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Altered Mental Status Medication Review Lung Sounds MAD Device

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Title: Altered Mental Status Medication Review Lung Sounds MAD Device


1
Altered Mental StatusMedication ReviewLung
SoundsMAD Device
  • ECRN Module I
  • 2010 CE
  • Condell EMS System
  • Prepared by Sharon Hopkins, RN, BSN, EMT-P

2
Objectives
  • Upon successful completion of this module, the
    ECRN will be able to
  • Describe elements of normal mental status.
  • Describe components of the neurological
    examination.
  • List the three components of the Glasgow coma
    scale.
  • Calculate the GCS.
  • List common causes of an altered mental status.

3
Objectives contd
  • Review Cincinnati Stoke Scale
  • Describe the FAST concept
  • Review Region X SOP Altered Mental Status
  • Explain the differences between the adult and the
    pediatric airway.
  • Describe the assessment of the airway and
    respiratory system.
  • Describe the various lung sounds auscultated
    during assessment.

4
Objectives contd
  • Discuss the methods for measuring oxygen and
    carbon dioxide in the blood in the prehospital
    setting.
  • Identify pre-hospital indications,
    contraindications, dosing, side effects, and
    special considerations of Dextrose, Glucagon,
    Narcan, Albuterol, Epinephrine 11000, Benadryl,
    Lasix, and Morphine.

5
Objectives contd
  • Describe the indications, contraindications,
    dosing, side effects, and special considerations
    for administering Narcan via the MAD tool.
  • Describe the MAD tool and the procedure for using
    the MAD tool.
  • Describe the indications, contraindications,
    complications, and the process for performing a
    cricothyrotomy in the field.

6
Normal Mental Status
  • Consciousness
  • Person is fully responsive to stimuli and
    demonstrates awareness of the environment
  • Altered level of consciousness
  • Some form of dysfunction or interruption in the
    central nervous system

7
Normal Mental Status
  • Patient is awake
  • Patient is alert aware of surroundings
  • Patient is oriented to person, place, time
  • Patient is cooperative
  • Patient carries on normal conversation
  • Patient able to follow/obey commands
  • Gait is even and steady

8
Altered Level of Consciousness
  • Hallmark sign of central nervous system injury or
    illness

9
Did You Know?
  • When perfusion is declining, the first indicator
    is a changing level of consciousness
  • The last indicator is a falling blood pressure

10
Assessing Mental Status - AVPU
  • A awake
  • V responds to verbal stimuli
  • P responds to painful stimuli
  • U- unresponsive

11
A Awake
  • Patient is awake, alert and aware of surroundings
  • OR
  • Patient may be awake but confused
  • Report what the patient is oriented to
  • Oriented to person but not place or time
  • Key is watching for a change in level of
    consciousness from the baseline taken

12
V Verbal Response
  • This would need to be evaluated prior to touching
    the unconscious patient
  • Problem If trauma is involved, need to manually
    control the C-spine before causing the patient
    any movement of the c-spine
  • If possible, call the patients name to check for
    response to verbal stimuli prior to making
    physical contact

13
P Painful Response
  • Does not necessarily mean you have to perform a
    painful task to check for response
  • Start with simple tactile contact touch
  • Add deeper stimulation if needed
  • Sternal rub
  • Pinch of thumb web space
  • Trapezius muscle squeeze (near neck)
  • Do not cause so much trauma as to leave
    marks/bruises
  • Observe for some kind of response with muscles

14
Patient Response
  • Patient response can include
  • Opening of eyelids even briefly
  • Fluttering of eyelids
  • Wrinkling of brows
  • Most important is looking for changes in the
    patients response from one evaluation/assessment
    to the next

15
U - Unresponsive
  • The patient has NO response at all
  • No moaning
  • No muscle twitch at all
  • No eyelid flutter
  • No wrinkling of the eyebrow
  • Muscles are flaccid with absolutely no response
    regardless of stimuli

16
Neurological Exam In the Field
  • AVPU what is level of consciousness?
  • Pupillary response
  • Movement of distal extremities
  • Wiggling fingers and toes
  • Sensation of distal extremities
  • Ability to feel contact with fingers and toes
  • GCS
  • lt10 or deteriorating mental status patient is
    considered critical and categorized as Category I
    trauma

17
Glasgow Coma Scale - GCS
  • The best score possible is given
  • More important is watching the trend than relying
    on any one score
  • Objective tool
  • All using the tool on the same patient should get
    the same score
  • Evaluate
  • Best eye opening
  • Best verbal response
  • Best motor response

18
GCS Eye Opening
  • 4 Spontaneous patients eyes are open
  • Does not have to be focusing
  • 3 Eyes open or motion is made to verbal
  • stimuli
  • Start with soft voice, may have to yell at
    patient to open eyes
  • 2 Eyes open with tactile or painful stimuli
  • Start with gentle touch may need to add more
    intense stimuli
  • 1 No eye opening no muscle motion at all

