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EMERGENCY MEDICAL SERVICES
This is an OSCE, OSPE review for all blocks of EMS program. All the information was taken from ACLS course, PALS course, PHTLS course National registry forms, Essentials of paramedic care “Brady”, MOSBY’s paramedic textbook, and doctors' preferences. It is written by a student, so mistakes could be found Hope you all the best Written by: Shatha Almoqait 0
TABLE OF CONTENT -­‐ Sub-­‐titles General statements Introduction to EMS BLS -­‐ Trauma -­‐ 5 Initial assessments 6 Airway \ Oxygen equipment 7 History taking 9 Vital signs Adult 10 Detailed physical examination 11 Cardiac arrest ( BLS ) 12 Choking 13 Radio communication and documentation 14 OSPE-­‐ Equipment familiarization 15 Trauma Assessment 16 Femur Fracture 17 Extrication Techniques. 18 Pneumothorax 19 OSPE Types of trauma 20 Anaphylaxis
Asthma
-­‐ Medical -­‐ Page No. 21 22 Drugs Administration
Drugs calculation
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24 27 TABLE OF CONTENT -­‐ Sub-­‐titles Cardiovascular System Respiratory system Pharmacology ECG Interpretation STEMI 36 ACLS -­‐ Pulseless VF \ VT 37 ACLS -­‐ VT with Pulse 39 ACLS -­‐ SVT 41 ACLS -­‐ Bradycardia 42 OSPE -­‐ Heart anatomy 43 OSPE -­‐ Rhythm diagnosis 44 OSPE -­‐ Resuscitation Medications 48 Rapid Sequence Intubation 49 LMA 50 OSPE-­‐ Capnography interpretation 51 OSPE -­‐ Capnography waveforms 52 OSPE -­‐ Ventilator settings 54 OSPE – chest X-­‐ray interpretation 55 OSPE -­‐ Drugs Antidotes 56 Drugs Overdose " Organophosphate poisoning “ 57 Drugs Overdose “Alcohol overdose" 58 Basic Paramedic Practice Head trauma Page No. 2
59 TABLE OF CONTENT -­‐ Nervous System Other Body Systems Advanced Paramedic Practice Sub-­‐titles Page No. Seizure 60 Hypoglycemia 61 Hyperglycemia 62 Stroke 63 Meningitis 64 OSPE – CNS system anatomy 65 OSPE -­‐ Nervous cell and Cranial nerves 66 OSPE -­‐ brain regions 67 OSPE -­‐ Sympathetic and Parasympathetic systems 68 OSPE -­‐ Anti-­‐seizure medications 68 Burn Management 70 Appendicitis 72 Urinary tract infection 73 Peptic ulcer 74 OSPE -­‐ Integumentary Emergencies 75 OSPE -­‐ Musculoskeletal Emergencies 76 OSPE -­‐ Endocrine Glands 78 OSPE -­‐ Referred Pain 79 OSCE -­‐ Severe Head Trauma 80 OSCE -­‐ Cardiac Arrest -­‐ ROSC
3
81 TABLE OF CONTENT -­‐ Sub-­‐titles OB\GYN Applied Paramedic Practice Page No. OSCE -­‐ Eclampsia 82
OSCE -­‐ Normal delivery 83 OSCE -­‐ Ectopic Pregnancy 84 OSCE -­‐ Neonatal Resuscitation 85 OSPE – congenital heart abnormalities 86 OSPE – complicated delivery 87 OSCE -­‐ Medical Transportation 89 OSCE -­‐ 12,15, and 18 ECG 90 PEDIATRIC CASES Title Page No. Vital signs -­‐ Pediatric 93 BLS-­‐ cardiac arrest 94 Choking 95 OSCE -­‐ Asthma 96 OSCE -­‐ Anaphylaxis 97 OSCE -­‐ CROUP 98 OSCE -­‐ Seizure 99 OSCE -­‐ Meningitis 100 OSCE -­‐ Hypoglycemia 101 OSCE -­‐ Hyperglycemia 102 Pediatric cardiac arrest-­‐ ALS 103 4
GENERAL STATEMENTS
• SCENE SAFTEY. • PERSONAL PROTECTIVE EQUIPMENTS. • MECHANISM OF INJURY FOR TRAUMA PATIENTS \ NATURE OF ILLNESS FOR MEDICAL PATIENTS. • NUMBER OF PATIENTS. • CONSIDER ADDITIONAL HELP IF NEEDED. • CONSIDER SPINAL IMMOBILIZATION FOR TRAUMA PATIENTS. • DISPATCH COMMUNICATION FOR ARRIVAL, MOVING THE SCENE, AND BRIEF INDORSMENT WITH ESTIMATED TIME OF ARRAIVAL. • FIRST IMPRESSION OF THE PATIENT. THE STATEMENTS MENTIONED ABOVE ARE ESSENTIAL FOR ALL OSCE STATIONS 5
INETIAL ASSESSMENT ( PRIMARY ASSESSMENT )
1-­‐ Determines responsiveness \ level of consciousness: A: The patient is alert, ( conscious ) V: The patient is responsive to Verbal stimuli; when the paramedic talks to him\her. P: The patient is responsive to Pain stimuli; when the paramedic hearts the patients U: The patient is Unresponsive. 2-­‐ Determines chief complaint: what is the patient complaining of? If the patient involved in trauma, If there any life-­‐threatening condition? 3-­‐ Assessment of A B C D: A: Airway: checking the airway, Is it clear? Is there any fluid that may obstruct the airway? B: Breathing: How is the patient breathing? Is the breathing normal? C: Circulation: checking for radial pulse, skin condition\Color: pale, cyanosed, sweaty, dehydrated, body temperature. Is there any obvious bleeding? If yes, stop bleeding should be initiated. D: Disability\ Decision making: Disability is special for trauma patient: the paramedic should ask the patient if he\she could move his\her extremities to see if the patient is able to move, or to detect if the patient has fractures or other problems that need be fixed before transporting the patient. Another way, by asking the patient to squeeze his\her hands. Also pushing his\her and pull foot toward the paramedic's hand. Decision making: Whether to transport the patient if the patient is critically ill ( Load and Go ) or to stay in the scene and treat the patient if the patient is not critically ill or the patient has something need to be fixed before transportation ( Stay and Play ). When to say ( Load and Go )? and When to say ( Stay and Play )? The paramedic should Load the patient and transport him\her if the patient has an abnormality in the A B C. ( patient is not stable ) for Example: when the patient has an obstruction in the airway, when the patient is not breathing (apnic), when the patient has abnormal circulation like excessive bleeding or cyanosed skin. Here, the paramedic should fix the problem immediately and transport the patient. Then the paramedic can complete the assessment in the ambulance while moving to the hospital. * Fluid in the mouth that obstruct the airway – suctioning the mouth. * Patient has difficulty in breathing – giving oxygen via non-­‐rebreather mask or nasal cannula. * Patient is bleeding – Stop bleeding by direct pressure. The paramedic can Stay in the scene and complete the assessment ( secondary assessment \ history taking\ vital signs ) if the patient is stable. 6
OXYGEN EQUIPMENT
. Nasal Cannula How much oxygen could deliver? 1-­‐6 Liter per min: 24-­‐45% when to use? *Medical patients without respiratory compromise. . Simple Face Mask How much oxygen could deliver? 5-­‐10 liter per min: 40-­‐55% when to use? *Useful for short term use. *Stable cardiac patients without signs or symptoms of cardiac compromise. *Patients with COPD who are not in respiratory distress.
Non-­‐Rebreathing Mask How much oxygen could deliver? 12 -­‐ 15 liter per min: 70-­‐100% when to use? *Useful in acute situation like: Asthma, COPD patients with respiratory distress. Bag-­‐ Valve Mask How much oxygen could deliver? 15 liter per min: 100% It provide high flow of oxygen with ventilation ( pressure ) when to use? *Respiratory failure 7
AIRWAY EQUIPMENT AND BASIC MANAGEMENT How to open the airway of unconscious patient? * Head-­‐tilt chin-­‐lift -­‐ when no neck injury suspected Useful links * Head-­‐tilt chin-­‐lift *Jaw thrust *OPA\NPA\ Suction * Jaw thrust – when neck injury suspected https://www.youtube.com/watch?v=wZ
2fbBOTvac * How to use oxygen cylinder https://www.youtube.com/watch?v=bb
vGuImF_38 Equipment used to open the airway: * OroPharyngeal Airway ( OPA ) * NasoPharyngeal Airway ( NPA ) -­‐ It is used to stabilized the tongue -­‐ It is contraindicated when gag reflex is present
-­‐ It is used to open the airway in patient who has gag reflex -­‐ It is contraindicated in patient with base skull fracture 8
HISTORY TAKING 1. SAMPLE S: Signs and Symptoms What are the signs that the paramedic see? What are the Symptoms that the patient describe? A: Allergy Does the patient have allergy of some medications, food, or allergy of dust, etc. M: Medications Is the patient taking some medications? And for what? And since when? P: Past medical history ( Hx ) Does the patient have past medical problems? Past hospitalizations? Any genetic problems or diseases? Past emergency visit for the same current situation? L: Last oral intake When was the last meal or last thing did the patient eat? And what was is ( food or meds?) E: Event led to this situation or event before this situation happened What was the patient doing before the signs and symptoms appeared? 2. OPQRST ( it is mainly for assessing the pain ) O: Onset How did the pain start? Was it sudden? Or gradually increased? P: Provocation What makes the patient feeling better And what makes the patient feeling worse? Q: Quality the paramedic ask the patient to describe the pain or discomfort like: Describe your pain? How does it look like? Is it like heaviness? Or stab-­‐like pain? etc. R: Radiation Does the pain radiate somewhere? S: Severity of the pain . The paramedic should ask the patient to evaluate the severity of the pain by giving the patient a score of 10; 1 is the least pain the patient feel while 10 is the worst pain the patient have ever experienced. T: Time When exactly the pain started? The paramedic could also ask for the duration of the pain. 3. Extra Questions ( advanced ) -­‐ past surgeries -­‐ pregnancies and other extra questions for female 9
VITAL SIGNS 1.
2.
3.
4.
5.
6.
