June/July 2014 CE - Advocate Health Care

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Transcript June/July 2014 CE - Advocate Health Care

Electrical Therapies
Case Scenarios
IDPH SITE CODE: 107200E-1214
REV 6.15.14
Upon successful completion of this module, the EMS
provider will be able to:
1. Actively participate in case scenario discussion.
2. Actively participate in review of a variety of EKG rhythms and 12
lead EKG’s.
3. Actively participate in review of selected Region X SOP’s.
4. Describe the intervention or treatment plan for the case presented
following Region X SOP guidelines.
Objectives cont’d
5. Actively participate in using your department
monitor/defibrillators to review the process of pacing,
synchronized cardioversion and defibrillation skills.
6. Review safety procedures observed when using electrical therapies.
7. Review CPR guidelines per the American Heart Association (AHA) 2010
8. Review responsibilities of the preceptor role.
9. Successfully complete the post quiz with a score of 80% or better.
Electrical Therapies for Patient Care
Usually used when the patient is unstable and
immediate therapies are required
Measuring patient stability = assessing perfusion
 Evaluate
level of consciousness
 Brain
function VERY sensitive to level of oxygen perfused
as well as glucose
 Reacts
 Evaluate
 Falls
quickly when O2 and glucose supplies drop
blood pressure
when all levels of compensation are exhausted
Transcutaneous Pacing (TCP)
Electrical pacing of heart through the skin
Beneficial in symptomatic bradycardia
 Sinus
 High-degree
 Second
 Third
 Atrial
 Any
heart block
degree Type II (Classical)
degree – complete
fibrillation with slow ventricular response
other bradycardic rhythm causes symptoms
Symptomatic bradycardia
 Patient’s
symptoms related to poor perfusion to
vital organs
 Patient
evaluated on THEIR response to their level
of perfusion; not just on the heart rate number
 Example
 Conditioned
athletes normally maintain
excellent perfusion with a heart rate in the 40’s
Monitoring electrodes placed in usual fashion
TCP pad placement
 Anterior
chest pad (-) placed in apical area
 Posterior
pad (+) placed in mid-upper back area
 Between
 Bone
spine and scapula
is poor conductor of electricity so avoid
placement over a bone
TCP Settings
Rate: 80 / minute
Sensitivity: Auto / demand
Output: mA started at 0 and turned up until capture noted
with lowest energy level
 Capture
evident with wide QRS complex following a pacer
Pain Management For TCP
TCP use is painful/uncomfortable for the patient
Administer Valium as a benzodiazepine to relax the patient
mg IVP/IO over 2 minutes
 May
repeat every 2 minutes as needed to a max of 10 mg
To manage pain, administer Fentanyl, an opioid
mcg/kg IVP/IO/IN
 May
repeat same dose in 5 minutes as needed to max 200 mcg
total dose
Watch for respiratory depression in both categories of meds
Synchronized Cardioversion
A controlled form of defibrillation with delivery of
lower energy settings
Used when the patient still has an organized rhythm
and a pulse
Electrical discharge delivered during R wave of
 Current
delivered on downslope of T wave (relative
refractory period) could cause the rhythm to
deteriorate into ventricular fibrillation (VF)
Stable vs. Unstable Tachycardia
In tachycardia, the ventricles contract so fast
they are unable to properly fill to capacity
Contract out smaller stroke volumes than normal
Leads to overall decrease in cardiac output
For stability:
 Check
level of consciousness - first indicator to
 Check
B/P - last indicator to change
Synchronized Cardioversion Indications 12
Unstable SVT
Unstable rapid atrial flutter /fibrillation (narrow complex
Unstable ventricular tachycardia (VT) or wide complex
Peds probable SVT with poor perfusion after no response
to meds
Peds possible VT with poor perfusion
Peds probable SVT or VT with adequate perfusion and
after no response to meds
Synchronized Cardioversion
The conscious patient should be sedated if at all possible!
