June/July 2014 CE - Advocate Health Care
Electrical Therapies Case Scenarios JUNE/JULY 2014 CE CONDELL MEDICAL CENTER EMS SYSTEM IDPH SITE CODE: 107200E-1214 SHARON HOPKINS RN, BSN, EMT-P REV 6.15.14 1 Objectives 2 Upon successful completion of this module, the EMS provider will be able to: 1. Actively participate in case scenario discussion. 2. Actively participate in review of a variety of EKG rhythms and 12 lead EKG’s. 3. Actively participate in review of selected Region X SOP’s. 4. Describe the intervention or treatment plan for the case presented following Region X SOP guidelines. Objectives cont’d 3 5. Actively participate in using your department monitor/defibrillators to review the process of pacing, synchronized cardioversion and defibrillation skills. 6. Review safety procedures observed when using electrical therapies. 7. Review CPR guidelines per the American Heart Association (AHA) 2010 Guidelines. 8. Review responsibilities of the preceptor role. 9. Successfully complete the post quiz with a score of 80% or better. Electrical Therapies for Patient Care Usually used when the patient is unstable and immediate therapies are required Measuring patient stability = assessing perfusion Evaluate level of consciousness Brain function VERY sensitive to level of oxygen perfused as well as glucose Reacts Evaluate Falls quickly when O2 and glucose supplies drop blood pressure when all levels of compensation are exhausted 4 Transcutaneous Pacing (TCP) Electrical pacing of heart through the skin Beneficial in symptomatic bradycardia Sinus bradycardia High-degree Second Third Atrial Any heart block degree Type II (Classical) degree – complete fibrillation with slow ventricular response other bradycardic rhythm causes symptoms 5 TCP 6 Symptomatic bradycardia Patient’s symptoms related to poor perfusion to vital organs Patient evaluated on THEIR response to their level of perfusion; not just on the heart rate number Example Conditioned athletes normally maintain excellent perfusion with a heart rate in the 40’s TCP 7 Monitoring electrodes placed in usual fashion TCP pad placement Anterior chest pad (-) placed in apical area Posterior pad (+) placed in mid-upper back area Between Bone spine and scapula is poor conductor of electricity so avoid placement over a bone TCP Settings 8 Rate: 80 / minute Sensitivity: Auto / demand Output: mA started at 0 and turned up until capture noted with lowest energy level Capture spike Evaluate perfusion LOC B/P evident with wide QRS complex following a pacer Pain Management For TCP 9 TCP use is painful/uncomfortable for the patient Administer Valium as a benzodiazepine to relax the patient 2 mg IVP/IO over 2 minutes May repeat every 2 minutes as needed to a max of 10 mg To manage pain, administer Fentanyl, an opioid 1 mcg/kg IVP/IO/IN May repeat same dose in 5 minutes as needed to max 200 mcg total dose Watch for respiratory depression in both categories of meds Synchronized Cardioversion A controlled form of defibrillation with delivery of lower energy settings Used when the patient still has an organized rhythm and a pulse Electrical discharge delivered during R wave of QRS Current delivered on downslope of T wave (relative refractory period) could cause the rhythm to deteriorate into ventricular fibrillation (VF) 10 Stable vs. Unstable Tachycardia In tachycardia, the ventricles contract so fast they are unable to properly fill to capacity Contract out smaller stroke volumes than normal Leads to overall decrease in cardiac output For stability: Check level of consciousness - first indicator to change Check B/P - last indicator to change 11 Synchronized Cardioversion Indications 12 Unstable SVT Unstable rapid atrial flutter /fibrillation (narrow complex tachycardia) Unstable ventricular tachycardia (VT) or wide complex tachycardia Peds probable SVT with poor perfusion after no response to meds Peds possible VT with poor perfusion Peds probable SVT or VT with adequate perfusion and after no response to meds Synchronized Cardioversion Sedation The conscious patient should be sedated if at all possible! This is a painful procedure But, do not delay procedure to sedate Sedation with benzodiazepine Versed Max 13 2 mg IVP/IO every 2 minutes titrated 10 mg total dose Pain control with Fentanyl 1 mcg/kg Repeated in 5 minutes; max total dose 200 mcg Set Up For Synchronized Cardioversion Activate synchronizer mode button Watch for flagging of the R wave Look and call “all clear” Hold oxygen source away from the patient Press and hold discharge buttons until machine