IMPORTANT ECRN INFORMATION!!!

Region X SOP’s revised






Effective February 1, 2012 for most of Region X EMS
ECRN’s and ED MD’s need to be familiar with the
changes
Complete the packet reviewing the changes
Submit the post quiz ASAP
Follow-up packet coming out shortly reinforcing
changes
Check date listed on cover page of SOP’s to note
new/old version
1
Region X SOP Changes
Equipment, Drugs, Skills
ECRN Mod III 2011 CE
Condell Medical Center
EMS System
2 hours CE Credit - IDPH
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Rev 1.20.12
2
Objectives
Upon successful completion of this module, the ECRN will
be able to:
Review changes to the Region X SOP’s beginning 2/1/12
 Discuss the action, indications, contraindications, dosing,
and side effects of Atrovent (Ipratropium), Etomidate,
Fentanyl, and Zofran (Ondansetron)
 Identify indications for use of the humeral site for IO
insertion
 Identify indications for placement of the King airway
 Review case scenario presentations
 Complete the 10 question quiz with a score of 80% or
better
3

Why Changes to the SOP’s?

Revisions made based on changes in
guidelines to practice in several
organizations:
 AHA
– conference every 5 years
 Impacts
BLS, PALS, ACLS, NALS
 ITLS
 International
Trauma Life Support
 Guidelines that impact trauma care
 EMSC
 Emergency
Medial Services for Children
4
How will these changes affect me?

Effective 1st shift of the day 2/1/12 EMS
will follow the revised Region X SOP’s
 This
may mean 0700 or 0800 for departments
in Region X
 Region
9 EMS providers have already adopted
these changes in 2011
5
Region X Members
The Condell EMS System members transport to
Condell and Lake Forest Hospitals
 Also transport to additional area hospitals
 Condell and Lake Forest also receive EMS
members from other Region X EMS Systems (ie:
Vista, Highland Park)
 Condell and Lake Forest also receive members
from Region 9 EMS Systems


ie: Lincolnshire, Buffalo Grove, Long Grove, Lake Zurich
 Most common Region 9 departments to transport to
Condell and Lake Forest Hospitals
6
Region X EMS Providers
Will begin to use new SOP’s 2/1/12

Condell EMS System
Countryside Fire
 Grayslake Fire
 Lake Forest Fire
 Libertyville Fire
 Mundelein Fire
 Round Lake Fire
 Wauconda Fire
 Lake Bluff Fire
 Knollwood Fire
 Murphy


Highland Park EMS
System
Deerfield Fire
 Glencoe
 Gurnee Fire
 Highland Park Fire
 Highwood Fire
 Northbrook Fire
 NIPAS
 Six Flags
 Superior Vernon Hills

7
Region X EMS Providers
Will begin to use new SOP’s 3/1/12

Vista EMS System
Antioch Fire
 Beach Park Fire
 Great Lake Fire
 Lake Villa Fire
 Newport Fire
 North Chicago Fire
 Waukegan Fire
 Winthrop Harbor Fire
 Zion Fire

Vista EMS Privates
ATEC
 Murphy
 Paratech
 Murphy



St. Francis EMS
System

Providers around the
Evanston based
hospital area
8
Global Changes Made

Oxygen administration
 (per
AHA) Oxygen should be administered to
patients with breathlessness, signs of heart
failure, shock or an arterial oxyhemoglobin
saturation <94%
 Insufficient
evidence to support routine
administration in uncomplicated AMI or ACS
without signs of hypoxemia or heart failure*

Bottom line: less use of routine O2
 *AHA 2010 Guidelines
9
Oxygen Administration
Supplemental oxygen is necessary to
prevent hypoxia and for cells to function
 During normal cellular metabolism;
oxygen changed to a byproduct

A
free radial toxic molecule
 Damages cell membranes

Normally, enzymes in cells destroy toxic
oxygen molecules
 Enzymes
produced at a fixed rate
 Enzymes insufficient in number when
metabolism increases
10
Excessive Oxygen





Cells function poorly in low O2 environments
As O2 availability increases, cellular function
increases
There is an end point to additional benefits
Over time excessive O2 can become harmful
Measurement in the field


Measurement in the hospital


SpO2 levels >94% is the goal
Blood gases
Cellular damage roughly evident by 24 hours
11
Oxygen Orders
Never withhold O2 from patients in
respiratory distress or who are hypoxic
 Administer O2 to those with smoke
inhalation
 To prevent complications, consider the use
of nasal cannula before the
non-rebreather mask
 Apply O2 just long enough to maintain
normal saturations

