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Title: Medical I Refresher Lecture


1
Medical I Refresher Lecture
  • Aaron J. Katz, AEMT-P, CIC
  • www.es26medic.net

2
Pharmacology
  • The study of drugs
  • Sources, characteristics and effects
  • Always refer to drugs as medications

3
  • EMTs can deliver some medications and can assist
    the patient in delivering some other medications

4
Meds EMTs can deliver
  • Oxygen
  • Oral Glucose
  • Activated Charcoal
  • Epinephrine injectors (EpiPen)
  • Aspirin

5
Meds that EMTs can assist
  • Prescribed inhalers
  • Nitroglycerin

6
Drug Names
  • Chemical
  • Generic
  • E.g. Ibuprofin, Nitroglycerin
  • Trade
  • E.g. Advil, Nitrostat

7
Important terms
  • Action
  • The therapeutic effect that a drug is expected to
    have on the body
  • Indications
  • Signs/Symptoms/Conditions for which a particular
    medication should be used
  • Contraindications
  • Signs/Symptoms/Conditions or patient for which a
    particular medication should NOT be used
  • Side effects
  • Any actions of a medication other than the
    desired ones

8
Drug Administration
  • Before administering any drug, know the four
    rights
  • Right patient
  • Right medication
  • Right dose
  • Right route

9
Medication Routes
  • Intravenous (IV)
  • Oral (PO)
  • Sublingual (SL)
  • Intramuscular (IM)
  • Intraosseous (IO)
  • Subcutaneous (SC)
  • Transcutaneous
  • Inhalation
  • Rectal (PR)

10
References
  • PDR
  • USP
  • Merck Manual
  • The Pill Book
  • Not an official guide, but a very good source
  • ePocrates

11
  • Survey of commonly used drugs

12
Anti-hypertensives
Accupril Cozaar Isoptin (Verapamil)
Lotensin Monopril Norvasc
Lopressor (Metoprolol) Toprol XL Tenormin (Atenalol)
Vasotec Zestril Calan (verapamil)
Prinivil
13
Diuretics
  • Lasix (Furosemide)
  • Bumex
  • Diazide
  • HCTZ
  • Hydrodiuril

14
Combination HTN, diuretics
  • Zestoretic
  • Prinzide
  • Vasaretic

15
Potassium supplements
  • K-Dur
  • K-Tab
  • Slo-K

16
Cholesterol Lowering
  • Lipitor
  • Mevacor
  • Lopid
  • Pravachol
  • Zocor
  • Crestor

17
Antianginals
Procardia XL (Nifedipine) Nitrostat (nitroglycerin)
Cardizem (Diltiazam) Isordil (Isosorbide Dinitrate)
Inderal (propranalol) Imdur (Isosorbide Mononitrate)
Capoten Corgard
18
Oral Anti-hyperglycemics
Diabeta (Glyburide) Diabenase
Glucotrol (Glipizide) Glucophage
Glynase (Glyburide) Micronase (Glyburide)
Avandia
19
Injected Anti-hyperglycemics
  • Humulin
  • Humalog
  • Lente
  • Lantus
  • And many others

20
Anti-epilepsy
  • Dilantin
  • Phenobarbitol
  • Depakote
  • Tegratol
  • Nerontin

21
Some cardiac meds
  • Lanoxin
  • Digoxin
  • Coumadin
  • Warfarin
  • Many of the anti-hypertensives and anti-anginals
    are used for cardiac conditions

22
Assorted respiratory inhalers
  • Atrovent
  • Combivent/Duoneb
  • Alupent
  • Proventil, Ventolin (Albuterol)
  • Intal
  • Serevant
  • Beclovent
  • Advair
  • Azmacort
  • Aerobid

23
Respiratory Emergencies
24
Review of airway anatomy
  • Nose/Mouth
  • Oropharynx/Nasopharynx
  • Epiglottis
  • Trachea
  • Cricoid cartilage
  • Larynx/vocal cords

25
Review of airway anatomy-2
  • Bronchi
  • Bronchioles
  • Lungs
  • Alveoli
  • Diaphragm

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Physiology
  • Inspiration
  • Expiration

33
Signs of normal breathing
  • Normal rate depth
  • Regular pattern of inhaling/exhaling
  • Good breath sounds bilaterally
  • Regular rise and fall of the chest bilaterally
  • Some movement of the abdomen

34
Signs of abnormal breathing
  • RRlt8 or RRgt24
  • Excessive respiratory muscle usage
  • Pale or cyanotic skin
  • Cool, diaphoretic (clammy) skin
  • Shallow or irregular respiration
  • Pursed lips

35
Signs of abnormal breathing
  • Pursed lips
  • Nasal flaring
  • Tripod positioning
  • Tachycardia
  • Altered mental status (AMS)
  • Agitated ? sleepy
  • Look for the yawn!

