Summer Emergencies Pacemakers Quick Trach April 2015 CE Condell Medical Center EMS System Site Code: 107200E-1215 Prepared by: Sharon Hopkins, RN, BSN Revised 4.16.15

Objectives Upon successful completion of this module, the EMS provider will be able to: 1. Distinguish the difference between heat cramps, heat exhaustion, and heatstroke. 2. List the steps of assessment for the patient involved in water emergencies. 3. Analyze signs and symptoms to determine the level of allergic reaction a patient is experiencing. 4. Actively participate in review of selected Region X SOP’s as related to the topics presented.

Objectives cont’d 5. Review pacemaker rhythms. 6. Actively participate in case scenario discussion. 7. Actively participate at the paramedic level in return demonstration of insertion of the Quick Trach. 8. Actively participate in ventilating a manikin at the appropriate ventilation rate for the situation. 9. Successfully complete the post quiz with a score of 80% or better.

Thermoregulation The ability to maintain or regulate a steady body temperature despite changes to the environment Hypothalamus at base of brain regulates temperature You can lose or gain heat from and within the body itself You can lose or gain heat by contact with the external environment The body’s core/normal temperature of deep tissues is normally 370C or 98.60F

Converting Temperatures 0F = 9/5 0C + 32 0C = 5/9 (0F – 32)

Thermal Gradient The difference in temperature between the environment (also called the ambient temperature) and the body Heat flows from the warmer environment (higher temp) to the cooler environment (lower temp) Wind and relative humidity (percent of water vapor in the air) affect heat gain and loss

Process of Transferring Heat Conduction Direct contact of one surface with another Convection Heat loss to air currents passing over the body Heat must be conducted and exposed to the air before being carried away by convection Radiation Heat loss via infrared rays Exposed body could lose 60% of total body heat in environment with normal room temperature

Transfer of Heat cont’d Evaporation Change of a liquid to a vapor Water or sweat evaporates from skin Heat loss is great via evaporation of fluids from the lungs Normal water loss from the skin and lungs is approximately 600 ml per day

Transfer of Heat cont’d Respiration Combines the mechanics of convection, radiation, and evaporation Accounts for a large proportion of heat loss Heat transfers from body to inspired air via convection and radiation Evaporation process in lungs humidifies inspired air During expiration, humidified air released to the environment creating on-going heat loss

Measuring Body Temperatures By touch – get a sense of cool, warm, hot Oral – normal 98.60F (370C) Rectal – 0.5 – 10F higher than oral Tympanic – 0.5 – 10F higher than oral Axillary – 0.5 – 10F lower than oral Core – area where most major organs are located In the field tympanic (ear) or rectal In the hospital bladder, heart with use of special catheters/measuring tools

Homeostasis Process of maintaining constant suitable conditions Body functions within small ranges of “normal” Hypothalamus at base of brain responsible for temperature regulation (i.e.: the “thermostat”) Body constantly compensating to maintain “normal” Core and peripheral temperatures Oxygen levels Energy supplies

Homeostasis of Core Temperature Body continually adjusting metabolic rate The rate in which the body consumes energy to maintain function required at the time Energy production = heat production Temperature controlled by dilating or constricting blood vessels Dilation of blood vessels – flushed skin Constriction of blood vessels – pale skin

Temperature Control To decrease the body temperature Blood vessels dilate to expose more vessel surface space to the skin Excess heat carried from core to the periphery close to the skin; heat dissipates from skin to environment To increase body temperature Blood vessels constrict to shunt warm blood away from superficial veins near skin and back into deeper veins near the core Shivering increases the metabolic rate and generates heat

Risk Factors Impacting Environmental Illness Age Especially very young and elderly Poor general health Fatigue Predisposing medical conditions (i.e.: Diabetes – damages autonomic nervous system & interferes with thermoregulatory input) Certain meds – prescription and OTC Level of acclimatization – adjustment to the environment

Factors Influencing Impact of Environmental Challenges Length of exposure Intensity of exposure Environmental factors Humidity – influences evaporation rate Wind – influences convection

Heat Emergencies - Hyperthermia Condition involving unusually high body core temperatures Usually involves a transfer of heat from the external environment Could include excessive heat production within the body Could occur with use/abuse of certain medications Malignant hyperthermia is a severe response to use of certain anesthetics