12
Global Changes Made

IV fluid challenge language
 Formula
for all persons: 20ml/kg
 Reassessment performed at every 200 ml
increment
 Adults:
If signs or symptoms of shock or
hypoperfusion, administer fluid challenge in 200 ml
increments. Titrate to desired response.
 ie: adults may require 1-2 L
 Peds 1-15: Adjust flow rate based upon condition
and weight; administer IV fluid challenge 20
ml/kg; repeat as needed
13
“Desired Response” for Fluid
Challenge
Evaluate level of consciousness
 Evaluate blood pressure

 Goal
is to maintain adult B/P >90 systolic
 Evaluate skin parameters
 Drier?
 Warmer?
 Less

pale?
Auscultate lung sounds
 Keep
lungs dry
14
Global Changes Made
Standardized adult systolic B/P >90
 Medication route

 Any
med given IVP can be given IO
 IN (intranasally via MADD) may take
precedence over IVP/IO routes (active seizure
and no IV access)
 If
 IN
IV access established, use IV over IN
meds: Narcan, Glucagon, Fentanyl, Versed
 Same
dose amount as IVP/IO route
15
Global Changes Made

“Securing the airway”
Not a new term
 A vague term to indicate to secure the airway (make
the patient ventilate/breath and oxygenate) in
whatever method works for the situation
 Patient positioning – most under used technique
 Oro/pharyngeal airways
 Supportive bagging via BVM
 Advanced airway – King, combitube, endotracheal
tube

16
Airway Control

Not all patients need to be intubated in
the field
 Technique
takes time
 Could delay transport time to perform
 Could increase risk of additional problems
(ie: vomiting with aspiration)

If airway is “secured” using an alternate
method of intubation, ventilation and
oxygenation have been achieved,
anticipate placing an advanced airway in
the ED, not in the field
17
Global Changes Made

Once intubated, methods to secure the
tube
 Tape
 Commercial
tube holder
 Cervical collar
 Studies conducted prove that immobilizing
the neck prevents dislodgment of the distal
end of the airway that was placed
18
Global Changes Made

Ventilation rates



Guidelines from 2010 AHA changes
Respiratory rates for patient with a pulse and no
advanced airway in place
Supportive BVM for assistive ventilations

Adult (puberty and beyond): 1 breath every 5-6
seconds


Child (1 to puberty): 1 breath every 3-5 seconds


10-12 breaths per minute
12-20 breaths per minute
Neonate: 1 breath per second
19
Global Changes Made

CPR changes
 Switch
compressors every 2 minutes (5 cycles)
 Push harder/faster; breathe slower
 Compression
rate:
 Infant/child/adult: at least 100 compressions per
minute
 Coordination
ventilations/compressions
 Prior
to intubation, compressions paused for
2 ventilations
 After intubation, compressions continuous;
ventilations interposed during compressions
20
Ventilation Rate Via Advanced Airway

Ventilate once every 6-8 seconds
 8-10

breaths per minute
During CPR, compressor does not pause if
advanced airway is in place
 Ventilations
are interposed during compressions
For compressions – push faster/push harder
 For ventilations – SLOW DOWN!!!

21
Global Changes Made

After defibrillation, NO PULSE CHECK
 Immediately

resume compressions
Perform pulse check after 2 minutes of
CPR and only if a rhythm is viewed that
should produce a pulse
22
Global Changes Made

Return of Spontaneous Circulation – ROSC
 If
patient regains a pulse after cardiac arrest,
outcome improved if patient is cooled for
12-24 hours
 ROSC defined
 Pulse
maintained for at least 5 minutes
 Systolic B/P >90
 EMS
to place ice packs in axilla, around groin
and neck, and over IV site
 ED
can continue or change to their internal
procedures
23
Global Changes Made

Withdrawing resuscitative efforts
Patient is normothermic adult
 Unwitnessed arrest/unknown downtime
 Airway secured, IV/IO placed
 Patient remains in asystole
 No response to at least 20 minutes ALS care

Provide name of ED MD terminating efforts
 EMS may need to bring the body to the ED



Extenuating circumstances, EMS may be unable to
leave the body at the scene
May need to transport to the ED
24
Advanced Directives
EMS cannot honor Living Wills
 EMS CAN honor

 Valid
DNR – must be with the patient
 Durable Power of Attorney for Healthcare
 Agent does not speak for patient until
patient no longer able to speak for
themselves
25
Global Changes Made

Transport to Grayslake and Lindenhurst
free standing ED
 Acceptable
as closest appropriate facility for
BLS transports
 No IV required in the field
 No EKG monitor applied in the field
26
Medication Changes to
the Region X SOP’s
Region 9 made these changes in 2011
 Changes follow AHA guidelines

 If
you have taken a recent ACLS, PALS or BLS
class, the changes should not sound new
27
Medication Changes

Medications
Modified/Changed



No Lidocaine in cardiac
patients
No Atropine in PEA or
asystole
More reliance on
Versed for active
seizures stick
exposure)

Medications added





Atrovent (Ipratropium
Bromide)
Etomidate
Fentanyl
Zofran (Ondansetron)
New indications
added

Lidocaine for IO
needles in nonarrested patient
28
Why Medication Deletions?

