Transcript Simcoe Spring 2010 CME

Beausoleil, Muskoka
& Rama
CME 2010
Agenda
• Didactic:
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STEMI update
TOR
King LT
Anaphylaxis
• Skills
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Neonatal Resuscitation
Cardiac arrest & KING LT
Breath sounds
IM injection
IV start, fluid and dextrose administration
• Scenarios
• KAT
General Housekeeping
• Did your name, address,
telephone, cell phone or email
change since the last CME?
• If so please fill out a medic info
sheet!
THANK YOU
Auditing Housekeeping
• Please ensure the use of
– 010 Vital signs code.
• Document Vital signs pre and post each
medication administration on the ACR, not
as a group at the bottom of the ACR
• Do not use a procedure code (i.e. 615
NTG) when you are ruling out NTG
administration. Use 030 ALS assessment
What do I attach to the ACR?
From the LP15 printouts:
• Vital sign log
• ECG with O2Sat waveform (Plethysmograph)
• All 12 Lead ECG’s with patients name
recorded on each ECG.
TIME = Cardiac Muscle
Patient Presentation
33% of patients with confirmed MI present with S & S other than chest
discomfort. This group compared with those that present with chest discomfort are:
• Likely to be older (74 v 67)
• Women (49% v 38%)
• Diabetic (33% v 25%)
• Prior heart failure (26% v 12%)
• Longer delay to assessment (8% v
5%)
• Less likely to be diagnosed (22% v
50%)
• Less likely to receive treatment
(25% v 74%)
• Most likely to die (23% v 9%)
Pre-Hospital 12 Lead
• Perform a history and physical exam
• Patients ≥40 kg with signs and symptoms
of cardiac ischemia you must acquire a 12
lead ECG
– Software will interpret findings
• STEMI positive ECG
• LP 12 *****Acute MI Suspected******
• LP 15*** Meets ST Elevation MI Criteria****
• STEMI negative ECG
All other statements
12 Lead ECG acquisition
• Must be performed on all patients
presenting with signs and symptoms of
cardiac ischemia
• Must input age and sex
12 Lead ECG acquisition
• 3 ECGs will be done on these patients:
– First on scene as early as possible
– Second prior to departure
– Third upon arrival at medical facility
TOR
When to call the BHP for
termination of resuscitation?
Medical TOR (page 42)
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Age > 18 years old
No ALS procedures
Cardiac in nature
3 No shocks on scene
• Witnessed by EMS or Fire?
• Any shocks delivered?
• Was there a ROSC?
• YES or uncertain = continue resuscitation & transport
• NO = continue resuscitation and PATCH to BHP for
medical TOR & continue transport.
Trauma TOR (page 23 & 24)
Trauma TOR
• Age > 16 years old
• Blunt trauma = Big pads
– Shock delivered, transport
– No shock, No pulse, HR>0, transport
– No shock, No pulse, No HR, patch for trauma TOR
• Penetrating trauma = Petite pads (Electrodes)
– HR >0, ED <20 minutes, transport
– HR >0, ED >20 minutes, patch for trauma TOR
– HR 0, patch for trauma TOR
• Trauma patients that have received a TOR after a patch
are to be left on the scene.
King LT
Click on video to start
King LT versus LMA
KING LT
• Size 3,4,5
• Inflation volume
• Esophageal
• Blind insertion
• 2 cuffs
– Distal cuff inflates in the
esophagus
– Proximal cuff inflates at the
base of the tongue
LMA
• Size
• Inflation volume
• Supraglottic
• Visualized insertion
• Single cuff
Neonatal Resuscitation
NRP (page 32)
Birth
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• Prepare equipment
• Team approach
• 30 second blocks
Clear of meconium?
Breathing or crying?
Good muscle tone?
Color pink?
Term gestation?
Routine Care
·
·
·
Yes
Provide warmth
Clear airway
Dry
No
30 sec
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·
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Provide warmth
Position/clear airway (as necessary)
Dry, stimulate, reposition
Give O2 (as necessary)
·
Evaluate respirations,
heart rate and color
Apnea
Breathing
HR ≥100 & pink
Supportive Care
Ventilating
HR ≥100 & pink
Ongoing Care
or HR <100
30 sec
·
Provide positive-pressure
ventilation (BVM)
HR <60
HR ≥60
Meconium present?
