Curriculum Update: SOP and Bradycardia Rhythm Review Based on SOPs March 2005

1
Curriculum UpdateSOP andBradycardia Rhythm
ReviewBased on SOPs March 2005

• Condell Medical Center
• EMS System
• October 2006
• Site Code 10-7200E-1206
• S Hopkins, RN, BSN, EMT-P

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Objectives

• Upon successful completion of this program, the
  EMS provider should be able to
• identify indications, contraindications, dosing,
  special considerations, and side effects of
  medications used in the Region X SOP
• participate in rhythm review
• state the indications and site of choice of the
  IO needle
• participate in rhythm identification practice
• successfully complete the quiz with a score of
  80 or greater

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Introduction - Adult Intraosseous (IO) Infusion

• Can be useful
• when there is a need for IV access and an IV
  cannot be established in 2 attempts or 90 seconds
  
• May be helpful to use immediately in cardiac
  arrest or profound hypotension with altered
  mental status

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Adult IO Contraindications

• Fracture of tibia or femur (consider alternate
  extremity)
• Infection at intended site
• Previous orthopedic procedure to the area (ie
  knee replacement, IO previous 480)
• Preexisting medical condition (ie tumor near
  site, peripheral vascular disease)
• Inability to locate landmarks (ie significant
  edema)
• Excessive tissue at site (ie morbid obesity)

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Adult IO Procedure

• BSI protection including face/eye shield
• Fill 10 ml syringe with normal saline.
• Prime connecting tubing (1 ml) leaving 9 ml in
  syringe and leave syringe connected to tubing
• Identify landmarks
• just medial to tibial tuberosity on flat portion
  of proximal tibia (same site for pediatrics)
• FYI intramedullary vessels do not collapse even
  in critically ill patients

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Adult IO Procedure contd

• Cleanse insertion site
• Prepare EZ-IO driver and needle set
• Stabilize leg with non-dominant hand
• do not place your hand under patients leg
• Insert EZ-IO needle at 900 angle

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Adult IO Procedure contd

• Activate driver by depressing trigger on handgrip
  while maintaining firm steady pressure on
  driver
• most insertions accomplished under 10 seconds
• Once decreased resistance is felt, or needle
  flange touches skin (whichever is first), release
  the trigger
• While stabilizing hub, remove driver from needle
  set

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Adult IO Procedure contd

• Remove stylet by rotating counterclockwise
• place stylet in sharps container
• Connect primed EZ-connect tubing
• Using syringe, flush with remaining 10 ml normal
  saline
• observe for swelling or
  extravasation around site
• to improve flow rate,
  give 10 ml bolus
  normal saline rapid IVP

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Adult IO Procedure contd

• Confirm needle placement
• most reliable indicators
• needle firmly in bone
• fluid infuses well
• inability to aspirate does not mean non-placement
• if placement is in doubt, leave needle in place
  with connecting tubing syringe attached and ED
  staff can reevaluate site

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Adult IO Procedure contd

• Attach EZ-connect to IV tubing begin infusion
• any drug given IVP can be given IO
• dosages, onset, peak concentrations virtually
  identical to those given IVP
• IO route is preferred over ETT route
• Apply pressure to IV bag to facilitate flow
• flow rates will be slower than IV routes due to
  anatomy of IO space
• pressure may be applied manually or with a blood
  pressure cuff

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Adult IO Procedure contd

• Secure tubing to leg
• Apply wristband supplied with equipment
• offers 24 hour hot line for questions
• reminds staff to remove EZ-IO within 24 hours
• Frequently reassess pressure to IV bag
• Monitor EZ-IO site and patient condition
• infection rates are low (0.6)
• another EZ-IO may be used in same limb after 48
  hours
• check calf area for swelling after any fluid bolus

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Adult IO Procedure Patient Feedback

• Pain felt during insertion equivalent to
  bumping shin on a table (5/10)
• lasted lt 10 seconds
• Similar levels of pain felt
  when IV infusions started at
  max rates
• your patients will not be
  conscious!