19
GCS Verbal Response
  • 5 Oriented to person, place, and time
  • 4 Pleasantly confused
  • 3 Inappropriate words
  • You can understand the word(s) spoken but they
    are not within context
  • 2 Incomprehensible words sounds
  • No intelligible word understood moans and
    groans makes noises
  • 1 Silent no noise is made at all

20
GCS Motor Response
  • 6 Obeys commands
  • 5 Localizes pain / purposeful movement
  • Can push you away or grab at the noxious stimuli
    (IV, collar, bandaging, your hands)
  • 4 Withdrawal
  • No longer localizing, just withdraws/pulls away
    to get away from annoying/painful stimuli (IV,
    collar, bandaging, your hands)

21
Motor contd
  • 3 Flexion to pain
  • Arms flex/bend slowly toward center of chest when
    any stimuli applied
  • 2 Extension to pain
  • Arms slowly extend and curl inward and legs
    straighten when any stimuli applied
  • 1 No movement at all

22
GCS Results
  • Score range 3 15
  • Minor head injury 13 15
  • Moderate head injury 9 12
  • Severe head injury (coma) - lt8
  • Significant mortality risk
  • Consider intubation or other means to secure the
    airway

23
GCS Practice
  • Read the following case scenarios
  • Determine the best eye opening, verbal response,
    motor response
  • When the response is asymmetrical, award the
    highest points possible
  • Dont guess or assume what you think they really
    can do
  • Award points for what is performed
  • Be objective
  • Note Answers follow the practice slide

24
GCS Case 1
  • Patient lying in the bed (no trauma), eyes are
    closed
  • You need to yell the patients name and then the
    eyelids flicker
  • They are mumbling
  • They are grabbing at your hands and pushing you
    away. They have pulled out the IV.

25
GCS Case 1 Score
  • Eye opening 3
  • Responded to loud voice
  • Verbal response 2
  • Mumbling is incomprehensible words/sounds
  • Motor response 5
  • Patient can recognize (localize) what feels
    obnoxious and what he wants to stop so they are
    grabbing at you and pulling at equipment
  • Total GCS - 10

26
GCS Case 2
  • Patient is lying in the street watching you
    approach
  • They mumble as you talk to them
  • They are grabbing at your hands and pushing you
    away

27
GCS Case 2 Score
  • Eye opening 4
  • Spontaneous doesnt necessarily indicate
    focusing
  • Verbal response 2
  • Mumbling, moaning, groaning
  • Motor response 5
  • Purposeful movement by grabbing at what the
    patient perceives as noxious stimuli
  • Total GCS - 11

28
GCS Case 3
  • Patient watches your approach and acknowledges
    your presence
  • Patient answers most questions and thinks you are
    their relative come to visit
  • Patient able to move left arm to command but not
    able to move right arm (new onset possible
    stroke)

29
GCS Case 3 Score
  • Eye opening 4
  • Spontaneous
  • Verbal response 4
  • Pleasantly confused
  • Motor response 6
  • Highest possible score based on the arm that can
    and does move
  • Total GCS - 14

30
GCS Case 4
  • Childs eyelids flicker when deformed extremity
    is manipulated
  • Child moans out when painful areas are
    manipulated
  • Child pulls away when touched and tries to turn
    away from EMS

31
GCS Case 4 Score
  • Eye opening 2
  • Response to painful stimuli
  • Verbal response 2
  • Moans and groans are incomprehensible words /
    sounds
  • Motor response 4
  • Withdrawing from what is sensed as painful
    stimuli
  • Flexion would be slow flexing of arms toward
    center of chest this patients response is not
    flexion
  • Total GCS 8 (Protect airway consider
    intubation)

32
GCS Case 5
  • Patients eyes remain closed no eyelid movement
    at all
  • There are no sounds heard from the patient
  • The patient straightens their arms, twists their
    wrists, arches their back, and straightens their
    legs when stimulated

33
GCS Case 5 Score
  • Eye opening 1 (no response)
  • Verbal response 1 (no response)
  • Motor response 2
  • Abnormal extension
  • The worse level of response prior to no response
    at all
  • Total GCS 4
  • Patient is critical Category I
  • Patient usually needs some airway intervention

34
Common Causes of Altered Mental Status
  • A acidosis, alcohol
  • E Epilepsy
  • I Infection (brain, sepsis)
  • O Overdose
  • U Uremia (kidney failure)
  • T Trauma, tumor, toxins
  • I Insulin hypo or hyperglycemia
  • P Psychosis, poison
  • S Stroke, seizure

35
Initial Patient Assessment
  • Airway
  • Open or obstructed
  • Maneuvers needed to open
  • Head tilt / chin lift
  • With trauma, modified jaw thrust
  • Breathing
  • Quality
  • Quantity (eyeball assessment at this time)

