Condell Medical Center
EMS System
August 2008 CE
Site code #10-7200E1208
Prepared by: Sharon Hopkins, RN, BSN, EMT-P

• Upon successful completion of this module, the EMS provider should be able to:
– Identify the differences between a Category
I, II and III trauma patient
– State transport decisions for trauma patients based on Region X guidelines
– Understand what the mechanism of injury is and the information it provides
– Understand the difference between the index of suspicion and the general impression

– Describe assessment and treatment appropriate for the patient with traumatic insult based on Region X
SOP’s
• Burns, tension pneumothorax, sucking chest wound, flail chest, pericardial tamponade, eviscerated organs
– Successfully calculate the GCS and RTS given the patient’s parameters
– Identify and appropriately state interventions for a variety of EKG rhythms
– Identify ST elevation on a 12 lead EKG
– Successfully identify the landmark and perform chest needle decompression
– Actively participate in trauma scenario discussion
– Successfully complete the quiz with a score of 80% or better

• In the age groups from 1 to 44, unintentional injury is the leading cause of death
• 45 and over, the leading causes of death are disease
– cardiovascular disease and cancers
• These statistics point to a financial burden placed on the patient as well as society for unintentional injuries
• Source: National Vital Statistics System, National Center for Health
Statistics, CDC

• Prepared and committed to handle all types of specialty trauma 24/7
• Provides leadership and resources to other levels of trauma care in the Region
• Participates in data collection, research, continuing education, and public education programs
• Level I: Evanston Hospital, St. Francis in
Evanston
• Level I non-Region X: Advocate Lutheran
General, Froedtert (Wisconsin)

• Increased commitment to trauma care for the most common trauma emergencies with surgical capability available 24/7
• Participates in data collection, continuing education, and public education programs
• Level II: Condell, Glenbrook, Highland
Park, Lake Forest, Rush North Shore, Vista
Medical Center East (VMH)

Additional Level II Trauma Centers
- Not Geographically In Region X
• Centegra – McHenry, Illinois
• Good Shepherd Hospital (GSH) –
Barrington, Illinois
• Northwest Community Hospital (NWCH) –
Arlington Heights

• Systolic B/P < 90 on 2 consecutive readings (or peds
< 80)
–Transport to the highest level
Trauma Center within 25 minutes
–25 minute clock starts from the time of injury

• Traumatic arrest, isolated burns >20%
–Transport to the closest Trauma
Center
• No airway
–Transport to the closest
Emergency Department

• Category I Trauma Patient
–Unstable vital signs
–Based on anatomy of the injury
–Transport to the highest level
Trauma Center within 25 minutes
–25 minute clock starts from the time of injury

• Category II Trauma Patient
–Based on mechanism of injury
• High potential for injury but patient is stable for now
–Based on existence of co-morbid factors that increase the risk of complications to recovery
–Transport to the closest Trauma
Center

• Category III Trauma Patient
– All other traumatic injuries and routine care is being provided
– Isolated traumatic injury (generally GCS
>10)
• Isolated fractures
• Minor burns
• Lacerations
– Transport the patient to the closest
Trauma Center

• The process and forces that cause trauma
• Mentally recreate the incident from the evidence noted
• Identify strength of forces involved
• Identify direction forces came from
• Identify areas of the patient’s body most likely affected by the forces
• Start to identify the mechanism of injury during the scene size-up

• Adults
– Generally turn away & present lateral surfaces
– Anatomically, impact is low on the body
– Injuries to tibia, fibula, femur, knee, lateral chest, upper extremity, then head & neck
• Pediatrics
– Generally turn and face the vehicle
– Injuries anatomically higher on the body than adults
– Injuries to femur, pelvis and then those sustained when run over or pushed aside by the vehicle

• Rotational (38% of MVC)
– Injuries similar to frontal & lateral
– Deceleration is usually more gradual & injuries less serious although the vehicles look worse
• Frontal (32% of MVC)
– Up and over pathway
• Femur fractures
• Blunt abdominal injury via compression
• Lower chest injuries after steering wheel impact
• Head & neck injuries with windshield impact

