Case Presentation 1

Does the cat have your tongue?

• You are working a day shift at Fleet Centre on an ACP & PCP car and get a call for a patient with difficulty breathing at a downtown school @ 12:30 hours. • Police and Fire are already on scene.

• When you arrive you find a thin, white 13 year old female patient conscious and in obvious distress. • FD has applied oxygen via NRB Mask.

• What do you want to do?

Does the cat have your tongue?

• LOC - Conscious - obtunded / fatigued • A swollen lips, flushed face, patient still protecting A/W ?

• B obvious distress!, RR 50 ++ laboured, inspiratory stridor, unable to talk more than 1 word sentences, A/E  decreased bilaterally, with diffuse inspiratory and expiratory wheezes. • C HR sinus tach @ 120/ min no ectopics, - Monitor is being applied.

• D pupils 6mm perl. GCS 14

Does the cat have your tongue?

• Sample history is being obtained while you start an IV.

• S - skin dusky - rash & hives tightness in chest and throat patient c/o of SOB+++, onset shortly after being stung by a bee. • A - llergic to penicillin and bee stings • M - Ventolin, EPI Pen • P - Asthma • L - 15 minutes ago • E - was outside after lunch and “stung” by a bee • IV is in!

• blood sugar is 5 mmol

Does the cat have your tongue?

• Physical Exam Reveals: – No JVD - Trachea midline (you think) – A/E diffuse wheezes heard bilaterally – ABD - soft, non tender, non distended – Central and Peripheral hives and edema – Weak palpable radial pulses • Vitals – HR 120 / min – BP 100 / 750 – RR 50 / min laboured and fatigued – Sats 78% – Pupils 8mm PERL – GCS 14?

– Flushed face - dusky extremities

Does the cat have your tongue?

• What do you want to do?

• EPI or Airway?

– EPI 0.3 mg SQ (1:1000) • Is there a concern for this patients airway?

• How would you like to manage the airway?

– Oral intubation concerns?

• LOC • Hypotension (not yet) – Blind Nasal Intubation technique • Just had nasal reconstruction (can’t nasally intubate) – Now what?

Does the cat have your tongue?

• Patch – Dr. says “what do you want?” – facilitated / sedated airway?

• BHP asks “ is it going to be a difficult A/W?

• Explain…..

LEMON

• L - Look • E - Evaluate • M - Mallampati (1 - 4) • O - Obstruction • N - Neck 1 point 2 points 2 points 2 points 1 point 2 or more equals difficult

Does the cat have your tongue?

• You think you are in?????

• How would you confirm the tube location?

– ETCO2 / Ausculation / Sats / Misting of tube – What do you see with the ETCO2 Tracing • 10 second (strip) 50 30 10 0

Does the cat have your tongue?

• Explain this tracing that appears on the monitor shortly after the patient is intubated and moved to the stretcher.

– Rebreathing?

– Bronchospasm? (changed?) – Kinked tube?

– Circuit disconnect?

– Extubation?

• The tube was accidentally pulled out as patient started to seize.

Does the cat have your tongue?

• What would you like to do?

• Reassessment reveals • seizuring and apnic patient?

• Treatment ?

– Glucose?

– Valium 5 mg IV (repeat 2 min prn) • Seizure has stopped but patient is still apnic.

– LOC GCS 3 – HR 140 /min sinus no ectopics – sats not registering ?

• Intubation?

Does the cat have your tongue?

• Unable to identify any structures or visualize the cords.

• You place the tube. – is this ok ?

– no different than blind nasal • Confirmation methods: – Visualize cords X – Misting of tube X (nothing noted - not reliable ) – Sats X (no reading) – Auscultation – ETCO2  ( no A/E)  ( ? ) • What does it mean?

• What colour would this be? (capnometer)

Does the cat have your tongue?

• What would you do?

• Extubate? or visualize – Patient is extubated - Ventilation attempted • When you ventilate the stomach gets rises / bigger.

– Is this normal?

– How can you tell?

• You hear air bubbles in gastric region when you auscultate.