36
Initial Assessment contd
  • Circulation
  • Quality
  • Quantity (dont count get estimate of range)
  • Disability need to obtain baselines
  • AVPU
  • GCS
  • Expose to examine
  • Cant evaluate or fix what you cant see

37
Assessment Tools
  • AVPU
  • Alert (interpreted as an awake patient)
  • Responds to verbal stimuli
  • Responds to painful stimuli
  • Unresponsive

38
Assessment Tools
  • GCS
  • Best eye opening response
  • Best verbal response
  • Best motor response
  • Scores range from the lowest of 3 to highest of
    15
  • Obtain and document GCS on all patient calls

39
Cincinnati Stroke Scale
  • Obtain for suspicion of TIA or stroke
  • Evaluate for facial droop
  • Check the patients symmetry during a broad, big
    smile (teeth showing)
  • Evaluate for arm drift
  • Check for weakness in holding arms outstretched,
    palms up, for 10 seconds
  • Evaluate for clear speech
  • Have patient repeat words listening for clear
    speech patterns

40
Airway Protection and the Stroke Patient
  • Crucial - high mortality rate for aspiration
  • Is airway patent and can patient protect their
    own airway?
  • Check if patient is able to handle swallow own
    saliva
  • Detailed/involved swallow study done in-hospital
  • Patient speaks in clear unobstructed voice
  • Interventions to consider
  • Have suction on and ready
  • Ability to quickly turn patient onto their side

41
FAST - Public Educational Tool
  • Tool developed by organizations for public
    recognition of stroke and to encourage FAST
    action

42
Region X SOP Altered Mental Status
  • Consider etiology
  • If cause of problem can be identified, then
    interventions can be focused
  • Diabetes check blood sugar
  • Drug overdose what are the environmental clues
  • Poisoning environmental evidence around
  • Alcohol related environmental evidence use
    your nose

43
SOP Altered Mental Status
  • Maintain airway
  • Patency extremely important
  • Evaluate rate and quality
  • If respirations inadequate, ventilate
  • 1 breath every 5-6 seconds all patients infancy
    to elderly
  • Intubate as necessary
  • Use C-spine precautions as indicated
  • If any doubt, err on side of extra precautions
  • Provide Routine Medical Care
  • IV O2 - monitor

44
SOP Altered Mental Status
  • Obtain blood glucose level
  • If lt60 treat
  • Adult - Dextrose 50 50 ml IVP
  • Child 1 15 Dextrose 25 2 ml/kg
  • Infant lt1 Dextrose 12.5 4 ml/kg
  • Dilute 11 ratio D 25 with normal saline
  • Equal amounts of product make 11 dilution
    (Dextrose and normal saline)

45
Treating Altered Mental Status
  • In absence of IV access
  • Adult Glucagon 1 unit (1 ml) IM
  • Pediatrics lt 15 Glucagon 0.1 mg/kg IM
  • Max dose of 1 mg
  • Practice math 44 pound child with no IV access
  • How many kg?
  • 44 ? 2.2 20 kg
  • 20 kg x 0.1mg/kg 2 mg
  • How much Glucagon do you give?
  • Max of 1 mg (max drugs at adult dose)

46
Altered Mental Status contd
  • If patient not alert, respirations decreased, or
    narcotic overdose suspected
  • Narcan 2mg IN/IVP/IO
  • Repeat every 5 minutes as needed until desired
    effect
  • Quality of respirations have improved
  • Dont need patient to be 15 on GCS
  • Dont need patient awake necessarily
  • Maximum total dose 10 mg
  • Transport

47
Altered Mental Status contd
  • Note
  • Attempt to identify substances involved
  • If not a safety hazard, obtain and transport
    substance container with the patient
  • Consider use of restraints prior to
    administration of Narcan
  • Patient may become violent when level of
    consciousness improves

48
  • Adult Airway Pediatric airway
  • Note funnel shaping of pediatric airway

49
Notice Difference in Tongue Size
  • Adult airway
  • Pediatric airway

tongue
50
Pediatric airway Differences
  • Jaw smaller
  • Teeth softer and more fragile
  • Tongue relatively larger
  • Potential to produce more obstruction
  • Epilgottis floppier and rounder
  • Recommend straight Miller blade over curved
    Macintosh for intubation
  • Larynx more superior anterior
  • Higher and more forward
  • Funnel shaped due to underdeveloped cricoid
    cartilage
  • Under age 10 cricoid cartilage narrowest part of
    airway
  • Ribs and cartilage softer and more pliable
  • Children rely on diaphragm muscle for breathing

51
Airway Assessment
  • Inspection
  • Begin as you are approaching the patient
  • Auscultation
  • Listen for audible sounds, then use stethoscope
  • Palpation
  • Can gather a lot of information through the art
    of touch

52
Assessment of Airway
  • Initial assessment
  • ABCs
  • Airway open?
  • Fully open with adequate air exchange?
  • Partially or fully obstructed with poor air
    exchange?
  • Are they breathing?
  • Look for chest rise and fall
  • Listen for air movement
  • Feel for air movement
  • Do they have a pulse?

