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The Medical Patient The Renal System; Hypertensive Emergencies

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Title: The Medical Patient The Renal System; Hypertensive Emergencies


1
The Medical Patient The Renal System
Hypertensive Emergencies
  • Condell Medical Center
  • EMS System
  • October 2008 CE
  • Site Code 10-7200E1208

Prepared by Sharon Hopkins, RN, BSN, EMT-P
2
Objectives
  • Upon successful completion of this module, the
    EMS provider should be able to
  • List the components and function of the urinary
    system
  • State signs and symptoms of chronic kidney
    disease
  • Define hemodialysis
  • Identify the differences between AV fistulas and
    AV shunts implications in the field
  • Apply the Renal SOPs given a scenario
  • List the steps in performing an abdominal
    assessment

3
  • Describe the physical assessment of the patient
    with flank pain
  • Describe the management of the patient with flank
    pain
  • Define the criteria for a hypertensive emergency
  • List the signs and symptoms of hypertensive
    emergencies
  • Describe the rationale for treatment using Lasix
    and Nitroglycerin for hypertensive emergencies
  • Describe the proper technique to obtain a blood
    pressure
  • Describe the components of a neurological
    assessment

4
  • Successfully calculate the GCS given the findings
    of the patient assessment
  • Return demonstrate pupillary assessment
  • Return demonstrate the in-line Albuterol
    set-up
  • Return demonstrate the preparation of an
    Amiodarone IVPB set-up
  • Identify and appropriately state interventions
    for a variety of EKG rhythms
  • Identify ST elevation on a 12 lead EKG
  • Successfully complete the 10 question quiz with a
    score of 80 or better

5
Urinary System
  • Contains 4 major structures
  • Kidneys
  • Vital organs
  • Located in upper abdomen retroperitoneal area
  • 1 behind the spleen 1 behind the liver
  • Ureters
  • Urinary bladder
  • Urethra

6
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7
Function of the Urinary System
  • Major functions
  • Maintains blood volume via proper balance of
    water, electrolytes, and pH
  • Retains key compounds (ie glucose) and
    eliminates wastes (ie urea)
  • Monitors and maintains arterial blood pressure
    (in addition to other mechanisms)
  • Regulates erythrocyte (RBC) development

8
Urinary Bladder
  • Storage receptacle for the production of urine
    until it is convenient or necessary to void
  • Fully distended can hold 500 ml of urine
  • The more distended the bladder, the more
    vulnerable to blunt trauma
  • After urination, the bladder contains about 10 ml
    of fluid

9
Chronic Kidney Disease
  • Can be from a specific kidney disease or as a
    complication from other conditions
  • Diabetes
  • 1 reason in USA for need for kidney transplant
  • Hypertension
  • Kidney inflammation (glomerulonephritis)
  • Inflammation of blood vessels (vasculitis)
  • Polycystic kidney disease

10
Chronic Kidney Disease
  • Diseased or injured kidneys
  • Blood flow through the renal system decreases
  • Inflammatory changes occur in the glomeruli
  • A group of capillaries where blood is filtered
    into a nephron (structure that produces urine)
  • Capillary walls thicken decreasing permeability
  • Glomerular filtration rate (GFR) is reduced
  • Volume of blood filtered per day thru glomeruli

11
Symptoms of Chronic Kidney Disease
  • Most common symptoms
  • Swelling, usually of lower extremities
  • Fatigue
  • Weight loss, loss of appetite
  • Nausea and/or vomiting
  • Change in urination
  • Reduction in volume or frequency
  • Change in sleep patterns
  • Headache
  • Itching high levels of phosphorus in system
    dry skin
  • Difficulties with memory or concentration

12
Complications of Chronic Kidney Disease
  • Hypertension
  • May be a leading cause but can also develop in
    the early stages as a complication
  • Anemia
  • Decreased production of red blood cells
  • Bone disease
  • Disorders of calcium and phosphorus
  • Malnutrition
  • Altered functional status and well-being

13
Dialysis
  • Dialysis is required when the kidneys fail and a
    transplant is not performed
  • Peritoneal dialysis uses a catheter thru the
    abdominal wall to filter the blood