Heart rate ( HR ) Respiratory rate ( RR ) Blood pressure ( BP ) Body temperature Blood Oxygen saturation Blood glucose level 1. Heart Rate Normal range ( 60 -­‐ 100 ) less than 60 : Bradycardia more than 100: Tachycardia 2. Respiratory rate Normal range ( 12 -­‐ 20 ) less than 12: Bradypnea more than 20: Tachypnea 3. Blood pressure Normal range ( systolic: 90-­‐120, Diastolic: 60-­‐80 ). Ideal blood pressure: 120\80 Systolic blood pressure > 120 with diastolic blood pressure > 80 : Hypertension systolic Blood pressure < 90 with diastolic blood pressure < 60: Hypotension . range my vary from book to book. 4. Body temperature Normal temperature 36 or 37 less than 36: Hypothermia more than 37: Hyperthermia 5. Blood Oxygen saturation Normal range 95% -­‐ 100% less than 95%: Desaturation 6. Blood glucose level ( it is recently considered as a vital sign ) Normal range in mg\dL: ( 80 -­‐ 100 ) less than 80: Hypoglycemia more than 100: hyperglycemia Normal range in mmol\L: ( 4 -­‐ 6 ) less than 4: Hypoglycemia more than 6: hyperglycemia 10
DETAILED PHYSICAL EXAMINATION The paramedic should be looking for DCAPBITLS D: deformity. C: contusion. A: abrasion. P: penetration B: burn. E: instability. T: tearing. L: laceration. S: 1. The head and face: Looking for DCAPBETLS. Examine the pupils: reactive or not, dilated (>3mm) or constricted (<3mm). Examine the nose, mouth, and ear for bleeding or foreign bodies. " Do I see any blood in my gloves?" is an important question. 2. The neck: Looking for DCAPBETLS. Looking for tracheal deviation ( tension pneumothorax ). Looking for GVD ( indicate cardiac problem ). Examine the posterior part of the neck for any fractures or deformities. 3. The chest: Looking for DCAPBETLS. Examine the clavicle, ribs and sternum for any fractures. 1. Inspect the chest ( it is about exposing the chest ). 2. Palpation: ( putting the hands on the chest to look for symmetrical movement of the chest during breathing ). 3. Percussion: to examine the fluid and the air. ( air: resonance, is the normal of the chest. Fluid: Dull, is the normal of the abdomen ). 4. Auscultation: to listen for the heart sound, air entry for both lungs. 4. The abdomen: Looking for DCAPBETLS. 1. Inspect the abdomen ( it is about exposing the abdomen ). 2. Palpation: ( for quadrants: upper right quadrant [URQ], upper left quadrant [ULQ], lower right quadrant [LRQ], and lower left quadrant [LLQ] ). 3. Percussion: to examine the fluid and the air. ( air: resonance, is the normal of the chest. Fluid: Dull, is the normal of the abdomen ). 4. Auscultation: to listen for the abdomen sound. 5. The pelvic: Looking for stability 6. The femur: Looking for DCAPBETLS. Looking for fractures. 7. The legs and foots: Looking for DCAPBETLS. Looking for fractures. Checking the pulse. 8. The shoulder and arms: Looking for DCAPBETLS. Examine for fractures. Checking the radial pulse. 9. The back: Looking for DCAPBETLS. Examine for fractures by moving above the spinal column. 11
BLS -­‐ CARDIAC ARREST Scenario: you found a 76 years old man who suddenly collapsed. 1. Verbalizing scene size up ( general statement; page no.2 ) 2. check for responsiveness ( AVPU ) 3. Start with C A B: C: check for carotid pulse for 10 seconds with visualizing the chest to see chest rise No pulse, No chest rise 1. Activate EMS 2. Ask the second rescuer to bring AED 3. Expose the chest, start chest compressions in the nipple line: rate 30 compressions\ 2 breaths = One cycle continue CPR till AED is available. 4. Attach AED, follow AED instructions High Quality CPR: https://www.youtube.co
m/watch?v=qfrkv7Ayfwk
&index=2&list=PLJm0SqP
XlgNHXqDywFuGG_QjMZ
Rutrd_4 Shockable rhythm Non-­‐shockable rhythm Deliver shock, resume CPR immediately for 2 mins Continue CPR rate: 30 \ 2 for 2 mins 2MINS 1. check for pulse 2. Switch rules 3. Analyze rhythm by AED 12
ADULT CHOKING Scenario: you found a 37 years old man gasping in the restaurant. His wife told you he started gasping suddenly while he was eating salad. The patient is cyanosed and could not talk. 1. Verbalizing scene size up ( general statement; page no.2 ) 2. Inform the patient that you will help him. 3. If the patient is able to talk, encourage him to cough. Useful link illustrating the steps of management for adult choking: https://www.youtube.com/watch?v=2ynXaipnGRU 13
RADIO COMMUNICATION AND DOCUMENTATION Medical documentation should include: 1. Patient’s age and gender. 2. Level of consciousness or mental status ‫ﻡمﺎﻗﺭرﻷﺍاﻝلﻣﺟﻟﺍا ﺔﻳﯾﺎﻬﮭﻧ ﻥنﻳﯾﺳﻭوﻗ ﻥنﻳﯾﺑ ﻲﻟﺍا ﺩدﺍاﺩدﻌﺗﻟﺍا ﺕتﻘﺣ ﺎﻬﮭﺳﻔﻧ ﻲﻫﮬﮪھ‬
3. Patient’s chief complaint 4. OPQRST \ SAMPLE A 42 years old man (1) 5. Patient’s vital signs (1)= 1. Patient age and gender. 6. Pertinent physical exam findings 7. Interventions done by EMS Example: A 42 years old man (1) is conscious, alert, and oriented (2) complaining of chest pain (3) started suddenly 30 mins ago (4:O). The pain is sharp like a knife stabbing (4:Q) that radiates to the left shoulder (4:R). The severity of the pain is 7 of 10 (4:S). Patient has no allergy, no medications, and patient is medically free 4:A,M,P. Vital signs are: BP 165\91, HR 100, SpO2 96%, BGL 5 mmol\L, RR 25, Temp 36.75. Based on physical examination, everything is normal (6). Oxygen supplement is initiated via nasal cannula 4lpm, and IV access is done to keep vein open. On radio communication: 1. Unit identification 2. Patient’s age and gender 3. Level of consciousness or mental status 4. Patient’s chief complaint 5. Brief OPQRST \ SAMPLE 6. Patient’s vital signs ( could be brief ) 7. Brief pertinent physical exam findings 8. Management done by EMS 9. Estimated time of arrival Example: Alpha1 to dispatch (1): we have a 42 years old conscious man (2,3) complaining of chest pain started suddenly 30 mins and radiates to the left shoulder (4,5). Patient is medically free (5). Vital signs are normal except: BP 165\91 and RR 25 (6). Based on physical examination, everything is normal (7). Oxygen via nasal cannula 4lpm is initiated, and IV access is done to keep vein open (8). Estimated time of arrival is 15 mins (9). On Trauma cases, mechanism of injury should be stated and documented. Example, 42 years old man involved in car accident lateral impact who found ejected from the car approximately 5meters. Patient is unconscious …. etc. 14
EQUIPMENT FAMILIARIZATION Tool Name Uses Cervical collar Cervical spine immobilization Suction machine To suction fluids in the mouth in order to clear the airway Normal saline Fluid replacement in hypovolemic patients Monitor To check vital signs, ECG, capnography, to deliver shock in arrested patients, etc. Laryngoscope For intunation 15
TRAUMA ASSESSMENT Common Scenario: you are dispatched to 37 years old man who involved in motor vehicle accident, and you have to assess the patient. 1. Verbalizing scene size up ( general statement; page no.2 ) 2. check for responsiveness ( AVPU ) 3. Ask the patient to not move if the patient is conscious 4. Start with A B C: A: Airway: checking for patency. Suction if fluid presents, OPA for unconscious patient with absent gag reflex. Apply C-­‐collar. B: Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Auscultate the chest to check for equal air entry bilaterally. Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the patient's condition C: Circulation: Checking for radial pulse, skin condition\Color: pale, cyanosed, sweaty, dehydrated, body temperature. Is there any obvious bleeding? If yes, stop bleeding should be initiated. D: Disability\ Decision making: Disability: by asking the patient if he\she could move the extremities. Also by check PMS (Pulse, Motor, Sensation). Also it can be done by doing quick physical examination. Decision making: Whether to transport the patient if the patient is critically ill ( Load and Go ) or to stay in the scene and treat the patient if the patient is not critically ill or the patient has something need to be fixed before transportation ( Stay and Play ). Log rolling and examine the back of the patient. Put the patient on backboard and head blocks. Correct any abnormality before moving ( fix and go ) 5. Determine GCS. 6. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). Also, fix and go (patient is hypotensive: give normal saline. Patient is desating: increase O2, etc.) 7. History taking if possible ( SAMPLE, OPQRST ) 8. Detailed physical examination: from head to toe. 9. Reassess the patient. 16
FEMUR FRACTURE Scenario: you are dispatched to 23 years old man who involved in motor vehicle accident and ejected from the car. 1. Verbalizing scene size up 2. check for responsiveness ( AVPU ) 3. Ask the patient to not move if the patient is conscious 4. Start with A B C: A: Airway: checking for patency. Suction if fluid presents, OPA for unconscious patient with absent gag reflex. Apply C-­‐collar. B: Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Auscultate the chest to check for equal air entry bilaterally. Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the patient's condition C: Circulation: Checking for radial pulse, skin condition\Color: pale, cyanosed, sweaty, dehydrated, body temperature. Is there any obvious bleeding? If yes, stop bleeding should be initiated. D: Disability\ Decision making: + GCS. Disability: by asking the patient if he\she could move the extremities. Also by check PMS (Pulse, Motor, Sensation). Also it can be done by doing quick physical examination. In case of femur fracture, the patient will not be able to move the fractured leg. Expose the area, look for DCAPBTLS, and check PMS. Indications of traction splint: mid-­‐shaft closed femoral fractures with absent distal pulse. contraindications: open femoral fracture. multiple fractures in the same leg. For example, pelvic and femur fracture at the same time. Check for PMS before and after the procedure. Consider strong analgesia if the patient is conscious and feeling severe pain. Decision making: Whether to transport the patient if the patient is critically ill ( Load and Go ) or to stay in the scene and treat the patient if the patient is not critically ill or the patient has something need to be fixed before transportation ( Stay and Play ). Log rolling and examine the back of the patient. Put the patient on backboard and head blocks. Correct any abnormality before moving ( fix and go ) 5. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). Also, fix and go (patient is hypotensive: give normal saline. Patient is desating: increase O2, etc.) 6. History taking if possible ( SAMPLE, OPQRST ) 7. Detailed physical examination: from head to toe. 8. Reassess the patient. Useful link illustrating the use of sager splint: https://www.youtube.com/watch?v=kdcoz73B_uE 17
EXTRICATION TECHNIQUE Common Scenario: you are dispatched to 23 years old man who involved in motor vehicle accident. On arrival, you find the patient still inside the car. The patient is complaining of back pain. 1. Verbalizing scene size up 2. check for responsiveness ( AVPU ) 3. Ask the patient to not move if the patient is conscious 4. Start with A B C: A: Airway: checking for patency. Suction if fluid presents, OPA for unconscious patient with absent gag reflex. Apply C-­‐collar. B: Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Auscultate the chest to check for equal air entry bilaterally. Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the patient's condition C: Circulation: Checking for radial pulse, skin condition\Color: pale, cyanosed, sweaty, dehydrated, body temperature. Is there any obvious bleeding? If yes, stop bleeding should be initiated. D: Disability\ Decision making + GCS: Disability: by asking the patient if he\she could move the extremities. Also by check PMS (Pulse, Motor, Sensation). Also it can be done by doing quick physical examination. The patient needs to be extracted from the car by using KED ( Kendrick Extrication Device ) Indicated in: Stable patient who complains of neck or back pain. contraindicated in: unstable patient. ( abnormalities in A B C ) 5. One will stabilize the head from the back. 6. Applying C-­‐collar 7. Check PMS before applying the device. 8. Slide the device from the back of the patient. 9. Apply the straps as the following statement ( My Baby Looks Happy Today ) M: middle torso strap, B: bottom torso strap, L: leg straps, H: head strap, and T: top torso strap. 10. Check PMS after applying the device. 11. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). 12. History taking if possible. 13. Reassess the patient. Useful link illustrating the use of KED: https://www.youtube.com/watch?v=HAtyB-­‐UEN7Y NOTE: the order of applying the straps is not followed properly. The right order is : middle, bottom, leg, head, and then the top. 18