53
Airway Assessment contd
  • Inspection
  • Evaluate adequacy of breathing
  • Note any signs of trauma
  • Assess skin color
  • Paleness and diaphoresis due to sympathetic
    stimulation in early respiratory compromise
  • Cyanosis if deoxygenated (LATE SIGN!!!)
  • Patient positioning
  • Tripod leaning forward (CHF? Asthma?)
  • Orthopnea cant lay down (CHF? Asthma?)

54
Inspection contd
  • Observe for dyspnea
  • May cause or be caused by hypoxia
  • Prolonged dyspnea can lead to anoxia (absence of
    oxygen)
  • Is dyspnea a new onset or perhaps chronic in the
    patient with long standing COPD

55
Abnormal Respiratory Patterns
  • Kussmauls
  • Deep, slow or rapid, gasping breathing
  • Commonly found in diabetic ketoacidosis in
    attempt to blow off excess CO2 (acid)
  • Cheyne Stokes
  • Progressively deeper, faster breathing
    alternating with gradually shallow and slower
    breathing
  • Indicates brainstem injury

56
Respiratory Patterns contd
  • Biots
  • Irregular pattern of rate and depth with sudden,
    periodic episodes of apnea
  • Indicates increased intracranial pressure
  • Central neurogenic hyperventilation
  • Deep, rapid respirations
  • Indicates increased intracranial pressure
  • Agonal
  • Shallow, slow, or infrequent breathing
  • Indicates brain anoxia, impending death

57
Respiratory Assessment contd
  • Auscultation
  • Listen 1st audibly for any abnormal sounds
  • Have patient cough to clear loose secretions
  • Then listen with stethoscope
  • Right and left apex (under clavicles)
  • Right and left bases (8th 9th intercostal
    space, midclavicular)
  • Right and left lower thoracic back or right and
    left midaxillary line (lateral chest wall)

58
Auscultation contd
  • Posterior aspect preferable to anterior surface
  • Less tissue mass
  • Lungs closer to the surface
  • Less interference with heart sounds
  • Anterior and lateral sections of the chest are
    more accessible especially in supine patients
  • Evaluate for symmetrical equality
  • Keep stethoscope in place long enough to hear end
    of exhalation
  • Many abnormal sounds heard first at end of
    exhalation

59
Abnormal Lung Sounds
  • Snoring
  • Partial obstruction of upper airway, usually from
    tongue
  • Patient needs airway repositioned
  • Gurgling
  • Accumulation of fluids (blood, vomitus, other
    secretions) in upper airway
  • Stridor
  • Harsh, high-pitched sound heard on inhalation
    usually indicates laryngeal edema or constriction

60
Lung Sounds contd
  • Wheezing
  • Musical, squeaking, or whistling sound heard in
    inspiration and/or exhalation
  • Indicates bronchiolar constriction
  • Asthma, COPD
  • Quiet
  • Diminished or absent breath sounds ominous
  • Indicates serious problem with airway, breathing,
    or both

61
Lung Sounds contd
  • Crackles (rales)
  • Fine, bubbling sound heard on inspiration, sounds
    like velcro ripping
  • Indicates fluid in smaller airways
  • CHF
  • Pneumonia
  • Gas exchange may be compromised
  • Rhonchi
  • Course, rattling noise heard on inspiration
  • Associated with inflammation, mucus, or fluid in
    bronchioles
  • Gas exchange may be compromised
  • Chronic bronchitis

62
Airway Assessment
  • Palpation
  • Often forgotten assessment tool
  • Palpate chest wall for
  • Tenderness
  • Symmetry
  • Abnormal motion
  • Crepitus (bone crunching)
  • Subcutaneous emphysema
  • Air leakage into tissue

63
Pulse Oximetry
  • Measures hemoglobin oxygen saturation in
    peripheral tissue
  • Non-invasive means to measure effectiveness of
    oxygenation and ventilation
  • Continually reflects changes
  • May detect changes faster than assessment of
    vital signs

64
Pulse Oximetry
  • Place probe over a peripheral capillary bed
  • Fingertip, toe, earlobe
  • 2 sensors take measurements of light reaching
    them from 2 light emitting diodes
  • Oximeter calculates ratio of light received
  • Influenced by amount of oxygenated versus
    deoxygenated hemoglobin
  • SpO2 determined

65
Suggested SpO2 Results
  • 95 99 - normal
  • 91 -94 - mild hypoxia
  • Perform additional evaluation
  • Administer supplemental oxygen
  • 86 91 - moderate hypoxia
  • Perform additional evaluation
  • Administer 100 supplemental oxygen
  • lt85 - severe hypoxia
  • Immediate intervention required