– Down and under pathway
• Lower leg injuries from sliding under the dash
• Chest injuries with steering wheel impact
• Collapsed lungs from breath holding at time of impact
– Ejection
• 27% of fatalities
• 2 impacts – with interior vehicle & then the objects outside the car (ground, trees, fences, etc)

• Lateral impact (15% of MVC; 22% of all MVC fatalities)
– Much less structural steel for protection between victim and impact site
– Vehicle damage may not look severe but internal injury potential is high
– Upper & lower extremity fractures on impact side
– Lateral compression with a large amount of internal injury to chest & abdominal organs
– Unrestrained passengers are missiles and add to injuries other passengers already sustained

• Rear end (9% of MVC)
– Head rotates backward and then snaps forward
– Less neck injury if the head rest is in place
• Rollover (6% of MVC)
– Occupant experiences impact every time vehicle impacts a point on the ground
– Vehicle sides and roof provide less crumple zones for absorbing impact forces
– Ejection is common in unrestrained persons

• Your anticipation of injury to a body, region, organ, or structure based on identification of the mechanism of injury
• Your index of suspicion is honed from experience and time on the job

• Formed from mechanism of injury and index of suspicion
• Will guide the EMS provider regarding a direction on how to proceed in caring for this patient and be a guideline on choosing which SOP to follow

Documentation To Include of The
Complaint
• O - onset
• P – provocation/palliation
• Q - quality
• R - radiation
• S – severity (0 – 10)
• T – timing – when did it start

• Provide answers to:
–Who (the patient you’re caring for)
–What (happened)
–When (did it happen)
–Where (which body part)
–How (did it occur)

• Routine trauma care
• To remove gross contamination, gently rinse with normal saline
– DO NOT use distilled water to irrigate open wounds
– Normal saline is isotonic and less harmful to tissue
• Cover stump with damp (normal saline) sterile dressing and ace wrap
– Ace provides uniform pressure to stump
• Cover wounds with sterile dressing

•
•
•

Pain Management Including for
Adult Burns
• Morphine for pain control
–2 mg slow IVP over 2 minutes
–May repeat every 2 minutes as needed to a maximum of 10 mg
–Watch for respiratory depression
–Monitor for a drop in blood pressure due to vasodilation from the medication

• Immobilize the patient
– High potential for traumatic injury
• Muscle spasms during contact with source
• Thrown when power source cut
– Assess for dysrhythmia – place on cardiac monitor
– Assess distal neurovascular status of affected part
– Cover wounds with dry sterile dressings

• High risk for airway compromise
• Note presence of wheezing, hoarseness, stridor, carbonaceous sputum, singed nasal hair
• High flow oxygen via non-rebreather mask
• Monitor for need of advanced airway device
– ETT
– Combitube if trained and approved

• Consider need for HAZ-MAT involvement
• If powdered chemical, first brush away excess dry material
• Remove clothing if possible
• Flush burned area with sterile saline
• If eye involvement, remove contact lenses and flush continuously with sterile saline
• Avoid contamination of noninvolved areas

• Superficial – 1 st degree
– Cool burned area with saline
– <20% BSA involved, apply sterile saline soaked dressings
– >20% BSA, apply dry sterile dressing
• Do not overcool major burns or apply ice directly to burned areas

• Partial or full thickness (2 nd or 3 rd degree)
– Wear sterile gloves and mask while burn areas are exposed
– Cover burn wound with dry sterile dressings
• Preventing air flow over exposed burn areas reduces pain levels
– Place patient on clean sheet on stretcher
– Cover patient with dry clean sheets and blanket – protect from hypothermia

Infant differences: back 13%, each buttocks 2.5%, each entire leg 14%

• Adult patient who reached over a charcoal grill just as the match was thrown onto the soaked coals
• Injury is restricted to the right arm
• What type of burn is this?
• Using the Rule of Nines, what is the TSBA burned?
• What type of care is appropriate?
• How can the pain be managed?
• What does the documentation look like?