Eliminating Excessive Heat Body’s attempt to eliminate excessive heat: Diaphoresis – due to sweating mechanism Evaporation process to reduce the temperature Increased skin temperature to touch – due to vasodilation Moves more blood volume to the skin surface to induce radiation, conduction, convection Flushing due to vasodilation process

Heat Cramps / Muscle Cramps Caused by overexertion and dehydration in high temperature situations Sweating is a response to lower the body temperature Sodium (salt) is transported to the skin Water follows sodium Water on skin surface cools body via evaporation

Heat Cramps cont’d Loss of electrolytes due to sweating Can cause intermittent skeletal muscle cramping Extremities Abdominal muscles Patient generally remains alert and complains of weakness

Heat Cramp Signs and Symptoms Dizziness Syncope/near-syncope Stable vital signs Body temperature normal or slightly elevated Skin moist and warm

Treatment Heat Cramps Consider what is making the patient symptomatic Aim your therapy at the source of the problem Remove from the offending environment Remove clothing as necessary to facilitate cooling Patient education goals Cooling techniques Appropriate hydration guidelines

Heat Exhaustion An acute reaction to heat exposure The most common heat emergency Patient can lose 1-2 L of fluid per hour Loses sodium and water Dehydration and electrolyte loss from sweating often account for the signs and symptoms noted

Heat Exhaustion – Body Responses General vasodilation Pooling of blood volume mimics a decrease in blood volume Leads to a decrease in cardiac output History of exposure to a heated environment helps with the diagnosis If treatment is not instituted, the patient may progress to heat stroke

Signs and Symptoms Heat Exhaustion Increased body temperature (>37.80C / 1000F) or Cool and clammy with heavy perspiration Rapid and shallow respirations Weak pulse Diarrhea Muscle cramps Weakness May have loss of consciousness

Forming Your General Impression History and assessment very important Need clues to determine a working diagnosis to know which treatment plan to institute In the presence of the following CNS signs &/or symptoms consider interventions for heat stroke Headache Anxiety Paresthesia - pins and needles sensation Impaired judgment Psychosis

Treatment Heat Exhaustion Move to a cooler environment Remove as much clothing as possible, as indicated Begin to fan the patient -  air currents (convection) Keep patient supine IV fluid challenge Adult: 200 ml increments; titrated with frequent reassessments Note: adult formula also calculated at 20 ml/kg Peds: 20ml/kg; repeat to max of 60 ml/kg; titrated

Heatstroke True environmental emergency Hypothalamic temperature regulation lost Hyperthermia leads to cell death and damage to brain, liver, kidneys Indications of heat stroke Central nervous system imbalance Body temperature usually >1050F (40.60C) Absence of sweating

Heatstroke – Hot & Dry or Hot & Wet? Sweating stops usually from destruction of sweat glands or due to dysfunction from sensory overload Patient may still be covered with sweat though from earlier exertion (i.e.: marathoner, construction worker) Classic heatstroke – hot, red, dry skin Exertional heatstroke– hot, moist skin

Classic vs Exertional Heatstroke Predisposing factors for classic heatstroke Age Diabetes Other medical conditions Predisposing factors for exertional heatstroke Generally person in good health Excessive ambient temperature with excessive exertion with prolonged exposure and poor acclimation

Exertional Heatstroke – Big Problems Severe metabolic acidosis From excessive lactic acid accumulation Lactic acid develops as by-product during anaerobic metabolism Hyperkalemia – excessive potassium moved from the cell into the bloodstream Released from injured cells or created due to renal failure (poor clearing capability) or development of metabolic acidosis

Signs and Symptoms Heatstroke Hot skin that is dry or moist Very high core temperature Deep respirations (blowing off acids) that become shallow, rapid and later slow Rapid, full pulse initially then slow Hypotension with low or absent diastolic Confusion or disorientation or unconsciousness CNS impairment – headache, anxiety, impaired judgment, paresthesia, psychosis Possible seizures