66
SpO2 Error Results
  • Current equipment more accurate less error
    readings
  • False readings possible
  • Carbon monoxide exposure false high
  • High-intensity lighting near sensors
  • Hemoglobin abnormalities
  • Absent peripheral pulses
  • Hypovolemia severe anemia
  • SpO2 may be normal but the amount of hemoglobin
    available is low
  • Coordinate readings with patient assessment

67
Capnography
  • Graphic recording or display of measurement of
    expired CO2 over time
  • End-tidal CO2 (ETCO2) measurement of CO2
    concentration at end of expiration
  • Provides information
  • Systemic metabolism (production of CO2)
  • Circulation
  • Ventilation

68
How Does CO2 Circulate?
  • CO2 is normal end product of metabolism
  • Transported by venous system to right side of
    heart
  • Pumped from right ventricle ? pulmonary artery ?
    lungs and pulmonary capillaries
  • Diffuses into alveoli
  • Removed from body via exhalation

69
Poor Perfusion States
  • Shock, cardiac arrest, pulmonary embolism,
    bronchospasm, incomplete airway obstruction (ie
    mucous plugging)
  • Perfusion decreased
  • ETCO2 will reflect pulmonary blood flow and
    cardiac output
  • Will not reflect ventilation in poor perfusion
    states

70
End Tidal CO2 Detector
  • Contains pH sensitive chemically impregnated
    paper to estimate ETCO2 level
  • Color change is reversible
  • Will reflect changes breath to breath
  • Paper will be unreliable if contaminated with
    acidic drugs or gastric contents
  • Tool placed near elbow on BVM

71
Interpreting the ETCO2
  • Yellow indicates measured CO2 being exhaled
  • Evaluate after 6 breaths
  • Tan low levels of CO2 measured
  • Misplaced tube or poor carbon dioxide production
  • Evaluate tube positioning
  • Evaluate patient perfusion
  • Blue or purple no CO2 being measured
  • Suspect unsuccessful intubation

72
ETCO2
  • Applications
  • Verify placement of endotracheal tube
  • Assess effectiveness of CPR
  • CO2 levels fall abruptly at onset of cardiac
    arrest
  • CO2 levels begin to rise with effective CPR

73
  • Medication Review
  • (Information based on Region X EMS usage)
  • Indication
  • Contraindication
  • Dosing
  • Side effects
  • Special considerations

74
Dextrose
  • Carbohydrate used to raise the sugar level
  • No contraindication in suspected hypoglycemia
  • Administered when the blood sugar level is less
    than 60
  • Dose based on age
  • Adult 16 and over 50 50 ml slow IVP
  • 1 15 D 25 - 2 ml / kg slow IVP
  • lt1 D 12.5 - 4 ml / kg slow IVP
  • Mix 11 dilution with D25 and normal saline

75
Dextrose contd
  • Local vein irritation may occur especially when
    small veins are used
  • If glucagon was administered and then an IV site
    is secured, retest the blood sugar level
  • If blood glucose remains lt60 and patient
    condition not improved, administer Dextrose

76
Glucagon
  • Hormone to stimulate breakdown of glycogen
    (stored form of glucose)
  • Patient may have an allergic reaction if they
    have allergies to proteins
  • Adult dosing 1 mg (1 unit) IM
  • Pediatric dosing up to 15 years old 0.1
    mg/kg (max dose 1 mg 1 unit)

77
Glucagon contd
  • Observe for nausea and vomiting
  • May take up to 20 minutes for Glucagon to be
    effective
  • Will not have any effect if there are no stores
    of glycogen in the liver
  • Patient requires rapid transport and continued
    efforts at IV access
  • Drug must be reconstituted prior to administration

78
Albuterol
  • Ventolin, Proventil
  • Bronchodilator with onset 5 15 minutes after
    inhalation
  • Used in asthma, to reverse bronchospasm in COPD,
    and bronchospasm laryngeal edema of an
    allergic reaction
  • All patients inhale 2.5 mg via nebulizer

79
Albuterol contd
  • May cause tachycardia restlessness
  • Has greater influence in the lungs than on the
    heart
  • Less effective if patient taking beta blockers at
    home (usually for hypertension meds end in
    alol)
  • Beta blockers block bronchodilation response
  • Offer aerosol mask if patient unable to keep
    mouthpiece sealed between lips

80
Albuterol Kit and Masks
Connected to O2 source
2.5 mg / 3 ml
  • Watch for signs of exhaustion
  • May need to be bagged

Available in adult and pediatric sizes
81
Epinephrine via Nebulizer
  • In presence of croup/epiglottits
  • If patient not responding to 2 doses of
    Albuterol, provide alternate treatment
  • Epinephrine 11000 1 ml mixed with 2 ml
    normal saline
  • Mix in nebulizer
  • Connect to oxygen to create a mist
  • Assist patient while inhaling the mist
  • Nebulized Epinephrine for moderate to severe cases