 This
is a painful procedure
 But,
do not delay procedure to sedate
Sedation with benzodiazepine
 Versed
 Max
2 mg IVP/IO every 2 minutes titrated
10 mg total dose
Pain control with Fentanyl 1 mcg/kg
 Repeated
in 5 minutes; max total dose 200 mcg
Set Up For Synchronized
Activate synchronizer mode button
Watch for flagging of the R wave
Look and call “all clear”
Hold oxygen source away from the patient
Press and hold discharge buttons until machine
discharges on next R wave
 Will
be momentary delay
Assess the monitor and patient
Flagging the R Wave
Precautions with Cardioversion
Patients in atrial fibrillation >480 not on anticoagulants
have increased risk of blood clot formation in quivering
Cardioversion causes the atria to contract and could
break off a clot increasing risk for stroke
Avoid cardioversion if at all possible on atrial fibrillation
patient until detailed and further evaluation can be
completed (if possible)
Non-synchronized delivery of energy during any
part of the cardiac cycle
Cells depolarized allowing them to repolarize
Electrical therapy causes the heart to contract
 The
goal is to allow the SA node (dominant
pacemaker) to take over the electrical control of
the heart
Defibrillation Back Ground
Most defibrillator units are biphasic
This waveform allows use of less energy
 Less
energy = less myocardial/tissue damage
Current moves in one direction and then travels
back in the opposite direction
Need to know YOUR respective manufacturer’s
recommendation for energy settings
 Suggestion:
place a label next to screen with YOUR
setting recommendations
Increasing Success Rate for
Time from onset of VF – sooner the better
 Perform
CPR ONLY until the defibrillator is set up and
ready to go
Pad placement
to right of upper sternum below clavicle
to left of left nipple anterior axillary line over apex of
 Do
not place over pacemaker or internal defibrillator
Confirm pads are secured tightly to chest wall with no
air gaps
Set Up For Defibrillation
Perform CPR while setting up machine and
placing pads
Hold CPR to analyze rhythm
Confirm VF or pulseless VT
Charge unit as recommended by manufacturer
 May
perform CPR just until unit is charged
Look and call “all clear”
Hold oxygen source away from patient
Depress defib buttons
Resume CPR for 2 minutes
Shockable Rhythms
Pulseless VT
Polymorphic VT
Course VF
Results post
Now check
for a pulse
Summary Electrical Therapies
Know YOUR particular brand monitor/defibrillator
Know how to operate YOUR equipment
Check equipment every shift for adequate
stocking of supplies
Know how to trouble shoot YOUR equipment
Acknowledge when YOUR equipment requires
regular monitoring electrodes to be placed IN
ADDITION to defib/pacing/cardioversion pads
Obtaining and Transmitting 12 Lead
Review placement of electrodes for obtaining
12 lead EKG’s
Review YOUR equipment process for transmitting
to the hospital
Remember to state in report YOUR interpretation
for presence/absence of ST elevation
THEN read word for word the print-out
Electrode Placement for 12 Lead EKG’s
For every person, each precordial lead placed in
the same relative position
V1 - 4th intercostal space, R of sternum
V2 - 4th intercostal space, L of sternum
V4 - 5th intercostal space, midclavicular
V3 - between V2 and V4, on 5th rib
V5 - 5th intercostal space, anterior axillary line
V6 - 5th intercostal space, mid-axillary line
Case Scenario Discussions
Read the cases presented
Discuss what your general impression is
Determine appropriate interventions based on
the most current Region X SOP’s dated “IDPH
Approved April 10, 2014”
 Pocket
 Full
sized protocols being printed by the
size copies forwarded to the Medical Officer
for department distribution
Case Scenario #1
49 y/o male got arm caught in
machine at work
Large open wound noted to left
Large amount of blood loss
Make-shift tourniquet applied by
Case Scenario #1
What are the steps in controlling bleeding?
 Direct
pressure with gloved hand
 Direct
pressure with gauze
 Elevation
not found to have any advantage or
 Pressure
points usually not effective
 Operator
error – not enough pressure applied
tourniquet placed if bleeding not controlled
Case Scenario #1
What are the steps for CAT application?
 Place
as far distally as possible at least
2 inches proximal to wound on bare skin
 Tighten
windlass until bleeding stops; pulse
no longer palpable
 Monitor
for further bleeding
 Consider
 Lower
pain management
leg injuries may require tourniquet
placement on thigh vs calf
Case Scenario #1
 Would
you remove tourniquet applied by
 Case
by case decision
 Most
tourniquets in this situation have been
inappropriately applied and with improper
would remove the tourniquet to evaluate
the site and then treat based on EMS
Case Scenario #1- Identify the
Sinus tachycardia
Regular R to R intervals; rate 130
P waves rounded, upright
PR interval 0.12 – 0.20 seconds
Case Scenario #1
What would you do for pain control with stable vital signs?
 Administer
 May
Fentanyl 1 mcg/kg IVP/IN/IO
repeat same dose in 5 minutes
 Maximum
total dose 200 mcg
What side effects should you watch for with Fentanyl?