PNEUMOTHORAX Common Scenario: you are dispatched to 45 years old man who involved in motor vehicle accident frontal impact. 1. Verbalizing scene size up ( General statement; page no.2 ) 2. check for responsiveness ( AVPU ) 3. Ask the patient to not move if the patient is conscious 4. Start with A B C: A: Airway: checking for patency. Suction if fluid presents, OPA for unconscious patient with absent gag reflex. Apply C-­‐collar. B: Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Auscultate the chest to check for equal air entry bilaterally. Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the patient's condition. C: Circulation: Checking for radial pulse, skin condition\Color: pale, cyanosed, sweaty, dehydrated, body temperature. Is there any obvious bleeding? If yes, stop bleeding should be initiated. D: Disability\ Decision making + GCS: Disability: by asking the patient if he\she could move the extremities. Also by check PMS (Pulse, Motor, Sensation). Also it can be done by doing quick physical examination. In case of pneumothorax, the following signs and symptoms could appear: 1. Shortness of breath. 2. Tachypnea, tachycardia. 3. Low SpO2. 4. Unequal or unilateral chest rise. 5. Decreased or absent air entry in the affected side. 6. Tracheal deviation in severe pneumothorax ( the trachea deviates AWAY from the affected side ). Types of Pneumothorax
Opened Pneumothorax • Apply high folw oxygen via non-­‐rebreather mask • put a sterile gauze on the wound and put a plaster on tree sides • open an IV access and give normal saline as needed. • transport the paxent quickly to the hospital • consider advance airway if needed. Closed Pneumothorax • Apply high folw oxygen via non-­‐rebreather mask • Apply needle decopression, gauge 16 in mid-­‐clavicle line, second intercostal space, Apove the third rib. • open an IV access and give normal saline as needed. • transport the paxent quickly to the hospital • consider advance airway if needed. 19
OSPE Types of Trauma Blunt trauma
Penetrating trauma
Evisceration
Amputation
Contusion
Upper Laceration
Open fracture
Asphyxia
20
ANAPHYLAXIS Common scenario: you have a 27 years old lady complaining of shortness of breathing "SOB". 1. Verbalizing scene size up ( General statement; page no.2 ) 2. check for responsiveness ( AVPU ) 3. Start with A B C: A: Airway: checking for patency. Suction if fluid presents, OPA for unconscious patient with absent gag reflex. B: Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Auscultate the chest to check for equal air entry bilaterally. Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the patient's condition. C: Circulation: Checking for radial pulse, skin condition and body temperature. D: Decision making: load and go if the pt's critical, stay and complete assessment if the pt's not critical. Determin the GCS. In case of anaphylaxis, the common signs and symptoms are: SOB, wheezing on chest auscultation, tachycardia, tachypnea, skin redness and rash all over the body. 4. Obtain quick history to rule out other causes: -­‐ Do you have allergy? -­‐ what did do before the symptoms appeared? 5. if it's obvious that this is hyperreaction, Administer epinephrine 1:1,000 0.2 to 0.5mg every 10 to 15 minutes up to two doses as needed. For pediatrics: 0.01mg\kg for max. 0.5mg IM. It is crucial even before checking A B C. ONLY IF IT IS CLEARLY STATED THAT THE PT HAS ANAPHYLAXIS NOW! 6. give high flow oxygen via non-­‐rebreather mask. If respiratory distress still present, nebulizer could be given (Albuterol 5mg+ Ipratroprium 0.5 mixd with normal saline) 7. Reassess A B C after administering the epinephrine, consider Advanced Airway if losing the airway is highly suspected! 8. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). With 12 leads ECG 9. Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem. 10. Physical Examination: Head to toe checking for the rashes, chest auscultation for ear entry sound and heart sound. 11. IV\IO access, NS fluid as needed based on the pt's BP. Dextrose if the pt's hypoglycemic. 12. Reassessment after each intervention. 13. In case of anaphylactic shock " severe hypotension ", continuous epinephrine infusion: 1-­‐10mcg\min. 21
ASTHMA EXACERBATION Common scenario: you are dispatched to a 20 years old lady complaining of shortness of breath "SOB" 1. Verbalizing scene size up ( General statement; page no.2 ) 2. check for responsiveness ( AVPU ) 3. Start with A B C: A: Airway: checking for patency. Suction if fluid presents, OPA for unconscious patient with absent gag reflex. B: Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Auscultate the chest to check for equal air entry bilaterally. Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the patient's condition. C: Circulation: Checking for radial pulse, skin condition and body temperature. D: Decision making: load and go if the pt's critical, stay and complete assessment if the pt's not critical. In case of Asthma, the common signs and symptoms are: SOB, wheezing on chest auscultation, tachycardia, tachypnea, high BP, and agitation or lethargy depending on the severity of deoxygenation. The pt prefers to set up instead of lying down. 4. Obtain quick history to rule out other causes: -­‐ Do you have allergy? -­‐ what did do before the symptoms appeared? Usually, the patient will till the paramedic that he\she is asthmatic. 6. Put the pt on high flow oxygen via non-­‐rebreather mask. 7. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). With 12 leads ECG. Assessing the severity of Asthma Severity Mild Moderate Severe Ability to speak Mental status Full sentences Normal Incomplete sentences Unable to speak Life-­‐
Unable to thretening speack continue to next page Anxious, Agitated or Lethargy Collapsed 22
Signs and syptoms Vital signs Expiratory wheezing -­‐ SpO2 >94% Expiratory Wheezing, setting position. Respiratory distress. Audible inspiratory and expiratory wheezing, setting position, Using accessory muscle, abdominal breathing. -­‐ SpO2 <94%, >90%, tachycardia, tachpnea. Dyspnoea, cyanosis Drop of all V.S -­‐ SpO2 <90%, -­‐ tachycardia, -­‐ tachypnea, -­‐ BP CONT. 8. Give the pt 2 puffs if he\she has puffer. Prepare the nebulizer: -­‐ Salbutamol "AKA. albutarol or ventoline": Adult: 1.25-­‐5mg n 3cc NS. Pediatric: 0.63-­‐2.5mg in 3cc NS. In case of moderate to severe asthma, the paramedic could duble the does. Aslo, the dose could be repeated as needed. -­‐ Ipratropium "AKA. Atrovent": Adult: 0.5mg in 3cc NS. in compained solusion " Salbutamol+Ipratropium": 0.5 mg Ipratropium+2.5mg Salbutamol. 9. Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem. 10. Physical Examination: Head to toe. 11. IV\IO access, NS fluid as needed based on the pt's BP. Dextrose if the pt's hypoglycemic. 12. Magnesium sulfate ( in hospital setting ) for moderate asthma: -­‐ Pediatric: 50-­‐75 mg per kg IV -­‐ Adult: 2g IV Slow IV push ( over 20 mins ). FOR SEVERE ASTHMA: -­‐ Epinephrine: 300-­‐500 mcg IM 13. REASSESS THE PT AFTER EACH INTERVENTION. 23
DRUGS ADMINISTRATION 1. IM 24
CONT. 2. IV -­‐ hand hygiene and gloves. -­‐ prepare the equipment: * tourniquet
alcohol swap
needles with different gauges
Extension
NS flush
Gauze
Plaster
Sharp container
-­‐ Put the tourniquet, and palpate the vein. -­‐ if confident, put alcohol swap ( circle motion from inside to outside ) -­‐ insert the needle. -­‐ if there is flush-­‐back of blood: stop inserting the needle and start introducing the catheter. -­‐ If there is no flush-­‐back of blood: put a gauze above the top of the catheter apply gentle pressure on the gauze, and pull the catheter. Apply plaster above the gauze. -­‐ apply pressure above the catheter and pull the needle. -­‐ put the needle in the sharp container. -­‐ connect the extension to the catheter, release the pressure, and release the tourniquet. -­‐ connect normal saline flush to the extension and flush it: *smooth fluid movement, no resistance, no pain: the catheter is in the correct place. *there is resistance, pt feeling pain, there is bulging: the catheter is in the incorrect place. -­‐ secure the catheter if it's in the correct place by putting a plaster above the top of the catheter. -­‐ If the catheter is in the incorrect place: put a gauze above the top of the catheter apply gentle pressure on the gauze, and pull the catheter. Apply plaster above the gauze. 25
CONT. 3. Subcutaneous "SC": 26
DRUGS CALCULATION When calculating how much of a drug is required, working with the formula helps the accuracy of the calculation. Always remember this formula: 𝐰𝐡𝐚𝐭 𝐲𝐨𝐮 𝐰𝐚𝐧𝐭
×
𝐰𝐡𝐚𝐭 𝐲𝐨𝐮 𝐡𝐚𝐯𝐞
𝐐𝐮𝐚𝐧𝐢𝐭𝐲 𝐢𝐭 𝐜𝐨𝐦𝐞𝐬 𝐢𝐧 𝟏
Examples: 1. A patient requires 4 mg of Morphine IV. Morphine is available as 10mg\ml. How many mls will you draw up? 2. Gentamycin 360 mg is prescribed. Gentamycin is available as 80mg\2ml. How many mls will you draw up? 3. Haloperidol 3 mg IV is charted. Haloperidol is available as 5mg/ml. How many mls is required? 1. METRIC CONVERSIONS kg g: 1kg x 1000 = 1000g g mg: 1g x 1000 = 1000mg mg mcg: 1mg x 1000 = 1000mcg When we multiply by 1000 we move the “decimal point” three places to the right 0.5g == ?? mg 0.5 x 1000 == 500mg If we are converting from a lighter unit to a heavier unit we move the decimal point three places to the left for each conversion. Example: 1. Atropine 0.6 mg = ? mcg If we are moving across two conversions, we repeat the process twice. For example from grams to micrograms: 3gm converted to micrograms Step one: 3 x 1000 = 3000mg Step two: 3000mg x 1000 = 3,000,000mcg 27
CONT. 2. MG/KG DOSE CONVERSION: Example: The patient is charted 15mg/kg/day. The patient weighs 75kg. a) How much is the total dose per 24 hours? b) How much will the patient receive every 8 hours? 3. INFUSION FLOW RATES: To obtain the hourly rate, divide the volume of fluid to be infused by the number of hours fluid to be infused over. Example: a 1000ml infused over 12 hours !"""
!"
= 83.3ml/hr rounded down to 83ml/hr Exercise: 1. A 1L bag is to be infused over 6 hours. Calculate how many mls per hour the patient will receive? 2. How many ml/hr would a patient receive if they were to have 500ml of fluid infused over 6 hours? Fluids are infused using a giving set, requiring a “drop per minute” rate. The giving sets are: Standard Metriset = delivers 20 drops per ml. Micro giving set = delivers 60 drops per ml. Always ensure you use the appropriate calibration in your calculations. 28
CONT. 4. DROP PER MINUTE: Infusion Calculation 𝑻𝒐𝒕𝒂𝒍 𝒇𝒍𝒖𝒊𝒅 𝒊𝒏 𝒎𝒍𝒔
𝒕𝒐𝒕𝒂𝒍 𝒉𝒐𝒖𝒓𝒔 ×𝟔𝟎 𝒎𝒊𝒏𝒔
× 𝑮𝒊𝒗𝒊𝒏𝒈 𝒔𝒆𝒕 𝒄𝒂𝒍𝒊𝒃𝒓𝒂𝒕𝒊𝒐𝒏
𝟏
Example: 1. A patient is prescribed Sodium Chloride 1000ml to be infused over an 8-­‐hour period. A standard giving set is being used. Calculate the drops per minute. 𝟏𝟎𝟎𝟎
×𝟐𝟎 = 𝒅𝒓𝒐𝒑𝒔 𝒑𝒆𝒓 𝒎𝒊𝒏𝒖𝒕𝒆 𝟖×𝟔𝟎
Exercise: 1. Your patient is prescribed a 1000ml infusion of Sodium Chloride 0.9% with 40 mmol of Potassium to be given over 6 hours. Using a micro giving set, calculate the drops per minutes he will receive. EXTRA EXERCISE "For pharmacology block": 1. Prescription states 0.5mg/kg/hr. You have a bag of 250mg in 50ml and the patient's weigh is 70kg. At what rate (ml/hr) do you set the pump? 2. Prescription states 0.5mg/kg/min. You have a syringe of 250mg in 50ml and the patient's weigh is 70kg. At what rate (ml/hr) do you set the pump? 3. Prescription states 3mcg/kg/min. You have a syringe of 100mg in 50ml and the patient's weigh is 70kg. At what rate do you set the pump (ml/hr)? 29
CONT. 4. Prescription for IV digoxin 187.5mcg. You have a vial of 0.5mg in 2ml. What volume contains the dose you need? 5. Prescription for IV aminophylline 350mg in 100ml to be given over 30 mins. You have some vials, 250mg in 5ml. A. What volume of aminophylline injection do you add to the bag? b. What rate do you set the pump at (ml/hour)? 6. Prescription for dopamine 2mg/kg/hour. You have a 70kg patient and a syringe of 800mg in 50ml. What rate do you run the syringe at (ml/hour)? 7. Prescription for IV doxapram 0.1mg/kg/min. You have a 90kg patient and a bag of 500mg in 250ml. What rate do you run the syringe at (ml/hour)? 8. Prescription for IV noradrenaline 10mcg/kg/min. You have a 60kg patient and a syringe of 16mg in 50ml. What rate do you run the syringe at (ml/hour)? 30
CONT. 9. You need to give 500mg of dextrose. You have a 250ml bag of 5% dextrose. How many ml do you need to give? 10. You need to give 5ml of 0.375% bupivacaine. You have a 10ml ampoule of 0.5% bupivacaine and some water for injections. Useful link for extra Quizzes: http://nursing.flinders.edu.au/students/studyaids/drugcalculations/page.php?id=1 31
ANSWERS 1. A patient requires 4 mg of Morphine IVI. Morphine is available as 10mg/ml. How many mls will you draw up? 0.4mls 2. Gentamicin 360 mg is prescribed. Gentamicin is available as 80mg/2ml. How many mls will you draw up? 9mls 3. Haloperidol 3 mg IVI is charted. Haloperidol is available as 5mg/ml. How many mls is required? 0.6mls 2. MG/KG DOSE CONVERSION: The patient is charted 15mg/kg/day. The patient weighs 75kg. a) How much is the total dose per 24 hours? = 15X75= 1,125mg\24hrs b) How much will the patient receive every 8 hours? 1,125mg is the total mgs in 24 hrs. to find the amount in 8hrs, we have first to find how much mgs in 1 hour, then multiply it by 8. = 1,125mg ÷ 24 = 46.8mg\h = 46.8×8 = 375mg\8hrs. 3. INFUSION FLOW RATES: 1. A 1L bag is to be infused over 6 hours. Calculate how many mls per hour the patient will receive. 166.6 mls → 167 mls rounded 2. How many ml/hr would a patient receive if they were to have 500ml of fluid infused over 6 hours? 83.3 mls 83 mls rounded 4. DROP PER MINUTE: 1. Your patient is prescribed a 1000ml infusion of Sodium Chloride 0.9% with 40 mmols of Potassium to be given over 6 hours. Using a micro giving set, calculate the drops per minutes he will receive. 1000 60
×
= 166.6 𝑑𝑟𝑝𝑜 𝑝𝑒𝑟 𝑚𝑖𝑛𝑢𝑡𝑒. 360
1
32