Treatment Heat Stroke Move patient to cool environment Remove unnecessary clothing Fluid challenge Adult 200 ml increments (formula 20 ml/kg) Peds 20ml/kg to a max of 60 ml/kg Rapid cooling procedures Douse towels or sheets with water and place over patient Fan body – increases air current flow (convection) Cold packs to lateral chest wall, groin, axilla, neck, temples, behind knees

Shivering Shivering raises body core temperature To stop shivering Can occur in the setting of too rapid of a cooling process To stop shivering Adult: Valium 5 mg IVP/IO over 2 minutes Can repeat same dose in 2 minutes titrated to the max Peds: Valium 0.2 mg/kg over 2 minutes Can repeat same dose in 15 minutes titrated to the max Total maximum is 10 mg for the adult Total max for peds is 5 mg (<5 years old) and 10mg (>5 y/o)

Water Emergencies Drowning Outcome Respiratory impairment from submersion or immersion in a liquid Outcome Mortality – death Morbidity – developing a medical problem No morbidity – no problem A leading cause of death in children Most drownings occur in freshwater – the swimming pool

Sequence of Events of Drowning Submersion Struggle with attempt at breath holding Instinctive inspiratory and swallowing efforts made Water enters mouth, posterior oropharynx, and stomach Apnea causes rise in retained CO2 levels; decrease in O2 Hypoxia stimulates trigger to gasp Acidosis is developing Reflexive laryngospasm and bronchospasm occur Minimizes amount of water actually measured in lungs

Sequence cont’d Reflex swallowing continues Gastric distension,  for vomiting and aspiration Hypotension, bradycardia then death occur Water enters lungs (before laryngospasm or after laryngeal relaxation) Water in airways blocks gas exchange in alveoli Even small amount of water washes away surfactant Atelectasis develops (alveolar collapse)

Surfactant A thin film substance in alveoli that keeps them open Decreases pressure needed for subsequent inflation Without adequate levels of surfactant, alveoli collapse Blood shunted past collapsed alveoli and is not oxygenated before it is perfused throughout the body

Drowning Outcome determined by degree of anoxia Goal of therapy directed at reversing anoxia Prehospital interventions and treatment is the same regardless of the source of the drowning – freshwater versus saltwater

Factors Affecting Survival Cleanliness of water source Length of time submerged Age of victim General health status of victim Positive influence on outcome – immediate recognition of the drowning and initiation of immediate CPR

Treatment Near Drowning Routine medical care Spinal precautions Consider CPAP in the adult if indicated If stable (awake, alert, warm and dry, B/P >90 in adult, then transport

Treatment Near Drowning cont’d Anticipate need for ventilation support Anticipate vomitus and laryngospasms Suction available for vomitus Positive pressure ventilations (i.e.: BVM) for laryngospasms Many drowning victims may have foaming present Focus on oxygenation and ventilation more than on suctioning Protect the patient from heat loss Remove wet clothing, cover body as much as possible

Treatment Unstable Near Drowning Altered Mental Status; B/P <90 Secure airway Assess for hypothermia If normothermic, treat dysrhythmias per protocol If hypothermic, also follow hypothermic protocol Assist ventilations as indicated BVM – 1 breath every 5 – 6 seconds 1 breath every 3-5 seconds infant and child to 8 Advanced airway 1 breath ever 6 -8 seconds

Immune System Responsible for fighting infection The principle system involved in allergic reactions Goal- rid body of offending foreign material (antigen) Components found in blood, bone marrow, and lymphatic system Additional systems affected in immune response Cardiovascular Respiratory Nervous Gastrointestinal

Immune Response To destroy or inactivate pathogens, abnormal cells, or foreign molecules Activation of cascade of events triggered by exposure to foreign substance – an antigen Immune system directs attack on foreign substance to deactivate or destroy offending agent There is a chemical attack of antibodies on the invading agent or antigen

Immune Response cont’d Primary response Initial (first time) exposure to an antigen Antibodies developed to respond at subsequent exposures Secondary response Release of antibodies, upon recognition of the antigen, to facilitate removal of offending antigen

Histamine Potent chemical Principle chemical released in allergic reaction Goal of histamine release Minimize body’s exposure to the antigen Bronchoconstriction -  lung exposure Increased intestinal motility - move antigen thru system Vasodilation - remove antigen from circulation Increased vascular permeability - remove antigen from circulation

