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Shock

Mod I 2013 ECRN CE

Condell Medical CenterEMS System

Site Code: 107200E-1213

Prepared by: Sharon Hopkins, RN, BSN, EMT-P

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Objectives

Upon successful completion of the program the ECRN will be able to:

1. Review the circulatory system. 2. Describe the pathophysiology, signs and symptoms of different mechanisms of shock. 3. Describe the stages of shock and the signs and symptoms of the stages as the patient progresses from compensated shock through decompensated shock to irreversible shock.

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Objectives cont’d

4. Describe unique elements of shock in special populations (i.e.: pregnancy, elderly, children). 5. Discuss appropriate interventions and treatment of the various mechanisms of shock. 6. Review case scenarios presented. 7. Identify the pre-tibial and humeral sites and insertion of an IO needle. 8. Review process of removing an IO needle 9. Review process of removing the King airway 10.Successfully complete the post quiz with a score of 80% or better.

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Circulatory System

Closed system for transport of oxygen and nutrients dissolved in blood and for the removal of waste material

Comprised of 3 components The pump = heart The fluid = blood The container = blood vessels

Any one of these functioning poorly will affect the whole system

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The Pump

The heart is the pump Functions under 2 systems

High power system Arterial side

Lower power system Venous side

Body’s function dependent on an adequate stroke volume Amount of blood pumped with each

contraction Approximately 70 ml for the average adult

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Influences on Stroke Volume

Preload Amount of blood returning to the heart Dependent on venous return

Venous system functions as a storage container

Cardiac contractile force The greater the stretch (i.e.: volume) the greater

the recoil the better the strength of contraction Influenced by circulating catecholamine's

Epinephrine and norepinephrine Controlled by sympathetic nervous system

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Stroke Volume cont’d

Afterload Resistance against which ventricles have to

contract Determined by degree of peripheral vascular

resistance met Dictated by degree of vasoconstriction

present The greater the resistance (degree of

vasoconstriction) the smaller the volume of blood (i.e.: stroke volume) able to be pumped out of the heart due to higher pressures met in the vascular system

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Cardiac Output

Amount of blood pumped out of the heart in one minute is the cardiac output

Calculated on a formula

Stroke volume x heart rate = cardiac output

Ex: 70ml x 80 bpm = 5600 ml blood/minute

A change (reduction or increase) in stroke volume and/or heart rate will impact cardiac output

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Blood Pressure

Dependent on cardiac output and degree of vascular resistance

Calculation of B/P: B/P = cardiac output (CO) x peripheral vascular

resistance (PVR)

To increase B/P cardiac output or peripheral vascular resistance

To decrease B/P cardiac output or peripheral vascular resistance

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Perfusion

All body cells require constant supply oxygen and nutrients

Waste products must be removed Build-up is harmful to the functioning of the

body Multi-system coordination needed to supply

oxygen & nutrients and remove waste Circulatory system Respiratory system Gastrointestinal system

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Hypoperfusion

This is shock! Inadequate delivery of oxygen and

essential nutrients to all tissues Inadequate removal of wastes from tissue

Most critical tissues in the bodyBrainHeart Kidneys

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Pathophysiology of Hypoperfusion

Usually a result of inadequate cardiac output Factors that could affect cardiac output

Inadequate pumping preload cardiac contractile strength heart rate Excessive afterload (high resistance in arterial

system decreasing stroke volume that gets pumped out) Inadequate fluid level Inadequate container

Dilated vessels (poor systemic vascular resistance) Leaking vessels

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Pathophysiology of Shock

A very complex process Causes can vary Signs and symptoms can vary

BUT… Basic definition holds across the span

Shock = inadequate tissue perfusion!

Ultimate outcome = impaired cellular metabolism

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Pathophysiology - Impaired Cellular Metabolism All cells dependent on adequate supplies of

oxygen and glucose to function In any type of shock, there is a disconnect in

the use of oxygen and glucose Aerobic metabolism changes to anaerobic In the absence of oxygen, breakdown of

glucose hindered Primary source of energy, glucose, not available

to the cell Glucose does not provide energy until it is

broken down inside the cell

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Impaired Use of Oxygen

Harmful by-products produced Lactic acid & other metabolic acids accumulate

Acidic condition of blood not favorable to normal bodily function

Hemoglobin not able to bind with and carry oxygen

Cellular stores of ATP used up and not replaced

Energy production, essential for metabolism of cells, decreases

Sludging of blood develops Slowed blood flow due to pumping of heart

and vasodilation of vessels

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Impaired Use of Glucose

Glucose must be transported into the cell Step necessary for a process where glucose