82
Epinephrine 11000
  • A drug that mimics the sympathetic nervous system
  • Stimulation on the vessels trigger
    vasoconstriction
  • Will raise the blood pressure
  • Stimulation in the lungs triggers bronchodilation
  • Will improve air exchange
  • Useful in asthma, COPD, allergic reactions with
    airway involvement, and anaphylaxis

83
Epinephrine 11000 contd
  • Use with caution in the elderly and those
    with heart disease
  • Can strain the heart by increasing the workload
    of the heart (rate and force of contractions)
  • Adult dosing allergic reaction with airway
    involvement 0.3 mg SQ
  • Adult dosing anaphylaxis 0.5 mg IM
  • Faster absorption in poor perfusion

84
Epinephrine 11000 contd
  • Pediatric dosing up to 15 years of age
  • Allergic reaction with airway involvement
  • Epi 11000 - 0.01 mg/kg SQ
  • Max single dose 0.3 ml (0.3 mg)
  • May repeat every 15 minutes
  • Anaphylaxis
  • Epi 11000 0.01 mg/kg IM
  • Max single dose 0.3 ml (0.3 mg)
  • IM faster absorption in poor perfusion state
  • May repeat every 15 minutes

85
Epinephrine 11000 contd
  • May cause
  • Tachyarrhythmias
  • Palpitations
  • Restlessness
  • Anxiety
  • Headache
  • May increase oxygen demand in the heart
  • Use cautiously in elderly and those with heart
    disease

86
Benadryl - Diphenhydramine
  • Antihistamine to block the release of histamine
    in allergic reactions
  • Max effect in 1 3 hours
  • Duration of effect 6 -12 hours
  • Medication must be continued over several days or
    symptoms will rebound
  • Useful in allergic reactions including anaphylaxis

87
Benadryl contd
  • Avoid use in severe, uncontrolled asthma and COPD
  • Adult dosing
  • Stable allergic reaction 25 mg slow IVP or IM
  • Allergic reaction with airway involvement
    anaphylaxis 50 mg slow IVP or IM
  • Pediatric dosing 1 mg/kg IVP
  • Stable allergic reaction max dose 25 mg
  • Allergic reaction with airway involvement or
    anaphylaxis max dose 50 mg

88
Benadryl contd
  • May cause drowsiness, headache, confusion,
    wheezing, palpitations, hypotension, nausea,
    vomiting, drying of secretions
  • Elderly particularly sensitive to effects of
    Benadryl
  • Watch for hypotension and drowsiness

89
Lasix (furosemide)
  • Diuretic that stops reabsorption of sodium and
    chloride in the kidneys
  • Triggers dilation of the venous system
  • Could drop blood pressure
  • Decreases pre-load
  • Amount of blood returning to the heart
  • Onset of venodilation immediate
  • Onset of diuretic effect within 15 20 minutes

90
Lasix (furosemide) contd
  • Useful in CHF and pulmonary edema
  • Venodilation useful in hypertensive crisis
  • Slight risk in persons allergic to sulfa drugs
    (typically antibiotics)
  • Dosing is 40 mg IVP/IO
  • If patient is on Lasix, they are sensitized to it
  • Use the larger dose of 80 mg IVP/IO

91
Lasix (furosemide) contd
  • May cause headache, dizziness, hypovolemia,
    nausea
  • Patient may experience temporary hearing loss and
    ringing in the ears with repeated doses given
    rapid IVP/IO over a period of time

92
Morphine
  • Narcotic analgesic (opioid)
  • Reduces anxiety
  • Creates a euphoric feeling
  • Depresses the central nervous system (CNS)
  • Reduces pain sensation
  • Dilates venous blood vessels
  • Decreases blood return to the heart (pre-load)
  • Useful in ACS, pulmonary edema, pain
  • Potentiates versed during conscious sedation
  • Helps versed to be more effective

93
Morphine contd
  • Dosing
  • 2 mg given slow IVP (over 2 minutes)
  • May repeat every 2-3 minutes
  • Maximum total dose is 10 mg
  • Side effects
  • Hypotension
  • Respiratory depression
  • Bradycardia
  • Altered level of consciousness

94
Morphine contd
  • Opioids cause pupils to constrict
  • Use cautiously when other depressant drugs have
    been taken
  • Includes alcohol
  • Reversal agent is Narcan
  • Adult dosing 2 mg IVP
  • May repeat every 5 minutes max total 10 mg
  • Pediatric dosing lt 20kg 0.1 mg/kg IVP/IO/IM
  • Max total dose is 2mg
  • gt 20kg 2 mg IVP/IO/IM

95
Narcan
  • Narcotic antagonist with an onset within
    2 minutes
  • May cause withdrawal symptoms including seizures
  • Adult dose 2 mg IN/IVP/IO
  • Repeated every 5 minutes as needed up to 10 mg
  • Pediatric dose up to 15 years weight based
  • lt20 kg (44) 0.1 mg/kg IVP/IO/IM
  • gt20 kg (44 - typically a 4-6 year old)
    2 mg IVP/IO/IM

