Integration of Revised
Region X SOP’s
February 2012 CE
Condell Medical Center
EMS System
Site Code: 107200E -1212
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Rev 2.29.12
1
Objectives
 Upon successful completion of this module, the
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EMS provider will be able to:
1. Identify treatment protocols per current
Region X SOP’s.
2. Explain rationale for treatment based on
assessment of the patient.
3. Given a variety of scenarios, utilize the
SOP’s to determine treatment indicated for
the patient.
4. Given a variety of EKG rhythms, identify
the rhythm and discuss treatment.
5. Successfully complete the post quiz with a
score of 80% or better.
2
Region X SOP’s
 Region X SOP’s went into effect
February 1, 2012
 This CE module will incorporate
reinforcing the SOP’s by working in small
groups
 A scenario will be presented
 Work as a small group using the SOP’s as
a reference to determine appropriate
treatment
3
Case Scenario #1
 EMS is called to the scene for a 87 yearold male who “fell”
 The patient is unconscious and
“bystander” CPR is being performed
 Patient didn’t “fall”; was helped to the ground
 EMS arrives on the scene, the scene is
safe
 EMS approaches the patient who is lying
on the ground, not moving
4
Case Scenario #1
 Upon arrival EMS needs to reassess the patient
for evidence of breathing and presence of a
pulse
 There is no pulse, continue CPR
 What equipment will be required?
 First piece of equipment to attach is the
monitor
 Identifying the rhythm drives care to be
delivered
 Need vascular access
 Anticipate additional methods to further
secure the airway beyond BVM
5
Point of discussion…
 How do you perform 1 and 2 man CPR on
an adult?
 30:2 ratio compression to ventilations
 Compressions at a rate of at least 100/ minute
 Once advanced airway placed, ventilate once
every 6-8 seconds
 How often do you switch CPR compressors?
 Every 2 minutes (after 5 cycles)
 Getting tired, you get sloppy, technique suffers
6
Case Scenario #1
 What is the rhythm (NO PULSE!!!)?
 PEA
 What interventions are required?
7
Case Scenario #1
 CPR
 Searching for causes (H’s and T’s)
 Begin fluid challenge if breath sounds are
clear
 Epinephrine 1:10,000 1 mg IVP/IO
 May repeat every 3-5 minutes
 If return of spontaneous circulation, follow
ROSC Hypothermia Induction
8
Point of discussion…
 What methods are used to secure an
airway?
 Positioning – easiest, quickest, least attempted
 BVM
 May need oro/nasopharyngeal support
 Endotracheal tube (ETT)
 Most secure method to protect the airway
 King airway
 If 2 failed attempts with ETT or difficult airway
 Combitube
 Limited situations
9
Case Scenario #1
 SOP’s utilized - PEA
Emergency Cardiac Care, Universal Adult (pg
6)
Pulseless Electrical Activity, Adult (pg 10)
Ref: CPR Guidelines (pg 85)
Skill: Intraosseous Infusion, Adult (pg 78)
Ref: ROSC Hypothermia Induction (pg 88)
10
Case Scenario #2
 EMS is called to the scene of a private
residence for a 25 year-old female with
abdominal pain
 Upon arrival the patient is lying on the
couch appearing uncomfortable, pale, with
shallow breathing
 Patient is hugging a bucket and has the
dry heaves
 Patient weighs 160 pounds
11
Case Scenario #2
 What information is important to obtain during
assessment for any patient with abdominal pain?
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O – onset – what were they doing?
P – what provokes/palliates it (makes it better)?
Q – what is the quality in their own words?
R – does it radiate? If yes, where?
S – how severe on a scale of 0 10?
T- what time did is start?
 Have you inspected the site and have you
palpated the abdomen?
12
Case Scenario #2
 What information is important to obtain for a
female with complaints of abdominal pain?
 Ask about the potential for pregnancy
 When was the last menstrual period (LMP)?
 Need to consider an ectopic pregnancy
 Patient may not even be aware she is
pregnant
13
Case Scenario #2
 What care is to be provided to this patient
after obtaining the history of illness and
SAMPLE?
 Pain scale with reassessment
 If SpO2 >94% does not need oxygen
 EKG monitor (not indicated)
 Careful - some “abdominal problems” may be
cardiac issues masking as abdominal
 IV access for medication administration
 Fentanyl 0.5 mcg/kg IVP/IN/IO for pain
 Zofran 4 mg IVP over 30 seconds for nausea
14
Point of discussion…
 If the patient weight falls in between on the
SOP scale, what dose is followed?
