1. Curriculum Update: SOP and Bradycardia Rhythm Review Based on SOP’s March 2005 Condell Medical Center EMS System October 2006 Site Code #10-7200E-1206 S Hopkins, RN, BSN, EMT-P

2. Objectives Upon successful completion of this program, the EMS provider should be able to: –identify indications, contraindications, dosing, special considerations, and side effects of medications used in the Region X SOP –participate in rhythm review –state the indications and site of choice of the IO needle –participate in rhythm identification practice –successfully complete the quiz with a score of 80% or greater

3. Introduction - Adult Intraosseous (IO) Infusion Can be useful: –when there is a need for IV access and an IV cannot be established in 2 attempts or 90 seconds May be helpful to use immediately in cardiac arrest or profound hypotension with altered mental status

4. Adult IO Contraindications Fracture of tibia or femur (consider alternate extremity) Infection at intended site Previous orthopedic procedure to the area (ie: knee replacement, IO previous 48 0 ) Preexisting medical condition (ie: tumor near site, peripheral vascular disease) Inability to locate landmarks (ie: significant edema) Excessive tissue at site (ie: morbid obesity)

5. Adult IO Procedure BSI protection including face/eye shield Fill 10 ml syringe with normal saline. Prime connecting tubing (1 ml) leaving 9 ml in syringe and leave syringe connected to tubing Identify landmarks –just medial to tibial tuberosity on flat portion of proximal tibia (same site for pediatrics) –FYI: intramedullary vessels do not collapse even in critically ill patients

6. Adult IO Procedure cont’d Cleanse insertion site Prepare EZ-IO driver and needle set Stabilize leg with non-dominant hand –do not place your hand under patient’s leg Insert EZ-IO needle at 90 0 angle

7. Adult IO Procedure cont’d Activate driver by depressing trigger on handgrip while maintaining firm & steady pressure on driver –most insertions accomplished under 10 seconds Once decreased resistance is felt, or needle flange touches skin (whichever is first), release the trigger While stabilizing hub, remove driver from needle set

8. Adult IO Procedure cont’d Remove stylet by rotating counterclockwise –place stylet in sharps container Connect primed EZ-connect tubing Using syringe, flush with remaining 10 ml normal saline –observe for swelling or extravasation around site –to improve flow rate, give 10 ml bolus normal saline rapid IVP

9. Adult IO Procedure cont’d Confirm needle placement –most reliable indicators: needle firmly in bone fluid infuses well –inability to aspirate does not mean non- placement –if placement is in doubt, leave needle in place with connecting tubing & syringe attached and ED staff can reevaluate site

10. Adult IO Procedure cont’d Attach EZ-connect to IV tubing & begin infusion –any drug given IVP can be given IO –dosages, onset, & peak concentrations virtually identical to those given IVP –IO route is preferred over ETT route Apply pressure to IV bag to facilitate flow –flow rates will be slower than IV routes due to anatomy of IO space –pressure may be applied manually or with a blood pressure cuff

11. Adult IO Procedure cont’d Secure tubing to leg Apply wristband supplied with equipment –offers 24 hour hot line for questions –reminds staff to remove EZ-IO within 24 hours Frequently reassess pressure to IV bag Monitor EZ-IO site and patient condition –infection rates are low (0.6%) –another EZ-IO may be used in same limb after 48 hours –check calf area for swelling after any fluid bolus

12. Adult IO Procedure Patient Feedback “Pain” felt during insertion equivalent to bumping shin on a table (5/10) –lasted < 10 seconds Similar levels of pain felt when IV infusions started at max rates –your patients will not be conscious! Dr. Miller, EZ-IO developer after practice insertion of device

13. EZ-IO Device FYI: –Same drill will eventually be used for pediatric and adult insertion of IO device –Needle size will change to adapt to population receiving IO –Hands-on practice will take place in future CE

14. Electrical Conduction System SA AV node Bundle of His Right & Left Bundle Branches Purkinje Fibers

15. Sinus Bradycardia Rate: < 60 bpm Rhythm: regular P waves: positive, upright, rounded, precede each QRS, all look relatively alike PR interval: 0.12 - 0.20 seconds; relatively constant QRS: <0.12 seconds (unless intraventricular conduction delay is present)