EXTRA EXERCISES: 1. Prescription states 0.5mg/kg/hr. You have a bag of 250mg in 50ml and the patient weigh is 70kg. At what rate (ml/hr) do you set the pump? First, find how much mgs will you give the patient per hour: 0.5×70= 35mg\hour Second, we you have to find How many mls in 35mg: !"×!" !"#
= 7𝑚𝑙\hr 2. Prescription states 0.5mg/kg/min. You have a bag of 250mg in 50ml and the patient weigh is 70kg. At what rate (ml/hr) do you set the pump? First, find how much mgs will you give the patient per min: 0.5×70= 35mg\min but we need it mg\HOUR, So: 35×60= 2,100mg\1hour. Second, we have to find How many mls in 2,100mg: !"×!,!"" !"#
= 420𝑚𝑙\hr 3. Prescription states 3mcg/kg/min. You have a syringe of 100mg in 50ml and the patient's weigh is 70kg. At what rate do you set the pump (ml/hr)? First, find how much mcgs will you give the patient per min: 3 × 70kg = 210mcg\min. but we need it mcg\HOUR, So: 210×60= 12,600mcg\hour. Next, the prescription is in micrograms, but in your syringe you have milligrams. We need to be in the same units by converting mcg into mg "dividing by 1000" : 12 600mcg/hr ÷ 1000 = 12.6mg/hr. Finally, we have to find How many mls in 12.6mg: 12.6 x 50 / 100 = 6.3ml/hr 4. Prescription for IV digoxin 187.5mcg. You have a vial of 0.5mg in 2ml. What volume contains the dose you need? 0.5mg = 500mcg 187.5mcg x 2ml / 500mcg = 0.75ml 33
CONT. 5. Prescription for IV aminophylline 350mg in 100ml to be given over 30 mins. You have some vials, 250mg in 5ml. A. What volume of aminophylline injection do you add to the bag? 350mg x 5ml / 250mg = 7ml b. What rate do you set the pump at (ml/hour)? 60 min x 100ml / 30 min = 200ml/hour. 6. Prescription for dopamine 2mg/kg/hour. You have a 70kg patient and a syringe of 800mg in 50ml. What rate do you run the syringe at (ml/hour)? Prescription really says 2mg/kg/hour: = 2mg x 70kg = 140mg/hour. = 140mg x 50ml / 800mg = 8.75mlSo 8.75ml per hour 7. Prescription for IV doxapram 0.1mg/kg/min. You have a 90kg patient and a bag of 500mg in 250ml. What rate do you run the syringe at (ml/hour)? Prescription really says: 0.1mg/kg/minute. = 0.1mg x 90kg = 9mg/minute. 9mg/minute = 9 x 60mg/hour = 540mg/hour The rate is: 540mg x 250ml / 500mg = 270ml. So, 270ml per hour. 8. Prescription for IV noradrenaline 10mcg/kg/min. You have a 60kg patient and a syringe of 16mg in 50ml. What rate do you run the syringe at (ml/hour)? AN.6 1. Prescription really says: 10mcg/kg/min. =10mcg x 60kg = 600mcg/min 2. 600mcg x 60 min = 36000mcg/hr =36000 / 1000 = 36mg/hr The rate is: 36mg x 50ml / 16mg = 112.5ml. So, 112.5ml\hour 34
CONT. 9. You need to give 500mg of dextrose. You have a 250ml bag of 5% dextrose. How many ml do you need to give? 5% means 5g in 100ml, which is the same as 5000mg in 100ml. So: 500mg x 100ml / 5000mg = 10ml 10. You need to give 5ml of 0.375% bupivacaine. You have a 10ml ampoule of 0.5% bupivacaine and some water for injections. 1. We need 5ml of 0.375% solution. This means 0.375g in 100ml. So in 5ml: 0.375g x 5ml / 100ml = 0.01875g (18.75mg) (line 1) 2. We have a 0.5% solution (which contains 0.5g (500mg) in 100ml). We need only 18.75mg. So: 18.75mg x 100 / 500 = 3.75ml. Which means in each 18.75mg, there is 3.75ml of our 0.5% solution. So, we take 3.75ml (18.75mg), top it up to 5ml with water for injection "WFI", and we then have 18.75mg in 5ml (which is 0.375% as shown in line 1). 35
ST Elevation Myocardial Infarction ( STEMI ) Common signs and symptoms: chest paint, SOB, epigastric pain, shoulder pain, heaviness on the chest, etc. 1-­‐
2-­‐
3-­‐
4-­‐
1. Scene size up 2. check for responsiveness ( AVPU ) Assessment and Management: A B C D: Airway: checking for patency. OPA for unconscious patient with absent gag reflex Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition. Decision making: mainly pt with STEMI is critical with time window of 3hrs, so load and go Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem, past surgeries like heart catheterization. 12 leads ECG: ST elevation in leads II, III, and AVF: inferior STEMI ST elevation in leads V1, V2: septal STEMI ST elevation in leads V2, V3, and V4: anterior STEMI ST elevation in leads V1, V2, V3, V4: anteroseptal STEMI ST elevation in leads I, aVL, V5, V6: lateral STEMI ST elevation in leads I, aVL, V2, V3, V4, V5, V6: Anterolateral STEMI. 5-­‐ IV access for ( KVO, fluid and drug administration if needed). NS for hypotension, D50 for hypoglycemia. 6-­‐ MONA: ( Morphine, Oxygen, Nitroglycerine, Aspirin ) Aspirin: 324mg chewing tablets Nitroglycerine: 0.4mg sublingual tablet ( IF SYSTOLIS BP >100 ). Oxygen: as stated above: nasal cannula, NRM, or BVM based on the pt's condition. Morphine: IF REALLY NEEDED ( start with low dose: 2-­‐2.5 as an example ). 7-­‐ Reassessment after the interventions for the VS. 8-­‐ Physical examination; heat to toe Consider advanced airway ( LMA, intubation ) if respiratory failure is suspected or unconscious pt with uncontrolled breathing. Rapid transportation to the nearest hospital that contains cathlab with early notification to the hospital. Time window is 3 hours! 36
ACLS -­‐ PULSELESS VF \ VT Common scenario: you are dispatched to 68 years old man who was found unresponsive 1. Scene size up 2. check for responsiveness ( AVPU ) 3. Start with C A B: C: check for carotid pulse for 10 seconds with visualizing the chest to see chest rise No pulse, No chest rise 1. Activate EMS for more help 2. Expose the chest, start chest compressions in the nipple line: rate 30 compressions\ 2 breaths = One cycle continue CPR till the paddles are attached by another rescuer. 3. Put OPA or NPA 4. Analyze the rhythm that is seen in the monitor Shockable rhythm VF\VT Non-­‐shockable rhythm Asystole\ PEA Deliver unsynchronized shock 200J, resume CPR immediately for 2 mins IV \ IO access Shockable rhythm VF\VT Deliver unsynchronized shock 200J, resume CPR immediately Epinephrine 1 mg 2MINS 1. check for pulse 2. Switch rules 3. Analyze rhythm by AED 2MINS Shockable rhythm VF\VT 1. check for pulse 2. Switch rules 3. Analyze rhythm by AED Deliver unsynchronized shock 200J, resume CPR immediately Amiodarone 300 mg Continue CPR rate: 30 \ 2 for 2 mins IV \ IO access Non-­‐shockable rhythm Asystole\ PEA Continue CPR rate: 30 \ 2 Epinephrine 1 mg repeat every 3-­‐5 mins Non-­‐shockable rhythm Asystole\ PEA Continue CPR rate: 30 \ 2 2nd dose: Epinephrine 1 mg 37
CONT. 2MINS Shockable rhythm VF\VT 1. check for pulse 2. Switch rules 3. Analyze rhythm by AED Deliver unsynchronized shock 200J, resume CPR immediately 2nd dose: Epinephrine 1 mg Non-­‐shockable rhythm Asystole\ PEA Continue CPR rate: 30 \ 2 3rd dose: Epinephrine 1 mg 2MINS Shockable rhythm VF\VT 1. check for pulse 2. Switch rules 3. Analyze rhythm by AED Deliver unsynchronized shock 200J, resume CPR immediately 2nd dose: Amiodarone 150 mg Non-­‐shockable rhythm Asystole\ PEA Continue CPR rate: 30 \ 2 4th dose: Epinephrine 1 mg If the rhythm is During CPR, look for Hs and Ts Toxins Tamponade (cardiac) Tension pneumothorax Thrombosis (coronary and pulmonary) Trauma. Hypovolemia Hypoxia. Hydrogen ion (acidosis) Hyper-­‐/hypokalemia Hypoglycemia Hypothermia. . IF THE PT RETURNED TO SPONTANEOUS CIRCULATION, FOLLOW ROSC PROTOCOL. 38
ACLS -­‐ VT WITH PULSE Common scenario: you are dispatched to 68 years old man with frequent syncopal attacks. 1. Scene size up 2. check for responsiveness ( AVPU ) 3. Start with A B C: Assessment and Management: A B C D: Airway: checking for patency. OPA for unconscious patient with absent gag reflex Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition. Decision making: mainly pt with palpitation is critical with time window of 3hrs, so load and go -­‐ While checking A B C, Connect the monitor (Specially paddles or 4 leads ECG to detect any dysrhythmia early) and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). HR typically ≥ 150 if it’s tachyarrhythmia. Pt’s Condition?
YES!
Sedation+ synchronized cardioversion.
SEE QRS
Narrow QRS >0.12
• Regular: 50-­‐100J • Irregular: A. Biphasic: 120-­‐200J B. Monophasic: 200J NO!
• Hypotension? • Altered level of consciousness? • Signs of shock? • Ischemic chest discomfort? • Acute heart failure? SEE QRS
Wide QRS >0.12 Wide QRS >0.12
1. 12 leads ECG 2. Adenosine (only if regular and monophasic): 1st dose: 6mg rapid push 2nd dose: 12mg rapid push. • Regular: 100J • Irregular: defibrillation dose "not synchronized". Narrow QRS >0.12
A. 1. 12 leads ECG 2. Vagal maneuvers 3. Adenosine "if regular" Continue next page
4. Beta-­‐blocker 5. calcium channel blocker 39
•
-­‐ Reassess after each Intervention. Consider advanced airway ( LMA, intubation ) if respiratory failure is suspected or unconscious pt with uncontrolled breathing. BE prepared in case the rhythm changed to pulseless. -­‐ Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem, past surgeries like heart catheterization. Rapid transportation with early notification to the receiving hospital. 40
ACLS -­‐ SUPRAVENTRICULAR TACHYCARDIA COMMON SCENARIO: you are dispatched to 49 years old man who is complaining of SOB and palpitation. 1. Scene size up 2. check for responsiveness ( AVPU ) Assessment and Management: 1-­‐ A B C D: Airway: checking for patency. OPA for unconscious patient with absent gag reflex Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition. Decision making: mainly pt with STEMI is critical with time window of 3hrs, so load and go 2-­‐ Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). 3-­‐ Connect the electrodes and analyze the rhythm heart rate more than 160 or 170 with un-­‐visualized P waves: SVT 4-­‐ Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem, past surgeries like heart catheterization. 5-­‐ If the pt is stable: -­‐ try vagal maneuver or valsalva maneuver ( ask the pt to hold the breath) -­‐ if it's not effective, administer Adenosine 6 mg ( push fast and followed by NS flush with elevating the hand ) the second dose is 12 mg. -­‐ If it's not effective, connect the paddles, set the monitor on synchronized cardioversion 50 -­‐ 100 J. Consider analgesia if pt is conscious. 6-­‐ If the pt is unstable, give sedation “Etomidate 0.2\kg, or propofol 1.5mg\kg, or midazolam 0.2mg\kg”, and go for synchronized cardioversion 50 -­‐ 100 J 7-­‐ Reassess the pt 41
ACLS -­‐ BRADYCARDIA Common scenario: you are treating a 70 years old man who is complaining of decreased level of consciousness. 1. Scene size up 2. check for responsiveness ( AVPU ) 3. A B C D: Airway: checking for patency. OPA for unconscious patient with absent gag reflex Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition. Decision making: mainly pt with STEMI is critical with time window of 3hrs, so load and go 4. History taking ( SMAPLE -­‐ OPQRST ) 5. Connect the monitor and paddles, take full vital signs. Identify the rhythm: 1. sinus bradycardia: normal sinus rhythm but the heart rate less than 50 bpm. 2. First degree heart block: there will be prolongation in the PR interval > 5 small boxes 3. Second degree heart block: MOZBIT l: PR interval prolongation, more prolongation, more prolongation, then drop of QRS. And the cycle repeats itself. MOZBIT ll: PR interval is constant, then QRS drop. 4. Third degree heart block: disassociation between P waves and QRS waves. If pt is a symptomatic: just monitoring If pt is symptomatic: administer Atropine 0.5 mg IV, repeat every 3-­‐5 mins for max. 3mg Atropine is not effective in second and third degree heart block. TRANSCUTANEOUS PACING: It's indicated if the pt is hemodynamically unstable Conscious pt needs analgesia ( fentanyl 100mg for example ) STEPS: 1. Attach the paddles 2. Put the rate at 60 3. Set the currency at 5 mA, and increase it by 5 till you see QRS complex after each shock (capturing) 4. If captured, increase the currency 2-­‐5 mA. 5. Continue monitoring the patient and reassess vital signs. Consider chronotropic drugs as an alternative to pacing: ( if pacing is not available for example) -­‐ Epinephrine infusion: 2 -­‐ 10 mcg \ min. -­‐ Dopamine: 2 20 mcg \ kg \ min 42
OSPE -­‐ HEART ANATOMY Coronary Arteries 43
OSPE -­‐ RHYTHM DIAGNOSIS Normal Sinus Rhythm Atrial Tachycardia Supraventricular Tachycardia " SVT" Atrial Fibrillation Continue Next page
44
OSPE -­‐ RHYTHM DIAGNOSIS Atrial Flutter Sinus Bradycardia 1st Degree heart block " Atrioventricular Block" 2nd Degree heart block-­‐Type 1 (Mobitz I/Wenckebach) Continue Next page
45
OSPE -­‐ RHYTHM DIAGNOSIS 2nd Degree Heart Block-­‐ Type 2 (Mobitz II/Hay) 3rd Degree Heart Block Ventricular Tachycardia – Monomorphic Ventricular Tachycardia – Polymorphic Continue Next page
46
OSPE -­‐ RHYTHM DIAGNOSIS Ventricular Tachycardia – Torsades de Pointes Ventricular Fibrillation Asystole Pulseless Electrical Activity "PEA" 47
OSPE -­‐ RESUSCITATION MEDICATIONS Medication Adenosine Epinephrine Dose indications 1st dose: 6mg IV 2nd and 3rd dose: 12mg IV Rapid push followed by rapid push of NS flush. SVT, monomorphic ventricular tachycardia with pulse 1 mg IV concentration: 1;10000 Cardiac arrest Atropine 0.5 mg IV Bradycardia Magnesium sulfate 1-­‐2 g IV push Torsado de point Amiodarone For pulseless dysrhythmia: 1st dose: 300mg IV 2nd dose: 150mg IV For dysrhythmia with pulse: 1st dose: 150mg IV 2nd dose: 300mg IV VF, VT Epinephrine infusion 0.1-­‐0.5mcg\kg\min Post cardiac arrest Dopamine 5-­‐10mcg\kg\min Post cardiac arrest 48
