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Endocrinology, Gastrointestinal Disorders, RenalUrology Disorders, Rhythm Review

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Title: Endocrinology, Gastrointestinal Disorders, RenalUrology Disorders, Rhythm Review


1
Endocrinology, Gastrointestinal Disorders,
Renal/Urology Disorders, Rhythm Review
  • Condell Medical Center
  • EMS System
  • ECRN CE

Prepared by S. Hopkins, RN, BSN, EMT-P
2
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

3
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

4
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

5
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

6
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

7
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

8
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

9
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10
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

11
Negative Feedback Mechanism
12
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

13
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

14
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

15
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16
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17
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

18
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19
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

20
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

21
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

22
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

23
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

24
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

25
Adrenal glands
Adrenal glands
Kidneys
26
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

27
Moon Face
28
Cushings Syndrome Signs Symptoms
29
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

30
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)

31
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

32
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

33
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

34
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

35
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

36
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

37
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

38
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

39
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

40
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

41
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)

42
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

43
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

44
Gastrointestinal System
45
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

46
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

47
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

48
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

49
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

50
Referred Pain Anterior View
51
Referred Pain Posterior View
52
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

53
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

54
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

55
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

56
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

57
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

58
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

59
Crohns Disease
  • Signs and symptoms
  • GI bleeding
  • frequent diarrhea
  • abdominal cramping
  • diffuse abdominal pain
  • nausea/vomiting/diarrhea
  • fever and chills
  • weakness, anorexia, weight loss

60
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

61
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

62
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

63
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

64
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

65
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

66
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

67
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

68
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
69
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

70
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?

71
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

72
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

73
Renal Calculus (Kidney Stones)
74
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

75
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

76
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)

77
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

78
  • Identifying a variety of EKG rhythms and
    knowing the Region X SOP for that particular
    rhythm

79
Rhythm Identification
  • What is this rhythm?
  • What is your intervention?

80
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

81
Rhythm Identification
  • What is this rhythm?
  • What intervention is necessary?

82
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)

83
Rhythm Identification
  • What is this rhythm?
  • What intervention is necessary?

84
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

85
Rhythm Identification
  • What is this rhythm?

86
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

87
Rhythm Identification
  • What is this rhythm?
  • What intervention is necessary?

88
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?

90
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

91
Rhythm Identification
  • What is this rhythm (the patient has no pulse)?
  • What intervention is necessary?

There is no pulse!
92
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

93
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?

94
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
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