 Fentanyl
is an opioid so watch for respiratory depression
 Reversible
with Narcan – narcotic antagonist
 Cardiovascular
effects (i.e.: drop in blood pressure) not a problem
with Fentanyl like it may be with Morphine
Case Scenario #1
When would the QuikClot dressing be used?
 Failure
to control bleeding after application of tourniquet
 Bleeding
not controlled with direct pressure to nonextremity areas
Should the initial dressings remain in place?
 No;
QuikClot needs to be placed directly over the wound
to be effective
Is direct pressure still required with Quikclot?
 Yes
for 2-3 minutes or until bleeding stops
 Do
not peek at the wound which disturbs the clot
Case Scenario #1 Follow-up
To OR on day of admission
 Large
soft tissue injury with numerous small metallic foreign
 Non-displaced
 OR
fracture ulnar styloid
for exploration and repair of wound
Initially unable to extend wrist but able to move 3rd,
4th, 5th digits slightly
3 days later reports electrical shooting pain to left
mid forearm
4 days later discharged home; some movement of
Case Scenario #2
72 year-old patient presents with palpitations
and indigestion for several hours
VS: B/P138/88; P – 84; R – 18; SpO2 98%
Vague on their history but takes meds but
doesn’t know what for
General impression?
 Worse
case scenario – cardiac
 Other
considerations – “ill”
What’s Your Interpretation?
Ventricular paced rhythm
Case Scenario #2
False ST elevation
 Paced
 Left
bundle branch block (LBBB)
There is an appearance of ST elevation but NOT in the
presence of an acute myocardial infarction process
Patient evaluated and treated in field based on signs
and symptoms
Bit more challenging for everyone to assess for
presence of acute process
Is ST Elevation Present In This EKG?
ST elevation II, III, aVF
Hold NTG and morphine until consulted with Medical Control
What About This EKG?
Left bundle branch block
EKG Interpretation
Looks like ST elevation in chest leads V 1 – V4
Actually, this is left bundle branch block (LBBB) that also
can give appearance of ST elevation that does not
indicate an acute process
Remember the hints for determining a LBBB pattern
 Widened
 Possibly
 Think
notched QRS (rabbit ears)
of a car’s turn signal
 If
wide QRS predominately negative in V1, consider left
bundle branch block
 If
wide QRS predominately positive in V1 consider right
bundle branch block
Case Scenario #3
32 year-old patient presents with 2 hours of
dyspnea with increasing wheezing and
increasing difficulty breathing
Patient in tripod position
Pale, slightly damp, VERY anxious
B/P 138/84; P – 98; R 32; SpO2 95%
Bilateral inspiratory and expiratory wheezing
What is your general impression?
Case Scenario #3
Impression – Acute asthma
 Confirmed
with history
Would you administer oxygen?
 Yes
– presence of respiratory difficulty even
though pulse ox is over 94%
What interventions need to be provided to help
this patient?
 Supplemental
 Bronchodilators
Case Scenario #3
Treatment Based on Region X SOP’s
Adult Routine Medical Care
Albuterol 2.5 mg/3ml mixed with Atrovent 0.5 mg/2.5 ml
neb treatment
 Needs
O2 flow rate of 6 lpm to generate a mist
If no improvement, repeat above medications
If no improvement, administer Albuterol alone as a neb
For severe distress, contact Medical Control to consider
Epinephrine 1:1000 at 0.3 mg IM
Case Scenario #3
 When
is a repeat of the Duoneb of Albuterol
and Atrovent automatic in the Region X
Adult and child asthma
Adult and child allergic reactions with wheezing
Case Scenario #3
 What
are the benefits of Albuterol and Atrovent?
 Albuterol is a bronchodilator
mostly on receptors in the lungs (Beta 2)
effects on receptors in the heart (Beta 1)
but may cause an increase in heart rate
 Atrovent
is an anticholinergic that acts as a
 Combination
therapy increases the dilating
effects in the bronchioles
Case Scenario #3
 Describe
wheezing and how you assess for it
 Wheezes
are continuous high-pitched musical
sounds similar to a whistle
 Air
is moving through partially obstructed airways
 First
appear at end of exhalation
to not move your stethoscope to the
next site too prematurely
heard during inspiration and exhalation
indicate a worsening condition
Case Scenario #4
EMS is called for a 32 y/o patient with altered level of
VS: B/P 100/56; P – 72; R – 12; SpO2 98%; GCS 11 (3, 3, 5)
History: Diabetes (blood sugar 32)
What is your impression?
