Endocrinology, Gastrointestinal Disorders, Renal/Urology Disorders, Rhythm Review

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Endocrinology, Gastrointestinal Disorders,
Renal/Urology Disorders, Rhythm Review

• Condell Medical Center
• EMS System
• ECRN CE

Prepared by S. Hopkins, RN, BSN, EMT-P
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Objectives

• Upon successful completion of this module, the
  ECRN should be able to
• identify the function of the endocrine system
• distinguish a variety of medical disorders of the
  endocrine system
• describe the type of pain experienced for
  gastrointestinal and genitourinary disorders
• identify and appropriately state interventions
  for a variety of EKG rhythms
• understand a variety of Region X SOPs and the
  ECRN impact
• successfully complete the quiz with a score of gt
  80

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Endocrine System

• Composed of glands that secrete hormones into the
  circulatory system
• Helps regulate various metabolic functions
• Hormones function in a lock and key fashion
• All hormones operate
  within a feedback system

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Hormones

• Act on target organs elsewhere in the body
• Control and coordinate wide spread processes on
  organs, tissues, or general effects on the entire
  body
• homeostasis
• reproduction
• growth development
• metabolism
• response to stress

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Endocrine Glands

• Hypothalamus
• located deep within the cerebrum of the brain
  serves as a connection between the central
  nervous system (CNS) and the endocrine system
• secretes hormones that make other endocrine
  glands secrete hormones
• Pituitary - anterior posterior
• located in the brain size of a pea
• secretes hormones essential to growth,
  reproduction, and water balance in the body

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Endocrine Glands contd

• Thyroid
• 2 lobes located in anterior neck
• plays important role in controlling metabolism
• Parathyroid
• normally 4 glands found next to thyroid gland
• secretes hormone to increase blood calcium levels

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Endocrine Glands contd

• Thymus gland
• located in mediastinum behind sternum
• during childhood secretes a hormone critical in
  maturing T lymphocytes (cells responsible for
  cell-mediated immunity)
• Pancreas
• located in upper retroperitoneum behind stomach
• secretes digestive enzymes for digestion of fats
  proteins
• controls production or inhibition of the hormones
  glucagon insulin

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Endocrine Glands contd

• Adrenal gland
• located on superior surface of each kidney
• adrenal medulla - secretes the catecholamine
  hormones epinephrine norepinephrine
• adrenal cortex - secretes 3 steroidal hormones
• Gonads
• chief responsibility for sexual maturation or
  puberty and subsequent reproduction
• ovaries produce eggs
• testes produce sperm

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Regulation of Hormone Secretion

• Hormones operate within a positive or negative
  feedback system to maintain homeostasis
• Negative feedback
• Most common feedback mechanism
• Usually refers to an increase in the serum level
  of hormone or hormone-related substance that
  suppresses further hormone output
• Hormone production is stimulated when the serum
  levels fall

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Negative Feedback Mechanism
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Specific Disorders of the Endocrine System

• Disorders of the endocrine system arise from
• the effects of an imbalance in the production of
  one or more hormones
• the effects of an alteration in the bodys
  ability to use the hormones produced

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Specific Disorders of the Endocrine System

• Clinical effects of endocrine gland imbalance are
  determined by
• the degree of dysfunction
• the age and gender of the affected person

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Disorders of The Thyroid Gland

• Usually seen more as part of the medical history
  than as a medical emergency
• Complications of thyroid disorders more likely to
  be seen
• hyperthyroidism - too much thyroid hormone in the
  blood (goiter)
• thyrotoxicosis - prolonged exposure to excess
  thyroid hormones (Graves disease)
• hypothyroidism - inadequate thyroid hormone
• myxedema - long term exposure to inadequate
  levels of thyroid hormones

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Graves Disease

• A type of excessive thyroid activity
  characterized by a generalized enlargement of the
  gland (goiter), leading to a swollen neck and
  often protruding eyes (exophthalmos)
• More common in women than men (6 times)
• Typical onset young adulthood (20s 30s)
• May be due to an autoimmune process
  in which an antibody stimulates the
  thyroid cells
• Strong hereditary role in
• predisposition of the disorder

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Graves Disease

• Impact on EMS providers ED staff
• cardiac dysfunction is a common event prompting
  an ED visit
• tachycardia or new-onset atrial fibrillation in
  absence of cardiac history
• Other signs symptoms
• agitation, emotional changeability, insomnia,
  poor heat tolerance, weight loss with increased
  appetite, weakness, dyspnea