36
Some terms
  • Dyspnea
  • Difficulty breathing
  • Shortness of breath (SOB)
  • Apnea
  • No breathing
  • Hypoxia
  • Not enough oxygen

37
What causes us to breath
  • Normal individuals
  • Excessive CO2 levels in arterial blood
  • COPD patients
  • Low levels of O2 in arterial blood
  • COPD
  • Chronic Obstructive Pulmonary Disease
  • Emphysema
  • Chronic bronchitis

38
Causes of dyspnea
  • Obstructed lower airways
  • Due to fluid, infection, collapsed alveoli
  • Damaged alveoli
  • Damaged cilia in lower airways
  • Spasms, mucus plugs, floppy airways
  • Obstructed blood flow to lungs
  • Pleural space filled with air or fluid

39
Common respiratory disorders causing dyspnea
  • Airway infections
  • Acute Pulmonary Edema (APE)
  • COPD
  • Spontaneous pneumothorax
  • Asthma, allergies, anaphylaxis
  • Pleural effusion
  • Prolonged seizures
  • FBAO
  • Pulmonary embolism
  • Hyperventilation syndrome
  • Severe pain

40
Infections
  • Colds/flu
  • Bronchitis
  • Bronchiolitis
  • Pneumonia
  • Croup
  • Epiglottitis
  • ? History will often tell the story

41
Acute pulmonary edema
  • Not really a respiratory problem
  • A cardiac problem
  • Congestive Heart Failure (CHF)
  • TBD with cardiac emergencies
  • Severe dyspnea
  • Pink frothy, blood-tinged sputum

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COPD
  • Almost always caused by
  • Long-term smoking
  • Long term inhalation of bad things
  • Chronic bronchitis
  • Emphysema

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Chronic bronchitis
  • Damaged respiratory pathway cilia
  • Excessive mucus production
  • Cant cough out effectively
  • Very frequent bronchitis/pneumonia

47
Emphysema
  • Loss of alveolar elasticity and shape
  • Air pockets
  • Can not expel CO2

48
COPD
  • Most have elements of both diseases
  • Prolonged expiratory phase
  • Most common lung sound
  • Expiratory wheeze
  • Minor respiratory problemd exacerbates COPD
  • Patient is usually old

49
COPD
  • Altered mental state over time
  • Due to CO2 retention
  • Barrel shaped chest
  • Well developed respiratory muscles
  • Long term COPD may cause heart failure

50
Spontaneous pneumothorax
  • Collapsed portion of lung due to weakness in lung
    tissue
  • No apparent cause
  • Sudden SOB
  • Pleuritic chest pain
  • Common in asthmatic/COPD
  • Common in tall thin men

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Asthma/allergies
  • Reversible spasm of bronchioles
  • Excessive mucus production
  • Normal inspiration
  • Difficult expiration
  • Expiratory wheezing common
  • A quiet chest is an ominous sign
  • Be prepared for respiratory arrest
  • Be prepared to use BVM

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Status astmaticus
  • An asthma attack that cannot be broken after
    repeated doses of bronchdilators
  • Needs aggressive airway management
  • Needs rapid transport
  • Needs BVM

55
Pulmonary embolism
  • Embolus something in the circulatory system that
    travels from one place to a distant place and
    lodges there
  • Effective inspiration/expiration BUT
  • Vessels leading to alveoli are blocked by
  • Blood clots
  • Often following long bed rest
  • Air bubbles
  • Often following open neck injuries
  • Bone marrow
  • Often following a long-bone fracture
  • Amniotic fluid
  • Often following an explosive delivery

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Pulmonary embolism
  • Very often a dangerous complication of a DVT
  • Common in pt with varicose veins
  • perfusion/ventilation mismatch
  • Small emboli may cause no S/S

58
Pulmonary embolism
  • Common S/S
  • Dyspnea
  • Pleuritic chest pain
  • Hemoptysis
  • Cyanosis
  • Tachycardia
  • Tachypnia
  • A large embolus may cause sudden cardiac arrest

59
Hyperventilation
  • Overbreathing reduces CO2 level excessively
  • May be emotional in nature
  • May be a sign of MANY serious medical conditions
  • DO NOT WITHOLD Oxygen!
  • DO NOT HAVE THEM BREATH INTO A BAG!

60
Hyperventilation
  • Patient may describe
  • Numbness/tingling in hands/feet
  • Spasms in hands and feet
  • Called carpal-pedal syndrome
  • If all medical causes have been ruled out IN THE
    HOSPITAL, the condition is called
    Hyperventilation Syndrome

61
Treating the dyspneic patient
  • Calm approach!
  • Call for ALS EARLY!
  • Position of comfort
  • Almost always sitting upright
  • NEVER lie them down
  • Especially an APE patient
  • High concentration oxygen
  • Even for COPD patients
  • NRB if rate depth are adequate
  • BVM if not

62
Treating the dyspneic patient
  • Monitor V/S especially resp rate
  • Look for signs of sleepiness
  • Yawning
  • Slowing RR especially in COPD pt.
  • ? pt is becoming too tired to breathe
  • Respiratory failure
  • Breathe for them ? BVM