Lidocaine in cardiac patient
 Not
heavily studied
 Amiodarone proven to be more effective

Atropine in PEA and asystole
 Not
proven to be effective
 Removed from treatment
29
Control of Seizures

Why Versed over Valium for seizure
control with no IV access?
 Versed
can be given via IN with MADD
 Decreases
risk of needle exposure and therefore
needle stick during active seizure
 Versed
and Valium only stop the current
seizure; do not prevent future seizures
 If
seizure stops before full dose delivered, EMS
should stop administration of medication and
“bank” the extra dose
30
Why Adding a Bronchodilator?
Albuterol is a “rescue” bronchodilator
 Atrovent is a long acting bronchodilator

 One
dose sufficient for field treatment
 After mixing the 2 bronchodilators for the first
dose, can repeat the Albuterol alone as
needed
 Atrovent has no effect on cardiovascular
system
31
Atrovent (Ipratropium Bromide)
Actions
Bronchodilation of bronchial smooth
muscle
 Blocks action of acetycholine at
parasympathetic sites in bronchial
smooth muscle (an anticholinergic drug)
 Will dry up excessive secretions

Onset 5 - 15 minutes
 Duration 4 - 6 hours

32
Atrovent (Ipratropium Bromide)
Indications

Treatment of bronchospasm due to
asthma, COPD, bronchitis, emphysema
 Not used for immediate relief but for
maintenance of effects from
bronchospasm
Therefore helpful when mixed with
Albuterol
Albuterol used for the rescue,
Atrovent for the longer effects
If taken at home, can be repeated
x1 by EMS upon their arrival
33
Atrovent (Ipratropium Bromide)
Contraindications

Hypersensitivity to atropine

No age-related precautions
 Children
and elderly

Unknown if passes through to breast milk

Peanut allergies are related to the
metered dose prescription; not the
product used in Region X
34
Atrovent (Ipratropium Bromide)
Dosing

Adult and peds
 0.5mg
/ 2.5 mL ampule
 To be mixed with Albuterol in nebulizer cup
 First
dose only; Albuterol alone after first dose
35
Atrovent (Ipratropium Bromide)
Side Effects
Coughing
 Dizziness
 Insomnia, restlessness
 Nausea
 Dry mouth
 Headache

36
Why Changes to Drug Assisted
Intubation?
Name change to better reflect care provided
 Etomidate replacing Versed, Morphine,
Benzocaine for pre-sedation
 Continue to use Lidocaine if head insult
(medical or trauma) present

 Eliminates
cough reflex which would spike
intracranial pressure (ICP)
 Bolus sufficient; no drip required

Versed continues to be used for post
sedation
37
What is the Difference to Intubate
the Pediatric Patient?

Atropine added as a premedication
 Blunts
a bradycardic response that may be
triggered during the process of intubation
Lidocaine used to blunt the cough reflex if
head insult (medical or trauma)
 Etomidate used to sedate the patient
 Versed used to continue sedation postprocedure

38
Etomidate Actions
Nonbarbiturate hypnotic, sedative
 Short acting drug to produce rapid
anesthesia


Minimal cardiovascular effects
Onset 1 - 2 minutes
 Duration generally 3 - 5 minutes

39
Etomidate Indications

Sedation to relieve apprehension or impair
memory during intubation

Effects may be increased when combined
with other central nervous system (CNS)
depressants
40
Etomidate
Contraindications

Hypersensitivity to Etomidate

Labor and delivery
 Insufficient
data to support its use
 EMS to contact Medical Control for
clarification if situation presented
 ECRN to consult with ED MD for orders
41
Etomidate
Dosing

Adult and peds
 0.3 mg/kg slow IVP/IO
 Give over 30-60 seconds
 Maximum dose 20 mg
 Typical
20mg

150 pound person meets the max of
Too rapid an injection may result in hypotension
(Treat with fluid challenge) or short term muscle twitch
0.3 mg/kg is an average dose
 Dosing charts for adults and peds available in
back of the SOP’s

42
Etomidate Side Effects







Nausea and vomiting
Dysrhythmias
Breathing difficulties
Hypotension – treat with fluids
Hypertension
Transient involuntary muscle movement
Myoclonic activity (coughing, hiccups)


Appears as muscle twitching especially if given too
rapidly
 Usually resolves spontaneously, does not interfere
with ability to finish securing the airway
Pain at injection site

Less when larger, more proximal sites used
43
Why Add Fentanyl?