Histamine Release – Smooth Muscle Constriction Bronchoconstriction Minimizes amount of antigen that can enter the respiratory tract Abdominal cramping From increased gastric motility Diarrhea and vomiting Attempt to move antigen quickly through the system and eliminate it from the body

Histamine Release – Increased Capillary Permeability Third spacing – fluids (plasma) shift from intravascular to interstitial space Trying to move offending antigen out of circulatory system Angioedema especially of head, neck, face, upper airway Relative hypovolemia Decreased cardiac output Decreased tissue perfusion Impaired cellular function Cellular death

Histamine Release – Peripheral Vasodilation Decreased peripheral vascular resistance Less tone in blood vessels Less efficient circulation of blood Decreased preload – amount of blood returning to the heart Decreased after-load – the pressure the heart must pump against to move blood Blood pressure will drop Cardiac output drops

Allergic Reaction Exaggerated response by immune system to foreign substance (antigen) Repeated exposure results in much stronger immune response Hypersensitivity Unexpected, exaggerated reaction to an antigen Range from mild skin rashes to more severe systemic reactions throughout many more body systems

Anaphylaxis Most severe allergic reaction Usually occurs when an antigen enters the circulation Rapid and wide distribution facilitated through-out the body Most reactions occur within seconds In a few cases there may be a delay over an hour The more severe the reaction, the quicker the onset of signs and symptoms

Anaphylaxis Life-threatening emergency requiring prompt recognition and intervention Can develop in seconds; can cause death in minutes after exposure Develops after exposure and sets off biochemical reactions that could lead to shock and death Most common causative agents – injected penicillin and hymenoptera (bee and wasp) stings

Anaphylaxis – Presentation / Appearance Flushing Rash – fine, red, diffusely spread over entire body Itching Hives (urticaria) – wheal of red, raised bumps across body Swelling – 3rd space fluid shift Pallor and/or cyanosis

Anaphylaxis – Respiratory System Respiratory difficulty with tachypnea Sneezing, coughing – trying to rid offending antigen Wheezing, stridor – bronchoconstriction & edema Laryngeal edema – 3rd space fluid shift Laryngospasm – may cause difficulty in being able to speak Bronchospasm Labored breathing; use of accessory muscles

Anaphylaxis – Cardiovascular System Vasodilation Increased heart rate – compensation attempt Decreased blood pressure – from capillary leakage, peripheral vasodilation and eventual failure of compensatory mechanisms Development of acidotic and hypoxic environment Eventual fall in cardiac output

Anaphylaxis – Nervous System Dizziness Headache Change in level of consciousness Convulsions Tearing

Anaphylaxis – Gastrointestinal System Nausea and vomiting – to rid offending antigen Abdominal cramping – hypermotility Diarrhea – to rid offending antigen

Anaphylaxis – Ominous Signs Decline in respiratory rate Following increasing edema of tissues and initial dyspnea Bradycardia After compensatory mechanisms have failed Drop in blood pressure Significant 3rd space fluid shift has occurred along with peripheral vasodilation

Allergic Reactions Less severe immune response Gradual onset of signs and symptoms Milder signs and symptoms Normal mentation Adequate perfusion status of the patient Response could be localized to one particular area Ex: Forearm site for localized reaction to bee sting

Allergic Reactions May experience mild flushing, itching, and rash Urticaria (hives) may be present May experience mild bronchoconstriction Body still trying to minimize exposure to antigen Mild abdominal cramps and diarrhea Body still trying to rid self of offending antigen

Intervention of Allergic Reactions To know the correct intervention relies on an accurate and detailed assessment Goals Determine extent of immune response Allergic reaction or anaphylaxis

Interventions Epinephrine Benadryl Fluids Vasoconstrictor Bronchodilator Benadryl Antihistamine- stop release of histamine response Fluids Volume expansion

Region X SOP - Allergic Reaction Stable Hives, itching, red skin GI distress Alert, warm and dry; systolic B/P >90mmHg Ice pack to site Benadryl (antihistamine) 25 mg IVP slowly over 2 minutes or IM Peds Benadryl 1 mg/kg IVP to adult max of 25 mg