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Thyrotoxicosis

• A term that refers to any toxic condition that
  results from prolonged excess thyroid hormone
• Thyroid storm is a heightened and
  life-threatening manifestation of thyroid
  hyperfunction
• A relatively rare condition can be fatal
• Usually associated with exposure to physiological
  stress (trauma, infection)
• signs symptoms indicate extreme hypermetabolic
  state (high fever (1060F), irritability, delirium
  or coma, tachycardia, hypotension, vomiting,
  diarrhea)
• EMS field care - supportive, rapid transport

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Myxedema

• Rare condition of long term exposure to
  inadequate levels thyroid hormones
• 4 times more common in women
• Low metabolic state with poor organ function
• Lethargy, cold intolerance, ? mental function,
  puffy face, thin hair, pale cool skin
• Triggers for myxedema coma
• infection, trauma, cold temp

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Myxedema Coma

• Myxedema coma difficult to identify
• Impact on EMS providers ED staff
• Heart failure not uncommon
• Focus on maintenance of ABCs
• Monitor pulmonary and cardiac systems closely
• Rapid transport from the field is important
• Active rewarming in field not indicated
• may cause cardiac dysrhythmias
• vasodilation may cause cardiovascular collapse

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Disorders of Adrenal Glands

• Adrenal cortex - outer portion of adrenal gland
• Secretes steroidal hormones
• glucocorticoids - increase blood glucose levels
• mineralocorticoids - contributes to salt fluid
  balance
• androgenic hormones - influences similar to the
  gonads (role in puberty and reproduction)
• Two medical emergencies of the adrenal cortex
• Cushings syndrome
• Addisons disease

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Cushings Syndrome

• Caused by an abnormally high circulating level of
  corticosteroid hormones produced naturally by the
  adrenal glands
• May be produced
• Directly by an adrenal gland tumor
• By prolonged administration of corticosteroid
  drugs (ie Prednisone, hydrocortisone)
• By enlargement of both adrenal glands due to a
  pituitary tumor
• Relatively common problem of adrenals

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Adrenal glands
Adrenal glands
Kidneys
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Cushings Syndrome

• Characteristic appearance
• Face appears round (moon-faced) and red
• Trunk tends to become obese from disturbances in
  fat metabolism buffalo hump on back
• Limbs become wasted from muscle atrophy
• Mood swings , impaired concentration
• Purple stretch marks may appear on the abdomen,
  thighs, and breasts
• Skin often thins and bruises easily
• Weakened bones are at increased risk for fracture

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Moon Face
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Cushings Syndrome Signs Symptoms
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Management of Cushings Syndrome

• FYI higher incidence of cardiovascular disease
• stroke
• hypertension
• Fragile skin
• caution with IV starts
• handle the patient carefully to avoid trauma to
  their skin
• Treat symptoms as presented

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Addisons Disease

• Pathophysiology
• Reduction in Adrenal steroids
• Glucocorticoids
• Mineralocorticoids
• Androgens
• Most common cause is idiopathic atrophy of
  adrenal tissue (cause unknown)
• Less common causes include hemorrhage,
  infarctions, fungal infections, auto immune
  disease, therapy with steroids (ie prednisone)

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Addisons Disease

• Signs and symptoms
• Progressive weakness, fatigue
• Decreased appetite weight loss
• Hyperpigmentation of skin, especially over
  sun-exposed skin areas
• Disturbances in water electrolyte balance
• Low blood volume
• EKG changes
• Abrupt stoppage of steroids may trigger
  Addisonian crisis with cardiovascular collapse

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Addisons Disease

• Management
• Evaluate ABCs correct issues
• Cardiac status - watch for dysrhythmias and
  circulatory collapse
• Fluid resuscitation
• Respiratory status - evaluate SaO2 levels
• Blood glucose levels
• Hypoglycemia very common

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Diabetes Mellitus

• Disease marked by inadequate insulin activity in
  the body
• Glucose is important to all body cells but
  critical for the brain
• Glucose only substance used by the brain for
  energy
• Insulin maintains normal blood glucose levels
• Enables body to store energy as glycogen, protein
  fats
• Action of insulin allows glucose to flow into
  cells