RAPID SEQUENCE INTUBATION Before intubating the pt, we've to check for difficult airway. 1. Preparation; All equipment needed, qualified person, plan B like LMA. 2. Pre-­‐oxygenation; high flow O2, Bagging if needed. Avoiding hyperventilation. Duration at least 2 mins, Or SpO2 is 100% 3. Pretreatment: sedative, paralytic, and medication to reduce sensitivity of the laryngoscope ( not really needed ) A). Sedatives: Medication Midazolam Etomidate Ketamine Fentanyl Propofol Adult Dose 0.15-­‐0.3 mg\kg IV 0.3mg\kg IV 1.5mg\kg IV 2-­‐10mcg\kg IV 1-­‐2.5mg\kg IV Onset 60-­‐90 sec 10-­‐15 sec 60-­‐90 sec <60 sec 15-­‐45 sec Duration 15-­‐30 mins -­‐ 10-­‐20 mins -­‐ 5-­‐10 mins Etomidate and Propofol may be good choices as sedatives for TBI ( traumatic brain injury ). B). Paralytics: Medication Type Succinylcholine Depolarizing neuromuscular blocker Non-­‐depolarizing muscle relaxant Rocuronium Vecuronium Non-­‐depolarizing muscle relaxant Adult Dose 1.5mg\kg IV Onset 45-­‐60 sec Duration 6-­‐10 mins 1.2mg\kg IV 0.15mg\kg IV 60 sec 120-­‐180 sec -­‐ 45-­‐60 mins Succinylcholine is widely used as a paralytic for RSI. Extra medications: lidocaine 100mg IV may help in protection for increased ICP caused by intubation. 4. After administering the sedative and paralytic, insert the ETT 5. Six conformational elements for successful intubation: A). Direct visualization of the vocal cords B). equal chest rise C). CO2 detector D). Auscultation: epigastric, right and left med-­‐axillary line E). capnography. F). Good blood saturation 6. secure the tube 7. reassess the patient regularly. 49
LRYNGIAL MASK AIRWAY " LMA" 1. hand hygiene 2. prepare the equipment ( LMA with proper size based on the pt's weight, syringe, lubricant, tape). And check the tube before using it " inflate and deflate to insure that it's working" 3. plan B: OPA, NPA, etc. 4. ventilate the patient for 2 mins or till SpO2 is 100%. 5. position the patient (sniffing position ) 6. Conformation: " chest auscultation, CO2 detector, good SpO2, capnography " 50
OSPE -­‐ CAPNOGRAPHY Normal capnography wave and its interpretation: Phase Termed I A→B Baseline II III IV B→C C→D D→E expiratory upstroke alveolar plateau inspiratory down-­‐stroke Variables A: completion of inspiration B: beginning of expiratory C: slowing of exhaled flow D: end expiration = PET CO2 E: end inspiration 51
CAPNOGRAPHY WAVEFORMS Continue Next page
52
CAPNOGRAPHY WAVEFORMS. CONT 53
OSPE-­‐ VENTILATOR SETTINGS Scenario: you are treating a 38 years old man involved in car accident. On assessment, the patient has head trauma with GCS 7. The patient has irregular breathing at 8, hypertension and bradycardia. you sedated the patient and paralyzed him, then you intubated the patient and connect the tube to the ventilator. Write the ventilator settings that you will but the patient on? 1-­‐ Mood: Assist control, volume control. 2-­‐ Tidal volume: based on the pt's approx. weight ( weight × 10 ). But usually 450 -­‐ 500. 3-­‐ Respiratory rate: 12-­‐18 based on pt's need. 4-­‐ Inspiratory : Expiratory "I:E" ratio: 1: 2 5-­‐ FIO2: start with 100, decrease it if the patient is OK. 6-­‐ PEEP: 3-­‐5 but we always put it on 5. Other settings should be considered: -­‐ in patients with COPD and asthma: we lower the RR, and increase the expiratory phase in I:E ratio. For example. 1:3 or 1:4. -­‐ In patients pulmonary edema or near drowning: increase PEEP, It could work as CPAP. -­‐ In case of inhalation injury: High O2 volume is needed. 54
OSPE -­‐ CHEST X-­‐RAY What to see in CHX? we've A B C D E F interpretation: A - airway
D - diaphragms
B - bones
E - edges
C - cardiac
F - fields
55
OSPE -­‐ DRUGS ANTIDOTE Drug toxicity Atropine Benzodiazepine "Midazolam, Lorazipam, diazepam" Opiates " Morphine, Heroine" stimulants " amphetamine, Cocaine" Nitroglycerine Aspirin B-­‐blockers Signs and symptoms -­‐ Dry skin and mucous membranes. -­‐ Hypertension. -­‐ Altered mental status. -­‐ Sinus tachycardia. -­‐ Hyperthermia. Anti-­‐dote \Management ANTI-­‐DOTE: Physostigmine 0.5-­‐2mg IV ANTI-­‐DOTE: Flumazenil 0.2mg IV for maximum 3mg. -­‐ Consider advanced Airway in case of severe respiratory depression. -­‐ decreased level of ANTI-­‐DOTE: Naloxone consciousness 0.4mg IV for maximum "could be coma" 1.6mg. -­‐ Severe respiratory -­‐ Advanced Airway depression. should be prepared. -­‐ pin-­‐pointed pupils. -­‐ Tachycardia MANAGEMENT: -­‐Tachypnea Benzodiazepine 5mg -­‐ Hyperactivity -­‐ Hypertension -­‐ Hyperthermia -­‐ Decreased level of ANTI-­‐DOTE: Methylene consciousness blue 0.2 mg\kg "could be coma". -­‐ Consider Advanced -­‐ Involuntary eye Airway. movements. -­‐ NS for treating -­‐ Palpitation. Hypotension. -­‐ Hypotension. -­‐ Chest pain "angina" -­‐ Hypotension -­‐ Fluid contains -­‐ Pulmonary edema dextrose. -­‐ Agitation\ cerebral edema. ANTI-­‐DOTE: Glucagon -­‐ Bradycardia 1mg IV. -­‐ Hypotension -­‐ Benzodiazepines in -­‐ Seizure case of seizure. -­‐ Decreased level of consciousness. -­‐ SOB\ respiratory depression. -­‐ pin-­‐pointed pupils. 56
Side effect of the antidote -­‐ Increase sweating. -­‐ SOB. -­‐ Muscle weakness. -­‐ Bradycardia. -­‐ Headache\agitation. -­‐ Hyperventilation. -­‐ Nervousness. -­‐ Palpitations. -­‐ Diaphoresis. -­‐ Seizure: low possibility. -­‐ Hypertension -­‐ Runny Nose -­‐ Shivering -­‐ Sweating -­‐ Irregular breathing could happen. Respiratory depression -­‐ Dilated pupils. -­‐ Blurred vision -­‐ Confusion -­‐ Dark urine -­‐ Difficulty breathing -­‐ Dizziness\ lightheadedness. _ _ DRUGS OVERDOSE\ TOXICITY: ORGANOPHOSPHATE POISONING Scenario: you are dispatched to 17 years old man complaining of shortness of breath. 1. Scene size up 2. check for responsiveness ( AVPU ) 3. A B C D: Airway: checking for patency. OPA for unconscious patient with absent gag reflex Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition. Decision making: load and go if pt is critical, Stay and play if pt is uncritical. the paramedic can detect that it's organophosphate poisoning from taking history " SAMPLE -­‐ OPQRST " -­‐ In case of Organophosphate poisoning, the pt may have tachypnea\ SOB, warm skin with redness, tachycardia, Confusion, Crackles on chest auscultation. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). 12 Leads ECG. 5. put the patient on oxygen as needed. 6. IV access, NS in case of hypotension, dextrose in case of hypoglycemia. 7. After confirming that the pt's in organophosphate poisoning, Administer 1mg of atropine IV, repeat for no maximum dose until the symptoms relief. 8. Reassessment after administration of each dose. Side effects of Atropine: -­‐ Dry skin and mucous membranes. -­‐ Hypertension. -­‐ Sinus tachycardia. 9. Advanced Airway ( intubation, LMA ) should be considered in case of severe respiratory distress or failure or in case of coma with uncontrolled breathing. 57
DRUGS OVERDOSE\TOXICITY: ALCOHOL OVERDOSE Scenario: You are dispatched to a 34 years old man who was found unconscious, or who was found confused. 1. Scene size up 2. check for responsiveness "AVPU" 3. A B C D: Airway: checking for patency. OPA for unconscious patient with absent gag reflex. Suctioning if mouth secretion is present. C A B for unconscious pt. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation via nasal cannula, NRM, or BVM with assist ventilation based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition. Decision making: load and go in the pt's critical, stay and complete the assessment if the pt's uncritical. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). With 12 leads ECG. 5. Common signs and symptoms in case of alcohol overdose or alcohol toxicity: Seizure, confusion, severe vomiting, respiratory depression, Hypoglycemia, pin-­‐pointed pupils, etc. In severe cases, the pt may be unconscious for a long time with aspiration of vomitus. 6. Detailed history taking ( SAMPLE – OPQRST ) if possible. Similar events, recent hospitalization for the same problem. 7. Physical Examination: checking for the pupils, chest auscultation for ear entry sound and heart sound, neurological examination. 8. After confirming that the pt's in alcohol overdose, Administering the following is crucial: Hypotensive\ decreased level of consciousness\ uncontrolled vomiting with respiratory depression: A). Advanced airway ( INTUBATION): crush intubation in unconscious pt, RSI in conscious pt BUT be careful with the BP and RR. B). NS bolus to prevent the dehydration due to severe vomiting. C). Administering THIAMINE 100mg IV to prevent Wernicke-­‐Korsakoff syndrome D). Administering D50 50mg IV followed by NS flush in case of hypoglycemia. For Seizure: Administering benzodiazepine. For severe vomiting: administering antiemetic: metoclopramide: 5mg IV. 58
HEAD TRAUMA Scenario: you are dispatched to a 22 years old man involved in motor vehicle accident. 1. Verbalizing scene size up ( General statement; page no.) 2. check for responsiveness ( AVPU ) 3. Start with A B C: The first impression of pt with head trauma is hematoma in the head with abnormal movement of the patient. A: Airway: checking for patency. Suction if fluid presents, OPA for unconscious patient with absent gag reflex. B: Breathing: Assessing for respiratory rate, effort, and quality of breathing. Auscultate the chest to check for equal air entry bilaterally. Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the patient's condition. C: Circulation: Checking for radial pulse, skin condition, check for major bleeding. D: Disability\Decision making: load and go if the pt's critical, stay and complete assessment if the pt's not critical. In case of Cushing reflex, the common signs and symptoms are: Altered level of consciousness " agitation", irregular breathing, bradycardia, and hypertension with wide pulse rate "big difference between systolic BP and diastolic BP". 4. Quick physical examination to see if there is any fracture or major bleeding. mainly, pt with head injury is critical so they need early transportation and early notification to the hospital with estimated time of arrival. Stabilize any fracture before moving the patient. 5. After loading the patient. The priority for this patient after early transportation is to secure the airway and controlling the breathing. " stabilize ABC " It's done by assist ventilation via BVM with high flow oxygen, establishing 2 IV lines for medications administration. 6. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). 7. Rapid Sequence Intubation for conscious pt, Crush intubation for unconscious pt. " the details of RSI; the medications and its doses is illustrated in details HERE " 8. SAMPLE history if possible with time of the accident. 9. Detailed Physical Examination: A). checking for signs of head injury or basal skull fracture: . -­‐ Raccoon eyes, battle sign in the ears, nasal bleeding, or CSF leakage. . -­‐ Dilated\ constricted\ unequal pupils size\ unreactive pupils. B). Checking and fixing any abnormalities all over the body. 10. Reassessment every 5 mins. 11. document EVERYTHING " IF YOU DON'T WRITE IT, YOU DON'T DO IT " 12. For radio endorsement and medical documentation, SEE NEXT PAGE. 59
SEIZURE Scenario: you are dispatched to a 19 years old female who was found unconscious " postictal state", Or pt with active seizure, Or pt with uncontrolled seizure ( status epileptic ) 1. Scene size up 2. check for responsiveness "AVPU" 3. A B C D: Airway: NPA for seizing pt, OPA if unconscious pt with absent gag reflex. Putting the pt in the recovery position ( on the side to prevent aspiration of the vomitus ). Breathing: Assess for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing) for postictal state with oxygen administration, High flow oxygen ( 15lpm via NRM and NPA ) for seizing pt. Oxygenation via NRM, or BVM and assist ventilation based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition. Decision making: if there is any abnormality in the ABC; pt's critical, so load and go. If not, pt's uncritical, so stay in the scene and complete the assessment. In case of active seizure, Administer Midazolam 5mg IM. if giving in the deltoid area, give 2.5 mg in each arm. Midazolam could be given IV if available IV access " 0.15mg\kg " Consider Long-­‐acting benzodiazepine for epilepsy like lorazipam 0.1mg\kg. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL )+ 12 leads ECG. 5. IV access for ( KVO, fluid administration, another dose of benzo in recurrent seizure) 6. Normal slain bolus in case of low blood pressure\ dextrose ( D50) if hypoglycemia is present. 7. Checking for underlying cause: hypoglycemia, recent trauma, infection, etc ). 8. Reassessment after the interventions for the VS. especially for the respiratory rate. 9. Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem. Asking for the duration of the seizure. 10. Physical examination: head to toe Consider antidote of the benzodiazepine if complications happened ' respiratory depression" ( flumazenil 0.2mg IV ). 11. Advanced airway ( intubation or LMA ) in case of respiratory failure or unconscious pt with uncontrolled breathing. 12. High flow Oxygen, maintaining BGL, and fluid resuscitation are considered as the most benefit interventions for postictal phase.