Dr. Miller, EZ-IO developer after practice
insertion of device
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EZ-IO Device

• FYI
• Same drill will eventually be used for pediatric
  and adult insertion of IO device
• Needle size will change to adapt to population
  receiving IO
• Hands-on practice will take place in future CE

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Electrical Conduction System

• SA
• AV node
• Bundle of His
• Right Left Bundle Branches
• Purkinje Fibers

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Sinus Bradycardia

• Rate lt 60 bpm
• Rhythm regular
• P waves positive, upright, rounded, precede
  each QRS, all look relatively alike
• PR interval 0.12 - 0.20 seconds relatively
  constant
• QRS lt0.12 seconds (unless intraventricular
  conduction delay is present)

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Atrioventricular (AV) Blocks

• Delay or interruption in impulse conduction in AV
  node, bundle of His, or His-Purkinje system
• Classified according to degree of block and site
  of block
• PR interval is key in determining type of AV
  block
• Width of QRS determines site of block

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AV Blocks

• Clinical significance dependent on
• degree or severity of the block
• rate of the escape pacemaker site
• ventricular site will be slower than a junctional
  site
• patients response to that ventricular rate
• evaluate level of consciousness/responsiveness
  and blood pressure

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Second Degree AV Block Wenckebach, Mobitz Type I

• Rate atrial rate is greater than ventricular
  rate
• Rhythm atrial rate regular (P to P marches out)
  ventricular rate irregular (dropped QRS)
• P waves P waves all uniform, not all P waves
  followed by QRS
• PR interval getting progressively longer until
  there is a P wave without a QRS
• QRS lt 0.12 seconds

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Second Degree AV Block Classical, Mobitz Type II

• Rate atrial rate greater than ventricular
• Rhythm atrial regular (Ps to Ps march out)
  ventricular regular if degree of block is
  constant
• P waves normal in appearance not all followed
  by QRS
• PR interval constant for conducted beats
• QRS lt 0.12 seconds

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3rd Degree Heart Block - Complete

• Rate atrial rate greater than ventricular
  ventricular rate determined by site of escape
  rhythm
• Rhythm atrial regular (Ps to Ps march out)
  ventricular regular but no relationship to atrial
  
• P waves normal in appearance
• PR interval none (no relationship between atrial
  ventricular rhythms
• QRS narrow if junctional pacemaker site or wide
  if ventricular pacemaker site

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Helpful Tips

• Second degree Type I
• think Type I drops one
• Wenckebach winks when it drops one
• Second degree Type II
• think 21, 21, 21
• recognize the block can be variable or something
  other than 21
• Third degree - complete
• think completely no relationship between atria
  and ventricles

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How Can I Tell What Block It Is?
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Junctional Rhythms

• Rate 40 - 60 bpm
• Rhythm very regular
• P waves may occur before, during, or after QRS
  if visible are inverted in lead II, III, AVF
• PR interval if P wave present, usually shortened
  (lt 0.12 seconds)
• QRS normally lt 0.12 seconds, longer if
  aberrantly conducted

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Junctional Rhythms

• Rate determines description
• Junctional escape rhythm rate is 40-60 bpm
• Accelerated junctional rhythm rate is 61 -
  100 bpm
• Junctional tachycardia rate is over 100

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Treatment/Interventions Bradycardia

• Guided by presence and degree of signs and
  symptoms
• Atropine
• used to increase heart rate
• can increase rate of SA node discharge increase
  speed of conduction through AV node has little
  or no effect on contractility
• typical dose starts 0.5 mg IVP
• maximum dosage 3 mg IVP

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Additional Treatment

• Transcutaneous pacing
• no response to doses of atropine
• unstable patient with a wide QRS
• set pacing at a rate of 80 beats per minute in
  the demand mode
• start output (mA) at lowest setting possible and
  increase until capture
• Valium 2 mg IVP (increments to 10 mg) should be
  given to help with the chest discomfort