Case Study #1 – Patient with Burns

• Combination of superficial and partial thickness burns approx 4.5% TSBA (circumferential around forearm)
– Evidence of redness with a blistered area although blister is broken
• Appropriate care includes cooling burn, applying sterile saline soaked dressing (<20% TBSA)
• Additional helpful care
– Elevation of arm, removal of ring before fingers swell
• For pain control
– Morphine 2 mg slow IVP; can repeat 2 mg in
2 minutes up to 10 mg

• What, when, where, how
• Our 52 year-old patient received superficial and partial thickness burns approximately 20 minutes ago to her right forearm when reaching across flames from a charcoal grill.
• Detailed description of injury
• Description of intervention prior to EMS & that which EMS provided
• Response to intervention

Chest Injuries – Traumatic Arrest –
Category I Trauma
• Begin CPR
• Transport to closest Trauma Center
– A hospital on by-pass must take a patient in life threatening condition if they are the closest appropriate hospital
• Perform bilateral chest decompression
– Use common sense – does your scene size – up, evaluation of mechanism of injury and general impression indicate a potential chest wall injury?

Chest Injuries – Tension
Pneumothorax – Category I Trauma
• History of injury to the chest wall
• Diminished breath sounds
• Hyperresonance if percussion done
• Severe dyspnea
• Hyperinflation of chest
• Jugular vein distention
• Tachycardia
• Hypotension

• Landmarks anterior approach
–2 nd intercostal space in the midline of the clavicles
–Place prepared flutter valve needle over the top of the rib
• Avoids potential injury to vessels and nerves that run along the bottom of the rib

nd
• Feel for the top of the sternum
• Roll your finger tip to the anterior surface at the top of the sternum
• Feel the little bump near the top of the sternum
– This bump is the Angle of Louis
• From the Angle of Louis slide your fingers angled slightly downward toward the affected side following the rib space
– You are automatically in the 2 nd ICS
• Identify the midline of the clavicle
– The midline is more lateral than persons realize and usually runs in line with the nipple

Alternate Method to Find 2 nd
Intercostal Space
• Palpate the clavicle and find the midline
– The midline is farther out (more lateral) from the sternum than most persons realize
• Move your finger tips under the clavicle into the
1 st intercostal space
– 1 st rib is under the clavicle and is not palpated
– Spaces identified for the numbered rib above the space
• Feel for the firm 2 nd rib and palpate the soft space below the rib
– This is the 2 nd ICS

• Find your own 2 nd ICS
• Now find your neighbor’s 2 nd ICS
– Use both methods to find the landmark and decide which is easiest for you
• Documentation
– To include signs and symptoms
– Size of needle used (length and gauge)
– Site needle inserted into
– Response from the patient

• Long needle (preferably 2-3 inch) and large bore needle (preferably 12-14G)
• Flutter valve
• Cleanser to prepare skin overlying the site
• Method to secure needle in place
– Skin will most likely be diaphoretic
– Tape may not stick
– May need to maintain manual control of needle

Midline of clavicle
2 nd ICS
Angle of
Louis

Inserting the
Needle
• Remove proximal end cap from needle
– Will be able to hear trapped air escaping
• Needle inserted over top of rib
– Once hiss of air heard continue to advance catheter while withdrawing stylet
• Stabilize catheter as best as possible
• Patient should symptomatically improve
– Do not expect to hear improved breath sounds; takes time for the lung to reexpand

• EMS is called to the scene for a 52 year-old male with c/o sudden onset dyspnea with pain between his shoulder blades while watching TV at home. The patient is agitated, short of breath, with increased respiratory rate and SaO of 89%.
2
• Further assessment reveals decreased breath sounds on the right and clear on the left
• Vital signs: 98/62; HR 118; RR 32 and shallow
• Your impression & intervention plan?