 Safer to go to the lesser amount
 Can always give more medications but can’t get it
back if already delivered
 Can always do the math calculation for a
precise amount
15
Point of discussion…
 How fast can these medications be given?
 Fentanyl over 2 minutes
 Zofran over 30 seconds
 What side effects may occur?
 Fentanyl may cause respiratory depression
and muscle rigidity if given fast
 Zofran may cause involuntary movements;
often see drowsiness especially in children;
side effects are rare
16
Point of discussion…
 If respiratory depression occurs with
Fentanyl, what action is needed?
 Can use Narcan as a reversal agent
 Fentanyl is a synthetic narcotic
 Prepare to ventilate (bag) the patient
one breath every 5-6 seconds
17
Case Scenario #2
 SOP’s Utilized – Abdominal Pain
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Routine Medical Care, Adult (pg 5)
Pain Management, Adult (pg 34)
Nausea Management, Adult (pg 34)
Ref: CPR Guidelines (pg 85)
18
Case Scenario #3
 EMS responds to a call for a 83 year-old
female who fell. On arrival, the patient is
found to be lying on her side and states “I
can’t move my legs.”
 Patient is conscious and alert
 Pain in her hip and thigh is 10/10 if she
tries to move
 Patient weighs 180 pounds
19
Point of discussion…
 What question is important to ask for any call
involving a patient who has fallen?
 WHY did the patient fall?
 Syncope/dizziness?
 Think medical problem (ie: cardiac,
CVA) along with trauma
 Tripped?
 Think trauma
 Document WHY the patient fell and include in
the verbal report
 Consider need for c-spine immobilization
20
Case Scenario #3
 VS: 136/80; P – 60; R – 16; SpO2 98%
 What needs to be included in an orthopedic
assessment?
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MOI (mechanism of injury)
Consider additional injuries (ie: C-spine)
Appearance – Any deformity? Change in color?
Distal CMS/PMS/SMV before/after splinting
 All abbreviations in SOP dictionary
 Pain scale
 Reassessment/response to
treatment/interventions
21
Case Scenario #3
 How is pain addressed?
 RICE
 Rest, ice, compress, elevate
 Fentanyl 0.5 mcg/kg IVP/IN/IO
 May repeat same dose in 5 minutes
 Question…
 Are you likely to see cardiovascular changes
(ie: drop in B/P) with Fentanyl?
 Cardiovascular changes are NOT seen
22
Case Scenario #3
 SOP’s Utilized – Orthopedic Call
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Routine Medical Care, Adult (pg 5)
Pain Management, Adult (pg 34)
Region X Field Triage Criteria (pg 30)
Routine Trauma Care, Adult (pg 29)
 Document methods used to assess the patient
and if determined no need for spinal
immobilization/spinal motion restriction, include
that documentation
 Remember to consider distracting injuries
23
Case Scenario #4
 EMS is called for a 2 year-old male who is
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having a seizure
Dispatch reports child is unconscious and
breathing
On arrival, child found lying limp in
mother’s arms
Pale, respirations even, moaning, drooling
VS: P – 148; R 12; skin warm; withdraws
to pain & eyelids flutter
24
Case Scenario #4
 Parents state patient had been relatively
healthy with a “bit of a runny nose” last few
days but “not that sick”
 Patient was put down for a nap
 Parents heard thrashing and found patient
with seizure activity
25
Point of discussion…
 What is the patient’s GCS?
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E – 2 (flutter to pain)
V – 2 (moaning/incomprehensible words/sounds)
M – 4 (withdraws)
Total 8
 Immediate care necessary
 BVM
 12 breaths/minute NOT normal for a 2 year-old
 Normal respiratory rate for 2 year-old – 20-30 breaths/min
 Deliver 1 breath every 3-5 seconds
26
Case Scenario #4
 What interventions are necessary if patient
begins to have a seizure that does not
stop relatively quickly?
 Versed 0.1mg/kg IN/IVP/IO
 Titrated to control seizure
 Max 10mg
 May be repeated if seizure activity
continues/reoccurs
 Evaluate glucose level
 Blood glucose level 94
27
Point of discussion…
 Do all patients with an altered level of
consciousness need to have a glucose level
checked?
 YES!!!
 What’s most likely causing this child’s seizures?
