BLS 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?

BLS Arrives on Scene: General Appearance Work of Breathing Circulation Awake, alert, anxious Work of Breathing Dyspnea Circulation Hot, dry, red, patchy, swollen areas on skin of extremities and face

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

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? 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)

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? 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.

BLS SKILL REVIEW Epinephrine Auto-injector

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.

EpiPen for Anaphylaxis http://www.epipen.com/How-to-Use-EpiPen

Scenario 2 BLS/ALS

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 BLS can start IMC, but this patient warrants ALS protocols.

BLS/ALS A – patent B – dyspnea, rales audible from across the room 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 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

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!!! 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.

Medications of the month Albuterol

Albuterol 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

Albuterol Contraindications: Adverse Reactions: 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

MEDICATIONS OF THE MONTH Etomidate

Etomidate 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 10-20 seconds with duration of 3-5 minutes Indications: sedation for endotracheal intubation

Etomidate Contraindications: Adverse reactions: 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

Do Not Forget Your Med Checks!

Cardiac Rhythm of the Month

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) Antiarrhythmic drugs associated with torsade include the following: Class IA - Quinidine, disopyramide, procainamide Class III - Sotalol, amiodarone (rare), ibutilide, dofetilide, almokalant Other drug classes associated with torsade include the following: Antibiotics - Erythromycin, clarithromycin, azithromycin, levofloxacin, moxifloxacin, gatifloxacin, trimethoprim-sulfamethoxazole, clindamycin, pentamidine, chloroquine Antifungals - Ketoconazole, itraconazole Antivirals – Amantadine Antipsychotics - Haloperidol, phenothiazines, thioridazine, trifluoperazine, sertindole, zimeldine, ziprasidone[8] Tricyclic and tetracyclic antidepressants Antihistamines (histamine1-receptor antagonists) - Terfenadine, astemizole, diphenhydramine, hydroxyzine Cholinergic antagonists - Cisapride, organophosphates (pesticides) Diuretics - Indapamide, hydrochlorothiazide, furosemide Antihypertensives - Bepridil, lidoflazine, prenylamine, ketanserin Lithium Anticonvulsants - phenytoin, carbamazepine (possible) Oral hypoglycemic Citrate (massive blood transfusions) Cocaine Vasopressin (possible) Fluoxetine (possible) Conditions associated with torsade include the following: Electrolyte abnormalities - Hypokalemia, hypomagnesemia, hypocalcemia Endocrine disorders - Hypothyroidism, hyperparathyroidism, pheochromocytoma, hyperaldosteronism Cardiac conditions - Myocardial ischemia, myocardial infarction, myocarditis, bradyarrhythmia, complete atrioventricular (AV) block, takotsubo cardiomyopathy Intracranial disorders - Subarachnoid hemorrhage, thalamic hematoma, cerebrovascular accident, encephalitis, head injury Nutritional disorders - Anorexia nervosa, starvation, liquid protein diets, gastroplasty and ileojejunal bypass, celiac disease

Torsades de Pointes Patient presentation may include: Treatment: 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

Scenario 3 ALS

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

ALS 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 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: 100.4

Airways affected by asthma ALS Asthma Exacerbation Airways affected by asthma 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 Consider 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.

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 Follow your system’s specific policy/procedure for use of CPAP in asthma/COPD.

Als skill review Continuous Positive Airway Pressure (CPAP) System-specific procedure / policy

CPAP Prehospital indications for CPAP use: Congestive Heart Failure Asthma/COPD Drowning Carbon Monoxide Poisoning Pulmonary Infections Follow System specific policies for use of CPAP in these conditions.

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

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

Questions? Contact EMS Office