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Typical Blood Glucose Levels

• Healthy persons
• Overnight fast - 80-90 mg/dL
• 1st hour after a meal - 120-140 mg/dL
• lt80mg/dL reflects hypoglycemia
• gt140 mg/dL reflects hyperglycemia
• Intervention necessary
• Hypoglycemia -blood glucose lt60 mg/dL
• Hyperglycemia - blood glucose gt300mg/dL not
  uncommon

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Type I Diabetes

• Low or absent production of insulin in the
  pancreas
• Too much sugar, not enough insulin
• Patients require supplemental insulin
• If untreated, glucose levels rise
• excess glucose spills into urine patient loses
  large amounts of water (becomes dehydrated)
  fatty acids used as energy source resulting in
  ketosis from fat catabolism

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Untreated Type I Diabetes

• Signs symptoms due to elevated blood glucose
  levels
• Polydipsia (constant thirst)
• Polyuria (excessive urination)
• Polyphagia (ravenous appetite)
• Weakness
• Weight loss
• Above signs symptoms are what usually prompt
  people to seek a medical checkup for not feeling
  well

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Type II Diabetes

• More common than Type I diabetes (90 of cases)
• Moderate decline in insulin production and
  inefficient use of the insulin that is produced
• Risk factors heredity, obesity
• Treatment dietary changes, increased exercise,
  oral hypoglycemics (to stimulate insulin
  production), possible addition of insulin if
  necessary

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Diabetic Ketoacidosis(Diabetic Coma)

• Too much sugar, not enough insulin
• Onset slow (12 - 24 hours)
• Increased urination dehydration (warm, dry skin)
• Excessive hunger and thirst
• Tachycardia weakness (volume depletion)
• Ketoacidosis ? Kussmauls respirations (deep and
  rapid) to exhale get rid of increased CO2
  levels (an acid)
• Decline in mental function
• Low potassium - cardiac dysrhythmias

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Diabetic Coma - Hyperglycemia

• ABCs addressed
• Search for medic alert bracelet (EMS should check
  for insulin in refrigerator at home)
• Elevated blood glucose levels (not uncommon to be
  gt300)
• Fluid resuscitation to treat dehydration
• The higher the glucose level, the more critical
  the situation and the sicker the patient

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Insulin Shock - Hypoglycemia

• Too much insulin, not enough sugar
• Onset rapid
• Bizarre, unusual, inappropriate behavior
• Diaphoretic, tachycardic
• Seizures at critically low glucose levels
• These seizures are most effectively treated by
  administering Dextrose to restore the glucose
  levels
• Rapid recovery with correct treatment
• supplemental glucose

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Insulin Shock - Hypoglycemia

• ABCs addressed
• Search for medical alert bracelet (EMS to check
  for insulin in refrigerator at home)
• Treated when blood sugar drops below 60
• Obtain IV access to administer dextrose (EMS
  dosing)
• Adult - D50 (50 ml)
• Child (1to 15) - D25 (2 ml/kg)
• Child lt1 - D12.5 (4 ml/kg)
• 11 dilution of D25 and normal saline
• Lack of IV access (EMS dosing protocol)
• Glucagon IM adult 1 mg peds 0.1 mg/kg (max 1mg)

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Glucagon vs Dextrose

• Glucagon
• a hormone, not a sugar
• helps release stores of sugar if there are any in
  the liver does not supply sugar itself
• is not always effective can take up to 20
  minutes
• EMS calls and states they had no IV access,
  Glucagon was given, patient remains with an
  altered level of consciousness and now they have
  IV access. Can they give Dextrose IVP?
• The ECRN should order EMS to recheck the glucose
  level and, if indicated (lt60), administer Dextrose

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Gestational Diabetes

• Onset can occur during pregnancy
• While pregnant, most women require 2-3 times more
  insulin than would usually be required when not
  pregnant
• During pregnancy, must be treated with insulin vs
  oral medication
• insulin does not cross placental barrier oral
  diabetic medication does
• After delivery blood glucose levels usually
  return to normal

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Gastrointestinal System
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Gastrointestinal Emergencies

• GI system includes from the mouth to anus and all
  parts in between
• Risk factors for disease (usually self-induced)
• excessive alcohol consumption
• excessive smoking
• increased stress
• ingestion of caustic substances
• poor bowel habits
• Pain is the hallmark of acute abdominal problems
• visceral, somatic, or referred