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Patient Unresponsive To Therapy

• Consider the patient may be in cardiogenic shock
• Consider fluid challenge 200 ml may repeat once
• Evaluate breath sounds before after fluid
• Dopamine drip to maintain B/P gt100
• Start dopamine minidrip at 5 mcg/kg/min
• Tip - quick drip calculation take pts weight in
  pounds, take 1st 2 numbers, subtract 2. This is
  drip factor to start with (ie pt weight 210
  21 - 2 19 start drip at 19
  minidrips/minute)

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What Is This Rhythm?

• Sinus bradycardia
• At this rate the patient is expected to be
  symptomatic
• Treatment if symptomatic?
• Atropine for narrow complex QRS TCP if QRS wide

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What Is This Rhythm?

• Second degree Type I - Wenckebach
• Treatment usually not necessary as heart rate is
  usually near lower limit of 50s - 60s and
  patient is rarely symptomatic
• Monitoring is required for deterioration

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What Is This Rhythm?

• Second degree Type II - Classical (narrow
  complex)
• Overall ventricular rate is most often slow
  causing the patient to be symptomatic and
  requiring therapy

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What Is This Rhythm?

• Second degree Type II - Classical
• Wide QRS indicates the origin of the escape
  pacemaker site is low down in the conduction
  system
• TCP should be used ASAP if patient symptomatic

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What Is This Rhythm?

• Third degree heart block - complete
• P to Ps are regular R to Rs are regular
• There is no relationship between the atria and
  ventricles (no pattern or consistency with PR
  interval)

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What Is This Rhythm?

• Third degree - complete heart block with a wide
  QRS complex
• Treatment includes avoiding atropine and starting
  with TCP

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What Is This Rhythm?

• Junctional rhythm (P waves inverted)
• Inherent rate of AV node is 40 -60 bpm
• Treatment is based on symptoms and tolerance of
  patient

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What Is This Rhythm?
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What Is This Rhythm?

• Second degree Type I - Wenckebach
• For some patients, this may be their normal
  rhythm. For others, they may go back and forth
  between sinus rhythm and second degree heart
  block Type I without signs or symptoms

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What Is This Rhythm?

• Sinus bradycardia with wide QRS (bundle branch
  block pattern)
• Need to determine if patient is symptomatic or
  not before deciding on interventions needed

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What Is This Rhythm?

• Third degree heart block - complete
• With this appearance and heart rate, patient more
  than likely will be symptomatic
• If narrow QRS, start with atropine
• If wide QRS, patient needs TCP (omit atropine)

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Implanted pacemaker
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Paced Rhythm - 100 Capture
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What Is This Rhythm?

• Paced rhythm with single failure to capture
• Pacemaker wires may need to be repositioned at
  the hospital
• Carefully monitor EKG for further loss of capture

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Revised AHA CPR Guidelines

• The message
• focus is back to basics
• push harder, push faster
• 302 for adult 1 2 man child infant 1 man
  CPR
• 152 for child infant 2 man CPR
• rate of 100 compressions/minute
• perform 5 cycles of 302 CPR in 2 minutes and
  then prepare to defibrillate if needed
• switch CPR roles every 2 minutes due to
  exhaustion (if the compressor is tired, CPR will
  be sloppy and will not be effective)
• minimize CPR interruptions to lt 10 seconds

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CPR Changes contd

• perform CPR if there is any delay while charging
  defibrillator
• do not perform pulse checks unless you observe a
  rhythm that should provide perfusion
• after defibrillation immediately resume CPR
• do not stop to perform a rhythm check
• ventilations over 1 second
• once every 5-6 seconds via BVM to mouth
• once every 6-8 seconds with advanced airway in
  place (ETT, combitube, LMA)
• IV/IO drug route preferred over ETT route

