Spring 2007 Spring 2007 CMECME

Presented by:Presented by:

SOCPCSOCPC

AgendaAgenda Presentations:Presentations:

Trauma TORTrauma TOR Changes to Medical DirectivesChanges to Medical Directives High risk obstetrics and neonatal High risk obstetrics and neonatal

resusresus Add Ons:Add Ons:

Neonatal resuscitationNeonatal resuscitation

Termination of Termination of Resuscitation for Resuscitation for

the Trauma the Trauma PatientPatientSpring 2007 CMESpring 2007 CME

SOCPCSOCPC

Trauma TORTrauma TOR

Please refer to the following pages in Please refer to the following pages in the medical directives:the medical directives: PCP Blunt Traumatic Arrest Protocol: Page PCP Blunt Traumatic Arrest Protocol: Page

4747 ACP Blunt Traumatic Arrest Protocol: Page ACP Blunt Traumatic Arrest Protocol: Page

4848 Penetrating Traumatic Arrest Protocol: Penetrating Traumatic Arrest Protocol:

Page 49Page 49

Trauma TORTrauma TOR What is it?What is it?

New directive for treatment of VSA trauma New directive for treatment of VSA trauma patientspatients

Who does it apply to?Who does it apply to? Patients who are in cardiac arrest as a Patients who are in cardiac arrest as a

result of blunt or penetrating traumaresult of blunt or penetrating trauma AED use applies to patients who are ≥ to 8 AED use applies to patients who are ≥ to 8 PCP- manual mode applies to patients who PCP- manual mode applies to patients who

are ≥ to 1 and < 8are ≥ to 1 and < 8 ACP- manual defibrillation applies to ACP- manual defibrillation applies to

patients of all agespatients of all ages

Trauma TORTrauma TOR

Who can Trauma – Termination of Who can Trauma – Termination of Resuscitation be considered for?Resuscitation be considered for? Patients who are Patients who are ≥≥ to 16 years old to 16 years old

Patients who are < 16 years old will Patients who are < 16 years old will be resuscitated and transportedbe resuscitated and transported

What if the patient is obviously What if the patient is obviously dead?dead? These patients are Code 5 and are not These patients are Code 5 and are not

covered under this directivecovered under this directive

Blunt TraumaBlunt Trauma

Procedure:Procedure: Confirm absence of spontaneous Confirm absence of spontaneous

respirations and palpable pulse in a respirations and palpable pulse in a patient with signs of blunt traumapatient with signs of blunt trauma

Begin CPRBegin CPR Attach defib pads and assemble Attach defib pads and assemble

airway equipmentairway equipment Perform analysis or rhythm checkPerform analysis or rhythm check

Blunt TraumaBlunt Trauma

PCP:PCP: Shockable Rhythm:Shockable Rhythm:

If the rhythm is shockable deliver one shockIf the rhythm is shockable deliver one shock Continue CPR and transportContinue CPR and transport No further analysis en routeNo further analysis en route

Non-shockable Rhythm:Non-shockable Rhythm: Check pulse and continue CPR if neededCheck pulse and continue CPR if needed If there is no pulse If there is no pulse ANDAND

Monitor heart rate is > 0, initiate transportMonitor heart rate is > 0, initiate transport Monitor heart rate is = 0, contact BHP for Monitor heart rate is = 0, contact BHP for

possible trauma-TORpossible trauma-TOR

Blunt TraumaBlunt Trauma

ACP:ACP: Shockable Rhythm:Shockable Rhythm:

If the rhythm is shockable deliver one shockIf the rhythm is shockable deliver one shock Continue CPR and transportContinue CPR and transport No further defibrillation en routeNo further defibrillation en route

Asystole or PEA:Asystole or PEA: Continue CPR Continue CPR Contact BHP for possible trauma-TORContact BHP for possible trauma-TOR

Penetrating TraumaPenetrating Trauma

Confirm cardiac arrest Confirm cardiac arrest Absence of spontaneous respirationsAbsence of spontaneous respirations Absence of palpable pulseAbsence of palpable pulse Absence of pupillary responseAbsence of pupillary response Absence of movementAbsence of movement