discharges on next R wave Will be momentary delay Assess the monitor and patient 14 Flagging the R Wave 15 Precautions with Cardioversion Patients in atrial fibrillation >480 not on anticoagulants have increased risk of blood clot formation in quivering atria Cardioversion causes the atria to contract and could break off a clot increasing risk for stroke Avoid cardioversion if at all possible on atrial fibrillation patient until detailed and further evaluation can be completed (if possible) 16 Defibrillation Non-synchronized delivery of energy during any part of the cardiac cycle Cells depolarized allowing them to repolarize uniformly Electrical therapy causes the heart to contract simultaneously The goal is to allow the SA node (dominant pacemaker) to take over the electrical control of the heart 17 Defibrillation Back Ground Most defibrillator units are biphasic This waveform allows use of less energy Less energy = less myocardial/tissue damage Current moves in one direction and then travels back in the opposite direction Need to know YOUR respective manufacturer’s recommendation for energy settings Suggestion: place a label next to screen with YOUR setting recommendations 18 Increasing Success Rate for Defibrillation 19 Time from onset of VF – sooner the better Perform CPR ONLY until the defibrillator is set up and ready to go Pad placement 1 to right of upper sternum below clavicle 1 to left of left nipple anterior axillary line over apex of heart Do not place over pacemaker or internal defibrillator Confirm pads are secured tightly to chest wall with no air gaps Set Up For Defibrillation Perform CPR while setting up machine and placing pads Hold CPR to analyze rhythm Confirm VF or pulseless VT Charge unit as recommended by manufacturer May perform CPR just until unit is charged Look and call “all clear” Hold oxygen source away from patient Depress defib buttons Resume CPR for 2 minutes 20 Shockable Rhythms 21 Pulseless VT Polymorphic VT Course VF Results post defibrillation Now check for a pulse Summary Electrical Therapies Know YOUR particular brand monitor/defibrillator Know how to operate YOUR equipment Check equipment every shift for adequate stocking of supplies Know how to trouble shoot YOUR equipment Acknowledge when YOUR equipment requires regular monitoring electrodes to be placed IN ADDITION to defib/pacing/cardioversion pads 22 Obtaining and Transmitting 12 Lead EKG’s Review placement of electrodes for obtaining 12 lead EKG’s Review YOUR equipment process for transmitting to the hospital Remember to state in report YOUR interpretation for presence/absence of ST elevation THEN read word for word the print-out interpretation 23 Electrode Placement for 12 Lead EKG’s 24 For every person, each precordial lead placed in the same relative position V1 - 4th intercostal space, R of sternum V2 - 4th intercostal space, L of sternum V4 - 5th intercostal space, midclavicular V3 - between V2 and V4, on 5th rib V5 - 5th intercostal space, anterior axillary line V6 - 5th intercostal space, mid-axillary line 25 Precordial Lead Placement Case Scenario Discussions Read the cases presented Discuss what your general impression is Determine appropriate interventions based on the most current Region X SOP’s dated “IDPH Approved April 10, 2014” Pocket Region Full sized protocols being printed by the size copies forwarded to the Medical Officer for department distribution 26 Case Scenario #1 49 y/o male got arm caught in machine at work Large open wound noted to left forearm Large amount of blood loss evident Make-shift tourniquet applied by co-workers 27 Case Scenario #1 What are the steps in controlling bleeding? Direct pressure with gloved hand Direct pressure with gauze Elevation not found to have any advantage or disadvantage Pressure points usually not effective Operator EMS error – not enough pressure applied tourniquet placed if bleeding not controlled 28 Case Scenario #1 What are the steps for CAT application? Place as far distally as possible at least 2 inches proximal to wound on bare skin Tighten windlass until bleeding stops; pulse no longer palpable Monitor for further bleeding Consider Lower pain management leg injuries may require tourniquet placement on thigh vs calf 29 Case Scenario #1 Would you remove tourniquet applied by by-standers? Case by case decision Most tourniquets in this situation have been inappropriately applied and with improper technique EMS would remove the tourniquet to evaluate the site and then treat based on EMS assessment 30 Case Scenario #1- Identify the Rhythm Sinus