produces energy Glucose remaining in blood results in

hyperglycemia Alternative sources used to produce energy

Breakdown of fats (lipolysis) Amino acids from protein

Depletion of proteins in the system leads to organ failure

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Classifications of Shock

Generally classified based on cause Cardiogenic

Impaired pumping of heart Hypovolemic

Decrease in blood volume Obstructive

Obstruction interferes with return of blood to heart (i.e.: tension pneumothorax, tamponade)

Distributive Abnormal distribution and return of blood

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Semantics of Shock

Alternative classifications of shock Cardiogenic – pump problem Hypovolemic – volume problem Neurogenic – container/tank problem

(distributive) Anaphylactic - container/tank problem

(distributive) Septic - container/tank problem

(distributive)

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Identification of Shock

Need to identify the underlying cause of shock Correcting the cause is key element in

providing the right intervention for reversing the process

Many interventions can be universally applied to a variety of shock conditions

Some interventions have limited applications Ex: fluid challenges given aggressively in

hypovolemic shock could be harmful in the setting of cardiogenic shock

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Stages of Shock

3 stages Based on ability of body to compensate at

that point in time Based on signs & symptoms present

Reflect what is happening internally Stages are progressive and become more

serious Compensated Decompensated Irreversible

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Stages of Shock - Compensation

Initial stage of shock; body compensating Activated when a need triggered (i.e.: threat to

cardiac output) Patient can still maintain their blood pressure!!!

Sympathetic nervous systemSecretes epinephrine & norepinephrine

heart rate (1st indicator to notice!) cardiac contractility Vasoconstriction (seen as paleness)

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Stages of Shock - Compensation

Renin-angiotensin systemKidneys release renin

Triggers production of angiotensin II – a strong vasoconstrictor

Angiotensin II stimulates production of aldosterone

Kidneys reabsorb sodium and therefore water Noticed as a decrease in urine output

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Stages of Shock - Compensation

Antidiuretic hormone (ADH) secreted Kidneys triggered to reabsorb more water

Spleen Expels extra blood volume being stored

Approximately 200 ml of blood can be added to existing blood volume

Passive activity Fluid shifts from interstitial spaces into the

capillaries Skin feels drier

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Stages of Shock - Decompensation

Conditions causing shock are too serious or too rapidly progressing and compensatory measures

can no longer maintain preload Perfusion inadequate

Heart weakens Cardiac output falls even more

Reduced blood flow to the brain and vital function stimulation ceases

Appropriate interventions may still correct condition if applied early enough and body can respond

KEY: Blood pressure cannot be maintained and begins to fall

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Stages of Shock - Irreversible

Blood becomes even more acidic and hypoxic Systemic acidosis develops

Further deterioration of cells & tissues

Sludging of blood occurs in capillaries Minute blood clots formed

Capillaries leak fluid into interstitial space Correction of the condition is no longer

possible; cells beginning to die

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Evaluating Signs and Symptoms

“Classic” shock Altered mental status

1st change to be noted Anxiousness moving to lethargic

Skin pale, cool, clammy Pulse moving from normal to increasingly

faster and then slowing and disappearing Cardiac dysrhythmias develop and deteriorate

into asystole Blood pressure maintained until it finally falls

When B/P falls, compensation is over!

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Neurogenic/Distributive Shock

Injury to brain or spinal cord Loss of sympathetic tone Relative hypovolemia due to dilation of

arteries Warm, red, dry skin (vasodilation) Low B/P and pulse (no catecholamine

stimulation)

Key: hypotension, bradycardia, warm/dry skin

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Anaphylactic/Distributive Shock

Response of immune system to foreign substance

Usually the faster the reaction the more severe the case

Skin flushed, itchy, hives, swelling Respiratory distress

Coughing, wheezing, stridor Vasodilation, heart rate, B/P Nausea/vomiting, cramping Altered mental status

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Septic/Distributive Shock

Infection of bloodstream Signs and symptoms progressive Toxins cause vasodilation High fever