• Spontaneous tension pneumothorax
– They don’t all develop from trauma
• Begin supplemental oxygen support via nonrebreather, cardiac monitor, preparation for IV
BUT
• Quickly prepare for needle decompression while the above are being prepared
– Patients with a tension pneumothorax can’t wait and will deteriorate without needle decompression

Sucking Chest Wound – Category I
Trauma
• Most common with penetrating wounds
• Free passage of air between the atmosphere and pleural space if the open wound is at least 2 /
3 rd the size of the diameter of the trachea
– Size of trachea about the size of pt’s 5 th finger
• Air is drawn into the chest cavity
• Air replaces lung tissue
• Lung collapses

• Severe dyspnea
• Open chest wound
– Check anterior, posterior, axilla areas
• Frothy blood at wound opening
• Sucking sound as air moves in and out
• Tachycardia with hypovolemia

• Immediate treatment is to seal the opening
– May start by placing a gloved hand over the wound
– When able, place an occlusive dressing, taped on 3 sides, over the wound
• Wound now converted to a closed pneumothorax
• Monitor for signs of tension pneumothorax
– May need to lift a corner of the dressing to release trapped air via burping dressing

• 3 or more adjacent ribs broken in 2 or more places
– Segment becomes free with pardoxical chest wall motion during respirations
– Paradoxical movement more evident after the muscles splinting the flail segment fatigue
• Usually takes a tremendous amount of blunt trauma to cause a flail chest
• Often present will be associated severe underlying injury (ie: pulmonary contusion)
• Respiratory volume reduced and respiratory effort increased

• Place patient on the injured side (may not be possible to do this in the field based on mechanism of injury)
• High flow oxygen – nonrebreather mask
– Monitor for need to assist ventilations via BVM to deliver positive pressure ventilations
• Evidence of underlying pulmonary injury
• Effort and fatigue
• Pulse oximetry
• EKG monitoring
– Tremendous amount of force is delivered to the chest wall and cardiac injury is highly likely as a result

Pericardial Tamponade – Category I
Trauma
• Blood or other fluid fills the pericardial sac restricting cardiac filling & contractility
• Most often related to penetrating trauma
• Venous return to the heart is restricted
• Decreased cardiac output
• Pressure on the coronary arteries restricts blood flow to the myocardium

Pericardial Tamponade Signs &
Symptoms
• Usually history of penetrating trauma
• Agitated patient
• Diminished strength of pulses (weak and thready) with tachycardia
• Narrowing pulse pressure
– Diastolic & systolic numbers moving closer together
• Distended neck veins (JVD)
• Diaphoretic and pale
• Muffled, distant heart tones
• Hypotension

Treatment Pericardial Tamponade
• Treatment in the field is limited to being supportive
• Patient requires high index of suspicion and/or rapid identification with rapid transport
– In ED will perform needle thoracentesis and then transfer the patient to the OR for open heart surgery

• Restlessness and agitation
– You must consider  hypoxia,  shock,
 influence of alcohol and/or drugs
– This is one time you need to assess for all reasons of restlessness and not just stop when you discovered one cause – there may be more than one pathology going on at a time

2
• SaO
2 reading may be inaccurate in the presence of:
– Hemorrhagic shock with delayed capillary refill
– Hypothermia
– Lung damage
• Evaluate all parameters together to get the best overall picture in ventilated patient
– What does the ETCO
2 indicate?
– Are you able to ventilate the patient?
– Are there extenuating circumstances where the circulation is affected and would affect the pulse ox reading like those listed above?

• Your 34 year-old patient received a
GSW to the right upper abdomen.
• They are conscious and alert; B/P 90/62;
HR 120; RR 28; bleeding is minimal
• Category trauma?
• What are your interventions?

Case Study #3 – Category I Trauma
• Make sure the scene is secured
• Consider need for spinal immobilization
• During assessment of wound, consider thoracic injury in addition to abdominal injury depending on the angle of the GSW.
• Examine for an exit wound
– Check the back and the axilla
• Prepare for the worst – assume the patient will deteriorate before ED arrival
• Repeat VS: B/P 80/; HR 140; RR 32, remains conscious and in pain
• Transport to the highest level Trauma Center within 25 minutes

• Routine trauma care
• Question – is this an isolated abdominal wound or is it a combination abdominal/ chest wound?
– Need to treat patient for potential injuries of both body cavities
– EMS cannot determine in the field the angle of the trajectory
• Cover the wound and watch for evisceration
• Fluid resuscitation – keep B/P at low levels; the higher the B/P the faster the patient bleeds out