 Febrile
 Poisons/chemical exposure/accidental
overdose
 Head injury
 Tumor
28
Case Scenario #4
 SOP’s Utilized
 Routine Medical/Trauma Care, Pediatric
(pg 43)
 Altered Mental Status, Pediatric (pg 55)
 Seizures, Pediatric (pg 56)
 Febrile Seizures (pg 56)
 Ref: CPR Guidelines (pg 85)
 Ref: Vital Signs, Pediatric Normal (pg 93)
29
Case Scenario #5
 EMS is called to the scene for a 57 year
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old female feeling “ill”
Patient is lying on the couch awake but
sleepily answering questions
Pale, diaphoretic, feels lightheaded when
sitting up
Hx: diabetic, hypertension, old CVA
VS: B/P 86/56; P – 42; R – 20; SpO2 99%
Weight – 200 pounds
30
Case Scenario #5
 What’s the rhythm?
 Sinus bradycardia
31
Point of discussion…
 What indicators are present if the patient is
unstable due to the bradycardia?
 Stable and unstable patients can BOTH be
 Pale, diaphoretic, feel lightheaded
 If unstable
Altered level of consciousness
 First indicator to change
Hypotension is present
 Last indicator to change after
compensation is exhausted
32
Case Scenario #5
 What care is being provided to the
patient?
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IV access
Monitor – Sinus bradycardia
Atropine 0.5 mg rapid IVP/IO
Prepare for transcutaneous pacing
 If Atropine ineffective, administer Valium 2 mg
IVP/IO over 2 minutes (reduce anxiety)
 Begin pacing
 Manage pain with Fentanyl 0.5 mcg/kg IVP/IN/IO
33
Point of discussion…
 Is oxygen indicated?
 No respiratory distress
 SpO2 >94%
 But…
 Lightheaded
 Decreased perfusion
 Could be argument for applying per nasal
cannula and argument for withholding
 A clinical decision based on assessment
 If in doubt, contact Medical Control
34
Point of discussion:
 Where are the pads placed for the TCP?
 Anterior (-) chest pad in apical area
 Posterior (+) pad placed in mid upper back
between spine and scapula
 If the TCP was applied, what are the
settings?
 Rate 80/minute
 Sensitivity to “auto”
 mA – start at 0 and increase until capture
35
Case Scenario #5
 Application of pacing pads
 Anterior/anterior
Or
 Anterior/posterior
36
Point of discussion…
 Why are both Valium and Fentanyl being
used if the TCP is applied and activated?
 Valium takes the edge off, relaxes the patient
 Longer acting than Versed, so less repeat
doses may be needed
 Fentanyl issued for pain control
 Getting electrical current sent thru the body
80 times per minute
37
Case Scenario #5
 SOP’s utilized – Adult Bradycardia & AV
Blocks
Adult Routine Medical Care (pg 5)
Universal Adult Emergency Cardiac Care (pg
6)
Bradycardia and AV Block, Adult (pg 12)
Pain Management, Adult (pg 34)
Skill: Transcutaneous Pacing (pg 76)
38
Case Scenario #6
 You are called to the scene for a 43 year
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old patient with a “racing heart”
Patient is anxious, slightly agitated
States has been under a great deal of
stress, little sleep, taking Red Bull drinks
Warm and dry, lung sounds clear
VS: B/P 126/78; P – 170; R – 20;
SpO2 97%
39
Case Scenario #6
 What is the patient’s rhythm?
 SVT
40
Point of discussion…
 Is the patient stable or unstable?
 What do you assess?
 What makes someone unstable?
 First change is altered level of consciousness
 Last change is hypotension
 When can the valsalva maneuver be
performed?
 Stable SVT
 Stable rapid a fib/flutter (narrow complex)
41
Point of discussion…
 How does the “valsalva maneuver” work?
 Breath holding against a closed glottis
increases intrathoracic pressure
 Venous return decreases
 Cardiac output falls (CO = HR x stroke volume)
 B/P falls
 Initially heart rate increases to compensate
 When the breath is let out, sudden rise in
blood flow increases pressures
 The parasympathetic system is triggered with a
vagal response and the heart rate decreases
 Valsalva maneuver held for 10 seconds
42
Case Scenario #6
 Treatment stable SVT
 Valsalva
 Bear down for 10 seconds
 Adenosine 6 mg rapid IVP followed
immediately with 20 ml normal saline flush
 If no response in 2 minutes
 Adenosine 12 mg rapid IVP followed immediately
with 20 ml normal saline flush
 If no response in 2 minutes
 Verapamil 5 mg SLOW IVP over 2 minutes
 If no response in 15 minutes and B/P >90, repeat
Verapamil
43
Point of discussion…
 What does the patient often complain
about while receiving Adenosine?