14
Hemodialysis
  • Hemodialysis is a procedure in which a machine
    filters harmful waste and excess salt and fluid
    from your body
  • Access points are created to be functional within
    weeks and to last several to many years
  • Usual access point is the forearm

15
Fistulas and Shunts
  • Arteriovenous (AV) fistula
  • Most common type of access
  • Fistula created internally by sewing an artery to
    a vein forming a small opening between the two
  • Pressure from the arterial flow eventually
    enlarges and strengthens the vein
  • May take 6 weeks to heal but can last for years

16
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17
  • Arteriovenous (AV) graft
  • Access is similar to a fistula
  • A synthetic tube is used to surgically connect
    the artery to the vein
  • AV graft often heals within 2-3 weeks
  • With proper care, can last several years
  • Higher likelihood of forming clots or becoming
    infected than an AV fistula

18
Renal Dialysis
19
Hemodialysis
  • Most people treated with hemodialysis 3 times a
    week
  • Each session lasts approximately 3-5 hours
  • Some patients, at some dialysis centers, may
    choose daily dialysis
  • Usually performed 6 days per week for 2 21/2
    hours each session
  • Patients often report improved B/P and quality of
    life

20
Continuous Ambulatory Peritoneal Dialysis
  • CAPD is a self-care treatment where the patient
    instills dialysate fluid into the peritoneal
    (abdominal) cavity through a surgically implanted
    catheter through the abdominal wall
  • The dialysate stays in the abdominal cavity a
    prescribed period of time and then is drained out

21
CAPD Instructions
  • Do not disconnect the CAPD bags from the catheter
  • If the patient is transported, transport with the
    drainage bag remaining below the level of the
    patients waist
  • Do not infuse any fluids or medications directly
    into the catheter
  • This IS NOT an alternate IV site
  • Transport the patient with the CAPD intact

22
Renal Protocol Care of Patients with Grafts or
Shunts
  • Do NOT take B/P on arm with active fistula or
    graft
  • Do NOT start IV on arm with active fistula or
    graft
  • If site is bleeding, apply direct pressure
  • In case of arrest and no IV access consider IO
    site
  • Access of fistula or graft is only with contact
    to Medical Control

23
Care of The Renal Patient
  • Best to err on the side of conservative treatment
  • Monitor and support the ABCs
  • High flow O2 is appropriate to maximize
    respiratory efficiency
  • Carefully monitor fluid administration
  • Monitor cardiac rhythm for disturbances
  • Caregivers can help manage the additional
    equipment on the patient

24
Abdominal Pain Assessment
  • Chief complaint
  • The sign or symptoms that prompted the patient to
    call for help
  • Use an open ended question to determine the
    reason for the call
  • Why did you call us today? or
  • What seems to be the problem?
  • During the interview the chief complaint
    generally becomes more specific

25
Assessment
  • O onset of the problem
  • Did problem start suddenly or gradually?
  • What was patient doing at the time?
  • P provocation/palliation
  • What makes the symptoms worse? Better?
  • Q quality
  • In the patients own words how do they describe
    their pain (ie crushing, tearing, sharp, dull?)

26
  • R region/radiation
  • Where is the symptom?
  • Does it move?
  • If the patient uses one finger or isolates to one
    spot, the pain is considered localized
  • If the pain is described using both hands or
    indicating a larger area, the pain is diffuse
  • Is there referred pain (pain felt in a body area
    away from the source)?

27
  • S severity
  • Intensity of pain or discomfort
  • 0 10 scale
  • 0 is no pain 10 is the worse pain in your
    life
  • Can the patient be distracted?
  • Do they lie still or are they writhing about?
  • T time
  • When did the symptoms begin?