Often absent in elderly and very young Skin flushed to pale to cyanotic May have altered level of consciousness May have respiratory distress and abnormal

breath sounds

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Elderly Population & Shock

Some body system changes over time can increase risk factors for the elderly who are traumatically injured

Influence on changes Vulnerability increased for injury Body response to injury not as effective or

dramatic Less tolerant of interventions received Increased time of recovery of health status

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Elderly System Changes

Altered mental status common Poor historian

Hypertension common What looks like a “normal” B/P may be hypotension

in the person with hypertension

Atherosclerosis and arteriosclerosis more prevalent Stiffer blood vessels less able to respond with

adequate degree of vasoconstriction

Impaired swallowing increases risk for aspiration

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Elderly Changes cont’d

Bones more brittle Cough reflex diminished

Increased risk for aspiration Less air and gas exchange in lungs General decline in efficiency of renal system Less ability to fight infection via immune

system Perspires less Skin tears more easily; heals slower

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Physiological Changes of Pregnancy

Respiratory system oxygen demand & consumption

Cardiovascular system Cardiac output increases Maternal blood volume increased

Due to changes patient has a relative anemia May lose 30-35% of volume before signs &

symptoms of shock are evident Maternal heart rate by 10 - 15 beats per

minute Maternal B/P til end of 3rd trimester

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Supine Hypotensive Syndrome Usually occurs in 3rd trimester Large weight of uterus compresses inferior

vena cava when patient supine Reduces return of blood flow to the heart

Goal – avoid decrease in return of blood to the heart Transport patient tilted or turned to side

Preferably left side (Remember: “lay left”) Especially important after 5th month

If patient must remain flat (i.e.: CPR), then manually displace uterus to side

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Pediatric Population & Shock

Body systems less developed Decreased capacities compared to the adult Dehydration most common cause of

hypovolemia Pale, cool skin Diminished peripheral pulses Delayed capillary refill Change in mental status Decreased urination (i.e.: dry diapers, dark urine)

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Pediatric Population

Average blood volume is by body size Typical infant 80 ml/kg

Typical adult male 75 ml/kg

Typical adult female 65 ml/kg

By formula then: Infant = 300 ml total blood volume 200# adult male = 6,800 ml total blood volume 160# adult female = 4700 ml total blood volume

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Average Blood Volume by Size

Infant Child Adult

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Field Interventions for Shock

Frequent reassessments watching for changes/trends Every 5 minutes (or sooner) for unstable

patient If not documented, then not done

Follow ABC’s (CAB’s if arrested) Assess airway Assess quality of breathing Assess circulation / pulses / perfusion Assess neurological function

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Field Interventions for Shock

EMS to begin transport as soon as possible EMS alerts receiving hospital as soon as

possible EMS rapid trauma assessment

Identification of immediate, obvious life threats A quick head to toe examination Vital signs and history obtained Interventions begun as soon as possible

Transport should not be delayed to initiate additional interventions

IV/O2/monitor enroute in critical situation Fluid challenge is at 200 ml increments

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Field Interventions for Shock

Management of life threats in the field (usually same process in the ED) Interventions performed if situation found

Airway opened Ventilations supported

Via BVM – 1 breath every 5 – 6 seconds Via ETT or King airway – 1 breath every

6 – 8 seconds MUCH slower than usually practiced!!!

Needle decompression if tension pneumothorax Sucking chest wound sealed Major bleeding controlled

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Field Interventions for Shock

If failure to secure peripheral IV access, IO is the backup

If failure to place an endotracheal tube, King airway is the backup

These are urgent skills and each paramedic must be capable of using these tools without delay if necessary

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IO Access

Available when other alternatives are not Sites provide non-collapsible space when

peripheral veins have collapsed in shock Sites can be rapidly accessed Fluids and medications are rapidly absorbed

into the bloodstream Large amounts of fluid can be delivered

quickly (i.e.: 125 ml/min) Bony cortex provides stable base when

securing inserted IO needle

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Region SOP – IO Insertion Skill

Indications Shock, arrest, impending arrest Unconscious/unresponsive or conscious

critical patient without IV access 2 unsuccessful IV attempts or 90 second

duration or no visible sites

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IO Insertion Skill cont’d

Contraindication Insertion into extremity with a fracture Infection at insertion site Previous orthopedic procedure (knee

replacement, previous IO within 480) Pre-existing medical condition (tumor near

site, peripheral vascular disease) Inability to locate landmarks (significant

edema)