·
30 sec
·
Provide positive-pressure
ventilation (BVM)
Administer chest compressions
No
Yes
Baby Vigorous? *
Yes
No
Suction mouth, pharynx,
Provide BVM ventilation PRN
* Vigorous = Good muscle tone, strong
respiratory efforts, and HR>100
Continue with remainder of Initial Steps:
·
Clear mouth and nose of secretions
·
Dry, stimulate and reposition
·
Give O2 (as necessary)
What does meconium look like?
ANAPHYLAXIS REVIEW
Continuing Education
Outline
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Definition
Incidence
Pathophysiology
Signs and Symptoms
Diagnosis
Indication for Epinephrine SQ/IM
Case Presentation
Definition of Anaphylaxis
• A systemic reaction to a protein (antigen)
• Caused by the release of immunoglobulin
E (IgE)
• IgE acts on mast cells and basophils
• Mast cells and basophils release
chemical mediators; including histamine
• Histamine and other inflammatory agents
act on smooth muscle, connective tissue
and mucous glands
Picturehttp://www.world-drugs.net/generic_cetirizine_clip_image002.jpg
Incidence
• Difficult to get true numbers
• Many reactions are mild and not reported or
misdiagnosed
• Up to 15% of population may be at risk
Pathophysiology
• Anaphylactic and Anaphylactoid
reactions occur due to the systemic
release of chemical mediators from
mast cells and basophils
• Histamine is the primary mediator
involved in urticaria, bronchospasm
and anaphylactic shock
Pathophysiology
• Histamine binds
to H1 and H2
receptors
• Binding of
histamine to H1
and H2 receptors
mediates pruritis,
rhinorrhea,
tachycardia,
bronchospasm,
hypotension,
flushing and
headache
Signs and Symptoms
Skin:
• Itching, Urticaria
• Angioedema, flushing
Respiratory:
• Hoarseness, stridor
• Dyspnea, wheezing, rhinitis
GI:
• Nausea, vomiting
• Cramping, diarrhea
Pictures: http://healthsymptomspictures.com/wp-content/uploads/2009/11/anaphylaxis.jpg
Signs and Symptoms
Cardiovascular:
• Dizziness,Chest Pain (uncommon)
• Tachycardia, hypotension
Neurologic:
• Headache,
• decreased LOA (due to hypotension +/hypoxia),
• seizures-uncommon
Signs and Symptoms
• Skin findings are the most common BUT up
to 20% of patients do not have hives or other
skin symptoms
• Respiratory symptoms are the second most
common
• deaths result from severe bronchospasm and
airway and laryngeal edema
Diagnosis
Diagnosis is made clinically:
• History of exposure to possible allergen
followed by development of symptoms
consistent with anaphylaxis
• Development of urticaria, laryngeal edema,
bronchospasm and/or hypotension with
other signs associated with anaphylaxis
• Rebound reactions can occur up to 24 hours
later
Treatment ?
• First line is Epinephrine SQ/IM
• Other treatments: antihistamines,
corticosteroids, bronchodilators,
IV fluids without administration of
epinephrine fail to prevent or relieve severe
anaphylaxis
• Epinephrine in the setting of anaphylaxis
has greater benefit than risk
What are the Indications for Epi
SQ/IM
• Confirmed or suspected exposure to a
probable allergen
• Signs and symptoms of a severe
anaphylactic reaction
– Involvement of more than one body system
– E.g.: Urticaria and nausea
– E.g.: shortness of breath with wheezing
and facial edema
– OR any airway symptoms
Case Presentation
• 8 year old female began to have shortness of
breath with wheezing and tightness in her throat
while running a race at school
• EMS is called 20 minutes later because the
patient’s symptoms have not subsided and the
patient now has a hoarse voice
• Has had a similar reaction in the past but there
was no specific allergen found
• Pulse: 132, Resp: 24, BP: 80/62
Diagnosis?
Treatment?
QUESTIONS
Jeopardy