 Diabetic
reaction – hypoglycemia – insulin shock
What is your treatment goal?
 Raise
the blood sugar level
Case Scenario #4
 How
do you raise the blood sugar level in the
 If
IV access, administer Dextrose
based on age (D50%; D25%, D12.5%)
younger/more immature the IV site, the
weaker the concentration
 If
no IV access, Glucagon 1 mg IM/IN
 Oral
glucose gel (Glutose) 15 grams
Case Scenario #4
 Oral
Glutose gel – 15 grams
 Useful
in the patient who is able to tolerate oral
preparations, has an intact gag reflex and is able
to protect their own airway
 Available
for the patient in the above condition
with no access to food or fluids that would
otherwise be used to raise the blood sugar level
Case Scenario #4
Can this patient sign a release / refusal for transportation?
 Yes,
if certain conditions are met
 Patient
must be awake, alert, oriented
 Patient
must be able to understand risks and benefits
 Patient’s
blood sugar must be documented as being over 60
Document your discussion with the patient
Document your advice for transport
Document follow-up – personal physician; to call 911 if any
further problems
Document D/C of IV if applicable
Case Scenario #5
 42
y/o Spanish speaking male found at a job site
 Unclear
mechanism of injury with machinery
 Upon
EMS arrival male on steel conveyor belt
being held in sitting position by co-workers
 Obvious
facial trauma with possible broken jaw,
missing teeth, bleeding from mouth
 Able
to move toes and wiggle fingers
Case Scenario #5
 Patient
denied head, neck, back pain by
nodding head
 Assisted
 Mouth
to cot
suctioned as needed
 Fentanyl
 Patient
 How
1 mcg/kg given for pain
is 230 pounds
much Fentanyl is indicated?
mcg / 2.08 ml
Case Scenario #5
 Would
you have immobilized this patient with
significant trauma to the face, unclear the exact
mechanism of injury?
patient was not immobilized
What were some “red flags” for securing
 Non-English
 Unclear
speaking (medic interpreter was on call)
mechanism of injury
 Significant
trauma evident to face
Case Scenario #5
 When
is immobilization indicated?
 Evidence
 Known
of injuries above the level of the
or questionable mechanism of injury
 Unable
to clear with spinal immobilization
of injury, signs or symptoms,
patient reliability
Case Scenario #5
 Clearance
of cervical spine
awake and fully cooperative
free of pain, swelling, hematoma,
pain to palpation, no bony abnormality
distracting injures
range of motion by patient is pain free
passively (movement performed by
another person) attempt to move the head
Case Scenario #5
Patient struck in face with piece of machinery
Distracting injuries present
 This
patient had jaw fracture
 Significant
bleeding from mouth
Patient not reliable – arguable
 Non-English
 Helpful
that one of the paramedics on the scene
was Spanish speaking
Case Scenario #5
How would you immobilize a patient that cannot
tolerate traditional cervical collar?
Head blocks on backboard
Towel rolls taped into place
Manual control
Any creative method that gets the job done
Document unique actions taken and be descriptive
Document CMS before and after splinting
 Circulation,
movement, sensation
Case Scenario #5
Immobilization on backboard
 Patient
had significant bleeding from oral/facial injuries
If immobilized flat on backboard could have compromised
What would you have done?