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Primary Complication IO Insertion

Extravasation into soft tissue from infiltrated site Could cause compartment syndrome

Reference June 2012 CE for review of compartment syndrome

Bone fracture during insertion – rare Could occur with excessive force applied

Osteomyelitis – uncommon Generally from poor technique Leaving IO needle in >24 hours Multiple attempts at same site

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Equipment for IO Insertion

IV start pak Pre-filled syringe

10 ml 0.9 NS for adult insertion 5 ml 0.9 NS for pediatric insertion

IO kit Needle Primed EZ connect tubing Wristband

Drill Cleansing material

Chloraprep ampule; alcohol wipe Primed IV tubing inserted into IV bag Pressure bag

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IO Needle SizingNote: Gauge same for all sizes (15 G)

Pink for 3 – 39 kg (up to 88 pounds) 15 mm; 15 G

Blue for >40 kg (>88 pounds) 25 mm; 15 G

Yellow for excessive tissue over site & humeral head site 45 mm; 15G

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IO Needle Sizing Hint/Tip

Need to evaluate the site to determine the size needle to use

If you feel bone immediately under the site palpated, use the pink 15 mm needle Ex: palpate over wrist at base of thumb

If you palpate tissue over the site and not bone, use the blue 25 mm needle

If there is excessive tissue over the site or use of the humeral site, use the 45 mm needle

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Proximal Tibial IO Landmarks Need to identify the tibial tuberosity – a rounded

projection below knee cap Sits approximately 2 finger widths below the patella

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IO Site Identification – Proximal Tibia

Site must be viewed AND palpated Locate tibial tuberosity - bump over shin 2 fingers

below patella 1 finger width

medial (towards big toe)

In the very young, may not have a prominent tibial tuberosity

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Proximal Tibia Preferred site of choice 2 fingers BELOW

patella (kneecap) at tibial tuberosity MUST avoid epiphyseal plate of developing

child - could interfere with growth of that limb

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IO Site Identification – Humeral Head

Site must be viewed AND palpated Site avoided if surgical scars evident – hardware

may have been placed

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Greater Tubercle IO Site

Start palpating the mid-humeral shaft Work upwards toward the proximal aspect or

humeral head You will notice a protrusion

This is base of greater tubercle insertion site Move 1 cm (1/2 inch) above this point for insertion

Can place fingers on either side of humeral head to help identify the midline

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Humeral Site

Palpate 2 finger widths below acromium Find the most prominent spot of the humeral

head / greater tubercle YOU MUST BE ANTERIOR TO MIDLINE!!!

Could also palpate to the end of the clavicle Move 2 finger widths

toward the elbow

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Humeral Site Hints

Arm must be flexed with elbow tucked back

Site is anterior to midline

Site feels like a golf ball

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IO Access

Prep the identified site Chloraprep or alcohol wipe from IV start kit

Insert needle into site WITHOUT drilling Needle very sharp and will insert easily The needle stops when it touches bone

LOOK You must be able to see the

5mm mark to verify appropriateness of length of needle

5mm mark

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Visualizing 5 mm Marking Is the 5 mm mark visible? If yes, begin to drill

If no, the needle length is too short Move up to the next length needle and reinsert

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Angle of Insertion Tibial Site

Can insert needle at 900 angle Can insert needle at 10-150 angle toward the

foot – avoids growth plate (epiphyseal plate) Growth plate active while child still growing

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Using the IO Drill

You are drilling into a bone; not drywall!!! Insert needle until needle stops at bone Verify 5 mm mark Begin to drill Stop when you feel lack of resistance or “pop” Remove stylet Attach EZ connect tubing & confirm placement Connect primed IV tubing & secure tubing Confirm placement of pressure bag over IV bag Apply wrist band to same-side wrist

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Drilling Into Humeral Site

Humeral head NOT a weight bearing bone Bone density is softer than tibial area Needle may not be as secure in this site Hold needle in place as you remove the drill Immobilize the arm (i.e.: cot straps will work) to prevent

movement of arm & inadvertent dislodgment of needle Patient cannot be allowed to raise arm up DO NOT ALLOW PATIENT TO RAISE ARM

OVERHEAD!!! Use 45 mm yellow needle for humeral head site

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Confirming Insertion

One of the biggest complications of IO is extravasation due to faulty placement

All insertions MUST be confirmed After removal of stylet, aspirate with primed

10 ml syringe You may or may not see bone marrow

Regardless of what is aspirated, inject the saline

Observe for infiltration while feeling for any resistance to the injection

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Faulty IO Insertions Always confirm site and continue to monitor

placement Bilateral IO in infant; through and through

insertion Most likely palpate infiltration in calf area

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How Would You “Catch” This Faulty Placement???