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Review SOGs

• DNR status
• properly completed form must be present with
  patient
• can recognize old orange form or new watermelon
  colored form
• can be a reproduction on any color paper
• Closest hospital
• patient choice when possible allowable
• clinical condition of patient dictating
  destination
• lack of airway
• unstable, near arrest condition
• psych patient with no preexisting relationship
  elsewhere

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Cardiac Protocol Review

• Acute Coronary Syndrome
• chew aspirin to enhance absorption
• if patient reliable and took daily dose, do not
  need to repeat dose inform medical control if
  aspirin not given for any reason, document why
• if patient lt 35, give aspirin and then confer
  with medical control before giving nitroglycerin
  or morphine
• 12 lead if treating patient for acute coronary
  syndrome
• inform ED you are sending 12 lead

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• Tachycardia
• determine if the patient is stable or unstable
• evaluate blood pressure and level of
  consciousness
• if unstable needs cardioversion (start at 100 j)
• if stable, determine if QRS is narrow (think
  adenosine) or wide (think lidocaine)
• PEA/asystole
• think treat for potential causes (Hs Ts)
• PEA epi 1 mg if rate is lt60 atropine 1mg (max 3
  mg)
• asystole epi 1 mg atropine 1 mg (max 3mg)

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Stroke/Brain Attack

• Screen all patients for time of onset of symptoms
• assessment diagnostics must be completed and
  drug intervention must be started within 3 hours
  of onset (gt3 hours increases risk of intracranial
  bleed
• Therefore, the most important question is
• What time did your symptoms
• start?

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Cincinnati Prehospital Stroke Scale

• Facial droop
• ask patient to smile, big enough to show their
  teeth
• watch for droop and record as right/left sided
  droop or no droop
• Arm drift
• ask patient to close their eyes, hold arms out in
  front, palms up, for 10 seconds
• watch for right/left drift or none
• Abnormal speech
• abnormal is slurring words, using wrong words, or
  inability to speak

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In-Field Spinal Clearance

• A ? reliable patient ? without signs or symptoms
  of neck/spine injury and ? negative mechanism of
  injury does not require full spinal
  immobilization
• Document findings to support decision to not
  immobilize
• When in doubt, fully immobilize

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In-Field Spinal Clearance Criteria

• Positive mechanism of injury - immobilize
• high velocity MVC gt40 mph
• unrestrained occupant in MVC
• passenger compartment intrusion gt12
• ejection from vehicle
• rollover MVC
• motorcycle collision gt20 mph
• death in same vehicle
• pedestrian struck by vehicle
• falls gt2 times patient height
• diving injury

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In-Field Spinal Clearance

• Positive signs symptoms
• pain in neck or spine
• tenderness/deformity of neck or spine upon
  palpation
• paralysis or abnormal motor exam
• paresthesia in extremities
• abnormal response to painful stimuli
• For the presence of any above noted signs and/or
  symptoms, or gut instinct, the patient needs full
  spinal immobilization

52
In-Field Spinal Clearance

• Patient reliability questionable
• signs of intoxication
• abnormal mental status
• communication difficulty
• abnormal stress reaction
• ie person extremely upset over the incident
• If patient not reliable, full spinal
  immobilization required

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Interventions - Traumatic Injuries

• Tension pneumothorax
• needle decompression - 2nd or 3rd intercostal
  space midline of the clavicle, over the top of
  the rib
• Sucking chest wounds
• occlusive dressing secured on 3 sides
• watch for development of a tension pneumothorax
• lift edge of dressing to burp during exhalation
• Fluid resuscitation
• 20 ml/kg bolus normal saline
• adult reevaluate every 200 ml
• peds patient maximum of 3 boluses (60 ml/kg)

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Did You Remember?