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Visceral Pain

• Caused by inflammation, distention (inflation of
  the organ), or ischemia (inadequate blood flow)
• Pain vague, dull, or crampy
• Is generally diffuse and difficult to localize
• Examples (most often hollow organs)
• gallbladder (cholecystitis)
• appendix (appendicitis)
• Presentation (from sympathetic stimulation)
• nausea vomiting
• diaphoresis
• tachycardia

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Somatic Pain

• Produced by bacterial or chemical irritation of
  nerve fibers in the peritoneum (peritonitis)
• Is usually constant and localized to a specific
  area
• Often described as sharp or stabbing
• Examples
• ruptured appendix
• perforated ulcer
• inflamed pancreas
• Peritonitis can lead to sepsis death

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Somatic Pain

• Presentation
• Patient often hesitant to move
• Lies on their back or side with legs flexed to
  prevent additional pain from stimulation of the
  peritoneal area
• Often exhibits involuntary guarding of the
  abdomen
• Rebound tenderness often noted during the
  physical examination

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Referred Pain

• Pain in a part of the body considerably removed
  from the tissues that cause the pain
• Results from neural pathways from various organs
  passing thru or over a region where the organ was
  initially formed in the fetal stage
• Examples
• diaphragm injury refers pain to neck or shoulders
• dissecting abdominal aneurysm refers pain between
  shoulder blades
• appendicitis refers pain to periumbilical area
• gallbladder refers pain to right shoulder

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Referred Pain Anterior View
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Referred Pain Posterior View
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Disease Entities

• Upper GI Disease
• Gastroenteritis
• Gastritis
• Peptic ulcer disease
• Lower GI Disease
• Colitis
• Crohns disease
• Diverticulitis
• Bowel obstruction

• Other Organ Disease
• Appendicitis
• Cholecystitis
• Pancreatitis
• Acute hepatitis

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Gastroenteritis

• Inflammation of the stomach and intestines that
  accompanies numerous GI disorders
• Causes
• bacteria or viral infections, chemical toxins,
  and other conditions
• Signs and symptoms
• anorexia (loss of appetite), nausea, vomiting,
  abdominal pain
• EMS Field Management
• supportive

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Gastritis

• An acute or chronic inflammation of the gastric
  mucosa
• Causes
• hyperacidity
• alcohol or drug ingestion
• infection
• Signs and symptoms
• epigastric pain
• nausea and vomiting
• bleeding

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Peptic Ulcer Disease

• Erosions in the GI tract from gastric acid
• Duodenal ulcers - most frequently in proximal
  duodenum
• most common 25-50 years old in those under
  stress
• pain at night when the stomach is empty
• Gastric ulcers - in the stomach
• more common over 50 years of age in jobs
  requiring physical activity
• usually no pain at night pain on full stomach

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Peptic Ulcer Disease

• Causes of peptic ulcer disease
• H. pylori infection (treated with antibiotics)
• Nonsteroidal anti-inflammatory drug use
• aspirin, Motrin, Advil
• Acid stimulating products
• alcohol, nicotine
• Acid secreting tumor
• Zollinger-Ellison syndrome

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Colitis

• An inflammatory condition of the large intestine
  characterized by severe diarrhea and ulceration
  of the mucosa of the intestine (ulcerative
  colitis)
• Incidence - most often 20-40 year olds
• Cause is unknown
• Signs and symptoms
• Nausea, vomiting, weight loss
• Significant pain - cramping colicky
• Grossly bloody stools or stool containing mucus

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Crohns Disease

• A chronic, inflammatory bowel disease thought to
  be of autoimmune etiology, usually affecting the
  ileum, the colon, or both structures
• Exact cause unknown
• Most prevalent in white females, those under
  stress, and in the Jewish population
• The diseased segments associated with Crohns
  disease may be separated by normal bowel segments
  or skip areas
• Formation of fistulas from the diseased bowel to
  the anus, vagina, skin surface, or to other loops
  of bowel are common

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Crohns Disease

• Signs and symptoms
• GI bleeding
• frequent diarrhea
• abdominal cramping
• diffuse abdominal pain
• nausea/vomiting/diarrhea
• fever and chills
• weakness, anorexia, weight loss