Was correct length needle chosen for the site?

Did drilling stop when operator felt the “pop” or lack of resistance?

Was the calf area evaluated for signs of infiltration?

Does the IV fluid infuse well? Remember: Need to place pressure bag over

IV bag in order to obtain a flow

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Pain Control for IO Infusion for Conscious Critical Patient

Inserting the IO needle is relatively painless Rated 3/10 compared to peripheral IV start

Infusing of fluids causes discomfort Medicating with Lidocaine patient tolerance After confirmation of IO placement, slowly

inject Lidocaine over 60 seconds; wait 60 seconds; then begin fluid infusion Without waiting, the Lidocaine would be

washed out of the area and not be effective

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IO Infusion Reminder

Fluids and medication given via the IO site has rapid absorption into central circulation Comparable to IVP route

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EZ IO Pearls

Pressure bag is required for flow to overcome pressure in marrow cavity Will improve infusion rate

DO NOT apply pressure to the drill Let the drill do the drilling Putting pressure on the needle may cause

the needle to bend

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Removing IO Needle

Stop infusion Remove EZ IO extension tubing from hub of IO Attach any size syringe to the IO needle hub

Try 53 or 5 ml syringe; this will give you a “handle” to hold while removing the needle

Turn syringe clockwise to unscrew needle from bone Gently pull on the needle as you twist the syringe

Upon removal of needle, place band aid over site There is very little blood flow from site

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Removing IO Needle

Keep twisting, turning and pulling Needle goes in quickly but takes quite a few

turns to remove from the tibial area IO in humeral site not as secure and is removed

quicker

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Securing the Airway

A generic term that indicates the patient is being ventilated Ventilating = breathing

Positioning is simplest maneuver and most often overlooked

Measurement and placement of oropharyngeal or nasopharyngeal airways can help

Advanced airways for Region X include endotracheal tubes and King airways

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King Airway Access

Indications

Cardiac or respiratory arrest Unresponsive medical or trauma patient

without gag reflex Inability to place an endotracheal tube

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King Airway Contraindications

Height less than 4 feet Presence of gag reflex Ingestion of caustic substance Known esophageal disease

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BVM O2 source

King airway Size 3 (yellow) for patients 4 – 5 feet tall Size 4 (red) for patients 5 – 6 feet tall Size 5 (purple) for patients over 6 feet tall

Water soluble lubricant Large sized syringe Method to secure airway (i.e.: tape,

commercial holder)

King Airway Equipment

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King Airway Insertion

Distal tip back side of tube lubricated Avoid placing lubricant over

port holes Patient placed in supine position Non-dominate hand used to perform chin lift

holding mouth open Might want to grab tongue with gauze

Airway inserted with dominant hand Tip inserted starting at corner of

patient’s mouth Blue line on tube always kept

toward patient; away from inserter

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King Airway Insertion cont’d

Tube tip advanced to base of tongue and then rotated to midline Blue line still facing chin of patient

Without excessive force, tube advanced until base of colored connector even with teeth or gums

Pilot balloon inflated Size 3 = 50 ml air Size 4 = 70 ml air Size 5 = 80 ml air

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King Airway Insertion cont’d

BVM attached and ventilations begun Should meet with resistance

While ventilating, tube gently withdrawn until ventilations become easy and without resistance

Cuff inflation adjusted as needed Seal obtained at peak of ventilatory pressure

Placement confirmed Bilateral chest rise and fall Bilateral breath sounds No sounds over epigastric area

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King Airway Positioning

Airway in position Air passes into trachea from point between the

two cuffs

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ETT vs King Airway

ETT a superior piece of equipment in securing the airway More expertise to place,

though

King an acceptable backup Blind insertion

technique

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Removal of King Airway

Usually King replaced in the ED with ETT prior to hospital admission King is acceptable for short term use King does not protect the airway as efficiently as