16. Atrioventricular (AV) Blocks Delay or interruption in impulse conduction in AV node, bundle of His, or His-Purkinje system Classified according to degree of block and site of block –PR interval is key in determining type of AV block –Width of QRS determines site of block

17. AV Blocks Clinical significance dependent on: degree or severity of the block rate of the escape pacemaker site ventricular site will be slower than a junctional site patient’s response to that ventricular rate evaluate level of consciousness/responsiveness and blood pressure

18. Second Degree AV Block Wenckebach, Mobitz Type I Rate: atrial rate is greater than ventricular rate Rhythm: atrial rate regular (P to P marches out); ventricular rate irregular (dropped QRS) P waves: P waves all uniform, not all P waves followed by QRS PR interval: getting progressively longer until there is a P wave without a QRS QRS: < 0.12 seconds

19. Second Degree AV Block Classical, Mobitz Type II Rate: atrial rate greater than ventricular Rhythm: atrial regular (P’s to P’s march out); ventricular regular if degree of block is constant P waves: normal in appearance; not all followed by QRS PR interval: constant for conducted beats QRS: < 0.12 seconds

20. 3 rd Degree Heart Block - Complete Rate: atrial rate greater than ventricular; ventricular rate determined by site of escape rhythm Rhythm: atrial regular (P’s to P’s march out); ventricular regular but no relationship to atrial P waves: normal in appearance PR interval: none (no relationship between atrial & ventricular rhythms QRS: narrow if junctional pacemaker site or wide if ventricular pacemaker site

21. Helpful Tips Second degree Type I –think Type I drops one –Wenckebach “winks” when it drops one Second degree Type II –think 2:1, 2:1, 2:1 –recognize the block can be variable or something other than 2:1 Third degree - complete –think completely no relationship between atria and ventricles

22. How Can I Tell What Block It Is?

23. Junctional Rhythms Rate: 40 - 60 bpm Rhythm: very regular P waves: may occur before, during, or after QRS; if visible are inverted in lead II, III, & AVF PR interval: if P wave present, usually shortened (< 0.12 seconds) QRS: normally < 0.12 seconds, longer if aberrantly conducted

24. Junctional Rhythms Rate determines description: Junctional escape rhythm rate is 40-60 bpm Accelerated junctional rhythm rate is 61 - 100 bpm Junctional tachycardia rate is over 100

25. Treatment/Interventions Bradycardia Guided by presence and degree of signs and symptoms Atropine –used to increase heart rate –can increase rate of SA node discharge; increase speed of conduction through AV node; has little or no effect on contractility –typical dose starts 0.5 mg IVP –maximum dosage 3 mg IVP

26. Additional Treatment Transcutaneous pacing –no response to doses of atropine –unstable patient with a wide QRS –set pacing at a rate of 80 beats per minute in the demand mode –start output (mA) at lowest setting possible and increase until capture –Valium 2 mg IVP (increments to 10 mg) should be given to help with the chest discomfort

27. Patient Unresponsive To Therapy Consider the patient may be in cardiogenic shock Consider fluid challenge 200 ml; may repeat once Evaluate breath sounds before & after fluid Dopamine drip to maintain B/P >100 Start dopamine minidrip at 5 mcg/kg/min Tip - quick drip calculation: take pt’s weight in pounds, take 1 st 2 numbers, subtract 2. This is drip factor to start with (ie: pt weight 210#; 21 - 2 = 19; start drip at 19 minidrips/minute)

28. What Is This Rhythm? Sinus bradycardia At this rate the patient is expected to be symptomatic Treatment if symptomatic? Atropine for narrow complex QRS; TCP if QRS wide

29. Second degree Type I - Wenckebach Treatment usually not necessary as heart rate is usually near lower limit of 50’s - 60’s and patient is rarely symptomatic Monitoring is required for deterioration What Is This Rhythm?

30. Second degree Type II - Classical (narrow complex) Overall ventricular rate is most often slow causing the patient to be symptomatic and requiring therapy

31. What Is This Rhythm? Second degree Type II - Classical Wide QRS indicates the origin of the escape pacemaker site is low down in the conduction system TCP should be used ASAP if patient symptomatic

32. What Is This Rhythm? Third degree heart block - complete P to P’s are regular; R to R’s are regular There is no relationship between the atria and ventricles (no pattern or consistency with PR interval)

33. Third degree - complete heart block with a wide QRS complex Treatment includes avoiding atropine and starting with TCP What Is This Rhythm?