28
  • Associated symptoms
  • Are other symptoms present that are commonly
    linked to certain diseases that can help rule in
    or out your diagnosis?
  • Pertinent negatives
  • Are any likely associated symptoms absent?
  • Absence of symptoms can be information as helpful
    as presence of other symptoms

29
Assessment Pitfalls in the Chronic Renal Patient
  • The challenge to the medical professional is to
    separate the acute complaint from the chronic
    condition
  • What is new today that changes your status?
  • Many of these patients have unstable baselines to
    start with
  • Fluid and electrolyte imbalance
  • EKG disturbances

30
Physical Assessment - Abdomen
  • Boundaries run from xiphoid process to symphysis
    pubis
  • A full bladder will distort assessment and
    increase discomfort for the patient
  • To relax the abdominal wall or to ease pain, a
    pillow placed under the knees would be helpful
  • Start by asking the patient where it hurts
  • Examine painful areas last

31
  • Warm your hands and stethoscope
  • If hands are cold, palpate over clothing until
    hands warm up
  • Monitor facial expressions for pain or discomfort
  • Validate the facial expression
  • Often the patient scrunches their face in
    anticipation of pain
  • Assessment techniques to use
  • Inspection, auscultation, percussion, lastly
    palpation

32
Abdominal Assessment Techniques
  • Inspection
  • A visual review looking for abnormalities
  • Auscultation
  • Move the stethoscope in a circle approximately 2
    inches from the umbilicus listening for bowel
    sounds
  • Normal bowel sounds gurgle approximately every
    5-15 seconds

33
  • Percussion
  • Not often performed in the field
  • Helps determine size and location of organs
  • Determines gas, solid, and fluid filled areas
  • Tympany heard over most of abdomen
  • Dullness percussed over spleen and liver

34
  • Palpation
  • Palpate painful areas last
  • To increase comfort to patient, have them take
    slow, deep breaths thru open mouth
  • Flexing knees relaxes abdominal wall
  • Abdominal pain on light palpation indicates
    peritoneal irritation or inflammation
  • Voluntary guarding patient anticipates pain or
    is not relaxed
  • Involuntary guarding peritoneal inflammation
    (lining of abdominal cavity)

35
SOP Abdominal Pain Stable Patient
  • Routine medical care
  • Watch the patient for vomiting
  • Stable patient
  • Patient alert
  • Skin warm and dry
  • Systolic B/P gt 100 mmHg
  • Contact Medical Control for pain management

36
SOP Abdominal Pain Unstable Patient
  • Routine medical care
  • Watch the patient for vomiting
  • Unstable patient
  • Altered mental status
  • Systolic B/P lt 100 mmHg
  • Establish IV x2 if possible
  • Fluid challenge in 200 ml increments
  • 20 ml/kg in pediatric patient (max 3 challenges)
  • Contact Medical control for pain management

37
Flank Pain
  • Wheres the flank?
  • The area of the back below the ribs and above the
    hip bones
  • What organs lie in the flank areas?
  • The kidneys
  • What is a common reason for flank pain?
  • Renal calculi (aka kidney stones)

38
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39
Causes of flank pain
40
Kidney Stones
  • The formation of crystals in the kidneys
    collection system
  • Hospitalization common for pain control and fluid
    hydration
  • Additional inpatient treatment may be necessary
  • Lithotripsy sound waves used to break apart
    larger stones into smaller ones that can be
    passed during urination

41
Kidney Stones
  • More common in males
  • Suggestion of hereditary patterns
  • Risk factors include immobility and certain
    medications (anesthetics, opiates, psychotropic
    drugs)
  • Stones can form in metabolic disorders (ie gout)
  • Production of excessive uric acid and calcium

42
Stones From Calcium Salts
  • The most common type of stone
  • 75 85 of all stones
  • Calcium stones 2 3 times more common in men
  • Average age of onset 20 30 years
  • Familial indication
  • History of one stone and patient likely to form
    another one within 2 3 years

43
Struvite Stones
  • Represent 10 15 of all stones
  • Formation associated with chronic urinary tract
    infection or frequent bladder catheterization
  • Patients with spinal cord injuries
  • Patients with spina bifida
  • More common in women (due to their higher
    incidence of UTIs)

44
Uric Acid Stones
  • The least common of all stones
  • Form more often in men
  • Tend to occur with family histories so most
    likely a hereditary component
  • Half of patients with uric acid stones have gout