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Diverticulitis

• A diverticulum is a sac or pouch that develops in
  the wall of the colon
• Common development with advancing years
• Associated with diets low in fiber
• Diverticulitis is inflammation of diverticula
• Signs and symptoms
• Fever, anorexia, nausea, lower left
  sided pain, bright-red rectal bleeding
• Complications
• Hypovolemic shock and sepsis

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Bowel Obstruction

• A partial or complete blockage of the large or
  small intestines
• Causes
• adhesions, hernias, fecal impaction, polyps,
  tumors
• Signs and symptoms
• decreased appetite, nausea and vomiting, diffuse
  abdominal pain, constipation, and abdominal
  distention
• If untreated can lead to death

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Appendicitis

• A common abdominal emergency that occurs when the
  opening between the lumen of the appendix and the
  cecum is obstructed by fecal material or from
  inflammation from viral or bacterial infection
• Signs and symptoms
• early abdominal pain is diffuse, colicky, in
  periumbilical area (later RLQ), abdominal
  tenderness guarding, nausea,
  vomiting, chills, low-grade fever,
  anorexia
• If ruptured, increased risk of peritonitis

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Cholecystitis

• Inflammation of the gallbladder, most often
  associated with the presence of gallstones
• Incidence
• more common in women 30-50
• Signs symptoms
• pain, often colicky, in RUQ with referral to
  right shoulder
• pain often after high fat content meal
• nausea, vomiting common
• pale, cool, clammy skin (sympathetic response)
• Giving Morphine may increase spasms

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Pancreatitis

• Inflammation of the pancreas
• Alcoholism causes 80 of cases in the USA
• Signs and symptoms
• severe abdominal pain
• localized to LUQ or referred to back or
  epigastric area
• nausea and uncontrolled vomiting retching
• abdominal tenderness and distention
• fever, tachycardia, diaphoresis
• sepsis shock possible, 30-40 mortality

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Acute Hepatitis

• Inflammation of the liver
• Signs symptoms related to severity of disease
• Associated with the sudden onset of malaise,
  weakness, anorexia, intermittent nausea and
  vomiting, and dull right upper quadrant pain or
  referral to right shoulder
• Usually followed within 1 week by the onset of
  jaundice of skin sclera, dark urine, clay
  colored stool

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Risk Factors for Hepatitis A

• Spread by fecal-oral route
• Health care practice without BSI (body substance
  isolation) or infection control precautions
• Household or sexual contact with an infected
  person
• Living in an area with HAV outbreak
• Traveling to developing countries
• Poor handwashing hygiene practice especially
  after toileting
• Disease often self-limiting, lasts 2-8 weeks, low
  mortality rate

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Risk Factors for Hepatitis B

• Serum hepatitis transmitted as bloodborne
  pathogen - can stay active in body fluids outside
  body for days
• Health care practice without infection control
  precautions
• Infant born to HBV infected mother
• Engaging in sex with infected partners and/or
  multiple partners
• Drug use by injection
• Patients receiving hemodialysis
• Incidence ? with ?vaccine use

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Risk Factors for Hepatitis C

• Health care practice without infection control
  precautions
• Blood transfusion recipients before July 1992
• Engaging in sex with infected partners and/or
  multiple partners
• Drug use by injection
• Patients receiving
  hemodialysis
• 1 reason for liver transplant
  need in USA
• Currently no vaccine

1991
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Abdominal Pain - What Could
It Be?

• Naval area
• small intestine
• appendix
• Upper middle abdomen (called epigastric area)
• stomach disorders
• Left upper quadrant
• uncommon area for pain
• colon, stomach, spleen, pancreas
• Right upper quadrant
• gallbaldder, liver

• Lower middle abdomen
• colon disorder
• for women UTI, PID
• Lower left abdomen
• lower colon
• Lower right abdomen
• colon, appendicitis
• Right shoulder
• gallbladder
• Between shoulder blades
• pancreas

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Assessing Abdominal Pain

• Onset - when did it begin
• Provocation/palliation - what makes the pain
  worse/better
• Quality - described in the patients own words
• Region/radiation - if the patient can use one
  finger the pain is localized if the patient rubs
  their hands over the general entire abdomen it is
  diffuse
• Severity - on a scale of 0-10 (0 being no pain
  and 10 being the worse)
• Time - how long has the pain been present?