• If patient states anything, put it in quotes
• If information available, add angle patient shot from (ie: above, below) and distance from weapon
• If known, list type of weapon used
• Include results of inspection, auscultation, palpation
– Location of entrance and exit wound
– Size of wound(s)
– Assessment of the general area (ie: contusions, bleeding, swelling/distention, pain, powder marks)
• Preserve evidence as much as possible

• Your 10 year-old patient has a penetrating injury to the right leg above the knee while playing in his backyard
• Initial VS: B/P 90/70;
HR; 130; RR 32; no active bleeding
• Category trauma? Field interventions?

• Next VS: B/P 92/64; HR 110; RR 20.
• Stabilize foreign body in place
• Obtain distal neurovascular status
– Distal pulses
– Movement – “can you wiggle your toes?”
– Sensation – “close your eyes and tell me which toe I am touching”
• Document distal neurovascular status and describe how the foreign object is stabilized in place

• Your 62 year-old patient had abdominal surgery
1 week ago. Today at home he sneezed hard and felt a tearing sensation in his abdomen and called EMS.
• VS: B/P 100/60;
HR 110; RR 24
• No active bleeding
• What interventions are appropriate?

• Immediately cover the wound
– Need to minimize contamination
– Need to prevent more organs from protruding
– Need to prevent loss of fluids
• Place a saline moistened dressing over the exposed tissue
• Place dry gauze over the saline dressings
• Can place light manual control over the organs to prevent further evisceration especially during movement, coughing, sneezing, deep breaths

• 21 year-old drove into a metal fence. Upon EMS arrival, there is obvious external chest injury with bleeding. Coming closer to the patient, EMS can hear a sucking sound from the chest wound.
• Patient is alert, in pain, severe dyspnea
• VS: B/P 90/62; HR 130; RR 34; GCS 15
• Breath sounds L > R
• Look at the injury – what is your impression and what interventions are necessary?

• An adequate dressing will be difficult to achieve with such an extensive wound
– A gloved hand just won’t be enough to get started
• This patient may be a candidate for conscious sedation and intubation to provide positive pressure ventilation
• Reassessment VS: B/P 80/56; HR 140;
RR 36 GCS remains 15
• Transport is to highest level trauma center within 25 minutes

• Open chest wounds need to be covered ASAP with a non-occlusive dressing
• Carefully monitor if the treatment of the open chest wound converts the injury into a tension pneumothorax
• Carefully monitor the patient for the need for more aggressive airway control (ie: supportive ventilation via BVM or intubation)
– Initially can start O
2 rebreather mask therapy with a non-

• What – cause of the injury (penetration,
MVC, pedestrian, etc)
• When – the injury occurred
• Where – by body location
– “quadrant” refers to the abdomen
– Chest injuries uses reference such as anterior/ posterior, nipple line, upper/lower chest wall
• How – the injury occurred
• Expand and give detail description of the injury, treatment rendered, pt response

• Your 45 year-old patient is a construction worker who was accidentally shot in the head with a nail gun
• Upon arrival, the patient is awake, alert, talking (GCS 15)
• VS: B/P 132/78; HR 96; RR 20; complains of a minor headache; minimal bleeding at a few puncture wounds noted on the occipital area of the scalp (patient has thick hair).

• Consider any injury above the level of the clavicles to include a c-spine injury until proven otherwise and immobilize the patient
• Control bleeding
– The face and scalp have such a rich blood supply small wounds tend to bleed heavily
• Protect from further contamination
– The open wound may be in direct contact with the brain
• Document neurological evaluation to establish baseline for comparison (AVPU, GCS, movement)

• You are called to the scene for a 10 year-old female who has been run over by a bus
• As patient exited bus, she bent down to tie her shoe and was caught under the wheels of the bus
• Upon your arrival, you note a large amount of avulsed tissue with bleeding from the left hip, left buttock, and left upper thigh area
• The patient is screaming in pain
• VS: B/P 110/70; HR 110; RR 26 GCS 15
• What is your impression?
• What is your treatment plan?