45
Patient Assessment
  • Chief complaint almost always severe pain
  • Kidney stones considered to be the most painful
    medical condition
  • Pain started vague, dull, poorly localized
    (visceral pain) in one flank
  • Within 30 60 minutes pain is extremely sharp,
    remains in the flank and radiates downward and
    anteriorly to the groin

46
Physical Exam
  • Agitated, restless, uncomfortable patient
  • B/P and heart rate elevated with the pain
  • Skin typically pale, cool, clammy
  • Patient may not be able to lie still for
    abdominal examination
  • Observed urine sample may have gross hematuria or
    will be evident in lab analysis

47
Management
  • Position of comfort
  • Be prepared for vomiting (due to pain)
  • IV fluids for volume replacement and as a drug
    route, and to promote urine formation and
    movement through the system to flush through the
    stone
  • Analgesia for pain limited amounts used in the
    field often have minimal effect, if at all

48
SOP Flank Pain
  • SOP treatment same as abdominal pain
  • Call Medical Control to obtain pain medication
    orders
  • Be patients advocate for pain control
  • Kidney stones are considered the most painful
    human condition (just ask someone who has had
    one!)

49
Hypertensive Emergency
  • A life-threatening crisis with an acute elevation
    of the blood pressure
  • Systolic B/P gt 230 mmHg
  • Diastolic B/P gt 120 mmHg
  • Usually seen in patients with untreated or poorly
    controlled hypertension

50
Hypertensive Emergency
  • Signs and symptoms
  • Epistaxis nosebleed
  • The nasal tissue is very thin and prone to bleed
  • Headache
  • The worst headache in my life often indicates a
    subarachnoid bleed
  • Visual disturbances (ie blurred, blindness)

51
  • Restlessness
  • Confusion
  • Nausea and vomiting
  • Neurologicial changes
  • Altered mental status to seizures to coma
  • Complications
  • Hypertensive encephalopathy
  • Severe headache, vomiting, visual changes,
    paralysis, seizures, stupor, coma
  • Ischemic (clot) or hemorrhagic (bleed) stroke

52
Field Assessment
  • Chief complaint received is often headache
  • Additional accompanying complaints
  • Nausea and/or vomiting
  • Blurred vision
  • Shortness of breath
  • Epistaxis (nosebleed)
  • Vertigo (dizziness)
  • Level of consciousness may be normal, altered, or
    patient may be unconscious

53
Field Assessment
  • Findings
  • Skin may be pale, flushed, or normal
  • Skin may be warm or cool moist or dry
  • If hypertensive encephalopathy is present, it may
    cause left ventricular failure
  • Patient will be in pulmonary edema
  • Lung sounds clear unless in pulmonary edema
  • Pulse often strong and bounding

54
SOP - Hypertensive Emergency
  • Routine Medical Care
  • Obtain and record the B/P in both arms
  • Monitor record vital signs and neuro status
    every 5 minutes
  • Lasix 40 mg IVP
  • 80mg if already on Lasix at home
  • Contact Medical control for further orders
  • Possible Nitroglycerin order

55
Treating Hypertensive Emergencies
  • Initial goal
  • To achieve a progressive, controlled reduction in
    the blood pressure to minimize risks of
    hypoperfusion in the vascular beds in cerebral,
    coronary, and renal blood flow
  • Goal is not to reduce the blood pressure to
    normal levels as fast as possible

56
Why Give Lasix?
  • Lasix is a venodilator and a diuretic
  • By dilating blood vessels, blood pressure can be
    decreased
  • Venodilator effect noticed before evidence of
    diuretic effects are seen
  • Decreasing fluid volume is another method to
    reduce the blood pressure by reducing the volume
    to be pumped

57
Why Give Nitroglycerin
  • Primarily a venodilator
  • Will dilate the diameter of blood vessels
  • Decreases blood pressure
  • Especially useful in the patient with coronary
    ischemia
  • Still need to screen for use of Viagra or Viagra
    type drugs in the past 24-36 hours