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Management of GI Problems

• Majority of care is supportive and aimed at
  treating signs and symptoms presented
• Position of comfort with ability to protect
  airway in the case of vomiting
• Abdominal pain control - EMS needs to contact
  medical control for medication orders (Morphine 2
  mg IVP every 2 minutes, max 10 mg)
• IV to replace fluid loss (vomiting, diarrhea,
  internal hemorrhage)
• Shock (hypovolemic, septic) possible and then
  aggressive care required

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Renal/ Urology System

• Functions of the urinary system
• maintains blood volume
• maintains proper balance of water, electrolytes
  and pH
• retains key compounds in the bloodstream
• excretes waste
• controls arterial blood pressure
• Leading causes of end-stage renal failure
• poorly controlled diabetes
• uncontrolled or inadequately controlled ? B/P

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Renal Calculus (Kidney Stones)
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Renal Calculus

• Crystal aggregation in kidneys collecting system
• Severe pain due to movement of stone through the
  urinary system
• Kidney stones recognized as one of the most
  painful of human problems
• Pain starts subtle and quickly escalates

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Kidney Stone

• Pain starts vague over 1 flank quickly becomes
  sharp in flank and radiating down and around
  toward the groin
• Patient agitated, uncomfortable, restless
• Skin cool, pale, clammy
• B/P and heart rate elevated due to pain
• Nausea vomiting due to pain

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EMS Management-Kidney Stones

• Majority of care is supportive and aimed at
  treating signs and symptoms presented
• Position of comfort with ability to protect
  airway in the case of vomiting
• Flank pain - EMS needs to contact medical control
  for medication orders (ie morphine)
• (Abdominal/Flank Pain SOP)
• If patient is unstable with B/P lt100mmHg,
  establish IV sites and give fluid challenge (200
  ml increments)

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Prevention Strategies for Renal Calculus

• Increase water consumption
• Take daily supplements of Vitamin B6 and
  magnesium (to reduce formation of oxalates)
• Avoid foods that raise uric acid levels (ie
  anchovies, sardines)
• Reduce uric acid by eating a low-protein diet
• Limit salt intake to reduce the level of calcium
  oxalate in the urine
• Avoid foods containing calcium oxalate (ie
  chocolate, celery, grapes, strawberries, beans,
  asparagus

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• Identifying a variety of EKG rhythms and
  knowing the Region X SOP for that particular
  rhythm

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Rhythm Identification

• What is this rhythm?
• What is your intervention?

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Ventricular Tachycardia

• If stable with pulse
• Amiodarone 150 mg diluted in 100 ml D5W IVPB over
  20 minutes
• or (EMS choice)
• Lidocaine 0.75 mg/kg IVP bolus
• Contact Medical Control for further bolus/drip
  orders
• If no pulse - treat like ventricular fibrillation
• emphasis on good quality CPR
• switch CPR compressor every 2 minutes to keep CPR
  effective
• all shocks given at max joules singular

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Rhythm Identification

• What is this rhythm?
• What intervention is necessary?

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EMS Tx-Ventricular Fibrillation

• If arrest lt4-5 minutes, CPR until defibrillator
  ready
• If arrest gt4-5 minutes, CPR for 2 minutes
• Single shocks at max output of unit
• Epinephrine 110,000 1 mg every 3-5 minutes
• EMS choice of one antidysrhythmic alternated with
  Epinephrine
• Amiodarone 300 mg rapid IVP 1st dose
• repeat 150 mg IVP in 5 minutes (2nd dose) OR
• Lidocaine 1.5 mg/kg IVP 1st dose
• repeat 0.75 mg/kg in 5 minutes (2nd dose)

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Rhythm Identification

• What is this rhythm?
• What intervention is necessary?

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EMS Tx-Third Degree Heart Block

• If stable patient (?B/P LOC) - monitor
• If unstable patient narrow complex (QRS)
• Atropine 0.5 mg rapid IVP
• May repeat every 3-5 minutes to max of 3mg
• TCP if Atropine not effective
• If unstable patient wide complex (QRS)
• Begin TCP (Valium for comfort)
• If TCP ineffective, then Atropine 0.5 mg repeated
  every 3-5 minutes to a max of 3 mg
• When theyre alive, give them 0.5

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Rhythm Identification

• What is this rhythm?