Region X SOP – Allergic Reaction Stable with Airway Involvement Epinephrine 1:1000 0.3mg SQ May repeat in 5 minutes Peds dose Epi 1:1000 0.01 mg/kg SQ (max 0.3 mg) Benadryl 50 mg IVP slowly over 2 minutes or IM Peds dose Benadryl 1 mg/kg (max 50 mg) If wheezing Duoneb treatment Albuterol 2.5 mg with Atrovent 0.5mg If no improvement repeat Duoneb treatment If no improvement, albuterol alone

Region X SOP – Anaphylactic Shock Altered level of consciousness Systolic B/P <90 mmHg Secure airway Make sure patient can ventilate/breathe and is adequately oxygenated Goals of treatment Open airways Support vascular status

Adult Anaphylactic Shock Medications Epinephrine 1:1000 0.5 mg IM Can repeat in 5 minutes Benadryl 50 mg IVP/IO slowly over 2 minutes or IM IV/IO fluid challenge in 200 ml increments Duoneb treatment – Albuterol with Atrovent If no improvement, administer Albuterol alone every 5 minutes

Pediatric Anaphylactic Shock Medications Epinephrine 1:1000 0.01 mg/kg IM Max 0.3 mg/0.3 ml per single dose May repeat in 5 minutes Benadryl 1 mg/kg to max of 50 mg Fluid challenge 20 ml/kg Titrated to desired patient response Max 60 ml/kg Duoneb treatment – Albuterol with Atrovent If no improvement, administer Albuterol alone every 5 minutes

Continued Deterioration Anaphylaxis Contact Medical Control to consider Epinephrine 1:10,000 Adult 1:10,000 0.5 mg IVP/IO Peds 1:10,000 0.01 mg/kg IVP/IO Administer slowly This is adrenaline A strong cardiac stimulant!!! Have patient on the cardiac monitor

Epi Pens Prescribed medication for use by patients Adult dose (yellow) – 0.3 mg Peds dose (green) – 0.15 mg To activate Cap removed Gripped firmly – keeping fingers away from tip Jabbed into outer thigh and held in place 10 seconds Caution – needle remains exposed after activation Note: If patient’s EpiPen is ready to be used by them, don’t delay. Assist patient in using their pen; repeated doses, if necessary, of Epinephrine will be your stock

Pacemakers Artificial pulse generator that delivers an electrical current Stimulates depolarization Useful when normal pacemaker site (SA node) unreliable How would you know a patient has one? Patient tells you See it written in the history See the bulge under the skin Medic alert tag

Pacemaker Components Power source Conducting wire Return wire Battery unit called pulse generator Conducting wire Electrodes from the battery to the heart Return wire Wire that returns to the battery unit to complete the electrical circuit

Pacemaker Types - Temporary Usually used in acute setting and for relatively short periods of time (i.e.: acute MI) Pacing unit outside the body Transcutaneous – stimulus across the skin Transvenous – via venous vessel access Current measured in milliamperes (mA)

Pacemaker Type - Permanent Long term support anticipated Wires inserted surgically into the right heart Battery implanted in fatty layer pocket under the skin of the chest or abdominal wall May be inferior to right or left clavicle Usually opposite side to dominant hand Could be abdominal placement – rarer nowadays Could be combination with AICD Current AICD’s also have capability to pace

Pacemaker Sensing Parameters set on pacemaker determine if pacing stimulus is necessary or is withheld Demand mode – pacemaker functions only when patient’s own rate falls below a preset value Pacemaker functions on “demand” Most common type of pacemaker setting used Fixed mode – pacemaker will fire regardless of what the intrinsic (normal) conduction system does Infrequently seen nowadays

Pacemaker Types - Ventricular Single-chamber pacemaker Stimulates only the ventricles See spike followed by wide QRS Most common type of pacemaker implanted Can look like slow monomorphic VT at first glance But, spikes are present; history supports pacemaker

Pacemaker Type - Atrial Single chamber pacemaker Atria are depolarized Heart’s own conduction system used to stimulate the ventricles See spike followed by P wave and then normal QRS