58
Obtaining A Blood Pressure
59
Blood Pressure Measurement
  • Poor technique can result in inaccurate values
  • Patients arm should be at the same vertical
    height as the heart
  • The cuff bladder should fit snugly around the arm
  • The lower edge of the cuff should be placed 1
    inch above the brachial artery
  • The bladder should be centered over the brachial
    artery

60
  • The bell end of the stethoscope will produce
    better sounds
  • The diaphragm is easier to place and hold with
    one hand
  • The cuff and tubing should not be touching
    clothes which can give false sounds
  • After the cuff is pumped up, the air should be
    released slowly
  • Air released too fast may cause an inaccurate
    measurement to be read
  • Cracked tubing causes air to leak too fast

61
Obese Site B/P Cuff
  • Wrap the blood pressure cuff around the forearm
  • Center the bladder over the radial artery
  • Place the stethoscope over the radial artery
  • Obtain and document the blood pressure in the
    usual manner (ie 120/80)

62
Blood Pressure by Palpation
  • Rough estimation of the systolic value
  • Palpate for the loss of the radial or brachial
    pulse and continue to inflate the cuff an
    additional 30 points
  • Slowly release the air and when the pulse is
    first felt, this is the recorded systolic B/P
  • Document the reading as 100/palpation

63
Rough Estimate of Blood Pressure By Palpation
  • A rough guideline accuracy is debatable
  • If the radial pulse is palpated, the B/P is said
    to be roughly 80 mmHg
  • If the femoral pulse is palpated, the B/P is said
    to be roughly 70 mmHg
  • If only the carotid (central) pulse is felt, the
    B/P is said to be roughly 60 mmHg

64
A Neuro Assessment
  • Level of consciousness
  • A alert (means awake but not necessarily
    oriented spontaneous eye opening responds to
    voice but can be confused and has motor function
    )
  • V responds to verbal command no matter how
    slight and type of response
  • P responds to pain or tactile stimuli only
  • U unresponsive with no eye, voice, or motor
    response at all to voice or pain

65
  • Ask 2 questions to determine level of
    consciousness
  • What month is this?
  • How old are you?
  • Obtain the Glasgow Coma Scale (GCS) on all EMS
    patients
  • Best eye opening (4 points)
  • Best verbal response (5 points)
  • Best motor response (6 points)
  • Evaluate pupillary response

66
Performing a Pupillary Check
  • Ask patient to focus on an object (ie tip of
    your nose)
  • Bring the light in from the side and out the same
    way
  • Without shining in the eyes move the penlight
    into position for the opposite side and repeat

67
  • Vital signs
  • Signs of increasing intracranial pressure include
    increasing B/P and dropping heart rate
  • Check muscle tone and strength
  • Evaluate facial symmetry (smile)
  • Evaluate clarity of speech
  • The above 3 are the Cincinnati Stroke Scale
  • Arm drift, facial symmetry, speech
  • Additionally
  • Coordination or gait and sensory
  • Movement and sensation

68
Repeat Assessment
  • If you want to see where the patient is going,
    youve got to know where theyre coming from
  • GET A BASELINE EVALUATION
  • You can anticipate something happening if you are
    watching the trends
  • PERFORM REPEAT ASSESSMENTS AS OFTEN AS INDICATED
  • Prevents surprises

69
  • Need to constantly monitor the situation
  • Watch for trends
  • Anticipate surprises

70
Pain Management SOP
  • Routine trauma or medical care
  • Continuous patient monitoring
  • Respiratory status
  • SaO2
  • Blood pressure
  • Morphine
  • 2 mg slow IVP over 2 minutes
  • May repeat every 2 minutes
  • Maximum total 10 mg

71
Respiratory Depression Related to Morphine Use
  • Supportive oxygenation
  • If SaO2 is falling and ventilation rates are
    declining, consider supportive bagging
  • Ventilation rates for supportive bagging (AHA)
  • Adult 1 breath every 5 6 seconds
  • Pediatric patients 8 and less 1 breath every 3
    5 seconds
  • Narcan (narcotic antagonist)
  • 2 mg IVP if respiratory depression

72
Glasgow Coma Scale Exercise
  • Review the following 3 patients assessment
    findings
  • Evaluate for their GCS
  • Determine the best response and score the
    patients
  • Best eye opening 1 - 4 points
  • Best verbal response 1 5 points
  • Best motor response 1 - 6 points
  • Note GCS to be obtained on all patients!