Morphine dilates blood vessels
 Morphine
can cause a drop in blood pressure
so use may be more limited

Morphine longer lasting than Fentanyl
 Patient’s
ability to give detail regarding their
complaint may be obscured by the Morphine

Morphine can cause nausea/vomiting as a
side effect
 Less
incidence with Fentanyl
44
Fentanyl Actions
Opioid analgesic
 Alters pain reception
 Increases pain threshold


Also known as
 Duragesic
Onset 7-8 minutes
 Duration ½ - 1 hour

45
Fentanyl Indications
Sedation
 Pain relief
 Adjunct to general or regional anesthesia

In cardioversion, Versed (midazolam) used
for sedation and as an amnesic
 Fentanyl used for pain/discomfort

 Cardioversion
is a painful procedure!!!
46
Fentanyl Contraindications
Increased intracranial pressure (ICP)
 Severe hepatic (liver) or renal impairment
 Severe respiratory depression

Cautious use in bradycardia
 Readily crosses the placenta

 May
prolong labor if given in first stage of
labor or before cervical dilation of 4-5 cm
47
Fentanyl Dosing

Adult and peds
 0.5
mcg/kg slow IVP/IN/IO
 Administer
over 1-2 minutes
 IN route must be delivered rapidly to create a
mist; dispensing syringe can be paused as med
is being delivered
 Too rapid administration increases risk of skeletal
and thoracic muscle rigidity resulting in larygo and
broncho spasms and apnea
 In
5 minutes may repeat 0.5 mcg/kg slow
IVP/IN/IO
 Max total dose 200 mcg adult and peds
48
Fentanyl Side Effects





Mixing with benzodiazepines may increase risk
of hypotension and respiratory depression
 Narcan an effective reversal agent
 BVM should be available when medications
that can cause respiratory depressant are
being administered
Nausea, vomiting, diarrhea, constipation
 Less nausea noted than with use of Morphine
Dry mouth
Abdominal pain
Orthostatic hypotension
49
What Is Done for the Patient With
Nausea?

Primary concern is protecting the airway
 Positioning
 Suction
available
 Possible intubation

Once the nausea is relieved, other issues
may not need field treatment (ie: pain)
 Think
the volume of patients into the ED as
walk-ins that just want the nausea relieved
 These patients may also need hydration
50
Zofran (Ondansetron)
Actions

Antinausea, antiemetic

Half-life 3 – 6 hours
51
Zofran (Ondansetron)
Indications

Prevention/treatment of nausea and/or
vomiting
52
Zofran (Ondansetron)
Contraindications
Hypersensitivity to the medication
 Caution:

A
9/15/11 FDA Medwatch Safety Alert issued
for patients with long QT syndrome
 May develop tachydysrhythmia
(i.e.: Torsades)
 Watch for dysrhythmias
 Patient may complain of feeling a
racing pulse
 Palpate the pulse and compare with
the initial assessment
53
Zofran (Ondansetron)
Dosing
Adult 4 mg IVP/IO over 30 seconds
 Peds >40 kg 4 mg IVP/IO over 30 seconds
 Peds <40 kg 0.1 mg/kg IVP/IO over 30
seconds


May repeat same dose once after 10
minutes
54
Zofran (Ondansetron)
Side Effects
Anxiety
 Dizziness
 Drowsiness – especially noted in children
 Headache
 Fatigue
 Constipation, diarrhea
 Hypoxia
 Urinary retention

55
How Does EMS Control the Airway?
 Positioning
 Suctioning
 Assistive
ventilation via BVM
 Adjuncts
 Oro/pharyngeal
airway
 Advanced airways
Endotracheal tube
King airway
Combitube
56
The King Airway

Alternate airway device
 Supraglottic, supralaryngeal,
extraglottic, oropharyngeal
 Back up for failed or difficult intubation
attempts in the field
 Provides a ventilatory device
57
King Airway

A dual lumen supraglottic
airway
2
cuffs inflated via a single
port
 Device sits in the larynx
above the vocal cords
 Distal cuff seals esophagus
 Proximal cuff seals oropharynx
 Back of the throat
Balloons
inflated
58
59
King Airway Contraindications
Persons less than 4 feet tall
 Presence of a gag reflex