ETT Have suction available Use large syringe and remove air from cuff until

no more can be removed Remember: King airways can hold 50 – 80 ml air

in cuff Compared to ETT which holds average of 10 ml

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Removal of King cont’d

Remove King airway in steady extubation motion

Prepare to ventilate patient via BVM After patient assessment, place appropriate

airway device/support as needed ETT BVM support Supplemental oxygen if patient breathing on

their own

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Scenario Discussion

Review the following case studies Determine your general impression Determine what field treatment would be

appropriate Determine your rationale for your choice

Know why you chose the intervention you did

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Scenario #1

27 year-old patient involved in a MVC Restrained driver involved in T-bone on driver’s

side A & O x3; cooperative; looks uncomfortable C/o left sided abdominal pain Has bilateral lower leg closed fractures VS: B/P 126/82; P – 88; R – 18; SpO2 98% Abdomen firm; no bruising noted

What care would EMS provide?

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Scenario #1

Care to initiate Extrication with attention to spinal

immobilization Rapid head to toe assessment looking for life

threats Decision made regarding transport urgency Obtaining history and vital signs IV access considered – at scene vs enroute O2– no resp distress, SpO2 98%; consider on

case-by-case basis if O2 indicated Cardiac monitor appropriate

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Scenario #1

Reassessment Increased agitation Paler; slightly diaphoretic VS: B/P 102/78; P – 104; R – 24; SpO2 95%

What do these changes indicate? Early signs of shock

Changing level of consciousness (agitation) Becoming tachycardic B/P holding (watch for decrease) Watch for narrowing pulse pressure Pale & clammy

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Scenario #1 – Narrowing Pulse Pressure

Difference between systolic & diastolic B/P Normal = 40 (i.e.: 120/80 = 120 – 80 = 40) < 40 = poor heart function

Most common cause is drop in left ventricular stroke volume

In presence of trauma, suggests blood loss with insufficient pre-load (blood volume returning to the heart) and therefore creating a decrease in cardiac output

Note: Helpful detail to monitor in serial vital signs

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Scenario #1

What injuries might be considered? Spleen injury on left

Injury to a solid organ could cause heavy bleeding

Rib fractures causing pulmonary issues How was this patient initially categorized?

Category II trauma patient Need to provide condition update to receiving

hospital May need to re-categorize as a Category I

with deteriorating vital signs

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Scenario #1

What type of shock would this patient be experiencing? Hypovolemic

What compensatory mechanisms were in place? Maintaining peripheral vasculature resistance -

to maintain B/P and circulation Increased pulse rate – to maintain blood flow

and perfusion Sometimes confused with response to pain,

excitement, flight-or-fight response

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Scenario #1

EMS is unable to establish a peripheral IV They are preparing to establish IO access Can the tibial site be used in this case?

No, bilateral fractures present What would be an alternate site?

Humeral head How do you identify the humeral site?

Identify your own humeral site

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Scenario #1 – Humeral Site ID

Elbow MUST be resting posteriorly in tucked back position (i.e.: resting on the backboard)

Hand rests over navel Palpate “golf ball”

sized target over humeral head

Insert needle at 900 angle Document placement,

confirmation, and placement of wrist band

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Scenario #2 Roll over – 1 victim

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Scenario #2

EMS responded to a call for a 56 year-old male involved in a rollover

Patient was ejected; found on side of road Patient moaning, thrashing about (GCS 9) Obvious deformities noted right upper and

lower extremities In respiratory distress; uneven movement of

chest wall; crepitation palpated on left What category trauma is this patient?

Category I

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Scenario #2

Care is initiated in field and enroute What are field options if EMS is unable to

establish peripheral IV access? If IV access necessary, IO is inserted

What could be contraindications to an IO site? Injuries/fractures to the same side Evidence of infection at site

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Scenario #2

How do you know the IO is successful? Feel “pop” entering bone Needle stands up by self Able to aspirate bone marrow Able to flush without resistance Fluid flows effortlessly (using pressure bag)

What is the formula for an adult fluid challenge? Calculate 20 ml / kg Administer in 200 ml increments with frequent

reassessments

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Scenario #2

Evaluate this IO placement Is it okay??? NO!

Where is the proper insertion site???

Palpate your tibial site Review slides

49-51

x

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Scenario #2

Needle appearance when removed in ED

Excess pressure during insertion may bend/break the needle

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Scenario #3 74 y/o patient presented with severe chest

pain 9/10 for past 4 hours Pain radiates toward back and down left arm VS: B/P 142/92; P – 84; R – 22 SpO2 98%

Rhythm strip as below; what’s rhythm?

