Beausoleil, Muskoka & Rama

CME 2010

Agenda

• Didactic:– STEMI update– TOR– King LT– Anaphylaxis

• Skills– 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

• Likely to be older (74 v 67)Likely to be older (74 v 67)

• Women (49% v 38%)Women (49% v 38%)

• Diabetic (33% v 25%)Diabetic (33% v 25%)

• Prior heart failure (26% v 12%)Prior heart failure (26% v 12%)

• Longer delay to assessment (8% v Longer delay to assessment (8% v 5%)5%)

• Less likely to be diagnosed (22% v Less likely to be diagnosed (22% v 50%)50%)

• Less likely to receive treatment Less likely to receive treatment (25% v 74%)(25% v 74%)

• Most likely to die (23% v 9%)Most likely to die (23% v 9%)

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:

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

TORWhen to call the BHP for

termination of resuscitation?

Medical TOR (page 42)

• 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)

• Prepare equipment• Team approach• 30 second blocks

· Clear of meconium?· Breathing or crying?· Good muscle tone?· Color pink?· Term gestation?

· Provide warmth· Position/clear airway (as necessary)· Dry, stimulate, reposition· Give O2 (as necessary)

Routine Care· Provide warmth· Clear airway· Dry

· Evaluate respirations, heart rate and color

Supportive Care

· Provide positive-pressure ventilation (BVM)

Ongoing Care

· Provide positive-pressure ventilation (BVM)

· Administer chest compressions

Meconium present?

Baby Vigorous? *

Suction mouth, pharynx, Provide BVM ventilation PRN

Continue with remainder of Initial Steps:· Clear mouth and nose of secretions· Dry, stimulate and reposition· Give O2 (as necessary)

Birth

HR ≥60

or HR <100

HR <60

Apnea

Yes

Breathing

HR ≥100 & pink

HR ≥100 & pinkVentilating

No

No

No

Yes

Yes

* Vigorous = Good muscle tone, strong respiratory efforts, and HR>100

30 sec

30 sec

30 sec

What does meconium look like?

ANAPHYLAXIS REVIEW

Continuing Education

Outline

• 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, hypotensionNeurologic:• 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