Begin CPR Begin CPR Do not attach defib pads, attach Do not attach defib pads, attach

monitoring electrodesmonitoring electrodes

Penetrating TraumaPenetrating Trauma

PCP and ACP:PCP and ACP: If monitor heart rate is 0 AND there is no If monitor heart rate is 0 AND there is no

pupillary response AND no spontaneous pupillary response AND no spontaneous movement movement contact BHP for possible Trauma-contact BHP for possible Trauma-TORTOR

If monitor heart rate is > 0 and the emergency If monitor heart rate is > 0 and the emergency department is < 20 minutes away department is < 20 minutes away initiate initiate transporttransport

If monitor heart rate is > 0 AND no pupillary If monitor heart rate is > 0 AND no pupillary response AND no spontaneous movement AND response AND no spontaneous movement AND the emergency department is ≥ 20 minutes away the emergency department is ≥ 20 minutes away contact BHP for possible Trauma-TORcontact BHP for possible Trauma-TOR

Penetrating TraumaPenetrating Trauma

In order for a In order for a penetrating trauma patientpenetrating trauma patient to be considered VSA in addition to the to be considered VSA in addition to the heart rate being 0 the patient also must:heart rate being 0 the patient also must:

Have no pupillary reaction to lightHave no pupillary reaction to light Must have no spontaneous movementsMust have no spontaneous movements

If the pupils react to light full resuscitation If the pupils react to light full resuscitation must be attempted and the patient must be attempted and the patient transportedtransported

If there are no obvious signs of If there are no obvious signs of trauma treat the patient using full trauma treat the patient using full medical cardiac arrest directivesmedical cardiac arrest directives

PCP’s are expected to contact PCP’s are expected to contact BHP in these circumstances for BHP in these circumstances for possible Trauma-TOR without possible Trauma-TOR without waiting for ACP’s to arrivewaiting for ACP’s to arrive

Final NotesFinal Notes

Cardiac ArrestCardiac Arrest

Page: 53Page: 53

Cardiac arrests should all be started Cardiac arrests should all be started in AED modein AED mode

No drugs administered during 1No drugs administered during 1stst 2min round of CPR for VF only2min round of CPR for VF only

No longer require ETCO2 wave form No longer require ETCO2 wave form to confirm intubation (numerical to confirm intubation (numerical value in AED mode is sufficient)value in AED mode is sufficient)

Neonatal Resuscitation Neonatal Resuscitation AlgorithmAlgorithm

Page: 57Page: 57

Epinephrine dose has changed toEpinephrine dose has changed to

0.1ml/kg of 1:10,000 IV/IO or 0.1ml/kg of 1:10,000 IV/IO or

1ml/kg of 1:10,000 ETT1ml/kg of 1:10,000 ETT

FBAO – Cardiac ArrestFBAO – Cardiac Arrest

Page: 58Page: 58 ACPs skip procedure 3 & ACPs skip procedure 3 &

44

Return of Spontaneous Return of Spontaneous CirculationCirculation

Page: 60Page: 60 No age restrictionNo age restriction Procedure 6a:Procedure 6a:

Bolus of 10ml/kg prior to Bolus of 10ml/kg prior to dopamine administrationdopamine administration

Zoll “E” Series in AED Zoll “E” Series in AED modemode

Scenario #1Scenario #1 Firefighter first-on-scene with chest Firefighter first-on-scene with chest

compressions startedcompressions starteda) Direct fire to continue their Zoll AED Pro a) Direct fire to continue their Zoll AED Pro

protocol.protocol.b) Prepare your Zoll E-series and airway b) Prepare your Zoll E-series and airway

equipmentequipment..