73
GCS Exercise 1
  • You are assessing a 56 year-old patient
  • The patient is unresponsive. Nothing happens when
    you call the patients name. when you pinch the
    patient, their eyes open, then close.
  • When pinched, the patient says dont, stop and
    then is silent.
  • When pinched, the patient pushes you away

74
GCS Exercise 2
  • Your patient is a 16 year-old male.
  • Upon approaching, the patients eyes are open and
    they are looking around with an anxious look.
  • They do not answer questions they groan if
    pinched.
  • They do not follow commands. When touched, the
    patient grabs your arm and doesnt let go.

75
GCS Exercise 3
  • Your patient is an 8 month-old.
  • Their eyes are closed. There is no response to
    pinching.
  • When pinched, the patient groans weakly.
  • When pinched, the patient tries to pull away or
    turn away from the evaluator.

76
GCS Exercise Answers
  • GCS 1 total 11
  • Eye opening 2
  • Verbal response 4
  • Motor response 5
  • GCS 2 total 11
  • Eye opening 4
  • Verbal response 2
  • Motor response - 5
  • GCS 3 total 7
  • Eye opening 1
  • Verbal response 2
  • (groans to pain incomprehensible words)
  • Motor response 4
  • (withdraws to pain)

77
Skill In-line Albuterol
  • For Albuterol to have its bronchodilating
    effects, it must be delivered down into the lungs
  • If the patient cant inhale it in, we have to
    push it in

78
Normal use with corrugated tubing connected to
the T-piece
Kit connected to oxygen and run at 6 l/minute
(enough to create a mist). Nebulizer kept upright
at all times.
79
In-line Albuterol
  • Intubate the patient
  • While waiting to intubate, can bag the
    Albuterol into the lungs via in-line set-up thru
    ambu mask
  • Confirm placement in the usual manner
  • visualization
  • chest rise fall
  • 5 point auscultation
  • ETCO2 detector
  • Evaluated after 6 breaths are delivered

80
To adapt nebulizer to in-line use
  • Remove mouthpiece from T-piece and replace with
    BVM
  • Connect nebulizer to oxygen source

81
  • Corrugated tubing left in place on
    T-piece
  • Clear adaptor placed on distal end of corrugated
    tubing
  • Once intubated, clear adaptor connected to ETT

82
  • Albuterol will be effective if it gets into
    the bronchial system, not just into the back of
    the throat.
  • The BVM helps push the Albuterol where it will
    do the most good.

83
EKG Review Treatment
There is NO pulse!!!
6 second strip


The patient has no pulse!
84
EKG Interpretation 1
  • PEA with a rate over 60
  • CPR
  • Secure airway
  • Search for causes (6 Hs 5 Ts)
  • Establish IV/IO access
  • Epinephrine 110,000 1 mg IVP/IO every 3-5
    minutes
  • No Atropine rate over 60

85
6 Hs
  • Hypovolemia fluid challenge
  • Hypoxia supplemented oxygen flow
  • Hydrogen ion acidosis ventilate (breathe) for
    the patient
  • Hyper/Hypokalemia electrolyte imbalance
  • Hypothermia warm them up
  • Hypoglycemia screen all unconscious/altered
    level of consciousness patients for glucose level

86
5 Ts
  • Toxins think little kids getting into the wrong
    places (ie purses, cabinets)
  • Tamponade, cardiac
  • Tension pneumothorax needle decompression
  • Thrombosis, coronary
  • Thrombosis, pulmonary (embolism)
  • Trauma

87
EKG Review Treatment
88
EKG Interpretation 2
  • Strip A complete heart block
  • Strip B paced rhythm
  • Unstable Type II and 3rd degree heart blocks
  • Patient often unstable due to slow heart rate
  • Begin TCP
  • Rate 80/minute
  • Sensitivity auto/demand
  • Output lowest mA until capture