• Despite your valiant efforts to ventilate with: – Sniffing position (see next slide) – 2 person technique – 2 trumpets and an oral airway • You are unable to obtain a sat reading or hear air entry.

• HR is 81 no peripheral pulses are palpatable. (carotid) • What do you want to do?

Does the cat have your tongue?

Sniffing position for large adult vs. pediatric

Does the cat have your tongue?

• Cricothyroidotomy?

• Indications: – Inability to ventilate • Sniffing position • 2 person technique • 2 trumpets and OPA – Inability to intubate or correct by other measures – Patient not breathing • Contraindications for Cricothyroidotomy: – < 12 years of age – Unable to landmark – Trauma to neck • Describe technique:

Needle Cricothyroidotomy

This is a second line procedure that should be used if Seldinger techniques is not possible.

Provides temporary oxygenation but no ventilation

Cricothyroidotomy

2

Maintain landmarked site with one hand & insert the 6cc syringe with 18 guage TFE catheter and introducer needle. Advance needle on a 45 ° angle to the frontal plane in the midline in a caudad direction. While inserting needle draw back on syringe to verify when trachea has been found.

Cricothyroidotomy

3

Remove the syringe and needle leaving the catheter in place. Advance the soft, flexible end of the guidewire through the TFE catheter and into the airway several centimeters.

4

While holding on to the guidewire ensuring not to let it move. Carefully remove the TFE catheter.

Cricothyroidotomy

5

While holding the guidewire make a vertical incision with the # 15 short handle scapel blade to allow dilator to be inserted.

Cricothyroidotomy

Cricothyroidotomy

FINALLY

• The airway is secured. • Patient is being ventilated but compliance is poor. – Why ? (physiologic) • What shock process was happening?

• Why is patient hypotensive?

• Why did the patient have a seizure?

REVIEW DIFFICULT

AIRWAY

• LEMON assessment scale.

– Prior to taking TOTAL control of airway – May choose to facilitate intubation (versed) – May need to LOAD patient • Lidocaine  • Opiate • Atropine  • Defasiculating neuromuscular blocking agent

LEMON

• L - Look • E - Evaluate • M - Mal and Patti (1 - 4) • O - Obstruction • N - Neck 1 point 2 points 2 points 2 points 1 point 2 or more equals difficult

LEMON

• L - Look (visual assessment) 1 point (each) – Under / over bite – Big teeth – Facial hair – No neck – Barrel chest • Gut feeling tough tube!!!

LEMON

• E - Evaluate – Ability to open mouth 3 fingers – Anterior Larynx 3 fingers – Superior Larynx 2 fingers 2 points • Children and Asians have anterior and superior larynx.

LEMON

• M - Mallampati (1 - 4) – 1 = can see all of uvula 2 points – 2 = can see most of uvula – 3 = can see a part of uvula – 4 = can see none of uvula - all hard palate • Paramedics should lean to a 1 or 4 interpretation.

• O - Obstruction – Tumors – Hematoma – Swelling

LEMON

2 points

LEMON

• N - Neck 1 point – Immobility, unable for flex or extend neck – C -spine precautions – Kyphosis – Osteoporosis – Severe Rheumatoid Arthritis • 2 or more equals difficult airway is expected

Versed Midazolam HCL

• Classification: Sedative (anxiolytic and hypnotic) – CNS depressant (benzodiazepines, barbiturates, etc) • Mode of Action: – Inhibitory action of the GABA receptors (ý~aminobutyric acid)

:

• Benzodiazepines bind to specific, high affinity sites on the CNS cell membranes right beside the GBA receptors. When the GABA receptor is bound it is triggered to cause an increase in chloride conductance by increasing the the chloride ions into the cell. This causes a small hyperpolarization and moves the postsynaptic receptor away from its action potential.

• The binding of benzos to GABA receptors enhances the affinity of these receptors for this neurotransmitter, resulting in a more frequent opening of the chloride channels. This in turn hyperpolarizes the post synaptic receptor even more and further inhibits neuronal firing.