Pacemaker Type – AV Synchronous Dual-chamber pacemaker Both atria and ventricles are stimulated Atrial kick is restored Atria contract and therefore squeeze more blood to the ventricles prior to each contraction See spike followed by P wave and then spike followed by wide QRS

Pacemaker Malfunction – Failure to Capture Spike not followed by complex therefore no depolarization Causes: Battery failure, displacement of lead wire, energy (mA) too low, edema/scar tissue or perforation of myocardium, electrolyte imbalance Presentation: fatigue, bradycardia, low B/P, syncope

Failure to Capture EMS Intervention EMS intervention: reposition patient in case of loss of lead wire contact – turn patient onto left side May “float” lead wire into myocardial wall contact Follow symptomatic bradycardia protocol Administer Atropine 0.5 mg IVP Apply and prepare to begin operation of TCP

Pacemaker Malfunction – Failure to Sense / Competition Pacemaker fires regardless of the patient’s own rhythm No sensing of spontaneous myocardial depolarization There is potential competition for control of the heart Danger – pacemaker spike may fall on vulnerable downslope of T wave VF Causes Battery failure, fracture of wire, displacement of electrode tip

Pacemaker Malfunction – Runaway Pacemaker Pacemaker rate too fast but continues to capture Malfunction of impulse generator Not as common in newer models of pacemakers Typical pacemaker rate set around 70’s (beats per minute)

Pacemaker Malfunction – Battery Failure Absence of any spikes when they would be anticipated Can cause life-threatening situation where patient dependent on pacemaker to support a healthy heart rate Close patient monitoring and long battery life usually avoids this problem

Assessment of Patient Always check the patient first Determine perfusion status / mechanical response Evaluate the patient’s level of consciousness Evaluate blood pressure to determine perfusion Presence of radial pulse indicates B/P is present EKG strip is printable representation of electrical activity

Assessment of Paced Rhythm Does each spike capture? Each spike is followed by a complex Is rate reasonable? Are spikes competing with the patient’s rhythm? Is pacemaker functioning consistently and reliably?

Patient Management If pacemaker malfunctions, treat the patient and not necessarily their rhythm Don’t treat the pacemaker Provide a copy of the rhythm strip for documentation in the patient’s hospital medical record It is safe to touch a patient if the TCP is in use Electrical stimuli is not transferred to you

Transcutaneous Pacing – Potential Complications Coughing Skin burns Interference with sensing from patient agitation or muscle contractions Pain Failure to recognize non-capture Tissue damage 3rd degree burns

Documentation of TCP Use Initial and repeat EKG rhythms on patient chart Date and time pacing started Rate Output (mA) to obtain capture Patient’s response Intervention for comfort/pain control measures Valium 2 mg IVP/IO; repeated to max of 10mg A benzodiazepine to take the edge off Fentanyl 1 mcg/kg IVP/IO/IN; repeated in 5 minutes A synthetic opioid for pain control

QuickTrach Indications Contraindications Emergency assisted ventilations when all other means have failed Contraindications Tracheal transection; other measures are successful Adult device – size 4.0 mmID if >77# (>35 kg) Peds device – 2.0 mmID if 22-77# (10-35 kg) <22# (10 kg) – use needle cricothyrotomy procedure

Quick Trach Procedure Attempt to ventilate patient Assemble equipment Quick Trach kit – appropriate size BVM Skin prep material 4x4’s Position patient supine, neck hyperextended if able

Quick Trach Procedure cont’d Locate Cricothyroid membrane Inferior to thyroid cartilage (Adam’s apple) Superior to cricoid cartilage Palpate from notch upward 1st bone is cricoid cartilage Go to space just above this bone Cleanse site

Quick Trach Procedure cont’d Secure larynx laterally between thumb and forefinger Anchor and stretch skin slightly Puncture Cricothyroid membrane at 900 angle Confirm entry of needle to trachea Aspirate air through the syringe Change angle of insertion to 600 with tip pointed toward feet

Quick Trach Procedure cont’d Advance device to level of red stopper Red stopper assures proper initial depth insertion Stopper should now be snug against the skin Remove the stopper Hold needle and syringe firmly Slide only plastic cannula forward until hub of cannula snug against skin as you withdraw the needle Note: Similar maneuver when starting an IV and advancing the catheter as you retract the stylet