NSR

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Scenario #3- Is There ST Elevation?

V1 – V5

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Scenario #3

The patient proceeds to arrest and go into VF What is the first action after confirming VF?

Defibrillate Immediately begin CPR after defibrillation IV access established Airway secured

What medications are used for VF for EMS? Epinephrine 1:10,000 1 mg IVP/IO every 3-5 min Alternated with Amiodarone 300 mg IVP/IO

Repeated in 5 minutes with 150 mg IVP/IO

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Scenario #3

If patient cannot be intubated, what are EMS options? BVM (30:2 during CPR) King airway

One breath every 6 seconds via advanced airway

How does EMS decide on the size of the King? By patient height:

Size 3 (yellow) for 4-5 foot tall Size 4 (red) for 5-6 foot tall Size 5 (purple) for over 6 foot tall

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Scenario #3

A King airway is placed EMS is unable to bag the patient via the King Trouble shoot – what do you think the

problem is? Has the King airway been backed out far

enough? Airway should be repositioned until

bagging is easy and chest rise and fall is observed

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Scenario #4

EMS has 27 year-old male who was stabbed multiple times

Blood is evident on patient’s clothing No wounds are spurting blood

Patient is awake, agitated, pale, diaphoretic VS: B/P 110/70; P – 102; R – 24; SpO2 96%

Breath sounds diminished throughout but EMS feels they are present

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Scenario #4

Stab wounds evident upper R arm 2 sites noted upper anterior chest wall 1 site noted rib margin lower chest wall

What injuries should care providers be suspicious of? Pulmonary Cardiac Abdominal Soft tissue/orthopedic

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Scenario #4 Immediate care?

Open chest wounds covered immediately Need baseline vital signs at some point

Evaluating level of consciousness and radial pulses can provide helpful information on status of perfusion

Level of consciousness 1st thing to change when perfusion starts dropping

B/P last change when compensation no longer possible

To palpate a radial pulse one needs adequate cardiac output to a peripheral site which indicates level of blood pressure

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Scenario #4

Wounds are covered Appropriate EMS care provided Receiving hospital notified Transport already underway

Patient’s agitation increasing Becoming more tachycardic Having increased respiratory difficulty

What is the next appropriate action??? Return to evaluation of ABC’s Be suspicious for tension pneumothorax

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Scenario #4 – Tension Pneumothorax

What is field treatment for tension pneumothorax? Needle decompression

This patient already has chest wounds What would be done if tension pneumothorax

is suspected? Can lift edges of dressings Can insert a needle into the 2nd intercostal

space (ICS) middle of the clavicle, over top of rib

Evaluate all interventions provided

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Scenario #4 – Needle Decompression

Need to be more lateral than you expect Typically in vertical line with male nipple

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Verbal Report and Documentation

If a traumatic injury Need detail of mechanism of injury (MOI)

Fall – WHY did patient fall (Trip? Dizziness?)

MVC – what hit patient?/what did patient hit? What damage is there to vehicle? Include the safety components

used/not used (i.e.: seat belts, airbags, etc)

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Report & Documentation cont’d

Need detail of signs and symptoms If ANY complaint, what did assessment find? NOT good enough to chart “assessment done”

Does not provide details of what was found If a release, NOT helpful if patient later

presents to ED or calls 911 NO comparison data can be done; can’t tell

if there was a change in condition For extremity issue, include description of

injury and distal CMS/PMS/SMV

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Sample Documentation – What do you think??? 27 y/o M involved in MVC; signed a release

A & O x3; ambulatory. Struck from behind; wearing seatbelt c/o abdominal pain; has abrasion on L knee Denied loss of consciousness Advised of risks by not seeking medical

attention Signed a release

So, what do you think???

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Sample Documentation Critique

No description of MOI Helpful for anticipation of injuries

No detailed assessment of abdominal pain or knee abrasion If patient were to later call 911 or present to

the ED, no comparison for changes to the abdominal area can be made

No comparison for changes to the extremity can be made without baseline details of the initial evaluation

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Bibliography

Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady. 2013.

Region X SOP’s; IDPH Approved January 6, 2012. http://ccn.aacnjournals.org/content/31/2/76.ful emsstaff.buncombecounty.org (EZ IO for Buncombe

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