• What do the drugs for conscious sedation do?
• Lidocaine for head insult (trauma or medical)
• prevents the cough reflex (coughing would raise
  intrathoracic pressures which would transmit to
  the brain and raise intracranial pressures)
• Morphine - reduce anxiety pain facilitate a
  response to versed
• Versed - relax sedate patient act as amnesic
• Benzocaine - eliminate gag reflex
• to test for gag reflex in unconscious patient,
  stroke eyelashes - if blink reflex still present,
  patient still has gag reflex
• use short 1-2 second spray to back of throat

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• What drugs are good diagnostic tools to use for
  unknown unconscious person?
• Dextrose if glucose lt 60
• If glucagon given 1st and then IV established,
  reassess glucose level and can give D50 if needed
• Narcan 2 mg IVP
• useful in altered level of consciousness (ie to
  wake a patient up) and known/suspected narcotic
  overdose (to improve ventilation depth and rate)
• if you have to chase a patient around the room to
  administer narcan, then they dont need narcan yet

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• When does CPAP get initiated?
• Acute pulmonary edema, when patient remains alert
  and cooperative, blood pressure remains gt90
• When would CPAP need to be discontinued?
• Blood pressure drops below 90
• At any time the patient deteriorates further
• Diabetic emergencies
• Hypoglycemic needs glucose (sugar) to replace
  depleted stores
• brain most sensitive organ to low glucose levels
• Diabetic ketoacidosis (DKA) (glucose gt200) is
  dehydrated and needs fluid replacement

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• Allergic reaction/Anaphylactic shock
• Simple (hives, itching, rash), stable
• Benadryl 25 mg slow IVP or IM
• Simple with airway involvement
• Epinephrine 11000 0.3 mg SQ
• Bendadryl 50 mg slow IVP or IM
• If wheezing, albuterol 2.5 mg/3ml nebulizer
• Unstable (hemodynamically) with anaphylactic
  shock
• IV wide open
• Epinephrine 11000 0.5 mg IM (more predictable
  absorption than SQ in shock)

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• Heat emergencies
• Heat cramps - do not massage extremities
• Heat exhaustion - perspire, dizzy, headache
• IV fluid challenge
• begin gradual cooling
• Classic heat stroke - hot, dry skin altered
  level of consciousness
• IV fluid challenge
• rapid cooling (wet, cool towels cold paks fan)
• Exertional heat stroke - damp skin from activity
  just performed (ie marathon, construction
  worker)
• IV fluid challenge
• rapid cooling (wet, cool towels cold paks fan)

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• Hypothermia
• Frostbite
• rapidly rewarm (warm water, hot paks)
• Systemic hypothermia
• hot paks
• If no pulse and extremities stiff (cannot be
  flexed), limit defib attempts to 1st round
  withhold IV and meds perform CPR during
  transport
• If no pulse and extremities can be flexed, extend
  medications to longest limit between doses
• ie every 5 minutes versus 3 minutes

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• Burns - Morphine 2 mg IVP for pain control
• Electrical
• dry, sterile dressing EKG monitoring
• Chemical
• brush dry chemical off before irrigating
• consider need for HAZMAT team
• Inhalation
• O2 100 via nonrebreather or assist with BVM
• Thermal
• Superficial (1st degree) - moist saline dressings
• Partial thickness (2nd degree) - dry sterile
  dressing, transport pt covered with sterile sheet
• Full thickness (3rd degree) - dry sterile
  dressing, transport pt covered with sterile sheet

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OB Complications

• Placenta previa
• placenta implantation in lower part of uterus
  partially or completely over cervical opening
• painless, bright red vaginal bleeding
• Abruptio placenta
• premature separation of placenta from uterine
  wall
• trapped blood loss in uterus uterus firm
  painful
• increased mortality rate mother fetus
• Treatment aimed at repeat assessment and
  monitoring for treating shock
• Transport with patient lying/tilted left