63
Treating the dyspneic patient
  • The counting test
  • SAMPLE HISTORY
  • OPQRST medical assessment Qs
  • Onset
  • Provocation/Palliation
  • Quality (of any pain)
  • Radiation
  • Severity
  • Time
  • Interventions
  • Also, help them with prescribed inhalers

64
Cardiac Emergencies
65
Mechanical structure
  • Atria
  • Ventricles
  • One way valves
  • Pulmonary arteries
  • Pulmonary veins
  • Aorta
  • Coronary arteries
  • Provide O2 and nutrients to the heart muscle
  • Myocardium the heart muscle

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Electrical structure
  • SA Node
  • The dominant pacemaker
  • Internodal pathways
  • AV Node
  • Bundle of HIS
  • Bundle branches
  • Purkinje Fibers/Network

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Cardiovascular abnormalities
  • Atherosclerosis
  • Cholesterol/calcium deposit buildup
  • Arteriosclerosis
  • Hardening of the arteries
  • Ischemia
  • Temporary interruption of O2 to tissues
  • Infarction
  • Death of tissue after a period of uncorrected
    ischemia

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Risk factors
  • Controllable
  • Uncontrollable

75
Angina pectoris
  • Chest pain
  • Supply of O2 does not meet hearts requirement
  • Partial blockage
  • Spasm? (Prinzmetals Angina)

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Angina -- triggers
  • Exercise
  • Emotion
  • Fear
  • Cold
  • Large meal
  • elimination

78
Angina -- presentation
  • Crushing/squeezing pain in midchest, under
    sternum (substernal)
  • Radiation to jaw, arms, midback
  • Nausea
  • Dyspnea
  • Diaphoresis
  • Rarely lasts more than 15 minutes

79
Angina-promptly relieved by
  • Rest
  • Oxygen
  • Nitroglycerine
  • Dilates blood vessels
  • Increases blood flow to heart muscle

80
Acute myocardial infarction
  • AMI, MI, Heart attack
  • May have same S/S as angina, but
  • Longer in duration
  • Often not relieved with rest, O2, nitro
  • May be onset at rest with no triggers
  • ? Treat angina as AMI

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Complications of AMI
  • Sudden death
  • 40 never make it to the hospital
  • Arrhythmias
  • Most frequent cause of death in early hours
    following AMI
  • Congestive Heart Failure (CHF)
  • Cardiogenic shock
  • At least 40 of the heart is infarcted

83
Sad facts
  • Unfortunately, the left ventricle is the portion
    of the heart most often infarcted
  • The left ventricle is the highest powered portion
    of the heart
  • Pumping power of the heart may be severely reduced

84
Classical S/S of AMI
  • All, some or none of the following
  • Sudden onset of weakness, nausea, sweating
  • Crushing chest pain does not change with
    breathing
  • Pain radiating to jaw, arms, neck
  • Sudden arrhythmias causing syncopy
  • Acute Pulmonary Edema
  • Cardiac Arrest

85
Classical S/S of AMI -- 2
  • Vital signs -- commonly
  • Pulse increased, irregular
  • BP Usually normal dropping in cardiogenic shock
  • RR Usually normal, elevated in APE
  • Feeling of doom
  • Looks frightened
  • Denial
  • ? Diabetics and the elderly ?

86
Congestive Heart Failure
  • Pathophysiology
  • Right sided CHF
  • Left sided CHF

87
Right sided CHF
  • Dependent edema
  • Pedal edema, sacral edema
  • Enlarged liver
  • JVD
  • Due to back-pressure from damaged right ventricle
  • Chronic condition
  • People often live with it for years
  • Controlled by
  • Medication (Lasix, Digitalis)
  • Salt free diet

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Left sided CHF
  • APE
  • Fluid in the lungs due to back pressure from
    damaged left ventricle
  • Patient feels like they are drowning
  • Acute condition
  • Frequent recurrences
  • Often results in death
  • Controlled by
  • Medication (Lasix, Bumex, Digitalis)
  • Salt free diet
  • Often a result of long-standing HTN

90
APE Calls
  • Most of them are due to either
  • Poor diet control
  • They eat too much sodium filled foods
  • Poor compliance with medications
  • Lasix is a diuretic
  • Annoying side effects

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Cardiogenic Shock
  • Heart muscle is so damaged that it can no longer
    pump enough to meet bodily demands
  • Very high mortality rates
  • Even with the best treatment
  • S/S of shock immediately after or within hours or
    days of AMI

93
Treating the patient with CP
  • Calm reassuring approach
  • Cardiac arrest CPR/AED
  • High-con Oxygen
  • NRB or BVM PRN
  • Aspirin 162mg PO
  • Call for ALS EARLY!
  • For any cardiac/respiratory problem
  • Position of comfort
  • Usually sitting upright (dyspniac patient)
  • NEVER let an APE pt lie down!

94
Treating the patient with CP
  • Focused history
  • OPQRST and in addition
  • Previous MI history
  • Previous heart problems
  • Family history / risk factors
  • Monitor vital signs
  • Other interventions
  • Assist pt with prescribed nitro SL
  • If systolic BP gt 120

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