 Check
for presence of a blink reflex
 Stroke eye lashes looking for eye
movement
 Tap space between eyes at bridge of nose
to check for blink reflex
Known esophageal disease
 Caustic ingestion

60
Sizing

Color-coded size chosen based on patient
height
 4-5' tall– size 3–yellow
Think “3-4-5”
 5-6' tall – size 4 – red
Think “4-5-6”
 >6' tall –size 5–purple
Think “5-6”
61
Procedure

Patient pre-oxygenated via BVM
 May
need to insert an oropharyngeal airway
(OPA) or nasopharyngeal airway (NPA)
 Pre-oxygenated for 3 minutes
 Airway adjunct removed just prior to insertion
of King airway
62
Equipment

Equipment assembled and checked
 King airway
 Syringe
 Water-soluble lubricant
 BVM
 Stethoscope
 Device/tape to secure tube
63
King Balloon Inflation

After insertion, pilot balloon inflated with
appropriate volume of air
 Minimum
volume of air posted used initially
 Ranges printed on side of tube as reference
 Size 3 (yellow) – 45 - 60 mL
 Size 4 (red) – 60 – 80 mL
 Size 5 (purple) – 70 -90 mL

Do not leave syringe connected to pilot
balloon - will withdraw air out of cuffs
64
King Placement
While bagging, King airway gently and
simultaneously withdrawn until breath
sounds are auscultated and ventilation is
easier
 Cuff inflation adjusted as necessary if air
leak is heard

65
Confirming King Placement
5
point auscultation
 Negative epigastric sounds
 Bilateral breath sounds
 Equal rise and fall of chest
ETCO2 yellow or capnography 35-40 mm Hg
 Cervical collar applied to assist in maintaining
tube position

66
Nice to Know!
 “…no
inadvertent tracheal intubation,
which would lead to complete
obstruction of the airway occurred.

Genzwuerker H et al. The Laryngeal Tube: A New Adjunct for Airway
Management. Prehosp Emerg Care 2000; 4(2): 168-72.
67
What Does the ED Do With the King
Airway?
Initially, ED can use the King airway to
ventilate the patient
 Cannot deliver medications via a King or
combitube
 King does not protect the airway as
securely as an ETT

 ED
may replace the King with an ETT when
timing is right
 Equipment
available, right personnel are available
68
 Follow ED MD instructions
Removing the King Airway
Have alternate ventilation method ready
 Deflate the cuffs





One pilot port used for both cuffs
A minimum of 45 ml of air will need to be withdrawn;
most likely more
Withdraw air from the port until resistance felt
 Indicates cuffs are deflated
Remove the King airway like an ETT


Evaluate ventilations
Evaluate need for replacement device
69
What Alternative IV Access is
Available in the Field?

IO sites available
 All

ages
Sites used
 Peds
2
– tibial area
fingers below patella, 1 finger to the medial side
 Adult
– tibial area
 Humeral

site is backup if tibial site not available
All needles 15 G
 Difference
is in the length
70
EZ IO
An alternative IV access method
 Rapid placement possible
 Rapid entry into the bloodstream


Consider if patient NEEDS IV access or do YOU
just want IV access?

Remember in the patient with a stroke


Minimize IV sticks – they’ll be receiving fibrinolytics
that will affect clotting time
Want to facilitate rapid transport to ED
71
Highlights on EZ IO Needles
Needles referred to by their length
 15mm (pink), 25mm (blue), and 45mm
(yellow)
 Half of peds needs a 15mm needle and half
need 25mm
 Determine needle length needed by palpating
over the site
 Let the drill pull itself in, don’t push the needle
in
 Stop drilling when loss of resistance is felt

72
EZ IO Needles

Note the black
identifying line
mark on each
needle
 Need
to keep at
least one black
line visible once
needle touches
bone and prior
to drilling
73
EZ IO Needle Sizing
Needle tip inserted
into site until
resistance is felt
 The needle tip
is touching
bone
 If at least one
black mark is still
visible, there is
enough needle
length remaining
to secure into the
site

74
EZ IO 45 mm Yellow Needle

Used for obesity over the landmark site
 Some patients may be large in select
areas of their body but not in their
extremities
Think of the patient with
COPD
 Palpation and clinical
judgment used
75
EZ IO 45mm Needle

Recommended for the humeral site in all
patients over 40 kg (88 pounds)




A back-up site alternative to the tibial site
Humerus a relatively softer bone
 Not a weight bearing bone
Longer needle provides more stability in the bone
Needle aimed in slightly inferior (downward) direction
 Imagine the tip moving toward the arm socket or
toward an imagined space between the heart and
the spine
76
Humeral IO Site