Quick Trach Procedure cont’d Distal end of flexible tubing attached to Quick Trach hub BVM attached to proximal end of flexible tubing Helpful to have flexible tubing already attached to BVM Immediately begin to ventilate with 100% O2 Use pre-attached strap to secure device Make sure device is snug against skin Device can easily be coughed out Helpful to have one end of strap already attached to device prior to insertion

Quick Trach Use Confirm placement by auscultation and observation of chest rise Continuously monitor airway and lung sounds to ensure proper placement Monitor for over expansion of chest wall May need to detach BVM to allow for passive exhalation to allow deflation of lungs Note general improvement in patient’s overall condition

Case Scenario Discussion Review presentation of patient Determine your general impression Determine your treatment choice Use your SOP booklets as a resource Discuss reassessment steps Discuss documentation highlights related to the patient situation

Case Scenario #1 Patient works on a road crew Complains of feeling lightheaded and dizzy VS: 148/88; P – 90; R – 20; warm and sweaty History: hypertension, high cholesterol, diabetes General impression? Interventions?

Case Scenario #1 General impression Intervention Heat emergency (exhaustion) Consider diabetic problem (blood sugar 72) Consider other medical problems Intervention Remember to consider other causes of feeling lightheaded and dizzy Cool – remove from heat, remove extra clothing Fluids – 200 ml fluid bolus increments

Case Scenario #2 Person training for a marathon found collapsed on a trail; unknown length of time Temperature outside 940 and 85% relative humidity Unknown medical history Patient moans when touched Hot and moist VS: 86/62; P – 110; R – 28 and labored General impression? Interventions?

Case Scenario #2 General impression Interventions Heat stroke Acute medical problem – acute MI, brain insult Trauma Interventions Begin to cool – wet towels, fanning, air conditioning IV – O2 - monitor IV fluids – 200 ml incremental fluid challenges Remember to consider other causes of altered level of consciousness

Case Scenario #3 Your adult patient was drinking from a can of soda and was stung by a bee that was in the can Has swollen lips Complains of itchy throat and a feeling of swelling in the throat VS: 110/70; P – 98; R – 22; SpO2 97% General impression? Interventions?

Case Scenario #3 General impression Interventions Allergic reaction with airway involvement Interventions Consider IV – O2 - monitor Epinephrine 1:1000 0.3 mg SQ May repeat every 5 minutes Benadryl 50 mg slow IVP or IM If wheezing, Duoneb ( may repeat)

Case Scenario #4 Adult patient ate a dip and 15 minutes later complains of abdominal cramping, diarrhea, all over itching You can hear audible wheezing Confirmed bilateral wheezing – breath sounds barely audible VS: B/P 88/60; P – 116; R – 22 General impression? Interventions?

Case Scenario #4 Interventions General impression Anaphylactic shock IV – O2 – monitor Epinephrine 1:1000 0.5 mg IM (may repeat every 5 minutes) Benadryl 50 mg IVP/IO or IM Fluid challenge – 200 ml increments Duo neb (may repeat Albuterol neb if needed)

Case Scenario #5 Your 78 year old patient complains of pounding in their chest and generally not feeling well Pulse is irregular, skin warm and moist VS: B/P 92/50; P – 40; R – 18; SpO2 97% Hx: Hypertension, gout, CABG, pacemaker, high cholesterol General impression? Interventions?

Case Scenario #5 General impression Intervention Consider cardiac problem Intervention Apply cardiac monitor Consider obtaining 12 lead EKG, if possible, on cardiac calls What is this rhythm??? Paced rhythm with failure to capture

Case Scenario #5 Impression – Pacemaker with failure to capture Intervention Turn patient onto their left side May “float” catheter into position Support perfusion Consider Atropine dose Prepare for application TCP Consider need for Dopamine drip to support blood pressure Increases strength of cardiac contractions

Bibliography Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady. 2013. Region X SOP’s; IDPH Approved April 10, 2014. Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady. 2010. http://www.scientificamerican.com/article/why-does-lactic- acid-buil/ http://www.icufaqs.org/Pacemakers.doc http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html http://www.cdc.gov/norovirus/preventing-infection.html