96
Narcan contd
  • Side effects are rare. Watch for hypotension,
    nausea, vomiting, blurred vision, opiate
    withdrawal (including seizures)
  • Goal is to reverse severe respiratory depression
    NOT to have an awake talking patient
  • Duration of Narcan may be shorter than drug it is
    trying to counteract
  • Watch for return of symptoms

97
Alternate Medication Delivery - MAD
  • Mucosal atomization device
  • Tool to deliver medications via nasal route
  • Medication atomized into tiny particles
  • Nasal mucosa highly vascular
  • Immediate absorption into bloodstream
  • Onset of action within 3-5 minutes
  • Peak onset 15-20 minutes

98
Using Nasal Route - MAD
  • Unable to establish IV access
  • Medication administration indicated
  • Nasal mucosa intact and
    clear of blood and mucus

99
MAD
  • Luer tip can be connected to variety of sizes of
    syringe
  • White wedge fits firmly into nostril
  • Fine mist spray covers a large surface area
  • Medication adheres to nasal mucosa
    versus running down the throat
  • Each nostril can tolerate up to 1 ml volume
  • Narcan packaged 2mg/2ml will need to deliver 1
    ml in each nostril

100
Attaching MAD Tip to Syringe
  • Nasal cavity suctioned as needed to clear blood
    or secretions
  • Clear nasal passages enhance absorption of
    medication
  • Medication delivered in divided doses
  • Maximum of 1 ml per nares

101
Inserting MAD Nasal
  • Patients head controlled with one hand
  • Need to prevent movement
  • MAD gently but firmly placed into one nostril
  • Aimed upward and toward ear on same side
  • Syringe briskly compressed to deliver the drug as
    an atomized mist into nares

102
Dispensing Mist
  • Must briskly compress syringe to convert liquid
    drug to a fine atomized mist
  • Mist results in broader mucosal coverage better
    chance of absorption into the blood stream than
    drops that can run straight back into the throat.

103
MAD
  • Region X have implemented the MAD beginning with
    Narcan
  • IN documented for route of administration
  • Will have the potential in the future to add
    further medication using the MAD

104
Cricothyrotomy, QuickTrach
  • Indications
  • Assisted ventilations required and all other
    means have failed to secure an airway
  • Contraindications
  • Transected trachea
  • Less invasive maneuver will be effective
  • Note In ED, staff will need to assist the MD
    with this device do you know how?

105
Equipment
  • BVM
  • QuickTrach kit
  • gt77 pounds use 4 mm kit
  • 22 77 pounds use 2 mm kit
  • lt 22 pounds use needle cricothyrotomy
  • Skin prep material
  • Where is your airway kit kept in the ED?

106
QuickTrach Kit Contents
  • Needle with syringe
  • Cannula with wings for strap attachment
  • Extension tubing
  • Velcro strap

107
QuickTrach contd
  • Procedure (RN to assist MD)
  • Assemble equipment
  • Patient supine, neck hyperextended if no trauma
  • Locate cricothyroid membrane and cleanse site
  • Soft spot palpated just below Adams apple
  • Or, start at notch, run fingers up toward head
  • First ridge of bone palpated is cricoid cartilage
  • Membrane is just above this bony cartilage

108
Procedure contd
  • Anchor and stretch skin slightly
  • Puncture cricothyroid membrane at 900 angle
  • Aspirate syringe as needle enters trachea to
    confirm placement
  • Ability to freely aspirate air
  • Change angle of needle to 600 towards feet
  • Advance device until stopper is flush with skin
  • Remove stopper
  • Stopper will be snug avoid motion of needle
  • Slide plastic cannula forward until snug against
    skin as you remove needle and syringe
  • Advance cannula as you remove needle like
    starting an IV

109
Procedure contd
  • Hold cannula snuggly
  • Patient may reflexively cough and could dislodge
    cannula
  • Attach flexible connecting tube to cannula
    proximal end
  • Begin to bag/ventilate the patient immediately
  • Once every 6-8 seconds for all patients
  • Confirm placement
  • Auscultation lung sounds
  • Adequate chest rise
  • Finish securing cannula with neck strap

110
Case Study 1
  • Your patient called 911 after dropping her tea
    cup and being unable to move her right side
  • Conscious, cooperative, speech slurred
  • VS 175/110 P 98 R 18 pupils cataract
  • Initial care started (IV O2 monitor)
  • What is your impression?
  • What specific assessment should be done?

111
Case Study 1 contd
  • Impression
  • Acute stroke
  • Additional assessment
  • Cincinnati Stroke Scale
  • Facial droop
  • Arm drift
  • Speech
  • Transport decision
  • Is CT scan available at receiving hospital?

112
Case Study 2
  • EMS is at a local school for a patient with
    asthma
  • Assessment taken walking towards child
  • Sitting upright
  • In obvious distress
  • Use of accessory muscles neck, intercostal
  • Increased respiratory rate
  • Panic on their face
  • Impression
  • Severe acute asthma attack
  • Is assessment done after vital signs?

