Welcome to
RWJ MHS Education Program (formerly known as “Competencies”)
Hamilton, New Brunswick and Somerset Campuses January – March 2015
(01/16/2015 v1.0) 1
(01/16/2015 v1.0) 2
Please review this presentation in preparation for the education session in which you plan to participate. Time to complete this should be about 30 minutes. (Your eyesight is not failing….some of the graphics are a bit blurry.) This material is not divided into BLS or ALS…topics solely within the ALS scope of practice should be obvious. Since patients and their caregivers don’t read the certification patch on our uniforms, they neither note nor probably care who is an EMT, MICN or MICP…they just know we are the help they called for. We work as team….BLS providers are encouraged to review the ALS material. Anticipating what your ALS team members will do and your role in continuing your care can add to the efficiency of patient care. There is a lot to be done to take care of these patients and to interact with their caregivers.
A copy of these PowerPoint slides will be available at each
Education session
(01/16/2015 v1.0) 3
This presentation contain 2 parts
Part I – Congestive Heart Failure
Part II – Pneumothorax
(01/16/2015 v1.0) 4
03.10.03 Universal Patient Care – Assessment
Universal – MICU Use
Universal – Vascular Access
03.10.04 Airway Management
Airway-Intubation Protocol
Airway – Facilitated Intubation Protocol
03.10.19 Respiratory Distress – Pulmonary Edema
03.10.22 Trauma
(01/16/2015 v1.0) 5
You might find it helpful to review these RWJ Pediatric Patient Care Protocols
(01/16/2015 v1.0) 6
You might also find it helpful to review the sources used to prepare this presentation
Nancy Caroline’s Emergency Care in the Streets, 6th Edition, 2008. Jones and Bartlett Publishers Inc. and American Academy of Orthopaedic Surgeons Prehospital Emergency Care, 10th Edition, 2014. Joseph J. Mistovich and Keith J. Karren Prehospital Trauma Life Support, 7th Edition, 2011. Mosby, Inc. .
Part I Congestive Heart Failure
(01/16/2015 v1.0) 7
Definition
Review of A&P
Causes
Signs and Symptoms
Treatment BLS, ALS
(01/16/2015 v1.0) 8
Part I – Congestive Heart Failure
Heart in an ineffective pump
Too fast, too slow or too weak to empty its chambers and provide adequate cardiac output
As a result, blood backs up into the systemic system, the pulmonary system or both
(01/16/2015 v1.0) 9
Part I – Congestive Heart Failure
Definition
(01/16/2015 v1.0) 10
Part I – Congestive Heart Failure
Review of A&P
(01/16/2015 v1.0) 11
Part I – Congestive Heart Failure
Review of A&P
Left-Sided Failure
The left atria receives oxygenated blood from the pulmonary veins and moves it to the left ventricle. When the left ventricle…a powerful pump…is weakened, stiff, thickened or over stretched, it cannot pump all of the blood in its space out to the aorta. As result, the blood in the left atria does not empty and starts to back up into the pulmonary veins and the lungs. The alveoli within the lungs then fill with the backed up blood, especially the liquid component (plasma or serum), resulting in pulmonary edema. The oxygen that entered the lungs and alveoli is blocked from getting out of the alveoli and into the blood vessels to the left atria.
(01/16/2015 v1.0) 12
Part I – Congestive Heart Failure
Review of A&P
Right-Sided Failure
Often, but not always, occurs as a result of left-sided failure. As blood backs up from the left side of the heart and lungs, the right side of the heart has to work harder to pump deoxygenated blood into the lungs against the increased pressure of the pulmonary arteries. As a result the right ventricle becomes weakened, stiff, thickened, or overstretched. The right aria cannot handle the backup from the right ventricle and blood trying to enter the heart from the body (via the vena cavae) also starts to back up. The pressure in the blood vessels causes them to become engorged. As the vessels’ pressure increases, the blood, especially the liquid component (plasma or serum), leaks into the tissue, causing edema.
(01/16/2015 v1.0) 13
Part I – Congestive Heart Failure
Review of A&P
(01/16/2015 v1.0) 14
Part I – Congestive Heart Failure
Review of A&P
Heart failure causes a complex series of events that affect not only the heart, but also kidneys, blood pressure, liver function, and more. Here is a diagram that starts the explanation.
Acute:
MI (can affect right side and/or left side)
Use of certain drugs
Virus, bacteria (myocarditis, endocarditis)
Cardiac trauma
Non-compliance with medications to control CHF
Non-compliance with diet (i.e. low sodium) to control CHF
Chronic
Hypertension
Coronary artery disease
Previous MI
Heart valve dysfunction
Natural part of the aging process
(01/16/2015 v1.0) 15
Part I – Congestive Heart Failure
Causes
(01/16/2015 v1.0) 16
Part I – Congestive Heart Failure
Signs and Symptoms
EMS is often called because of difficulty breathing caused by CHF.