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OB Complications

• Hypertensive disorders of pregnancy have an
  unknown cause, generally occur in 1st pregnancy,
  and often near term
• signs symptoms preeclampsia
• headache, confusion blurred or double
• nausea vomiting vision
• protein spilled in urine hypertension
• excessive retention of fluid
• epigastric pain
• signs symptoms ecclampsia - same as above with
  the addition of seizures
• treat seizure activity with valium (crosses
  placenta)

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OB Complications

• Supine hypotensive disorder
• heavy weight of uterus, esp after 5 months, may
  put pressure on the inferior cava
• blood flow returning to the heart would be
  diminished
• patient may complain of dizziness be
  hypotensive
• Transport patient laying or tilted left -
  especially after the 5th month

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OB Complications

• Nuchal cord - cord around infant neck
• attempt to slip cord over the head
• if cord cannot be
  moved, clamp cut
  cord now
• have mother breath
  through contractions
  to avoid her trying to
  push during the
  emergency

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Newborn Inverted Pyramid
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Pediatric Critical Conditions

• Glucose level lt 60
• child gt 1 D 25
• child lt1 D 12.5 (equal parts D 25 normal
  saline for dilution)
• Allergic reactions
• local apply ice
• mild resp distress epi 11000 sq 0.01 mg/kg (max
  0.3 mg per single dose) albuterol 2.5 mg neb
• severe compromise epi 11000 sq 0.01 mg/kg (max
  0.3 mg per single dose) when IV/IO established,
  epi 110,000 0.01 mg/kg fluid bolus 20 ml/kg,
  albuterol 2.5 mg neb for wheezing

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Pediatric Critical Conditions

• Bradyarrhythmias
• Very different approach than for adults
• CPR if heart rate lt 60 and poor systemic
  perfusion
• Epi 110,000 IVP/IO or epi 11000 if ETT
• Atropine IVP/IO
• Peds arrest
• defib 2j/kg, then repeated at 4j/kg
• Drugs epi 110,000 IVP/IO
• lidocaine IVP/IO

68
Case Review What Is This Rhythm?

• Sinus bradycardia
• When is treatment required?
• If patient is symptomatic (decreased level of
  consciousness, hypotensive)

69
What Is This Rhythm?

• Second degree Type II - Classical
• Patients will be symptomatic due to the slowed
  ventricular heart rate
• Dont assume symptoms but evaluate each patient
  individually for their own threshold of tolerance

70
What Is This Rhythm?

• Accelerated junctional rhythm
• When is treatment indicated?
• When patient is symptomatic (decreased level of
  consciousness and hypotensive) - doubtful this
  patient would be symptomatic at rate of 70
• Treatment would be atropine if QRS is narrow

71
What Is This Rhythm?

• Paced rhythm - 100 capture rate 75 beats per
  minute
• Typical presentation of ventricular pacing wire

72
What Is This Rhythm?

• Sinus bradycardia
• Is treatment necessary at a rate of 50 beats per
  minute?
• Treatment/interventions depend on symptoms and
  tolerance of patient

73
What Is This Rhythm?

• Junctional escape rhythm with bundle branch block
  pattern (wide QRS) or possibly a ventricular
  escape rhythm
• At this rate and EKG appearance, the patient will
  most likely be symptomatic and in need of
  aggressive support, possibly CPR if in PEA

74
Case Review What Is This Rhythm?

• Junctional rhythm
• Rate 40-60 beats per minute no P wave activity

75
What Is This Rhythm?

• Second degree Type II - Classical
• Consistent PR interval when present, more P waves
  than QRS complexes

76
What Is This Rhythm?

• Second degree Type I - Wenckebach
• PR interval gets progressively longer until there
  is a dropped QRS
• Overall heart rate adequate and patient does not
  need therapy

77
What Is This Rhythm?

• Accelerated junctional rhythm

78
What Is This Rhythm?

• Third degree heart block - complete

79
What Is This Rhythm?

• Third degree heart block - complete
• The first 2 P waves are visible the last 2 are
  buried in the wide QRS complexes

80
Questions?