As a non-weight bearing bone, humerus
softer than tibia
 Will
need to immobilize arm to prevent
movement and possible needle dislodgement
 Note:
On EMS backboard, arm automatically
immobilized when patient strapped to board
 Secure
IV site to avoid inadvertent needle
removal
77
Lidocaine and IO IV Sites

Lidocaine is used to “marinate” the inside
of the bone
 The
area will be numbed so the infusion of
fluids will be less uncomfortable in the nonarrested patient

Once the stylet is removed, Lidocaine
injected slowly over 1 minute
 Adult
50 mg
 Peds 1 mg/kg (max 50 mg)
78
Lidocaine cont’d
Lidocaine moves out of the area and into
circulation if injected too quickly
 EMS will WAIT 1 minute after injection
 Line then flushed via the EZ IO connect
tubing
 Primed IV tubing connected to the EZ IO
connect tubing
 Pressure bag placed over the IV bag
 Infusion begun

79
Accessing the Humeral Site

Antiseptic preparation
 Can use cleanser supplied
in IV start pak
 Needle held until
taped or otherwise
secured into place

To play video double left click
(power point must be in slide
show mode)
80
Removing The IO Needle
Establish alternate IV site(s)
 Stop IO infusion system
 Remove IV tubing & EZ connect tubing
 Connect a syringe to the IO port

Any size syringe can be used
 Syringe allows you to grip something

Turn the syringe clockwise while maintaining a
light pull
 Continue to twist and pull until needle removed
 Cleanse area, apply band-aid
 Drops of blood may be all that are visible

81
Activating Alerts From Field
Information

Cardiac Alert
 Is
there ST elevation in contiguous leads?
 Discuss with ED MD

Neuro Alert/Stroke Alert
 Is
there at least 1 deficiency on Cincinnati
Stroke Scale
 Discuss with ED MD

Trauma Alert
 Does
patient meet criteria for Level I or II?
82
Acute Coronary Syndrome - ACS

When does EMS hold nitroglycerin and
need Medical Control consult?
 Presence
of ST elevation in II, III, aVF leads
 Inferior
wall MI relies on volume returning to heart
to maintain cardiac output
 B/P
< 90 systolic
 NTG
will vasodilate patient and potentially cause
hypotension
 Use
of Viagra type drugs last 24 - 48 hours
 May
get persistent hypotension that is not
responsive to normal measures
83
Acute Coronary Syndrome - ACS

Why is Aspirin important?
 Blocks
platelets from aggregating/collecting at
the ruptured plaque site

Who gets Aspirin?
 Basically,
everyone
 Unless the patient is very reliable and
extremely confident that they have taken their
dose, Aspirin to be given
 An
extra dose will not harm the patient
84
Case Scenarios
Put it into practice
 Read the following scenarios
 Determine appropriate course of action
 What was used in decision making?
 What critical thinking skills were used?
 What orders are necessary/appropriate?

85
Case Scenario #1
The general impression is that the
54 year-old patient has suffered a stroke
 Their breathing is shallow and at 4 per
minute
 They have no gag reflex
 What measures would be appropriate to
secure and protect the airway?

86
Case Scenario #1
Securing the Airway

Reposition the airway
 Head

Support ventilations via BVM
1

tilt / chin lift in absence of trauma
breath every 5-6 seconds (pulse is present)
If intubation is required
 Preoxygenated
for 3 minutes
 Equipment prepared
 Medications prepared
87
Case Scenario #1
Securing the Airway

Region X EMS medications
 Lidocaine
1.5 mg / kg IVP/IO
 To suppress the cough reflex to avoid an
increase in intracranial pressure in patients
with head insults
 Etomidate 0.3 mg/kg IVP/IO (max 20 mg)
 As hypnotic and sedative
 Post intubation Versed 2 mg IVP/IO every 2
minutes to max 20 mg
 To maintain sedation post intubation
88
Case Scenario #2

How is the size determined for the King
airway?

How is placement assessed after insertion
of the King airway?