13. REASSESS 60
HYPOGLYCEMIA Scenario: you are dispatched to a 40 years old female who was found unconscious. 1. scene size up 2. check for responsiveness 3. Start with ABCD: Airway: checking for patency. OPA for unconscious patient with absent gag reflex. C A B for unconscious pt. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation for pt with SOB, tachypnea: via NRM, or BVM based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition. Decision making: load and go if the pt's critical, stay in the scene and complete the assessment if the pt's uncritical. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ) + 12 leads ECG. "severe hypoglycemia could cause pulseless dysrhythmias" Signs and symptoms come with hypoglycemia: decreased level of consciousness\ confusion, dizziness, shortness of breath, coma state, SIEZURE, etc. -­‐ If the pt develops seizure, Administer benzodiazepine ( midazolam 5mg IM as an example ): BE CAREFUL WITH RR. If BGL's less than normal: -­‐ Oral glucose: if the pt's conscious, alert, and oriented. -­‐ Dextrose IV ( D50 ) 50mg: if the pt's is semi-­‐conscious, disoriented, unconscious. Pushing slowly followed by normal saline flush to prevent necrosis. -­‐ Glucagon 1mg IM: if no vascular access is obtained, contraindicated if the pt has allergy. 5. Reassess the pt's consciousness and the BGL. "repeat A B C if the pt's still unconscious". 6. Normal saline bolus if the pt's hypotensive. 7. Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem, past surgeries like heart catheterization. 8. Physical examination 9. Repeat VS every 5 mins if the pt's critical. 61
HYPERGLYCEMIA Scenario: you are dispatched to a 22 years old female complaining of epigastric pain. 1. scene size up 2. check for responsiveness 3. Start with ABCD: Airway: checking for patency. OPA for unconscious patient with absent gag reflex. C A B for unconscious pt. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation for pt with SOB, tachypnea: via NRM, or BVM based on the pt's condition. ASSESS for Kussmaul breathing. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition. Decision making: load and go if the pt's critical, stay in the scene and complete the assessment if the pt's uncritical. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ) + 12 leads ECG. " hyperglycemia could be accompanied with hyperlipidemia, so angina or MI may happen" Signs and symptoms come with hyperglycemia: headache, dizziness, shortness of breath or tachypnea, epigastric pain, nausea and vomiting, polyuria, fatigue, etc. 5. put the patient on oxygen as needed. Hyperglycemia either DKA or HHS causes dehydration, So FUILD is the most important management "20 cc NS\kg". 5. Reassess BGL. "repeat A B C if the pt's still unconscious". 6.Another NS bolus if the pt still dehydrated "there is signs of dehydration". 7. Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem, past surgeries like heart catheterization. 8. Physical examination 9. Repeat VS every 5 mins if the pt's critical. 62
STROKE Scenario: you are dispatched to a 73 years old man complaining of abnormal appearance or slurred speech. 1. scene size up 2. check for responsiveness 3. Start with ABCD:
Airway: checking for patency. OPA for unconscious patient with absent gag reflex. C A B for unconscious pt. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation for pt with SOB, tachypnea: via NRM, or BVM based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition. Decision making: load and go if the pt's critical, stay in the scene and complete the assessment if the pt's uncritical. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ) + 12 leads ECG. "hypoglycemia could resemble the signs and symptoms of stroke" If BGL is normal, check for Cincinnati score: 5. IV access for ( KVO, fluid and drug administration if needed). NS for hypotension, D50 for hypoglycemia. 6. Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem, past surgeries like heart catheterization. 7. Reassessment after the interventions for the VS. 8. Physical examination; pupils, chest auscultation for chest sound, heart sound, neurological exam "assessing the strength of the muscle, BMS, eye-­‐to-­‐finger exam, etc." 9. Consider advanced airway ( LMA, intubation ) if respiratory failure is suspected or unconscious pt with uncontrolled breathing. Rapid transportation to the nearest hospital that contains stroke team with early notification to the hospital. 63
OSCE -­‐ MENINGITIS Scenario: you are dispatched to a 58 years old woman complaining of severe headache and altered level of consciousness. 1. scene size up 2. check for responsiveness 3. Start with ABCD: Airway: checking for patency. OPA for unconscious patient with absent gag reflex. C A B for unconscious pt. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation for pt with SOB, tachypnea: via NRM, or BVM based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition. Decision making: load and go if the pt's critical, stay in the scene and complete the assessment if the pt's uncritical. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ) + 12 leads ECG. Signs and symptoms come with meningitis: headache, dizziness, shortness of breath or tachypnea, tachycardia, skin pale or redness, high temp, stiff neck, photophobia, etc. Patients with Meningitis my develop septic shock, so they present with high or low grade fever, tachycardia, tachypnea, and hypotension. YOUR PPE IS VERY IMPORTANT!! 5. IV Access, NS Bolus as needed " if the patient's in shock state, give 20cc\kg NS bolus". Dextrose in case of hypoglycemia. 6. Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem, past surgeries like heart catheterization. 7. Physical examination. 8. Repeat VS every 5 mins if the pt's critical. 64
OSPE -­‐ CNS ANATOMY AND PHYSIOLOGY 1. NERVOUS CELL ANATOMY: 2. BRAIN LAYERS Axon 1
2
3
4
5
1-­‐ Dura mater 2-­‐ Subdural mater. 3-­‐ Arachnoid mater 4-­‐ Subarachnoid mater. 5-­‐ Pia mater. 65
CONT. 3. CEREBRUM LOBES AND ITS FUNCTIONS: -­‐ Frontal lobe: •
•
Responsible for personality, and motor. Blood Supply: anterior cerebral artery, middle cerebral artery. -­‐ Parietal lobe: •
•
Responsible for sensation, and some of the motor. Blood supply: anterior cerebral artery, middle cerebral artery. -­‐ Temporal lobe: •
•
Responsible for speech. Blood supply: middle cerebral artery, posterior cerebral artery. -­‐ Occipital lobe: •
•
Responsible for vision Blood supply: posterior cerebral artery. 66
CONT. 3. MIDBRAIN ANATOMY AND PHYSIOLOGY 4
1
3
5
6
7
2
8
1-­‐ Cerebrum 9
2-­‐ Cerebellum: Responsible for coordination and complex motor. 3-­‐ Brainstem 4-­‐ Thalamus Responsible for processing sensory info. 5-­‐ Hypothalamus Responsible for hormones production (control) 6-­‐ Pituitary gland Responsible for release of hormones. 7-­‐ Midbrain Responsible for consciousness 8-­‐ Pons Responsible for the involuntary somatic and visceral motor 9-­‐ Medulla oblongata Responsible for autonomic visceral function (Cardiac, respiratory, and GI). 67
OSPE -­‐ SYMPATHETIC AND PARASYMPATHETIC SYSTEMS System\organ Pupils Heart rate Sympathetic effect Dilation Tachycardia Respiratory rate Tachypnea Vessels tone GI system Urinary system vasoconstriction Inhibited Relaxation Parasympathetic effect Constriction Norma heart rate or bradycardia Normal or Bradypnea " deep breathing" Vasodilation Activated Contraction "emptying" OSPE -­‐ ANTI-­‐SEIZURE MEDICATIONS DRUG ADULT DOSE Diazepam 0.2mg/kg up to 20mg at 2mg/min Lorazipam 0.1mg/kg IV max 10mg at 2mg/min 1ST LINE MEDICATIONS PEDS DOSE Onset, Duration 0.2-­‐0.5mg/kg IV/IO or 0.5-­‐1.0mg/kg PR up to 20mg 0.05-­‐0.1mg/kg IV 0.1mg/kg IV up to 10mg at Midazolam 1mg/min or 0.2mg/kg IM 0.15mg/kg IV Onset: 1min Duration: 20-­‐30min (longer PR) CNS/CV/Resp depression Onset: 2min Duration: >12hrs CNS/CV/Resp depression Onset: 1min Short duration 0.2mg/kg IM CONT. next page 68
Side Effect Less depression OSPE -­‐ ANTI-­‐SEIZURE MEDICATIONS 2nd LINE MEDICATIONS DRUG Phenytoin ADULT DOSE 20mg/kg IV at 50mg/min 15-­‐20PE/kg IV at Fosphenytoin 150mg/min or 20PE/kg IM 10-­‐20mg/kg IV at 30mg/min or Phenobarbital 20mg/kg IM PEDS DOSE ONSET, DURATION 20mg/kg IV at 1mg/kg/min Onset 10-­‐30min Long acting 10-­‐20PE/kg IV at 3mg/kg/min or 20PE/kg IM Same times once given Same as adult May rpt to 40mg/kg total Rapid onset. Long acting OTHER INFO Hypotension, arrhythmias Can be given faster. Expensive Resp/CV depression 3rd LINE MEDICATIONS DRUG Midazolam ADULT 0.15mg/kg IV, then 1mcg/kg/min up 1mcg/kg/min q15 PEDS As adult Propofol 1-­‐3mg/kg IV then 2-­‐10mg/kg/h Caution in <12yrs (reports of met. Acidosis) Valproic Acid 20-­‐40mg/kg IV over 5min then 5mg/kg/h As adult Pentobarbital 5mg/kg IV at 25mg/min As adult Isoflurane Via gen’l ETT anesthesia As adult 69
ONSET, DURATION OTHER Maintenance CNS/Resp/CV depression Maintenance CNS/Resp/CV depression Maintenance Hypotension Titr.to EEG Maintenance ETT/CV support Titr. to EEG Maintenance ETT/CV support OSCE -­‐ BURN MANAGEMENT Scenario: you are dispatched to a 37 years old man brought out by fire men from burned building. The scene is safe, and you have to approach the patient. 1. scene size up 2. check for responsiveness 'AVPU ' 3. Start with ABCDE: Airway: checking for patency. OPA for unconscious patient with absent gag reflex. C A B for unconscious pt. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation via NRM, or BVM based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition, look for major bleeding if present. Disability\ Decision making: load and go if the pt's critical, stay in the scene and complete the assessment if the pt's uncritical. If the patient has face or neck swelling, facial burn, or stridor, aggressively manage the airway by invasive airway devices "sedation, paralytic+ LMA or RSI " because the airway may be lost quickly. Exposure: Expose the patient, leave the adhesive part of the clothes. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ) + IV ACCESS. 5. Use Wallace rule of nines to estimate the body surface area that affected by burn. PEDIATRIC
ADULT
6. Use Parkland formula to estimate fluid resuscitation: " 4cc × kg × TBSA ". Half of the volume should be administer in the first 8 hrs of injury. CONT. 70
7. Irrigate the burned area with normal saline, and cover it with dry gauze. Cover the patient with burn sheet. 8. Detailed physical Examination. 9. Reassess ABC, and V.S. 10. Early notification to nearest hospital that contains burn unit. 71
OSCE -­‐ APPENDICITIS Scenario: you are dispatched to a 16 years old girl complaining of severe abdominal pain. 1. scene size up 2. check for responsiveness 'AVPU ' 3. Start with ABCDE: Airway: checking for patency. OPA for unconscious patient with absent gag reflex. C A B for unconscious pt. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation via NRM, or BVM based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition, look for major bleeding if present. Disability\ Decision making: Stay in the scene and complete the assessment if the pt's uncritical. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, SpO2, Temp, BGL ) 5. History taking ( SAMPLE -­‐ OPQRST ). Extra questions: " melena?, quality of vomiting if present ( forceful vomiting? hematemesis? The frequency of vomiting? ) " 6. Physical examination: " Inspection, Auscultation, percussion, and palpation ". Start away from the pain area. early signs of appendicitis are central sharp pain like stabbing "around the umbilicus" radiating to RLQ area, vomiting and diarrhea. McBruney and Psoas signs. 7. IV access, Analgesia for pain. Consider Anti-­‐emetic: Metoclopramide 5 mg IV. 8. transport the patient in a position of comfort. 9. repeat the vital signs en route. 72
OSCE -­‐ URINARY TRACT INFECTION Scenario: you are dispatched to a 63 years old man complaining of abdominal pain. 1. scene size up 2. check for responsiveness 'AVPU ' 3. Start with ABCDE: Airway: checking for patency. OPA for unconscious patient with absent gag reflex. C A B for unconscious pt. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation via NRM, or BVM based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition, look for major bleeding if present. Disability\ Decision making: Stay in the scene and complete the assessment if the pt's uncritical. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, SpO2, Temp, BGL ) 5. History taking ( SAMPLE -­‐ OPQRST ). Extra questions: Melena?, Hx of fever, pervious hospitalization for the same problem, Ask about the urine " polyuria or dysuria, frequency, hematuria, cloudy urine, burning sensation during urination, etc. 6. Physical examination: " Inspection, Auscultation, percussion, and palpation ". Start away from the pain area. Ask if there is prostate enlargement. signs of UTI are lower abdominal pain, dysuria, hematuria or cloudy urine, nausea, lethargy, Hx of fever. The pt's condition may deteriorate to septic shock, so the patient may present with tachycardia, tachypnea, high or low grade temperate, decrease level of consciousness, hypotension, pale skin with weak radial pulse. 7. IV ACCESS, Normal saline WITH CAUTION. " administering 100-­‐250ml then reassess the patient". Dextrose if the patient's hypoglycemic. Analgesia for pain. Consider Anti-­‐emetic: Metoclopramide 5 mg IV. 8. Transport the patient in a position of comfort. 9. Repeat the vital signs en route. 73
OSCE -­‐ PEPTIC ULCER Scenario: You are dispatched to a 48 years old woman complaining of severe abdominal pain. 1. scene size up 2. check for responsiveness 'AVPU ' 3. Start with ABCDE: Airway: checking for patency. OPA for unconscious patient with absent gag reflex. C A B for unconscious pt. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation via NRM, or BVM based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition, look for major bleeding if present. Disability\ Decision making: Stay in the scene and complete the assessment if the pt's uncritical. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, SpO2, Temp, BGL ) 5. History taking ( SAMPLE -­‐ OPQRST ). Extra questions: Melena?, Ask about the vomiting if present " hematemesis, frequency, amount, is it forceful vomiting?", Hx of fever, pervious hospitalization for the same problem. Dose the pain relief or increase by eating? 6. Physical examination: " Inspection, Auscultation, percussion, and palpation ". Start away from the pain area. signs of Peptic ulcer are sudden upper abdominal pain, hematemesis loos of appetite. The pt's condition may deteriorate to hypovolemic shock If forceful vomiting or severe melena is present, so the patient may present with tachycardia, tachypnea, decrease level of consciousness, hypotension, pale skin with weak radial pulse. 7. IV ACCESS, fluid resuscitation. Dextrose if the patient's hypoglycemic. Analgesia for pain. Consider Anti-­‐emetic: Metoclopramide 5 mg IV. 8. Transport the patient in a position of comfort. 9. Repeat the vital signs en route. 74
OSPE -­‐ INTEGUMENTARY EMERGENCIES Contusion Abrasion Laceration Allergic Wound infected Wound Necrotic Wound Sloughy Wound Ulcer Deep Burn 75