34. Junctional rhythm (P waves inverted) Inherent rate of AV node is 40 -60 bpm Treatment is based on symptoms and tolerance of patient

35. What Is This Rhythm?

36. Second degree Type I - Wenckebach For some patients, this may be their normal rhythm. For others, they may go back and forth between sinus rhythm and second degree heart block Type I without signs or symptoms

37. What Is This Rhythm? Sinus bradycardia with wide QRS (bundle branch block pattern) Need to determine if patient is symptomatic or not before deciding on interventions needed

38. What Is This Rhythm? Third degree heart block - complete With this appearance and heart rate, patient more than likely will be symptomatic If narrow QRS, start with atropine If wide QRS, patient needs TCP (omit atropine)

39. Implanted pacemaker

40. Paced Rhythm - 100% Capture

41. What Is This Rhythm? Paced rhythm with single failure to capture Pacemaker wires may need to be repositioned at the hospital Carefully monitor EKG for further loss of capture

42. Revised AHA CPR Guidelines The message: –focus is “back to basics” –push harder, push faster 30:2 for adult 1 & 2 man; child & infant 1 man CPR 15:2 for child & infant 2 man CPR rate of 100 compressions/minute perform 5 cycles of 30:2 CPR in 2 minutes and then prepare to defibrillate if needed switch CPR roles every 2 minutes due to exhaustion (if the compressor is tired, CPR will be sloppy and will not be effective) –minimize CPR interruptions to < 10 seconds

43. CPR Changes cont’d –perform CPR if there is any delay while charging defibrillator –do not perform pulse checks unless you observe a rhythm that should provide perfusion –after defibrillation immediately resume CPR do not stop to perform a rhythm check –ventilations over 1 second once every 5-6 seconds via BVM to mouth once every 6-8 seconds with advanced airway in place (ETT, combitube, LMA) –IV/IO drug route preferred over ETT route

44. Review SOG’s DNR status –properly completed form must be present with patient –can recognize old orange form or new watermelon colored form –can be a reproduction on any color paper Closest hospital –patient choice when possible & allowable –clinical condition of patient dictating destination lack of airway unstable, near arrest condition psych patient with no preexisting relationship elsewhere

45. Cardiac Protocol Review Acute Coronary Syndrome –chew aspirin to enhance absorption if patient reliable and took daily dose, do not need to repeat dose; inform medical control; if aspirin not given for any reason, document why –if patient < 35, give aspirin and then confer with medical control before giving nitroglycerin or morphine –12 lead if treating patient for acute coronary syndrome inform ED you are sending 12 lead

46. Tachycardia –determine if the patient is stable or unstable evaluate blood pressure and level of consciousness if unstable needs cardioversion (start at 100 j) if stable, determine if QRS is narrow (think adenosine) or wide (think lidocaine) PEA/asystole –think & treat for potential causes (H’s & T’s) –PEA: epi 1 mg; if rate is <60 atropine 1mg (max 3 mg) –asystole: epi 1 mg; atropine 1 mg (max 3mg)

47. Stroke/Brain Attack Screen all patients for time of onset of symptoms –assessment & diagnostics must be completed and drug intervention must be started within 3 hours of onset (>3 hours increases risk of intracranial bleed Therefore, the most important question is: “What time did your symptoms start?”

48. Cincinnati Prehospital Stroke Scale Facial droop –ask patient to smile, big enough to show their teeth –watch for droop and record as right/left sided droop or no droop Arm drift –ask patient to close their eyes, hold arms out in front, palms up, for 10 seconds –watch for right/left drift or none Abnormal speech –abnormal is slurring words, using wrong words, or inability to speak

49. In-Field Spinal Clearance A  reliable patient  without signs or symptoms of neck/spine injury and  negative mechanism of injury does not require full spinal immobilization Document findings to support decision to not immobilize When in doubt, fully immobilize