tachycardia Regular R to R intervals; rate 130 P waves rounded, upright PR interval 0.12 – 0.20 seconds 31 Case Scenario #1 What would you do for pain control with stable vital signs? Administer May Fentanyl 1 mcg/kg IVP/IN/IO repeat same dose in 5 minutes Maximum 32 total dose 200 mcg What side effects should you watch for with Fentanyl? Fentanyl is an opioid so watch for respiratory depression Reversible with Narcan – narcotic antagonist Cardiovascular effects (i.e.: drop in blood pressure) not a problem with Fentanyl like it may be with Morphine Case Scenario #1 33 When would the QuikClot dressing be used? Failure to control bleeding after application of tourniquet Bleeding not controlled with direct pressure to nonextremity areas Should the initial dressings remain in place? No; QuikClot needs to be placed directly over the wound to be effective Is direct pressure still required with Quikclot? Yes for 2-3 minutes or until bleeding stops Do not peek at the wound which disturbs the clot Case Scenario #1 Follow-up To OR on day of admission Large soft tissue injury with numerous small metallic foreign bodies Non-displaced OR fracture ulnar styloid for exploration and repair of wound Initially unable to extend wrist but able to move 3rd, 4th, 5th digits slightly 3 days later reports electrical shooting pain to left mid forearm 4 days later discharged home; some movement of fingers 34 Case Scenario #2 72 year-old patient presents with palpitations and indigestion for several hours VS: B/P138/88; P – 84; R – 18; SpO2 98% Vague on their history but takes meds but doesn’t know what for General impression? Worse case scenario – cardiac Other considerations – “ill” 35 What’s Your Interpretation? Ventricular paced rhythm 36 Case Scenario #2 37 False ST elevation Paced Left rhythms bundle branch block (LBBB) There is an appearance of ST elevation but NOT in the presence of an acute myocardial infarction process Patient evaluated and treated in field based on signs and symptoms Bit more challenging for everyone to assess for presence of acute process Is ST Elevation Present In This EKG? 38 ST elevation II, III, aVF Hold NTG and morphine until consulted with Medical Control What About This EKG? 39 Left bundle branch block EKG Interpretation Looks like ST elevation in chest leads V 1 – V4 Actually, this is left bundle branch block (LBBB) that also can give appearance of ST elevation that does not indicate an acute process Remember the hints for determining a LBBB pattern Widened Possibly Think QRS notched QRS (rabbit ears) of a car’s turn signal If wide QRS predominately negative in V1, consider left bundle branch block If wide QRS predominately positive in V1 consider right bundle branch block 40 Case Scenario #3 32 year-old patient presents with 2 hours of dyspnea with increasing wheezing and increasing difficulty breathing Patient in tripod position Pale, slightly damp, VERY anxious B/P 138/84; P – 98; R 32; SpO2 95% Bilateral inspiratory and expiratory wheezing What is your general impression? 41 Case Scenario #3 Impression – Acute asthma Confirmed with history Would you administer oxygen? Yes – presence of respiratory difficulty even though pulse ox is over 94% What interventions need to be provided to help this patient? Supplemental oxygen Bronchodilators 42 Case Scenario #3 Treatment Based on Region X SOP’s 43 Adult Routine Medical Care Albuterol 2.5 mg/3ml mixed with Atrovent 0.5 mg/2.5 ml neb treatment Needs O2 flow rate of 6 lpm to generate a mist If no improvement, repeat above medications If no improvement, administer Albuterol alone as a neb treatment For severe distress, contact Medical Control to consider Epinephrine 1:1000 at 0.3 mg IM Case Scenario #3 When is a repeat of the Duoneb of Albuterol and Atrovent automatic in the Region X SOP’s? Adult and child asthma Adult and child allergic reactions with wheezing Croup 44 Case Scenario #3 What 45 are the benefits of Albuterol and Atrovent? Albuterol is a bronchodilator Acts mostly on receptors in the lungs (Beta 2) Minimal effects on receptors in the heart (Beta 1) but may cause an increase in heart rate Atrovent is an anticholinergic that acts as a bronchodilator Combination therapy increases the dilating effects in the bronchioles Case Scenario #3 Describe wheezing and how you assess for it Wheezes are continuous high-pitched musical sounds similar to a whistle Air is moving through partially obstructed airways First appear at end of exhalation Important to not move your stethoscope to the next site too prematurely Wheezes heard during