 Critical
thinking skills needed here as well as past experience
could have helped
 Would
need to elevate backboard
 Consider
transport with backboard tilted to avoid
compromising airway
 Utilize
 Limited
to 10 seconds per attempt
Case Scenario #5 Follow-up
Patient diagnosed with C2-C3 subluxation
 Ligament
injury of 2 adjoining spinal bones that
have abnormally separated causing instability
 OR
for cervical fusion; cervical collar worn post
surgery to be worn 3 – 6 weeks
 Central
Open fracture mandible
 Jaw
cord syndrome
wired in OR
Left vertebral artery dissection
 Treated
with aspirin – anticoagulant
Case Scenario #5 Follow-up
Central Cord Syndrome
An incomplete spinal cord injury
 Middle
area of cervical spine affected
 Impairment
of arms and hands more than legs
 More
motor loss than sensory loss
 More
upper extremity than lower extremity loss
 More
distal than proximal muscle weakness
 Usually
due to hyperextension mechanism
Case Scenario #5 Central Cord cont’d 61
No cure; some people recover near normal
Improvement noted first in legs, then bladder,
then arms
 Hand
function recovers last if at all
Case Scenario #5 – Cord Syndromes
Named based on location of injury in relation to the spinal cord
Central Cord Syndrome
Anterior Cord Syndrome
 Spares
 Loss
upper extremities and touch
of motor, pain, temperature sensation
 Preserves
light touch, vibratory sensation, proprioception
(awareness of position of ones body)
Brown Sequard Syndrome
 Ipsilateral
(same side) motor & proprioceptive loss, light
touch, motor
 Contralateral
(opposite side) loss to pain and temperature
Case Scenario #5
Patient discharged to RIC (Chicago) 9 days post injury
Bilateral lower extremities 5/5 (normal strength and
Right upper extremity – 2/5
Remains weaker but with improvement
Left upper extremities
Grip 3-4/5
Left elbow flexion 3-4/5
Numbness shoulder to fingers
Time will tell what function/sensation returns
Case Scenario #5 – Lesson Learned
Assume spinal injury til
proven otherwise in blunt
 Note:
As swelling progresses, signs and
symptoms can intensify and worsen
Case Scenario #6
EMS called for 25 y/o with complaint of nausea
for past 8 hours
 Only
 VS:
vomited x1 – small amount of liquid
B/P 120/78; P – 86; R – 16; SpO2 99%
 Skin
warm and dry; negative for tenting
 Mouth
 Negative
 No
pertinent history
known allergies
 Meds
– daily multivitamin
Case Scenario #6
 What
medication is used to treat nausea
per Region X SOP’s?
 Zofran
 What
dose and routes can be used?
mg IVP; 4 mg po (oral)
 May
repeat in 10 minutes to total max 8 mg
for adults and pediatrics >40 kg (88 pounds)
<40 kg – Zofran 0.1 mg/kg IVP
Case Scenario #6
 When
can Zofran ODT be given?
 Patients
over 40 kg (88 pounds)
 Oral
disintegrating tablet (ODT) used when goal is
to relieve nausea and patient not suspected of
needing IV fluid
 To
document ODT source of Zofran
 “Time”
given, “Zofran ODT”, “4 mg”, (route) “po”
Case Scenario #6
 Indication
IV fluids may be required
 Repeated
episodes of vomiting especially
larger volumes
 Evidence
of dehydration
mucous membranes
hot/dry skin
Case Scenario #6
 How
do you administer Zofran ODT?
 Peel
open foil packet
not push pill thru foil – pill may crumble
 Place
tablet on patient’s tongue
 Inform
patient tablet will dissolve
quickly – before patient can even
consider thinking of swallowing pill
AHA CPR Guidelines
Infant – Child - Adult
 Compression
 Ratio
rate at least 100 / minute
compression to ventilations
 30:2
-1 & 2 man adult CPR
 30:2
– 1 man infant & child
 15:2
– 2 man infant & child
 Switch
rescuers every 2 minutes or 5 cycles
 Resume
CPR compressions immediately
following defibrillation attempts
Aha CPR Guidelines cont’d
 Compression
 Infant
– 1 ½ inches
 Child
- about 2 inches
 Adult
– at least 2 inches
 Once
intubated – asynchronous compressions
to ventilations
 Ventilate
1 breath every 6 – 8 seconds
(document 8-10 breaths delivered per minute)
Preceptor Role
 Be
 Be
 We
all started as students and “newbies”
 Invest
the time now to get “a good
product” in the long run
Hands-on Skills
 Field
trip to the ambulance
 Review
YOUR equipment
how to set YOUR equipment up
pacing (TCP)
12 lead EKG’s to hospital
Safety Precautions & Electrical Therapy
 If
BVM out and oxygen flowing to it, do not
leave on cot next to patient when not being
 Sheets/clothing
could become oxygen enriched
 Several
in-hospital cases of spark from defibrillation
causing a fire
 Hold
BVM off to the side during discharge of
electrical therapies
More Safety Tips
 If
patient intubated, remove BVM from
proximal end of ET tube during discharge
of electrical therapy
 Just
letting go of BVM puts excessive weight
on the ETT
 Could
inadvertently dislodge tube during
discharge of electrical therapy
 Remember
to call AND look “all clear”
prior to discharging electrical energy
Bledsoe, B., Porter, R., Cherry, R. Paramedic Care
Principles & Practices, 4th edition. Brady. 2013.
Mistovich, J., Karren, K. Prehospital Emergency
Care 9th Edition. Brady. 2010.
Region X SOP’s; IDPH Approved April 10, 2014.