How does the ED remove the King airway?
89
Case Scenario #2 cont’d

Sizing for the King airway
 Based
on height of patient
 4 -5 feet use size 3 (remember 3 – 4 – 5)
 5 – 6 feet use size 4 (remember 4 – 5 – 6)
 Over 6 feet use size 5 (remember 5 – 6)
 Colored tip of King airway indicates the size
 Size 3 – yellow
 Size 4 – red
 Size 5 - purple
90
Case Scenario #2 Placement cont’d
 Pilot
balloon inflation
 Size 3 - range 45 - 60 mL
 Size 4 – range 60 – 80 mL
 Size 5 – range 70 – 90 mL
 Air in cuff is adjusted, if necessary, to
maintain a seal
91
Case Scenario #2 cont’d

Assessing placement of King airway
 Observe
for bilateral rise and fall of chest
 Auscultate for negative epigastric sounds
 Auscultate for bilateral breath sounds
 Evaluate capnography
Tube secured with tape or commercial
holder
 Cervical collar applied to help secure tube
placement

92
Case Scenario #2 cont’d

How do you remove the King airway?
 Have
suction available
 Have alternate airway method prepared and
ready
 Withdraw the air from the cuffs
 One
pilot inflates/deflates both cuffs
 Amount of air can range from 45-90 ml of air
 Withdraw
the King airway similar to the ETT
93
Case Scenario #3

When would Zofran be necessary?

Zofran is given for nausea/vomiting
 Nausea
may be a symptom of the problem
 Nausea may be the result of administration of
Morphine (more common than with Fentanyl)
 Nausea may be present with withdrawal
symptoms after Narcan administered to a
heroin overdose
94
Case Scenario #3
What is the dose of Zofran?
 Adult

4

Pediatrics >40 kg (88 pounds)
4

mg IVP/IO over 30 seconds
mg IVP/IO over 30 seconds
Pediatrics < 40 kg (88 pounds)
 0.1

mg/kg IVP/IO over 30 seconds
Adult and peds dose tables in back of
SOP’s
95
Case Scenario #4

What interventions are required during asystole
and/or PEA?
CPR – CPR – CPR
 Rotate compressors every 2 minutes during
rhythm check
 Only medication will be Epinephrine 1:10,000
 Administered every 3-5 minutes
 Consider and start addressing possible causes –
the H’s and T’s
 Basically the same for adult and peds patients

96
Case Scenario #4

When do you perform a pulse check during CPR?

Pulse checks are only performed when the
presenting rhythm is one that should generate a
pulse


If no pulse up to 10 seconds, resume CPR
NO pulse check when observing VF or asystole on the
monitor
 You’ve done the first pulse check to know CPR was
indicated – that’s it for pulse checks VF &/or
asystole
97
Case Scenario #5

What are the H’s to consider during
resuscitation & what do you do?
 Hypovolemia
– give fluids 20mL/kg – reassess
as you are passing every 200 mL
 Hypoxia – add supplemental oxygen
 Acidosis – properly ventilate to blow off CO2
 Hyper/hypokalemia – consider the history
 Patient
on dialysis? Patient with hyperglycemia?
 Hypothermia
– are they warm or cold?
98
Case Scenario #6

What are the T’s to consider during
resuscitation?
 Toxins
– Is there a possibility of drug
exposure?
 Tamponade – What is the history?
 Tension pneumothorax – What is the history?
What are the breath sounds like? How easy is
it to bag the patient?
 Thrombosis – coronary or pulmonary – What
is the history?
99
Case Scenario #7

Why is Etomidate useful in the prehospital
setting?
Used as a short acting hypnotic (amnesic)
and to sedate the patient
 It acts quickly with a short duration (3-5
minutes)
 Used to facilitate intubation on the nonarrested patient

100
Case Scenario #8

How do I remove an IO needle?
 Shut
off IV tubing
 Disconnect tubing down to the IO needle hub
 Connect a syringe to the IO hub
 Gives
you something to hold onto
 Begin
twisting the needle clockwise as you
apply firm, steady outward pressure
 Twisting
syringe
counterclockwise will just disconnect the
 Once
needle removed, cleanse the site and
apply a band aid – minimal drops of blood
may appear
101
Case Scenario #9
The patient is in VF
 CPR was started until the defibrillator is ready
 A shock is delivered and CPR is immediately
resumed; compressors switch every 2 minutes
 What drugs are used during the VF field code?
 Epinephrine 1 mg IVP/IO every 3-5 minutes
alternated with
 Amiodarone 300 mg IVP/IO (repeated once in
3-5 minutes at 150 mg IVP/IO)
 Peds Amiodarone 5 mg/kg IVP/IO

102
Case Scenario #10

What is the difference between
monomorphic and polymorphic VT?

How are stable tachycardias treated?