inspiration and exhalation indicate a worsening condition 46 Case Scenario #4 47 EMS is called for a 32 y/o patient with altered level of consciousness VS: B/P 100/56; P – 72; R – 12; SpO2 98%; GCS 11 (3, 3, 5) History: Diabetes (blood sugar 32) What is your impression? Diabetic reaction – hypoglycemia – insulin shock What is your treatment goal? Raise the blood sugar level Case Scenario #4 How do you raise the blood sugar level in the field??? If IV access, administer Dextrose Strength based on age (D50%; D25%, D12.5%) The younger/more immature the IV site, the weaker the concentration If no IV access, Glucagon 1 mg IM/IN Oral glucose gel (Glutose) 15 grams 48 Case Scenario #4 Oral Glutose gel – 15 grams Useful in the patient who is able to tolerate oral preparations, has an intact gag reflex and is able to protect their own airway Available for the patient in the above condition with no access to food or fluids that would otherwise be used to raise the blood sugar level 49 Case Scenario #4 50 Can this patient sign a release / refusal for transportation? Yes, if certain conditions are met Patient must be awake, alert, oriented Patient must be able to understand risks and benefits Patient’s blood sugar must be documented as being over 60 Document your discussion with the patient Document your advice for transport Document follow-up – personal physician; to call 911 if any further problems Document D/C of IV if applicable Case Scenario #5 42 51 y/o Spanish speaking male found at a job site Unclear mechanism of injury with machinery Upon EMS arrival male on steel conveyor belt being held in sitting position by co-workers Obvious facial trauma with possible broken jaw, missing teeth, bleeding from mouth Able to move toes and wiggle fingers Case Scenario #5 Patient denied head, neck, back pain by nodding head Assisted Mouth to cot suctioned as needed Fentanyl Patient How 1 mcg/kg given for pain is 230 pounds much Fentanyl is indicated? 104 mcg / 2.08 ml 52 Case Scenario #5 Question Would you have immobilized this patient with significant trauma to the face, unclear the exact mechanism of injury? This patient was not immobilized What were some “red flags” for securing immobilization? Non-English Unclear speaking (medic interpreter was on call) mechanism of injury Significant trauma evident to face 53 Case Scenario #5 When is immobilization indicated? Evidence clavicles Known of injuries above the level of the or questionable mechanism of injury Unable to clear with spinal immobilization protocol Mechanism of injury, signs or symptoms, patient reliability 54 Case Scenario #5 Clearance Patient of cervical spine awake and fully cooperative Neck free of pain, swelling, hematoma, pain to palpation, no bony abnormality No distracting injures Full range of motion by patient is pain free Never passively (movement performed by another person) attempt to move the head 55 Case Scenario #5 Patient struck in face with piece of machinery Distracting injuries present This patient had jaw fracture Significant bleeding from mouth Patient not reliable – arguable Non-English Helpful speaking that one of the paramedics on the scene was Spanish speaking 56 Case Scenario #5 How would you immobilize a patient that cannot tolerate traditional cervical collar? Head blocks on backboard Towel rolls taped into place Manual control Any creative method that gets the job done Document unique actions taken and be descriptive Document CMS before and after splinting Circulation, movement, sensation 57 Case Scenario #5 58 Immobilization on backboard Patient had significant bleeding from oral/facial injuries If immobilized flat on backboard could have compromised airway What would you have done? Critical thinking skills needed here as well as past experience could have helped Would need to elevate backboard Consider transport with backboard tilted to avoid compromising airway Utilize suction Limited to 10 seconds per attempt Case Scenario #5 Follow-up Patient diagnosed with C2-C3 subluxation Ligament injury of 2 adjoining spinal bones that have abnormally separated causing instability OR for cervical fusion; cervical collar worn post surgery to be worn 3 – 6 weeks Central Open fracture mandible Jaw cord syndrome wired in OR Left vertebral artery dissection Treated with aspirin – anticoagulant 59 Case Scenario #5 Follow-up continued Central Cord Syndrome An incomplete spinal cord injury Middle area of cervical spine affected Impairment of arms and hands more than legs More motor loss than sensory loss More upper extremity than lower