113
Case Study 2 contd
  • Assessment performed
  • Observation / visual inspection
  • Initial ABCs
  • To determine presence of life threats
  • Breath sounds auscultated
  • Bilateral wheezing heard predominately on
    exhalation
  • Obtain vital signs
  • 98/62 P 110 R 28 and labored SpO2 94

114
Case Study 2 contd
  • Interventions required
  • IV O2 monitor - medication
  • Question
  • Do you need an IV established prior to
    administration of medication?
  • No, albuterol nebulizer should be started as soon
    as possible
  • Give verbal prompts to slow breathing down, to
    take deeper breaths, and to eventually take and
    hold a deep breath

115
Case Study 3
  • You are caring for a traumatically injured
    patient
  • When asking them to open their eyes, you yelled
    their name and their eye opened briefly and then
    closed again
  • They are using swear words during care provided
  • They are pulling off equipment and grabbing at
    your hands while you provide care
  • What is their GCS?

116
Case Study 3 contd
  • Eye opening
  • To verbal 3 points
  • Verbal response
  • Inappropriate words 3 points
  • Motor response
  • Purposeful movement 5 points
  • Total GCS 11 points
  • Indicates moderate head injury

117
Case Study 4
  • You are caring for a patient complaining of
    dyspnea
  • Your patient is 62 years-old
  • They are sitting in the tripod position
  • They are using accessory muscles and have an
    increased respiratory rate
  • With your stethoscope, you auscultate crackling
    sounds heard in the bases during exhalation

118
Case Study 4 contd
  • What are these breath sounds?
  • Crackles
  • What do these breath sounds indicate?
  • Fluid in the smaller airways
  • CHF, pulmonary edema, pneumonia
  • What medications may be indicated in the field
    (per SOP) for CHF?
  • Nitroglycerin venodilator
  • Lasix venodilator and diuretic
  • Morphine venodilator, reduce anxiety
  • And of course, oxygen
  • Intervention to add is CPAP

119
Case Study 5
  • You received a 7 year-old patient from a local
    school with an asthma attack
  • Your impression is an acute asthma attack
  • You begin supplemental oxygen and begin to
    prepare to provide interventions

120
Case Study 5 contd
  • If this is an asthma attack, what signs and
    symptoms do you expect?
  • Sitting up leaning forward
  • Dyspnea with shortness of breath
  • Increased respiratory rate
  • Use of accessory muscles
  • Dry mucous membranes
  • Possibly audible wheezing
  • Bilateral wheezing heard first on exhalation
  • Dry, nonproductive cough

121
Case Study 5 contd
  • If you cannot hear any breath sounds, what does
    this mean?
  • The airway is so constricted that no air is
    moving in or out ominous
  • What does wheezing sound like?
  • Whistling, musical sound that can be heard on
    inhalation and exhalation
  • The louder the breath sounds the more air that is
    exchanging

122
Case Study 5 contd
  • What medication is indicated?
  • Albuterol 2.5 mg (in 3 ml) nebulizer
  • How can you help maximize the effects of the
    treatment?
  • Calmly, quietly talk the patient through
    breathing
  • Get the patient to slow down the breathing
  • Get the patient to take some deeper breaths
  • Get the patient to inhale and hold their breath
    periodically to get the drug into the lungs

123
Case Study 6
  • You have an unresponsive male in his twenties
  • The patient responds to painful stimuli
  • The respirations are 6 per minute and shallow
  • Pupils are constricted
  • What is your impression?
  • What interventions were necessary in the field?

124
Case Study 6
  • Impression
  • Narcotic overdose
  • Interventions
  • Immediately support ventilations
  • Bag at a rate of once every 5-6 seconds
  • Protect the airway from aspiration
  • Administer Narcan 2 mg (via MAD if no IV)
  • Administer a maximum of 1 ml per nares if using
    MAD

125
Case Study 7
  • A patient is unable to be ventilated via BVM
  • What options are available?
  • Reposition the airway
  • Consider c-spine precautions if indicated
  • Attempt intubation
  • QuickTrach if unable to intubate
  • Needle cricothyrotomy if unable to identify
    landmarks

126
Case Study 7
  • Landmarks for Quicktrach
  • Soft space just inferior/below thyroid cartilage
    (Adams apple)
  • Or
  • Start in notch and move finger upward
  • Feel first bony prominence cricoid cartilage
  • Palpate for soft space above the cricoid cartilage

127
Bibliography
  • Bledsoe, B., Porter, R., Cherry, R. Paramedic
    Care Principles and Practices. Prentice Hall.
    2009.
  • Campbell, J. BTLS 5th Edition. Brady. 2004.
  • Region X SOP, March 2007 amended January 1,
    2008.
  • videolaryngoscopy.com//AdultCobalt-Airway.jpg
  • www.wolfetory.com
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