50. In-Field Spinal Clearance Criteria Positive mechanism of injury - immobilize –high velocity MVC >40 mph –unrestrained occupant in MVC –passenger compartment intrusion >12” –ejection from vehicle –rollover MVC –motorcycle collision >20 mph –death in same vehicle –pedestrian struck by vehicle –falls >2 times patient height –diving injury

51. In-Field Spinal Clearance Positive signs & symptoms –pain in neck or spine –tenderness/deformity of neck or spine upon palpation –paralysis or abnormal motor exam –paresthesia in extremities –abnormal response to painful stimuli For the presence of any above noted signs and/or symptoms, or gut instinct, the patient needs full spinal immobilization

52. In-Field Spinal Clearance Patient reliability questionable –signs of intoxication –abnormal mental status –communication difficulty –abnormal stress reaction ie: person extremely upset over the incident If patient not reliable, full spinal immobilization required

53. Interventions - Traumatic Injuries Tension pneumothorax –needle decompression - 2 nd or 3 rd intercostal space midline of the clavicle, over the top of the rib Sucking chest wounds –occlusive dressing secured on 3 sides –watch for development of a tension pneumothorax lift edge of dressing to burp during exhalation Fluid resuscitation –20 ml/kg bolus normal saline adult reevaluate every 200 ml peds patient maximum of 3 boluses (60 ml/kg)

54. Did You Remember? What do the drugs for conscious sedation do? Lidocaine for head insult (trauma or medical) prevents the cough reflex (coughing would raise intrathoracic pressures which would transmit to the brain and raise intracranial pressures) Morphine - reduce anxiety & pain; facilitate a response to versed Versed - relax & sedate patient; act as amnesic Benzocaine - eliminate gag reflex to test for gag reflex in unconscious patient, stroke eyelashes - if blink reflex still present, patient still has gag reflex use short 1-2 second spray to back of throat

55. What drugs are good diagnostic tools to use for unknown unconscious person? Dextrose if glucose < 60 If glucagon given 1 st and then IV established, reassess glucose level and can give D50 if needed Narcan 2 mg IVP useful in altered level of consciousness (ie: to wake a patient up) and known/suspected narcotic overdose (to improve ventilation depth and rate) if you have to chase a patient around the room to administer narcan, then they don’t need narcan yet

56. When does CPAP get initiated? Acute pulmonary edema, when patient remains alert and cooperative, blood pressure remains >90 When would CPAP need to be discontinued? Blood pressure drops below 90 At any time the patient deteriorates further Diabetic emergencies Hypoglycemic needs glucose (sugar) to replace depleted stores brain most sensitive organ to low glucose levels Diabetic ketoacidosis (DKA) (glucose >200) is dehydrated and needs fluid replacement

57. Allergic reaction/Anaphylactic shock Simple (hives, itching, rash), stable Benadryl 25 mg slow IVP or IM Simple with airway involvement Epinephrine 1:1000 0.3 mg SQ Bendadryl 50 mg slow IVP or IM If wheezing, albuterol 2.5 mg/3ml nebulizer Unstable (hemodynamically) with anaphylactic shock IV wide open Epinephrine 1:1000 0.5 mg IM (more predictable absorption than SQ in shock)

58. Heat emergencies Heat cramps - do not massage extremities Heat exhaustion - perspire, dizzy, headache IV fluid challenge begin gradual cooling Classic heat stroke - hot, dry skin; altered level of consciousness IV fluid challenge rapid cooling (wet, cool towels; cold paks; fan) Exertional heat stroke - damp skin from activity just performed (ie: marathon, construction worker) IV fluid challenge rapid cooling (wet, cool towels; cold paks; fan)

59. Hypothermia Frostbite rapidly rewarm (warm water, hot paks) Systemic hypothermia hot paks If no pulse and extremities stiff (cannot be flexed), limit defib attempts to 1 st round & withhold IV and meds; perform CPR during transport If no pulse and extremities can be flexed, extend medications to longest limit between doses ie: every 5 minutes versus 3 minutes

60. Burns - Morphine 2 mg IVP for pain control Electrical dry, sterile dressing; EKG monitoring Chemical brush dry chemical off before irrigating consider need for HAZMAT team Inhalation O 2 100% via nonrebreather or assist with BVM Thermal Superficial (1 st degree) - moist saline dressings Partial thickness (2 nd degree) - dry sterile dressing, transport pt covered with sterile sheet Full thickness (3 rd degree) - dry sterile dressing, transport pt covered with sterile sheet