Case Study #8 – Category I or II?
• General impression
– Category II minimally – pedestrian run-over
– Category I trauma – if unstable pelvis or 2 or more long bones (proximal bones) fractured and vital signs unstable
• Potential problems to consider & address
– Massive hemorrhage & control of hemorrhage
– Spinal injury
– Additional injuries
– Airway control
– Equipment to fit a 10 year-old
– Further wound contamination

• Tool used to evaluate and monitor a patient’s condition
• Evaluates
 Best eye opening
 Best verbal response
 Best motor response
• Serves as an indicator/predictor of survival
• To be performed on all EMS patients

• Possible total score 3 (lowest) – 15
(highest)
• Minor head injury – patient scores
13 – 15
• Moderate head injury – patient scores
9 – 12
• Severe head injury – patient scores <8
–Significant mortality risk

• The change in the GCS is more important than the absolute score
• Check for associated injuries
– Manage a head injury as a multiple injured patient until other injuries ruled out
• Stabilize the neck for any head injury
• Don’t assume the level of consciousness is altered just because of ETOH and/or drugs
– Is there an occult (hidden) injury present?
• Provide accurate, clear, detailed documentation

• Spontaneous (4) – eyes open; may or may not focus
• To voice (3) – prior to touching the patient, eyes will open to sounds around them or EMS calling/yelling to them to open eyes
– Often difficult to accurately assess due to EMS gaining immediate c-spine control so difficult at times to determine if patient responded to voice or touch (pain)
• To pain (2) – doesn’t necessarily imply you must apply painful stimulus, could be just to touch
– Flutter of eyelids is scored as 2
• None (1) – eyes remain closed with no eyelid flutter or other eye movement; eyes do not open

GCS – Verbal Response 1-5 Points
• Oriented (5)
• Confused (4)
– Words may be appropriate to situation but pt does not respond to questions
• Inappropriate words (3)
– Words are spoken and understood but nonsensical to the situation (“over there”)
• Incomprehensible words (2)
– Includes mumbling, unintelligible speech, moaning
• None (1)

GCS – Motor Response 1-6 Points
• Obeys command (6)
• Localizes pain (5)
– Patient who pulls equipment off; pushes your hands away; purposeful movement
– This patient knows where the obnoxious stimuli is contacting his body
• Withdraws to pain (4)
– Pt cannot isolate where they feel the noxious stimuli so just pulls back/withdraws
• Flexion (3) – arms bent towards midline when stimulated
• Extension (2) – arms extended when stimulated
• None (1) – remains flaccid

• Give the patient the best score possible
– If the patient moves the right side of their body but no movement on their left, score them for the movement they currently exhibit on the right
– If patient deteriorates, easier to see the drop or change in the GCS score
• When testing for responses, watch even for minimal activity like eyelid flutter or a grimace

• Acceptable noxious stimuli
– Armpit pinch or nailbed pressure
– Sternal rub, pinching web space between fingers, pinching shoulder muscle (trapezius)
– Earlobe pinch is out of favor
• Can cause movement of head & neck in response to the pain

RTS – Scoring 0 – 12 points

• Patient eyes are open and they watch you during the examination
• The patient is confused; they don’t remember how they got hurt and can’t remember the day of the week
• When you ask the patient to “show me 2 fingers”, they respond but are slow to do so
• VS: B/P 120/70; HR 88; RR 18
• Total GCS?
• Total RTS?

• The patient does not open their eyes
• The patient groans when pinched or an injured body part is touched
• The patient does not follow commands and will push your hands away when you touch them
• VS: B/P 96/68; HR 102; RR 22
• Total GCS?
• Total RTS?

• The patient’s eyes are open
• When asked “what month is this?”, the patient responds, “he, umm, he…my jacket. I don’t ..”
• If touched or pinched, the patient pulls away from the contact
• VS: B/P 132/72; HR 96; RR 16
• Total GCS?
• Total RTS?