OSPE -­‐ MUSCULOSKELETAL EMERGENCIES Anterior Shoulder Dislocation Supracondylar Fracture Colles Fracture Scaphoid Fracture Boxer’s Fracture Jefferson Fracture Hangman’s Fracture Pubic Rami Fracture Finger Fractures 76
OSPE -­‐ MUSCULOSKELETAL EMERGENCIES Open Book Fracture Central Dislocation Fractured Neck Of Femur Posterior Dislocation Fractured Shaft Of Femur Tib Fib Fractures Ankle Fracture Calcaneum 77
OSPE -­‐ ENDOCRINE GLANDS 1
2
3
4
5
6
7
8
9
10
. No. Gland Name And Its Major Function 1 Pineal Gland: Responsible for sleeping " biological Time " Hypothalamus Gland: Control center, thermoregulation, ANS 2 regulation, etc. Pituitary Gland: Milk production in female, testosterone 3 production in male. 4 Thyroid Gland: Regulates body metabolism 5 Parathyroid Gland: calcium control 6 Thymus Gland: Stimulates the development of T-­‐cells 7 Adrenal Gland: Sodium-­‐potassium balance 8 Pancreas Gland: Body Glucose balance 9 Ovary Glands in Female: Producing Egg cells 10 Testis Glands in Male: Development of Male characteristics 78
Some Hormones Melatonin Dopamine, Vasopressin TSH, Oxytocin, LH in female FSH in male T3, T4 Parathyroid hormone Thymosin Epinephrine, norepinephrine. Insulin, Glucagon Progesterone, estrogen Testosterone OSPE -­‐ REFERRED PAIN 2
1
1
3
4
12
5
6
11
7
8
10
9
No. Referred to 1 2 3 4 5 6 7 8 9 10 11 12 Liver and Gallbladder Lung and Diaphragm Heart Stomach Pancreas Ovary in Female Colon Kidney Urinary Bladder Ureter Appendix Small Intestine 79
OSCE -­‐ ROSC Scenario: You are dispatched to a 77 years old man unconscious. When you arrived, there was a bystander doing CPR. He informed you that the patient collapsed in front of him. He checked the carotid artery and he did not find a pulse. He activated EMS and started CPR until you arrived. 1. Scene size up. 2. Start CAB: Circulation: Check the carotid pulse for 10 seconds. Start CPR while your colleague attaches the pads or paddles and puts. Airway and Breathing: your colleague will insert OPA and BVM. 3. After 2 mins, analyze the rhythm, give 200j shock if the rhythm is shockable. If the patient Returned to Spontaneous Circulation " ROSC " follow the guideline: 80
OSCE -­‐ SEVERE HEAD TRAUMA Scenario: You are dispatched to a 31 years old man involved in motor vehicle accident. 1. Scene size up. 2. Check for responsiveness 'AVPU ' 3. Start with ABCDE: Airway: checking for patency. OPA for unconscious patient with absent gag reflex. C A B for unconscious pt. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation via NRM, or BVM based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition, look for major bleeding if present. Patients with severe head trauma usually present with all or one of the following: Altered level of consciousness " agitated or comatose", irregular Breathing, or unconscious with secretion in the mouth, bradycardia. Disability\ Decision making: A. Rapid assessment to check if there is fracture. B. Control the breathing by BVM, load and go. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, SpO2, Temp, BGL ) Cushing Triad sings in patients with severe head trauma: bradycardia at 60 or below, irregular breathing, and hypertension. Thus, the priorities for these patients are: securing the airway by intubation, managing HR and BP, and rapid transportation. 5. IV ACCESS, Initiating RSI by administering " sedative like Etomidate 0.3mg\kg, paralytic like Succinylcholine 1.5mg\kg " 6. Intubate the patient and connect him on the ventilator. 7. Reassess the ABCs. And V.S continuously. 8. Detailed physical examination: head to toe exam. 9. Early notification to the hospital. 81
OSCE -­‐ ECLAMPSIA SCENARIO: you are dispatched to a 22 years old pregnant lady seizing, or decreased level of consciousness "post-­‐ectal" CLASSIC SIGNS AND SYMPTOMS: headache, seizure " tonic-­‐clonic movement", decreased level of consciousness. Epigastric pain could present. Hypertension SBP>160 1. General statement "scene size up" 2. check for responsiveness ( AVPU ) 3. Start with ABCD " CAB for unconscious pt" Active Seizure
Post ectal
1. NPA 1. secure the airway 2. High flow oxygen 2. High flow oxygen 3. Remove all dangerous stuff that could harm the patient. 3. check for radial pulse, skin condition, establish and IV access. 4. Recovery position 4. Vital signs ( HR, RR, BP, Spo2, Temp, BGL ). 5. If IV access is not established yet, Administer Midazolam 5-­‐10mg IM 5. History taking ( SAMPLE, OPQRST, GPA ) 6. If IV access is available, Administer magnesium sulfate 10% 4-­‐6g IV over 20 minute. calcium gluconate is the antidote in case the pt becomes hypermagnesemic. 7. Rapid transportation 6. If the patient starts seizing, Administer magnesium sulfate 10% 4-­‐6g IV over 20 minute. calcium gluconate is the antidote in case the pt becomes hypermagnesemic. 7. Remove all dangerous stuff that could harm the patient. 8. Recovery position 8. Taking complete vital signs ( HR, RR, BP, Spo2, Temp, BGL ). 9. Rapid transportation 9. History taking ( SAMPLE, OPQRST, GPA ) 10. After stop seizure, Fluid resuscitation with caution, dextrose in case of hypoglycemia. 10. After stop seizure, establish IV access, Fluid resuscitation with caution, dextrose in case of hypoglycemia. 11. Reassessment of the vital signs
11. Reassessment of the vital signs
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OSCE -­‐ NORMAL DELIVERY SCENARIO: you are dispatched to a 31 years old pregnant lady is about to deliver. 1. General statement "scene size up" 2. check for responsiveness ( AVPU ) 3. Start with ABCD " CAB for unconscious pt" Head present
Already delivered
1. ensure privacy, position the mother on her back with knee flexion. 2. prepare the delivery kit. 3. High flow oxygen to the mother. 4. Connect the mother to the monitor. 5. Establish an IV line with NS as needed. 1. ABC for the mother and the baby. 2. cover the baby and do umbilical cord cutting suction the mouth then the nose. 3. APGAR score for the newborn. Ask for respiratory rate and heart rate. 4. rapid transportation to the hospital 5. stimulate breathing of the baby if he\she is not 6. Ask the mother to take deep breath and push breathing well. hard per each contraction. 6. ventilate the baby if he\she is bradypnic or 7. Support the baby's head HR< 100. 6. If the baby is delivered, put clamps on the umbilical cord " one clamp 5cm away from the baby, then space, then another clamp, then cut the umbilical cord between the two clamps. 7. emotionally support the mother, dry the baby, suction the mouth then the nose, and stimulate breathing. 7. start CPR 3:1 if HR<60. 8. Vital signs of the mother if the baby is stable. ( HR, RR, BP, Spo2, Temp, BGL ). 9. History taking from the mother ( SAMPLE, OPQRST, GPA ) 10. repeat APGAR score after 5 mins. 7. Rapid transportation to nearest hospital that contains L&D department. 11. Reassess the mother and the baby. 9. History taking ( SAMPLE, OPQRST, GPA ) 11. Reassessment of the vital signs for both the baby and the mother.
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OSCE -­‐ ECTOPIC PREGNANCY SCENARIO: you are dispatched to a 27 years old lady complaining of severe abdominal pain CLASSIC SIGNS AND SYMPTOMS: unilateral abdominal pain could be referred pain to the shoulder, vaginal bleeding may be absent, spotty, or minimal, nausea, vomiting, syncope. 1. General statement "scene size up" 2. check for responsiveness ( AVPU ) 3. Start with ABCD " CAB for unconscious pt" Airway: checking for patency. Suction if fluid presents, OPA for unconscious patient with absent gag reflex. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Auscultate the chest to check for equal air entry bilaterally. Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the patient's condition. Circulation: Checking for radial pulse, skin condition and body temperature. Decision making: load and go if the pt's critical, stay and complete assessment if the pt's not critical. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). 5. Detailed history taking ( SAMPLE – OPQRST -­‐ GPA ) Extra questions: -­‐ Is she pregnant? -­‐ Previous cesarean deliveries -­‐ Last menstrual period -­‐ History of previous gynecological problems -­‐ Present blood loss or vaginal discharge " despribe the discharge, is there any clot? " -­‐ History of trauma to the reproductive system 6. IV access " KVO, Fluid resuscitation if present of vaginal bleeding or signs of shock" 7. Physical exam after ensuring privacy and after taking the permission of the pt. 8. Stop bleeding in present by putting external pads. 9. Emotional support. 10. If ectopic pregnancy is suspected, pain killer is not recommended cus the pt may become bleeding and hypotensive rapidly. 11. In ensuring that it’s ectopic pregnancy, rapid transportation to nearest hospital that contain OBGYN department. 12. Reassessment of the vital signs 84
OSCE -­‐ NEONATAL RESUSCITATION Scenario: you approached to a 27 years old lady whose already delivered. The mother is stable, and she is worried about her baby who is not moving and not crying. You have to assess the baby. 1. Scene size up. 2. First 30 seconds after birth:
A. Dry the infant. B. Provide warmth. C. Position the infant. D. Suction the infant mouth & nose. E. Stimulate the infant. 2nd 30 seconds 1. Breathing: Normal
1. Breathing: Normal
2. HR: >100
2. HR: >100
3. Color: Pink
3. Color: cyanosed
1. Observe the baby.
1. Provide 100% Oxygen.
1. Start bagging with 100% oxygen. 1. Start bagging with 100% oxygen. 2. Transfer to NICU.
2. Transfer to NICU.
2. CPR 3:1
3. Transfer to NICU.
2. Transfer to NICU.
1. Breathing: Apnic or gasping.
2. HR: >100
85
1. Breathing: Apneic or gasping.
2. HR<60
OSPE – PEDIATRIC CONGINITAL HEART ABNORMALITIES Blood circulation Transition of great vessels
Tricuspid Atresia
Total Anomalous Pulmonary Venous Return (TAPVR)
Tetralogy of Fallot (TOF)
86
OSPE -­‐ OBGYN 1. Cord Prolapse: 2. Breech Presentation: 87
OSPE -­‐ OBGYN 3. Miscarriage: A B C D E Threatened miscarriage Inevitable miscarriage Incomplete miscarriage Complete miscarriage Missed miscarriage 88
OSCE -­‐ MEDICAL TRANSPORTATION Before Moving 1. Obtain complete endorsement from the dispatch. 2. Contact the receiving hospital and make sure that they are prepared to receive the patient and they have all the devices that the patient needs. 3. Prepare the devices that the patient needs during transportation " e.g. the patient's on ventilator, infusion pump, any other device " and check in before you move from the EMS station " e.g. check the battery of the monitor, ventilator, infusion pump, etc." 4. Check the oxygen cylinders. E.g. make sure you have two portable cylinders. On Arrival 1. Obtain complete endorsement from the doctor\nurse in the sending hospital\medevac, etc. 2. Start ABC : -­‐ check the airway " ETT if the patient's intubated: check the tube depth, check the cuff of the tube, suction the tube if needed " -­‐ check breathing: lung sound, check the chest tube if present, ask the doctor if the chest tube in normal position or not. -­‐ check circulation: check the IV line " Is it in or not by flushing NS ", ask since when has the IV established?. Check if there is central line. Do not flush NS in the line till you ensure know what kind of meds is infusing in the line " e.g. you can't flush NS in a line that contains inotropes or vasopressors." Make sure you have free IV access " KVO". 3. Complete physical examination: If check if there is bandages on the patient, ask when did they change it? ask if there is active bleeding? If there is urine catheter, ask since when, check if the urine container needs to be changed. 4. Take the vital signs that have been taken from the sending hospital\facility. 5. Take a new vital signs and document it. 6. Check the ventilator's settings? Check the infusion pump's settings. En route 1. Ensure the patient safety before you move the patient to the stretcher " e.g. infusion lines " 2. Take a new vital signs. Repeat it every 5 mins if the patient's critical. 3. Disconnect the patient from the sending hospital's devices and connect the patient on your devices. Make sure of the settings before you disconnect the patient. 4. Repeat ABC. 89
OSCE -­‐ 12,15, AND 18 ECG Common signs and symptoms: chest paint, SOB, epigastric pain, vomiting, shoulder pain, heaviness on the chest, etc. 1. Scene size up 2. check for responsiveness ( AVPU ) 3. ABC "WITHOUT USING THE MONITOR": fix and move A B C D: Airway: checking for patency. OPA for unconscious patient with absent gag reflex Breathing: RR, effort, and quality of breathing, Administer O2 via nasal cannula, NRM, or BVM as needed. Circulation: Radial pulse for regularity, strength of the pulse, heart rate, and skin condition. 4. Decision making: if there is abnormality in the ABC, load and go. 5. Connect the monitor and check the vital signs: ( HR, RR, BP, SpoO2, Temp, BGL ). 6. Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem, past surgeries like heart catheterization. 7. Obtain 12 leads ECG: Leads Affected area II, III, and AVF Inferior STEMI V1, V2 Septal STEMI V3, V4 Anterior STEMI V1, V2, V3, V4 Anteroseptal STEMI V5, V6 Lateral STEMI V3, V4, V5, V6 Anterolateral STEMI In case of Inferior or Septal STEMI, Right ECG is recommended: It is done by taking Lead V4 and put it in the right mid-­‐clavicle line, 5th intercostal space. After printing the strep, write V4R on V4. Indications of Posterior ECG: ST depression is V1, V2, V3, Inferior or lateral MI. V7: Posterior mid-­‐axillary line, at the level of V4. V9: left Para-­‐spinal line at the same level of V6. V8: between V7 and V9, at the same level of V5. THE MOST IMPORTANT THING, is to write V7, V8, V9 on the ECG after you print it. CONT in the next page 90
RIGHT AND POSTERIOR ECG 8. IV access for ( KVO, fluid and drug administration if needed). NS for hypotension, D50 for hypoglycemia. 9. MONA: ( Morphine, Oxygen, Nitroglycerine, Aspirin ) Aspirin: 324mg chewing tablets Nitroglycerine: 0.4mg sublingual tablet: Contraindicated in RIGHT VENTRICLE MI "Right ECG STEMI " and in SBP <100. Oxygen: as stated above: nasal cannula, NRM, or BVM based on the pt's condition. Morphine: IF REALLY NEEDED ( start with low dose: 2-­‐2.5 as an example ). 10-­‐ Reassessment after the interventions for the VS. 11-­‐ Physical examination; heat to toe. Consider advanced airway ( LMA, intubation ) if respiratory failure is suspected or unconscious pt with uncontrolled breathing. Rapid transportation to the nearest hospital that contains cathlab with early notification to the hospital. Time window is 3 hours! 91
PEDIATRIC CASES
92