extremity loss More distal than proximal muscle weakness Usually due to hyperextension mechanism 60 Case Scenario #5 Central Cord cont’d 61 No cure; some people recover near normal function Improvement noted first in legs, then bladder, then arms Hand function recovers last if at all Case Scenario #5 – Cord Syndromes 62 Named based on location of injury in relation to the spinal cord Central Cord Syndrome Anterior Cord Syndrome Spares Loss upper extremities and touch of motor, pain, temperature sensation Preserves light touch, vibratory sensation, proprioception (awareness of position of ones body) Brown Sequard Syndrome Ipsilateral (same side) motor & proprioceptive loss, light touch, motor Contralateral (opposite side) loss to pain and temperature Case Scenario #5 Patient discharged to RIC (Chicago) 9 days post injury Bilateral lower extremities 5/5 (normal strength and movement Right upper extremity – 2/5 Remains weaker but with improvement Left upper extremities Grip 3-4/5 Left elbow flexion 3-4/5 Numbness shoulder to fingers Time will tell what function/sensation returns 63 Case Scenario #5 – Lesson Learned Assume spinal injury til proven otherwise in blunt trauma Note: As swelling progresses, signs and symptoms can intensify and worsen 64 Case Scenario #6 EMS called for 25 y/o with complaint of nausea for past 8 hours Only VS: vomited x1 – small amount of liquid B/P 120/78; P – 86; R – 16; SpO2 99% Skin warm and dry; negative for tenting Mouth moist Negative No pertinent history known allergies Meds – daily multivitamin 65 Case Scenario #6 What medication is used to treat nausea per Region X SOP’s? Zofran What 4 dose and routes can be used? mg IVP; 4 mg po (oral) May repeat in 10 minutes to total max 8 mg for adults and pediatrics >40 kg (88 pounds) Peds <40 kg – Zofran 0.1 mg/kg IVP 66 Case Scenario #6 When 67 can Zofran ODT be given? Patients over 40 kg (88 pounds) Oral disintegrating tablet (ODT) used when goal is to relieve nausea and patient not suspected of needing IV fluid To document ODT source of Zofran “Time” given, “Zofran ODT”, “4 mg”, (route) “po” Case Scenario #6 Indication IV fluids may be required Repeated episodes of vomiting especially larger volumes Evidence of dehydration Tenting Dry mucous membranes Warm, hot/dry skin Sunken eyes 68 Case Scenario #6 How do you administer Zofran ODT? Peel open foil packet Do not push pill thru foil – pill may crumble Place tablet on patient’s tongue Inform patient tablet will dissolve Dissolves quickly – before patient can even consider thinking of swallowing pill 69 AHA CPR Guidelines Infant – Child - Adult Compression Ratio rate at least 100 / minute compression to ventilations 30:2 -1 & 2 man adult CPR 30:2 – 1 man infant & child 15:2 – 2 man infant & child Switch rescuers every 2 minutes or 5 cycles Resume CPR compressions immediately following defibrillation attempts 70 Aha CPR Guidelines cont’d Compression Infant depth – 1 ½ inches Child - about 2 inches Adult – at least 2 inches Once intubated – asynchronous compressions to ventilations Ventilate 1 breath every 6 – 8 seconds (document 8-10 breaths delivered per minute) 71 Preceptor Role Be nice Be kind We all started as students and “newbies” Invest the time now to get “a good product” in the long run 72 Hands-on Skills Field 73 trip to the ambulance Review Know YOUR equipment how to set YOUR equipment up Defibrillation Synchronized cardioversion Transcutaneous Transmitting pacing (TCP) 12 lead EKG’s to hospital Safety Precautions & Electrical Therapy If BVM out and oxygen flowing to it, do not leave on cot next to patient when not being used Sheets/clothing could become oxygen enriched Several in-hospital cases of spark from defibrillation causing a fire Hold BVM off to the side during discharge of electrical therapies 74 More Safety Tips If patient intubated, remove BVM from proximal end of ET tube during discharge of electrical therapy Just letting go of BVM puts excessive weight on the ETT Could inadvertently dislodge tube during discharge of electrical therapy Remember to call AND look “all clear” prior to discharging electrical energy 75 Bibliography Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady. 2013. Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady. 2010. Region X SOP’s; IDPH Approved April 10, 2014. http://www.merckmanuals.com/professional/ne urologic_disorders/spinal_cord_disorders/overvie w_of_spinal_cord_disorders.html http://lifeinthefastlane.com/ecglibrary/basics/left-bundle-branch-block/ 76
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