Pulmonary Edema may or may not be present.
Remember to access for chest pain, possible MI.
Position of function (normal mental status); usually sitting up with legs dependent (if safe to do so)
Oxygen: 10-15 lpm via NRB, as tolerated
Ventilation: assist as necessary
CPAP (PEEP) 10 cmH2O if any one:
Resp rate ≥26
Signs of resp distress, regardless of rate
SpO2≤ 94 with NRB
If SBP ≥ 100:
NTG 0.4mg every 5 minutes
Furosemide 20mg IV/IO (if fluid overload is certain)
12 Lead, STEMI Protocol, if indicated
Endotracheal Intubation (facilitated, RSI)
And more….. Review RWJ Adult patient Care Portocols 03.10.04, 03.10.19
(01/16/2015 v1.0) 17
Part I – Congestive Heart Failure
Treatment
(01/16/2015 v1.0) 18
End of Part I……. So, take a deep breath and on Part II.
Part II Pneumothorax
(01/16/2015 v1.0) 19
Definition
Review of A&P
Causes
Signs and Symptoms
Treatment BLS, ALS
(01/16/2015 v1.0) 20
Part II – Pneumothorax
Presence of air outside the lung and within the pleural space
Hemothorax often, but not always, present
(01/16/2015 v1.0) 21
Part II – Pneumothorax
Definition
Closed - a hole in the lung. The outside chest wall is intact. As the patient inhales or is ventilated with a BVM, air exits through the hole and into the pleural space
Open (“sucking” chest wound) – a hole on the outside of the chest wall that allows air to enter and exit the pleural space from the outside with ventilatory effort.
A combination of both open and closed – a hole in the lung and the outside chest.
Bilateral – hole in both lungs and/or both sides of the chest wall
(01/16/2015 v1.0) 22
Part II – Pneumothorax
Definition - Types
Simple – (open or closed) the hole(s) are not so big as to
pose an immediate life threat. Tension - As amount of air on the affected side increases, the
lung on the affected side can “collapse” under the pressure. As the amount of air and pressure further increases, the
heart and great vessels (vena cavae, aorta, and family), and unaffected lung can be pushed to the unaffected side.
The pressure (tension) around the heart, great vessels and unaffected lung can be so great as to prevent the heart from pumping, the great vessels from filling/emptying, and the unaffected lung from expanding.
(01/16/2015 v1.0) 23
Part II – Pneumothorax
Definition - Severity
(01/16/2015 v1.0) 24
Part II – Pneumothorax
Review of A&P
Closed Open Closed Tension
Chest Trauma
Any disease that causes stiff or weakened lung tissue, especially emphysema
BVM/Mechanical Ventilation
Can be spontaneous (classic is thin, tall male, age 18-20, with sudden shortness of breath)
(01/16/2015 v1.0) 25
Part II – Pneumothorax
Causes
These may be acute or progressive or stable
Agitation, discomfort
Dyspnea, use of accessory muscles
Diminished breath sounds on affected side
Tachycardia
Pale skin, cool, diaphoretic
Normal to low BP
Lowered PaO2 (< 94)
Open: hole in chest, air makes sucking noise on inhalation
(01/16/2015 v1.0) 26
Part II – Pneumothorax
Signs and Symptoms
As it progresses…..
If receiving manual ventilation, increasing resistance if felt when squeezing the BV device
Altered Mental Status
Cyanosis
Grossly diminished or absent breath sounds on the injured side
JVD (may not be present if hypovolemic due to trauma)
Hypotension
Trachea deviates away from affected side as tension develops (this is a late sign, and difficult to discern in patients with short, thick or muscular necks)
(01/16/2015 v1.0) 27
Part II – Pneumothorax
Signs and Symptoms
If hole on outside chest wall: cover wall with occlusive dressing…secure on 3 sides
Position of function: air rises, blood follows gravity Trauma: if appropriate, elevate head of board Non-Trauma: sitting up, position of patient comfort
Oxygen 10-15 lpm via NRB Assist ventilations, if indicated. Monitor resistance felt with BV device. If tension pneumothorax, perform Chest Needle Decompression, if all 3 are
present: 1. Severe respiratory distress
• Cyanosis and/or SpO2 ≤90% with NRB, BVM or ET
2. Diminished/absent breath sounds on affected side 3. SBP <90, ALS
IV/IO fluid to maintain SBP ≥90 and HR <120, 1L max. Pain and SBP ≥90
Morphine Sulfate 0.1mg/kg to 10mg max OR Fentanyl 1mcg/kg to 100mcg max
(01/16/2015 v1.0) 28
Part II – Pneumothorax
(01/16/2015 v1.0) 29
Part II – Pneumothorax
Chest Needle Decompression
2nd or 3rd Intercostal space, midclavicular line on the affected side
Thanks for your time…..see you at the Education Session!
Please bring your questions, comments, education and experience.
(01/16/2015 v1.0) 30
End of Part II – Pneumothorax