• Your patient’s eyes are closed but they open wide if the patient’s injury is touched
• The patient yells “don’t” or “stop” when there are pinched but does not answer questions or speak in sentences
• The patient will push your hands away when you touch them
• VS: B/P 108/64; HR 102; RR 18
• Total GCS?
• Total RTS?

• The patient’s eyes are closed but the eyelids flutter when you loudly call out their name
• The patient does not answer questions but will groan when touched but not say recognizable words
• The patient does not follow commands but will push away your hands when touched
• VS: B/P 80/52; HR 112; RR 12
• Total GCS?
• Total RTS?

• The patient’s eyes are closed but will open when the patient is touched
• The patient says “leave me alone” and “what are you doing?” and goes back to sleep. When eyes are open they respond “I don’t know” to questions
• They do not follow command and will push your hands away when touched
• VS: B/P 110/68; HR 88; RR 20
• Total GCS?
• Total RTS?

• #1 – GCS – 14 (4, 4, 6)
RTS – 12 (GCS 4; RR 4; B/P 4)
• #2 – GCS – 8 (1, 2, 5)
RTS – 10 (GCS 2; RR 4; B/P 4)
• #3 – GCS – 11 (4, 3, 4)
RTS – 11 (GCS 3; RR 4; B/P 4)
• #4 – GCS – 11 (2, 4, 5)
RTS – 11 (GCS 3; RR 4; B/P 4)
• #5 – GCS – 10 (3, 2, 5)
RTS – 10 (GCS 3; RR 4; B/P 3)
• #6 – GCS – 11 (2, 4, 5)
RTS – 11 (GCS 3; RR 4; B/P 4)

Treatment Symptomatic Bradycardia
• Bradycardia or Type I Wenckebach
– Atropine 0.5 mg rapid IVP
– May repeat every 3-5 minutes to total of 3mg
– If ineffective, begin pacing
• Type II or 3 rd degree heart block
– Begin TCP
– Valium 2 mg slow IVP for discomfort
– May repeat 2 mg IVP every 2 minutes to max 10 mg
– TCP set at rate 80/minute and start at lowest mA
– Watch for capture
– If TCP not effective, give Atropine 0.5 mg rapid IVP
– May repeat Atropine 0.5 mg every 3-5 minutes; max
3mg

Identify Rhythm Strip #2 –
6 second strip

• No treatment necessary for the rhythm
• Treat the patient’s complaint
• IF ACS, then
– Aspirin 324 mg chewed (faster absorption)
– Nitroglycerin 0.4 mg sl
• May repeat in 5 minutes; watch B/P
– Morphine if 2 nd NTG dose not effective
• 2 mg slow IVP
• May repeat every 2 minutes to max 10 mg
• Screen for recent Viagra type drug usage

Identify Rhythm Strip #3 –
6 second strip

Treatment Rapid Atrial Fibrillation
• Stable patient with B/P >100 mmHg
– Verapamil 5mg SLOW IVP over 2+ minutes
– If no response in 15 minutes & B/P stable, repeat 5mg SLOW IVP over 2+ minutes
• Unstable patient with B/P <100 mmHg
– Contact Medical Control for direction
• Afib patients at increased risk for atrial clots dislodging and migrating to the brain and the patient having an ischemic stroke

• Strip #1 – Second degree Type I -
Wenckebach (“drops one”)
• Strip #2 – Normal sinus rhythm
• Strip #3 – Atrial fibrillation - controlled

#1 – Identify ST Elevation

#3 – Identify ST Elevation

• EKG #1 – Leads V 1 - 4
• EKG #2 – Leads V 2 - 5
• EKG #3 – Leads II, III, aVF

• Bledsoe, B., Porter, R., Cherry, R. Paramedic
•
Care Principles & Practices 2 nd Edition Brady.
2006.
ITLS Bulletin. Case Study: ITLS Patient ETCO
June 2008.
2
.
• Region X SOP’s Eff date March 1, 2007; Revised
January
2008.
• www.chems.alaska.gov/ems/document/GCS
• www.merck.com
• www.swsahs.nsw.gov.au/