89
Comfort Measures For TCP
  • Valium 2 mg IVP slowly over 2 minutes
  • May repeat 2 mg IVP every 2 minutes
  • Maximum of 10 mg
  • Can touch the patient and not receive shocks
  • Its the patient that feels the electrical
    stimulation

90
EKG Review Treatment
91
EKG Interpretation 3
  • VT wide complex, until proven otherwise, is VT
  • 2 questions to ask for all tachycardias
  • Question 1 is patient stable or unstable
  • Evaluate LOC and B/P
  • If you are not perfusing, you cannot maintain an
    adequate level of consciousness or blood pressure
  • If unstable, prepare for immediate cardioversion
  • If stable, ask question 2

92
2nd Question To Ask if Stable Tachycardia
  • Question 2 is complex (QRS) narrow or wide?
  • Narrow think SVT
  • Adenosine is drug of choice
  • Wide think VT
  • EMS choice between Amiodarone or Lidocaine
  • Mixing the antidysrhythmics makes the heart more
    irritable
  • Let the ED know which drug therapy was started

93
  • If stable VT
  • Antidysrhythmic treatment
  • Amiodarone 150 mg diluted in 100 ml D5W IVPB
  • Draw up Amiodarone dose, add to 100 ml D5W IV bag
    and gently agitate to mix label the bag (drug,
    amount, time added)
  • Run thru mini-drip tubing piggyback into the
    primary IV line
  • Run over 10 minutes (rapid drip rate just below
    wide open)
  • OR Lidocaine 0.75 mg/kg IVP x1
  • Contact Medical Control for further orders

94
EKG Review Treatment
95
EKG Interpretation 4
  • Sinus bradycardia
  • If symptomatic/unstable (poor cardiac output with
    altered mental status and B/P lt100)
  • Atropine 0.5 mg rapid IVP
  • When theyre alive give them 0.5
  • May repeat every 3-5 minutes to a max of 3 mg
  • If ineffective begin TCP
  • If TCP ineffective, treat per Cardiogenic Shock
  • IV fluid challenge in 200 ml increments, Dopamine
    drip

96
Wheres ST elevation?
97
12 Lead Interpretation 1
  • ST elevation in exercise 1
  • V1 V3
  • 12 lead obtained in field
  • EMS to evaluate the 12 lead looking for patterns
    of ST elevation
  • I, aVL, V5, V6
  • II, III, aVF
  • Any contiguous V leads
  • EMS to call in what they see fax the 12 lead

98
Wheres the ST elevation?
99
12 Lead Interpretation 2
  • ST elevation in exercise 2
  • V2 V4
  • 12 lead obtained in field
  • EMS to evaluate the 12 lead looking for patterns
    of ST elevation
  • I, aVL, V5, V6
  • II, III, aVF
  • Any contiguous V leads
  • EMS to call in what they see fax the 12 lead

100
Wheres the ST elevation?
101
12 Lead Interpretation 3
  • ST elevation in exercise 3
  • II, III, aVF
  • 12 lead obtained in field
  • EMS to evaluate the 12 lead looking for patterns
    of ST elevation
  • I, aVL, V5, V6
  • II, III, aVF
  • Any contiguous V leads
  • EMS to call in what they see fax the 12 lead

102
Bibliography
  • Bledsoe, Porter, Cherry. Paramedic Care
    Principles Practices. 3rd Edition. Brady. 2009.
  • Burrows-Hudson, S. Chronic Kidney Disease. AJN.
    Feb 2005. Vol 105, No2.
  • http//en.wikipedia.org/wiki/Blood_pressure
  • http//en.wikipedia.org/wiki/AVPU
  • www.hospital-equipment.co.uk/images/taking-bl
  • www.mayoclinic.com/health/hemodialysis/DA00078
  • www.neuroexam.com/
  • www.strokestrategyseo.ca/pdf_docs/neurological20a
    ssessment
  • www.vascularweb.org/patients/NorthPoint/Dialysis_A
    ccess.html
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