 Hot, flushed feeling in the neck
 Feeling of chest pressure
 Feeling of not catching your breath
 Just warn your patient they may feel weird
for just a few minutes
 Have them inform you if they feel weird
44
Point of discussion…
 What do you remember about Verapamil?
 Inhibits movement of calcium movement
 Will decrease the heart rate, contractility, and
conduction
 Causes vasodilation
 Onset 1-2 minutes; duration 10-20 minutes
 Avoid use in any bradycardia and history of
WPW
 Watch for hypotension and bradycardia
45
Point of discussion…
 What’s WPW (Wolff-Parkinson-White)?
 Occurs in approximately 3/1000 persons
 Abnormal conduction from atria to ventricles
 AV node is bypassed
 Characterized by short PR interval (<0.12
seconds), long QRS, slurred upstroke of QRS
(delta wave)
 EKG observation made when heart rate normal
 Patient typically asymptomatic until
tachydysrhythmias occur
 Symptomatic due to increased heart rate
46
Wolff Parkinson White
 If rapid atrial fib with history of WPW, contact
Medical Control
 Amiodarone or cardioversion most likely to be
ordered
 Adenosine and Verapamil to be avoided
47
Case Scenario #6
 SOP’s utilized – Adult SVT
Adult Routine Medical Care (pg 5)
Universal Adult Emergency Cardiac Care (pg
6)
Supraventricular Tachycardia, Adult (pg 15)
48
Case Scenario #7
 EMS is called to the scene for a 69 year
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old patient who is “sick”
Spouse states patient had not been acting
right the past hour
Upon arrival, EMS notices patient
slouched in a chair with mumbling speech
Denies chest pain or SOB
VS: B/P 120/60; P – 92; R – 18; SpO2 97%
49
Point of discussion…
 Are you thinking stroke?
 What assessments are necessary?
 Blood glucose level
 Cincinnati stroke scale
 Facial droop
 Arm drift
 Speech
 Noting time of onset
 Last known time to
be normal
50
Point of discussion…
 What are the components of a neurological
exam in the field?
 Level of consciousness/mental state
 GCS
 Following commands
 Motor response
 Sensory response
 Pupils
 Reflexes and 12 cranial nerves not often
tested in the field
51
Point of discussion…
 Which rhythm is most often associated with
predisposing a patient to the possibility of having
a stroke?
 Atrial fibrillation
 Why?
 Clots can form in the stagnated blood in the
atria
 If one breaks lose, can lodge in the lungs or
brain
52
Point of discussion…
 How else may a stroke patient present?
 Abnormal feeling, vague complaint that might
not point to any specific disease process
 Weak, woozy, worried
 Motor abnormality
 GEC had a young patient who “couldn’t use their
left hand to text”
 Patient complaint “I can’t get out of bed”
 Headache
53
Case Scenario #7
 SOP’s utilized – Adult SVT
Adult Routine Medical Care (pg 5)
Universal Adult Emergency Cardiac Care (pg
6)
Stroke/Brain Attack (pg 24)
54
Case Scenario #8
 EMS is called for a 64 year-old male
complaining of left sided chest pain
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Pain is rated 7/10 and does not radiate
Started while he was taking out the garbage
Is feeling short of breath
Complains of nausea; denies vomiting
Patient is pale and diaphoretic
Hx of diabetes and hypertension
VS: B/P 120/78; P – 62; R- 22; SpO2 98%
55
Case Scenario #8
 What care is appropriate to initiate?
 12 lead EKG as soon as possible upon
contact with patient
 Interpretation drives rest of treatment!
 Aspirin 324 mg chewed
 Chewing hastens absorption
 Can be held if patient very reliable & took Aspirin
 Notify Medical Control and document why
Aspirin was held
 No harm if an extra dose is given to patient;
more harmful if not administered
56
Case Scenario #8
 Is there ST elevation?
57
Case Scenario #8
 ST elevation noted V5, V6, I, II, aVF with
reciprocal changes (ST depression) V1-3
58
Case Scenario #8
 What influence does the location of ST
elevation have on administration of
medications that cause venodilation?