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EMS Tx-Third Degree Heart Block (Complete)

• In bradycardias, always need to ask 2 questions
• 1 - Is the patient stable or unstable?
• Stable needs monitoring
• Unstable needs intervention
• 2 - Is the QRS narrow or wide?
• Narrow treated initially with Atropine
• Wide treated initially with TCP

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Rhythm Identification

• What is this rhythm?
• What intervention is necessary?

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EMS Tx-Second Degree Type II

• If stable patient - monitor
• If unstable patient narrow complex (QRS)
• Atropine 0.5 mg rapid IVP
• May repeat every 3-5 minutes to max of 3mg
• TCP if Atropine not effective
• If unstable patient wide complex (QRS)
• Begin TCP (Valium for comfort)
• If TCP ineffective, then Atropine 0.5 mg repeated
  every 3-5 minutes to a max of 3 mg
• When theyre alive, give them 0.5

89
Rhythm Identification

• What is this rhythm?
• What intervention is necessary?

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Second Degree Type I - Wenckebach

• If stable patient - monitor
• If unstable patient narrow complex (QRS)
• Atropine 0.5 mg rapid IVP
• May repeat every 3-5 minutes to max of 3mg
• TCP if Atropine not effective
• If unstable patient wide complex (QRS)
• Begin TCP (Valium for comfort)
• If TCP ineffective, then Atropine 0.5 mg repeated
  every 3-5 minutes to a max of 3 mg
• When theyre alive, give them 0.5

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Rhythm Identification

• What is this rhythm (the patient has no pulse)?
• What intervention is necessary?

There is no pulse!
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EMS Tx - PEA (rate under 60)

• Emphasis will be on good quality CPR
• CPR is 302 (compressions to ventilations)
• After intubation, breaths delivered once every
  6-8 seconds, compressor doesnt stop
• Search for causes (6 Hs, 5 Ts) treat them!
• Epinephrine 110,000 1 mg every 3-5 minutes
• If rate lt60, Atropine 1 mg every 3-5 minutes (max
  3 mg)
• If rate gt60, just Epinephrine good CPR

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Scenario 1

• EMS calls with report of a 56 year-old female
  with left sided abdominal pain
• Based on the report, the ED MD informs you to
  tell EMS they must transport this patient to the
  closest facility.
• The patient is alert and oriented and requests
  transport to a farther hospital
• Can the ED MD force EMS to transport this patient
  to the closest facility?

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Scenario 1

• A patient who is alert and oriented and can
  understand the risks and benefits has the right
  to request and expect transportation to the
  facility of their choice
• EMS should have the patient sign the release for
  not going to the closest facility
• Time should not be wasted in the field arguing
  with a patient about the facility to transport to
• As in the ED, not all patients make the same
  choice you would for healthcare issues but they
  do have the right to make THEIR choice

95
Scenario 2

• EMS is on the scene with a patient who had a
  diabetic reaction with a blood sugar initially of
  45. The current blood sugar is now 80.
• EMS calls to inform the ED that they are
  obtaining a release/refusal for further care and
  transportation
• How is the ECRN to respond to this radio call?

96
Scenario 2

• Verify if EMS needed any special orders
• Often times EMS calls in to document that Medical
  Control was aware of the release especially if
  there was something unusual about the call
• Releases/refusals/AMAs in the field can be
  obtained in regards to assessment, treatment,
  and/or transportation of the patient

97
Scenario 3

• EMS calls in and reports that they have a
  critical patient and will be providing an
  abbreviated radio report
• What does it mean to receive an abbreviated
  report and what information can you expect to
  receive as the ECRN?

98
Scenario 3

• An abbreviated radio report (SOP page 4) may be
  provided to Medical Control in situations where
  manpower is limited and/or the patients
  condition is critical
• Time in the field is more importantly spent with
  all focus on caring for the patient often all
  available personnel need to be caring for the
  patient and the driver needs to focus on driving
  to get everyone to the hospital as safe and fast
  as possible

99
Scenario 3

• Contents of an abbreviated radio report
• Identification of provider name, vehicle number
  and receiving hospital
• Nature of situation and protocol being followed
• Age and sex of patient
• Chief complaint and brief history of present
  illness/injury
• Airway and vascular access status
• Current vital signs
• Major interventions completed or being attempted
• ETA to receiving hospital
• EMS to provide detailed information upon ED
  arrival

100
THE END Complete quiz and return ASAP