61. OB Complications Placenta previa –placenta implantation in lower part of uterus partially or completely over cervical opening –painless, bright red vaginal bleeding Abruptio placenta –premature separation of placenta from uterine wall –trapped blood loss in uterus; uterus firm & painful –increased mortality rate mother & fetus Treatment aimed at repeat assessment and monitoring for & treating shock Transport with patient lying/tilted left

62. OB Complications Hypertensive disorders of pregnancy have an unknown cause, generally occur in 1 st pregnancy, and often near term –signs & symptoms preeclampsia: headache, confusion blurred or double nausea & vomiting vision protein spilled in urine hypertension excessive retention of fluid epigastric pain –signs & symptoms ecclampsia - same as above with the addition of seizures treat seizure activity with valium (crosses placenta)

63. OB Complications Supine hypotensive disorder –heavy weight of uterus, esp after 5 months, may put pressure on the inferior cava –blood flow returning to the heart would be diminished –patient may complain of dizziness & be hypotensive Transport patient laying or tilted left - especially after the 5 th month

64. OB Complications Nuchal cord - cord around infant neck –attempt to slip cord over the head –if cord cannot be moved, clamp & cut cord now –have mother breath through contractions to avoid her trying to push during the emergency

65. Newborn Inverted Pyramid

66. Pediatric Critical Conditions Glucose level < 60 –child > 1: D 25% –child <1: D 12.5% (equal parts D 25% & normal saline for dilution) Allergic reactions –local: apply ice –mild resp distress: epi 1:1000 sq 0.01 mg/kg (max 0.3 mg per single dose); albuterol 2.5 mg neb –severe compromise: epi 1:1000 sq 0.01 mg/kg (max 0.3 mg per single dose); when IV/IO established, epi 1:10,000 0.01 mg/kg; fluid bolus 20 ml/kg, albuterol 2.5 mg neb for wheezing

67. Pediatric Critical Conditions Bradyarrhythmias –Very different approach than for adults –CPR if heart rate < 60 and poor systemic perfusion –Epi 1:10,000 IVP/IO or epi 1:1000 if ETT –Atropine IVP/IO Peds arrest –defib 2j/kg, then repeated at 4j/kg –Drugs: epi 1:10,000 IVP/IO lidocaine IVP/IO

68. Case Review: What Is This Rhythm? Sinus bradycardia When is treatment required? If patient is symptomatic (decreased level of consciousness, hypotensive)

69. What Is This Rhythm? Second degree Type II - Classical Patients will be symptomatic due to the slowed ventricular heart rate Don’t assume symptoms but evaluate each patient individually for their own threshold of tolerance

70. What Is This Rhythm? Accelerated junctional rhythm When is treatment indicated? When patient is symptomatic (decreased level of consciousness and hypotensive) - doubtful this patient would be symptomatic at rate of 70 Treatment would be atropine if QRS is narrow

71. What Is This Rhythm? Paced rhythm - 100% capture; rate 75 beats per minute Typical presentation of ventricular pacing wire

72. What Is This Rhythm? Sinus bradycardia Is treatment necessary at a rate of 50 beats per minute? Treatment/interventions depend on symptoms and tolerance of patient

73. What Is This Rhythm? Junctional escape rhythm with bundle branch block pattern (wide QRS) or possibly a ventricular escape rhythm At this rate and EKG appearance, the patient will most likely be symptomatic and in need of aggressive support, possibly CPR if in PEA

74. Case Review What Is This Rhythm? Junctional rhythm Rate 40-60 beats per minute; no P wave activity

75. What Is This Rhythm? Second degree Type II - Classical Consistent PR interval when present, more P waves than QRS complexes

76. What Is This Rhythm? Second degree Type I - Wenckebach PR interval gets progressively longer until there is a dropped QRS Overall heart rate adequate and patient does not need therapy

77. What Is This Rhythm? Accelerated junctional rhythm

78. What Is This Rhythm? Third degree heart block - complete

79. What Is This Rhythm? Third degree heart block - complete The first 2 P waves are visible; the last 2 are buried in the wide QRS complexes