 Inferior wall MI’s (II, III, aVF) can involve the
right ventricle
 Right ventricle may lose capability to pump
blood to the lungs
 Venous return exceeds right atrium output and
blood accumulates in the right ventricle
 Patient may present with hypotension, JVD, and
clear lung sounds
59
Point of discussion…
 Hallmarks of right ventricular infarction
 JVD as blood backs up into the right ventricle
 Hypotension from a decreased blood volume
moving to the lungs and therefore returning to
the left ventricle to be distributed to the body
 Clear lung sounds – blood is NOT backing up
from the left ventricle to the lungs
 Shortness of breath and pulmonary edema may
occur related to decreased perfusion with
hypotension and hypoxia
60
Case Scenario #8
 What treatment is indicated?
 Patient complains of shortness of breath so
oxygen is indicated
 4L/nasal cannula would be adequate at this
point
 Aspirin is appropriate for the majority of
patients (ie: held for allergy)
 EMS held Nitroglycerin & Morphine; Medical
Control contacted & ordered Morphine
61
Case Scenario #8
 Morphine administered per online Medical
Control order
 2 mg IVP slowly over 2 minutes
 Patient became hypotensive at 70/50
 200 ml fluid bolus given which restored
pressure
 What needs to be closely monitored when
administering fluid challenges?
 Lung sounds watching for fluid overload
62
Point of discussion…
 Point of discussion…
 Did the morphine cause this response or
the inferior wall MI?
 Not known but good example of why
we must be very careful treatment
with this type of MI
 Patient can easily become
hypotensive which can be deadly
63
Point of discussion…
 What are side effects of nitroglycerin?
 Hypotension
 Headache
 Metallic taste to mouth
 What are side effects of Morphine?
 Hypotension
 Respiratory depression (reversed with Narcan)
and supported with BVM
 Decreased level of consciousness
64
Case Scenario #8
Cath Lab Results 100% blockage
circumflex artery – 2 stents placed
65
Point of discussion…
 What is the circumflex artery?
 A branch of the left anterior descending artery
(which is a branch of the left main artery)
 Feeds the inferior wall of the left ventricle and
part of the right ventricle
 Blockage produces elevation in II,III and AFV
 Elevation in leads II, III, aVF can also be caused
by blockage of the right coronary artery
66
Case Scenario #8
 SOP’s utilized – Acute Coronary Syndrome
Adult Routine Medical Care (pg 5)
Universal Adult Emergency Cardiac Care (pg
6)
Acute Coronary Syndrome, Adult (pg 13)
67
EKG Rhythm Strip Review
 Review and identify the following strips
 Analysis
 Rhythm regular or irregular?
 What is the rate?
 Are there P waves, upright, uniform, followed
by a QRS?
 What is the PR interval (norm 0.12 - .20 sec)?
 What is the QRS (norm <0.12 seconds)?
 What is the interpretation?
 What does the patient look like?
68
EKG Rhythm Review
 Be prepared to discuss
Why the rhythm could be dangerous for the
patient
Signs and symptoms expected
Treatment indicated based on signs and
symptoms
69
Strip #1
 Sinus bradycardia
 Treatment for bradycardia if symptomatic
70
Strip #2
 Ventricular fibrillation
 How do you know it’s not just a loose lead?
 Check the pulse
71
Strip #3
 Second degree type II – Classical
 Treatment for bradycardia if symptomatic
72
Strip #4
 Monomorphic VT
 Is patient stable or unstable?
73
Strip #5
 Atrial fibrillation
 Patient at increased risk for strokes
74
Strip #6
 Third degree heart block – complete
 Treatment for bradycardia if symptomatic
75
Strip #7
 Torsades – a form of Polymorphic VT
 If pulseless, treat as VF/pulseless VT
76
Strip #8
 NSR
77
Strip #9
NO PULSE!
 PEA – is Atropine given if rate is low?
 No, it was not found to be helpful
78
Strip #10
 Third degree heart block – complete
 Treatment for bradycardia if symptomatic
79
Bibliography
 American Heart Association. 2010 Guidelines for
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Cardiopulmonary Resuscitation.
Bledsoe, B., Porter, R., Cherry, R.. Essentials of
Paramedic Care 2nd Edition. Brady. 2011.
Campbell, J.E., International Trauma Life Support 6th
Edition. Brady. 2008
Phalen, T., Aehlert, B. The 12 Lead EKG in Acute
Coronary Syndromes. 2nd edition. Elsevier. 2006.
Region X SOP’s February 1, 2012; IDPH approval 1/6/12
http://www.ems1.com/print.asp?act=print&vid=397955
en.wikipedia.org/wiki/Wolff–Parkinson–White_syndrome
80