How are unstable tachycardias treated?
103
Monomorphic VT
Ventricular complexes having the same
shape and amplitude from beat to beat
 Complexes are generally wide (over 0.12
seconds); can be confused with SVT with
aberrancy
 Complexes can be stacked like blocks

104
Polymorphic VT

Ventricular complexes that vary in shape
and amplitude from beat to beat
 When
occurring in the presence of a long QT,
referred to as torsades de points
105
Determining Patient Stability
Level of consciousness first to change
when perfusion decreases
 B/P last to change – compensation is
exhausted
 Therefore:

 Evaluate
level of consciousness
 Evaluate blood pressure
 Then determine patient stability
106
Signs/symptoms and Tachycardia

Remember:
 Just
because you have signs or symptoms
does not make you unstable
 With
an elevated heart rate, how would you NOT
have some signs or symptoms?
 Diaphoresis
 Pounding in your chest
 Lightheadedness/dizziness
 Lowered blood pressure
 These
patients are “relatively” stable
 How is the patient doing???
107
Relatively Stable Tachycardia

SVT
 Valsalva
attempted
 Stimulates
rate
 Adenosine
vagus nerve to slow down the heart
rapid bolus tried
 1st
dose 6 mg with flush; repeat 12 mg with flush
 2nd dose can be given 1-2 minutes after 1st dose
 If
no response to Adenosine, Verapamil used
 5mg
SLOW IVP over 2 minutes
108
Relatively Stable Tachycardia

Rapid atrial fibrillation/flutter
 Valsalva
attempted
 Stimulates
rate
 Verapamil
vagus nerve to slow down the heart
5 mg SLOW IVP over 2 minutes
 If
no response, repeat in 15 minutes
 Monitor for drop in blood pressure

Adenosine not effective in atrial fibrillation
or flutter
109
Relatively Stable Tachycardia

Monomorphic wide complex tachycardia
 If
relatively stable try Adenosine (might be
SVT with aberrancy)
 If no effect in 2 minutes, hang Amiodarone
drip
 Amiodarone 150 mg diluted in 100 ml D5W
 IVPB over 10 minutes minimally
 Watch for hypotension
 May need to slow or stop infusion
110
Relatively Stable Tachycardia

Relatively stable
 Pt
should have some signs or symptoms but
still be conscious and with a pulse

Polymorphic wide complex tachycardia
 Assumed
to be ventricular in nature
 Amiodarone drip
 Amiodarone 150 mg diluted in 100 ml D5W
 IVPB over 10 minutes minimally
 Watch for hypotension
111
Unstable Tachycardia

Patient losing consciousness and blood pressure
falling



Doesn’t matter what the rhythm is, the patient needs
to be converted (synchronized)
Versed 2mg IVP/IO every 2 minutes to max 10 mg if
time to sedate
Synchronized cardioversion


100j, then 200j, then 300j, then 360j
After first sync cardioversion, if wide complex
tachycardia begin Amiodarone IVPB drip if not
already started

Then continue synchronized cardioversion attempts
112
Drug Matching

What drug makes the IV infusion more
tolerable via an IO site?
 Lidocaine
50 mg IO (peds 1 mg/kg – max 50 mg)
 Instill
over 60 seconds to bathe the area
 Let the medication sit for 60 seconds and then flush
the line

What drug is short acting for pain control and
does not negatively impact B/P?
 Fentanyl
 Bonus:
Can be given IN in absence of IV access
113
Drug Matching

What medication blunts a bradycardic
response to intubation in the pediatric
population?
 Atropine

0.02 mg/kg IVP/IO (max 0.5 mg)
What medication is the antidysrhythmic of
choice in the patient experiencing VF or
pulseless VT?
 Amiodarone
300 mg IVP/IO first dose; then
150 mg IVP/IO in 3 -5 minutes for adults
 Peds 5 mg/kg IVP/IO
114
Drug Matching

Which Benzodiazepine is useful for the
patient with an active seizure but no IV
access yet?
 Versed

which can be given via IN
Why is Atrovent added to the first dose of
Albuterol for the patient wheezing?
 Atrovent
reverses bronchospasms and is
longer lasting than Albuterol
 Repeat dosing of Atrovent not necessary
115
Bibliography






Collopy, K., Kivlehan, S., Snyder, S. Oxygen
Toxicity. EMSWORLD. January 3, 2012.
Hodgson, B., Kizior, R. Saunders Nursing Drug
Handbook 2009. Elsevier. 2009.
centegra.org/emergency-medical-services/emsnews/
www.co.bonner.id.us/EMS/BonnerCountyEMSTrai
ningDivision.htm
dailymed.nlm.nih.gov/…/drugInfo.cfm?id=18810
www.ems/.com/.../video/449861-Vidacare-EZIO/
116
Bibliography cont’d





emsstaff.bincombecounty.org/inhousetraining/ez
_io_Update/img/Pro
emsstaff.buncombecounty.org/…/kinglt_info.asp
www.medclip.com/index.php?page=videos&c=2
1
http://www.westyadkinvfd.com/KingLTDInservic
eGuide.pdf
Region X SOP’s February 1, 2012
117