If enrolling in ITD protocol attach airway tower to If enrolling in ITD protocol attach airway tower to firefighter BVM ASAPfirefighter BVM ASAP

c) At the end of the firefighter CPR interval, c) At the end of the firefighter CPR interval, disconnect pads from their Zoll AED Pro, disconnect pads from their Zoll AED Pro, connect pads into your Zoll E-series and press connect pads into your Zoll E-series and press Analyze. (This will skip pre-programmed upfront Analyze. (This will skip pre-programmed upfront CPR on the Zoll E-series and enable the auto-CPR on the Zoll E-series and enable the auto-analysis/auto-charge feature.)analysis/auto-charge feature.)

Zoll “E” Series in AED Zoll “E” Series in AED modemode

Scenario #2Scenario #2 Moving the patient to the ambulance with Moving the patient to the ambulance with

ongoing CPRongoing CPRa) Disconnect the defibrillation pads. (This a) Disconnect the defibrillation pads. (This

will avoid an inadvertent will avoid an inadvertent auto-analysis/auto-charge.)auto-analysis/auto-charge.)

b) Reconnect the defibrillation pads in back b) Reconnect the defibrillation pads in back of unit.of unit.

c) Press Analyze to do final rhythm analysis c) Press Analyze to do final rhythm analysis before transport.before transport.

d) Turn Zoll OFF then ON (This will disable d) Turn Zoll OFF then ON (This will disable the auto-analysis/auto-charge feature.)the auto-analysis/auto-charge feature.)

e) Ignore voice prompts from this point on.e) Ignore voice prompts from this point on.f) Transport.f) Transport.

Zoll “E” Series in AED Zoll “E” Series in AED modemode

Scenario #3 ROSCScenario #3 ROSCa) a) Turn Zoll OFF then ON. (This will disable Turn Zoll OFF then ON. (This will disable

the auto-analysis/auto-charge feature.)the auto-analysis/auto-charge feature.)

b) Ignore voice prompts from this point on b) Ignore voice prompts from this point on (unless patient re-arrests).(unless patient re-arrests).

b) If needed, disconnect pads temporarily to b) If needed, disconnect pads temporarily to move patient.move patient.

c) If patient re-arrests - Press Analyze (This c) If patient re-arrests - Press Analyze (This will enable the auto-analysis/auto-charge will enable the auto-analysis/auto-charge feature.)feature.)

Obstetrics Obstetrics ReviewReview

Spring 2007 CMESpring 2007 CMESOCPCSOCPC

Obstetrics Mini-ReviewObstetrics Mini-Review

Quick FactsQuick Facts Normal deliveryNormal delivery Abnormal Presenting PartAbnormal Presenting Part

Quick FactsQuick Facts

What is the normal gestational What is the normal gestational period?period?

What risks do premature babies What risks do premature babies face?face?

What risks do post term babies face?What risks do post term babies face?

Quick FactsQuick Facts

If the membranes are If the membranes are ruptured what colors in the ruptured what colors in the amniotic fluid would concern amniotic fluid would concern you and why?you and why?

Quick FactsQuick Facts

What is the average fetal heart rate (FHR) What is the average fetal heart rate (FHR) and where is the best place to listen for it? and where is the best place to listen for it?

If the woman is having a contraction and If the woman is having a contraction and the fetal heart decelerates to 100 or less, is the fetal heart decelerates to 100 or less, is that normal?that normal?

If possible, ALL pregnant women should go If possible, ALL pregnant women should go to a hospital that has what sort of services?to a hospital that has what sort of services?

If you saw this what would the If you saw this what would the steps to take?steps to take?

Stages of Labour Stages of Labour

Abnormal Abnormal PresentationsPresentations

Breech Presentations

Complete Breech

Incomplete Breech

Frank Breech

What if you saw this?What if you saw this?

Nuchal CordNuchal Cord

CERVIX

UTERINE WALL

NORMAL UMBILICAL CORD (55cm LONG) WITH CENTRAL INSERTION POINT INTO PLACENTA

PLACENTAL ATTACHMENT TO

THE UTERINE WALL

UNUSUALLY SOHRT UMBILICAL CORD WITH ECCENTRIC POINT OF INSERTION INTO PLACENTA

CORD WRAPPED AROUND NECK OF FETUS (NUCHAL)

Prolapsed cordProlapsed cord

Questions?Questions?