Benzodiazepines

• BENZODIAZEPINES: – receptors are only found in the CNS – have no analgesic or anti psychotic effects – do not affect the autonomic nervous system (still BP caution) – all have exhibit varied level of these actions: • Anxiolytic • Sedative / hypnotic • Anticonvulsant • Muscle relaxant

Benzodiazepines

• BENZODIAZEPINES: – Anxiolytic • at low doses they are anxiolytics, thought to selectively inhibit neuronal circuits in the brain’s limbic system.

– Sedative / hypnotic • all have these properties at high doses can cause hypnosis and respiratory depression and hypotension.

Benzodiazepines

• BENZODIAZEPINES: – Anticonvulsant • Several types are used to treat epilepsy however some don’t have a long enough half life to be useful – Muscle Relaxant • relax spasticity of skeletal muscle, by increasing presynaptic inhibition of the spinal cord.

• Pharmacology:

Benzodiazepines

– Absorption and distribution: • Lipophilic benzodiazepines are rapidly & completely absorbed after oral administration & distributed evenly throughout the body (IV & SQ as well) – Duration of actions: • Half lives of this classification of drug are VERY important for their clinical use. They are divided into 3 categories: Long acting: (Valium / Diazepam) Intermediate acting: (Lorazepam) Short acting: (Triazolam) • Several types are used to treat epilepsy however some don’t have a long enough half life to be useful – Metabolism & Excretion: • most are metabolised in the liver and therefore caution should be used when administering to people with hepatic dysfunction • eliminated in the urine.

• Adverse affects:

Versed Midazolam HCL

– Drowsiness and confusion – Hypoventilation – Tachycardia / bradycardia – Hypotension • Caution: – It will potentiate effects of alcohol and other CNS depressants • Versed in use by January - February 2002 • Dose: > or = 40 kg 0.01 - 0.1 mg/kg

Case Presentation 2

Grapes of Wrath

• You are working a weekend day shift on the mountain with another ACP and receive a call to respond code 4 for a patient trapped under a farm implement. • You arrive at a vineyard and walk across the field to the scene.

• When you arrive you find one, white 48 year old, 120 kg male patient conscious, alert ?(confused), c/o of SOB and Chest Pain. He is trapped under a tractor and some type of spreading machinery. • You have a police officer on scene and the Fire department is on scene.

• What are you concerns?

It’s all over but the whinning

• You notice white powder all over the scene and your patient.

– HMMMMM • Oxygen is has already been applied with NRB Mask by fire Sample history is being obtained while you start an IV.

• S - skin: RED, DRY - CP 4/10 tight chest (but is trapped) Pain does not increase with palpation or inspiration, However patient c/o of SOB, becoming more lethargic Crackles and wheezes throughout. Open compound tib/fib.

• A - llergic to tetanis • M - None • P • L - 2 hours ago - steak and egg breakfast • E - was fertilizing the field and the tractor rolled & pinned him • IV is in!- blood sugar is 5 mmol

It’s all over but the whinning

• Vitals: – RR 40 + shallow/ fatigued – HR 54 Sinus Bradycardia – BP 96/56 – SATS 88% – Pupils 2 mm perl – Skin RED, DRY, WARM – lethargic – incontinent (all fluids) • Would you like to intubate?

– Concerns?

• LOC • Hypotensive for versed • Vagus stimulation????

• ETCO2 Tracing Reveals this on a 15 second strip?

What are your queries what is causing this waveform?

You are loaded and ready to go

• What do you see?

• Rate?

• Regular?

• PR Interval Normal?

• Sinus?

• Ischemic - Currnet of injury patterns?

Cheer up it could be worse

• Difficult patient to manage - Poor +++ compliance.

• Querry?

– Organophosphate OD • Cholinergic (can be opposite) • RX Atropine +++ Get it all • Sympathomimetic ????

• On transport you see this on your ETCO2 monitor (explain) Bronchospasm & Rebreathing Ventolin & slow expiratrion to allow gas to escape

You Cheered Up & It Got Worse

• HR rises • BP falls • SATS FALL • Your patient looks worse What do you think?

You Cheered Up & It Got Worse

What do you think?

What can you do?

ONLY ONE THING WILL HELP!

Kneel down and whisper in their ear “walk away from the light”