VITAL SIGNS -­‐ PEDIATRIC -­‐ 4. Body temperature 5. Blood Oxygen saturation 6. Blood glucose level 1. Heart rate ( HR ) 2. Respiratory rate ( RR ) 3. Blood pressure ( BP ) 1. Heart Rate: based on the age 2. Respiratory Rate: based on the age Age Newborn -­‐ 3 months 3 months -­‐ 2 years 2 years -­‐ 10 years > 10 years Heart Rate 85 -­‐ 205 100 -­‐ 190 60 -­‐ 140 60 -­‐ 100 The rate decreases during sleeping phase Age Infant Toddler Preschooler School-­‐aged child Adolescent Heart Rate 30 -­‐ 60 24 -­‐ 40 22 -­‐ 34 18 -­‐ 30 12 -­‐ 16 3. Blood pressure Formula for children 1 year and above: ( Age per year X 2 ) + 70 Age Neonate ( 0 -­‐ 28 days ) Infant ( 1 -­‐ 12 months ) 1 year -­‐ 10 years > 10 years Systolic blood pressure < 60 < 70 Follow the Formula ( approx. < 70 ) Follow the Formula ( approx. < 90 ) 4. Body temperature -­‐ Same as Adult -­‐ Normal temperature 36 or 37 less than 36: Hypothermia more than 37: Hyperthermia 5. Blood Oxygen saturation -­‐ Same as Adult -­‐ Normal range 95% -­‐ 100% less than 95%: Desaturation 6. Blood glucose level ( it is recently considered as a vital sign ) -­‐ Same as Adult -­‐ Normal range in mg\dL: ( 80 -­‐ 100 ) less than 80: Hypoglycemia more than 100: hyperglycemia Normal range in mmol\L: ( 4 -­‐ 6 ) less than 4: Hypoglycemia more than 6: hyperglycemia 93
BLS -­‐ PEDIATRIC CARDIAC ARREST 1. Verbalizing scene size up ( general statement; page no.2 ) 2. check for responsiveness ( AVPU ) 3. Start with C A B: C: check the pulse for 10 seconds. In infant: check brachial pulse. In older child: check carotid pulse. No pulse, No chest rise 1. Expose the chest, start chest compressions for one cycle in the nipple line 2. Ask the second rescuer to bring AED 3. Activate EMS rate: 30 compressions\2 breaths if one rescuer. 15:2 if two rescuers = One cycle continue CPR till AED is available. 4. Attach AED, follow AED instructions High Quality CPR: https://www.youtube.com/w
atch?v=EoOSsmK2DKU https://www.youtube.com/w
atch?v=jQCBN2i_Xus note: check pulse and breathing at the same time. Shockable rhythm Non-­‐shockable rhythm Continue CPR rate: 30 \ 2 if one rescuer, 15:2 if two rescuers for 2 mins Deliver shock, resume CPR immediately for 2 mins 2MINS 1. check for pulse 2. Switch rules 3. Analyze rhythm by AED 94
BLS -­‐ PEDIATRIC CHOKING Scenario: you found a 6 months baby near to small pills. The baby is anxious and could not breath well. 1. Verbalizing scene size up ( general statement; page no.2 ) Useful link illustrating the steps of management for adult choking: https://www.youtube.com/watch?v=Gq1LEJ7JqkY 95
OSCE -­‐ ASTHMA Scenario: you are dispatched to a 6 years old boy complaining of SOB. Classic signs and symptoms: SOD, wheezing, tachypnea, tachycardia, low SpO2. 1. General statement "scene size up" 2. Check for responsiveness ( AVPU ) 3. PAT " Appearance, Breathing, Circulation " 3. Start with ABCD " CAB for unconscious pt" Airway: checking for patency. Suction if fluid presents, OPA for unconscious patient with absent gag reflex. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Auscultate the chest to check for equal air entry bilaterally. Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the patient's condition. Circulation: Checking for radial pulse, skin condition and body temperature. Capillary refill. Decision making: Load and go if the pt's critical. Transport the patient in a position of comfort, stay and complete assessment if the pt's not critical. 4. Put the patient on humidified oxygen. 5. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). 6. Detailed history taking ( SAMPLE – OPQRST ) 7. Salbutamol "AKA. albutarol or ventoline": Pediatric: 0.63-­‐2.5mg in 3cc NS. In case of moderate to severe asthma, the paramedic could duble the does. Aslo, the dose could be repeated 3 times back-­‐to-­‐back. -­‐ Ipratropium "AKA. Atrovent": Adult: 0.25mg in 3cc NS. in compained solusion " Salbutamol+Ipratropium": 0.25 mg Ipratropium+2.5mg Salbutamol. 8. IV acssess, NS 20cc\kg as needed, D25 or D10 in case of hypoglycemia. 9. Magnesium sulfate ( in the ER ) for moderate asthma or for patient who is not responding to the nebz: 50-­‐75 mg per kg IV Slow IV push ( over 20 mins ). FOR SEVERE ASTHMA: -­‐ Epinephrine: 0.01 mg for max. 300-­‐500 mcg IM 10. REASSESS THE PT AFTER EACH INTERVENTION. 96
OSCE -­‐ ANAPHYLAXIS Scenario: you have a 8 years old girl complaining of shortness of breathing "SOB". 1. Verbalizing scene size up 2. check for responsiveness ( AVPU ) 3. Start with A B C: Airway: checking for patency. Suction if fluid presents, OPA for unconscious patient with absent gag reflex. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Auscultate the chest to check for equal air entry bilaterally. Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the patient's condition. Circulation: Checking for radial pulse, skin condition and body temperature. Capillary refill. Decision making: load and go if the pt's critical, stay and complete assessment if the pt's not critical. In case of anaphylaxis, the common signs and symptoms are: SOB, wheezing on chest auscultation, tachycardia, tachypnea, skin redness and rash all over the body. 4. Obtain quick history to rule out other causes: -­‐ Does he\she have allergy? what did he\she do before the symptoms appeared? 5. If it's obvious that this is hyperreaction, Administer epinephrine 1:1,000 0.01mg\kg for max. 0.5mg IM every 10 to 15 minutes up to two doses as needed. It is crucial even before checking A B C. ONLY IF IT IS CLEARLY STATED THAT THE PT HAS ANAPHYLAXIS NOW! 6. Give high flow oxygen via non-­‐rebreather mask. If respiratory distress still present, nebulizer could be given (Albuterol 2.5mg+ Ipratroprium 0.25 mixd with normal saline) 7. Reassess A B C after administering the epinephrine, consider Advanced Airway if losing the airway is highly suspected! 8. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). With 12 leads ECG 9. Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem. 10. Physical Examination: Head to toe checking for the rashes, chest auscultation for ear entry sound and heart sound. 11. IV\IO access, NS fluid as needed based on the pt's BP. 12. Corticosteroids "dexamethasone" 16mg oral. Dextrose with normal salain if pt's hypoglycemic. 13. Reassessment after each intervention. 14. In case of anaphylactic shock " severe hypotension ", continuous epinephrine infusion: 1-­‐10mcg\min. 97
OSCE -­‐ CROUP Scenario: you are dispatched to a 3 years old boy complaining of SOB and fever. Classic signs and symptoms: fever, stridor, barking cough, tachypnea, tachycardia, low SpO2. 1. General statement "scene size up". 2. Check for responsiveness ( AVPU ). 3. PAT " Appearance, Breathing, Circulation ". 3. Start with ABCD " CAB for unconscious pt". Airway: checking for patency. Suction if fluid presents, OPA for unconscious patient with absent gag reflex. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Auscultate the chest to check for equal air entry bilaterally. Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the patient's condition. Circulation: Checking for radial pulse, skin condition and body temperature. Capillary refill Decision making: load and go if the pt's critical. Transport the patient in a position of comfort, stay and complete assessment if the pt's not critical. 4. put the patient on humidified oxygen. 5. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). 6. Detailed history taking ( SAMPLE – OPQRST ) 7. Nebulized Racemic epinephrine 0.5 mg "β-­‐2 agonist" 8. Corticosteroids "dexamethasone" 16mg oral. 9. IV acssess, NS 20cc\kg as needed, D25 or D10 in case of hypoglycemia. 10. reassess the patient's vital signs. 98
OSCE -­‐ SEIZURE Scenario: you are dispatched to a 19 years old female who was found unconscious " postictal state", Or pt with active seizure, Or pt with uncontrolled seizure ( status epileptic ) 1. Scene size up 2. check for responsiveness "AVPU" 3. A B C D: Airway: NPA for seizing pt, OPA if unconscious pt with absent gag reflex. Putting the pt in the recovery position ( on the side to prevent aspiration of the vomitus ). Breathing: Assess for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing) for postictal state with oxygen administration, High flow oxygen ( 15lpm via NRM and NPA ) for seizing pt. Oxygenation via NRM, or BVM and assist ventilation based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition. Capillary refill Decision making: if there is any abnormality in the ABC; pt's critical, so load and go. If not, pt's uncritical, so stay in the scene and complete the assessment. In case of active seizure, Administer Midazolam 0.1-­‐0.2mg\kg IM for max. 10mg. Lorazipam 0.1mg\kg per rectal for max. 4mg. If the medication is giving in the deltoid area, give 2.5 mg in each arm. Midazolam could be given IV if available IV access " 0.15mg\kg " Consider Long-­‐acting benzodiazepine for epilepsy like lorazipam 0.1mg\kg. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL )+ 12 leads ECG. 5. IV access for ( KVO, fluid administration, another dose of benzo in recurrent seizure) 6. Normal slain bolus in case of low blood pressure\ dextrose if hypoglycemia is present. 7. Checking for underlying cause: hypoglycemia, recent trauma, infection, etc. ). 8. Reassessment after the interventions for the VS. especially for the respiratory rate. 9. Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem. Asking for the duration of the seizure. 10. Physical examination: head to toe Consider antidote of the benzodiazepine if complications happened ' respiratory depression" ( flumazenil 0.2mg IV ). 11. Advanced airway ( intubation or LMA ) in case of respiratory failure or unconscious pt with uncontrolled breathing. 12. High flow Oxygen, maintaining BGL, and fluid resuscitation are considered as the most benefit interventions for postictal phase.
13. REASSESS 99
OSCE -­‐ MENINGITIS Scenario: you are dispatched to a 12 years old female complaining of severe headache and altered level of consciousness. 1. scene size up 2. check for responsiveness 3. Start with ABCD: Airway: checking for patency. OPA for unconscious patient with absent gag reflex. C A B for unconscious pt. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Oxygenation for pt with SOB, tachypnea: via NRM, or BVM based on the pt's condition. Circulation: Assessing the radial pulse for regularity, strength of the pulse, heart rate, and skin condition. Decision making: load and go if the pt's critical, stay in the scene and complete the assessment if the pt's uncritical. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ) + 12 leads ECG. Signs and symptoms come with meningitis: headache, dizziness, shortness of breath or tachypnea, tachycardia, skin pale or redness, high temp, stiff neck, photophobia, etc. Patients with Meningitis my develop septic shock, so they present with high or low grade fever, tachycardia, tachypnea, and hypotension. YOUR PPE IS VERY IMPORTANT 5. IV Access, NS Bolus as needed " if the patient's in shock state, give 20cc\kg NS bolus". Dextrose in case of hypoglycemia. 6. Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem, past surgeries like heart catheterization. 7. Physical examination. 8. Repeat VS every 5 mins if the pt's critical. 100
OSCE -­‐ HYPOGLYCEMIA Scenario: You are dispatched to a 9 years old boy complaining of altered level of consciousness. Common chief complaints: decreased level of consciousness, dizziness, shortness of breath, unconscious patient, semi-­‐conscious patient, etc. 1. Verbalizing scene size up 2. check for responsiveness ( AVPU ) 3. Start with A B C: Airway: checking for patency. Suction if fluid presents, OPA for unconscious patient with absent gag reflex. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Auscultate the chest to check for equal air entry bilaterally. Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the patient's condition. Circulation: Checking for radial pulse, skin condition and body temperature. Capillary refill. Decision making: load and go if the pt's critical, stay and complete assessment if the pt's not critical. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). If BGL is less than normal: -­‐ Oral glucose: if the pt's conscious, alert, and oriented. -­‐ Dextrose IV ( D25 ) 2ml\kg OR (D10) 5ml\kg: if the pt's is semi-­‐conscious, disoriented, unconscious. -­‐ Glucagon 1mg IM: if no vascular access is obtained, contraindicated if the pt has allergy. 5. Reassess the pt's consciousness and the BGL. ( repeat A B C if the pt's still unconscious ). 6. Normal saline bolus if the pt's hypotensive. 7. 12 leads ECG; severe hypoglycemia could cause pulseless dysrhythmias. 8. Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem, past surgeries like heart catheterization. 9. Physical examination: Head to toe 10. Repeat VS every 5 mins if the pt's critical. Pt with hypoglycemia may develop seizure, so considering benzodiazepine ( midazolam 5mg IV as an example ). 101
HYPERGLYCEMIA Scenario: You are dispatched to 8 years old girl complaining of epigastric pain. Common chief complaints: headache, dizziness, shortness of breath or tachypnea, epigastric pain, nausea and vomiting, polyuria, fatigue, etc. 1. Verbalizing scene size up 2. check for responsiveness ( AVPU ) 3. Start with A B C: Airway: checking for patency. Suction if fluid presents, OPA for unconscious patient with absent gag reflex. Breathing: Assessing for respiratory rate, effort, and quality of breathing (shallow, normal, or deep breathing). Auscultate the chest to check for equal air entry bilaterally. Oxygenation via nasal cannula, NRM, or BVM with assisting ventilation based on the patient's condition. Assess for Kussmaul breathing. Circulation: Checking for radial pulse, skin condition and body temperature. Capillary refill. Decision making: load and go if the pt's critical, stay and complete assessment if the pt's not critical. 4. Connect the monitor and check the vital signs: ( HR, RR, BP, Spo2, Temp, BGL ). If BGL is more than normal: pts with hyperglycemia ( either DKA or HHNS ) have severe dehydration, so FLUID resuscitation is one of the most important interventions. 5. 20cc\kg over 20min 6. Reassessment after the interventions for the VS. 7. 12 leads ECG; hyperglycemia could be accompanied with hyperlipidemia, so angina or MI may happen. 8. Detailed history taking ( SAMPLE – OPQRST ), similar events, recent hospitalization for the same problem, past surgeries like heart catheterization. 9. Physical examination: from head to toe. 102
PALS -­‐ VF \ PULSELESS VT Scenario: You are dispatched to 4 years old boy who was found unconscious. 1. Verbalizing scene size up 2. check for responsiveness ( AVPU ) No pulse, No chest rise 1. Activate EMS for more help 2. Expose the chest, start chest compressions in the nipple line: rate 30 compressions\ 2 breaths = One cycle if one rescuer. 15\2 if two rescuers. continue CPR till the paddles are attached by another rescuer. 3. Put OPA or NPA 4. Analyze the rhythm that is seen in the monitor Shockable rhythm VF\VT 1. Deliver unsynchronized shock 2J\kg, resume CPR immediately for 2 mins IV \ IO access Shockable rhythm VF\VT Deliver unsynchronized shock 4J\kg, resume CPR immediately Epinephrine 0.01mg\kg repeat every 3-­‐5 mins Shockable rhythm VF\VT Non-­‐shockable rhythm Asystole\ PEA 2MINS 1. check for pulse 2. Switch rules 3. Analyze rhythm 2MINS 1. check for pulse 2. Switch rules 3. Analyze rhythm Continue CPR for 2 mins IV \ IO access Non-­‐shockable rhythm Asystole\ PEA Continue CPR Epinephrine 0.01mg\kg repeat every 3-­‐5 mins Non-­‐shockable rhythm Asystole\ PEA Continue CPR Epinephrine 0.01mg\kg every 3-­‐5 mins Deliver unsynchronized shock 4J\kg, resume CPR immediately Amiodarone 5mg\kg. for torsado de point, magnesium sulfate 25-­‐50mg\kg for max.2g 103