Region X SOP Review

1
Region X SOP Review

• June 2009 CE
• Condell Medical Center EMS System
• Site code 107200E-1209

Prepared by Sharon Hopkins, RN, BSN, EMT-P
2
Objectives

• Upon successful completion of this module, the
  EMS provider will be able to accomplish the
  following
• Identify the location for V1-V6 chest lead
  placement when obtaining a 12 lead EKG.
• Identify ST elevation when presented with a 12
  lead EKG.
• Identify when Aspirin, Nitroglycerin, and
  Morphine should be administered for an acute
  coronary syndrome recognize ST elevation.
• Identify the Region X SOP criteria for treating
  asystole/PEA, bradycardia, and ventricular
  fibrillation/pulseless ventricular tachycardia.

3
Objectives contd

• List the 6 Hs and 5 Ts that could be causative
  factors for cardiac events understand
  appropriate interventions.
• Identify pad placement for transcutaneous pacing.
• Identify indications and dosing for Lidocaine,
  Versed, Morphine, and Benzocaine for Conscious
  Sedation SOP.
• Identify criteria for a Category I and Category
  II trauma patient.
• Identify transport decisions for a Category I and
  Category II trauma patient.
• Actively participate in scenario
  practice/discussion.

4
Interpreting the SOPs

• System members are to begin using the SOPs to
  initiate treatment without delay in patient care
• Medical Control is to be contacted as soon as
  feasible
• An alternate order of listed interventions may be
  appropriate based upon patient assessment
• ie based upon assessment, Narcan may be
  administered before Dextrose

5
Cardiac Patient - ACS

• Use critical thinking skills to consider a
  variety of patient complaints as possibly linked
  to an acute coronary event
• Women (who often present with weakness and
  unusual fatigue, shortness of breath, dizziness,
  nausea and vomiting)
• Elderly (who often present with fatigue and
  weakness, shortness of breath and epigastric
  discomfort)
• Patients in second degree type II or complete
  heart block
• An acute MI is present until proven otherwise

6
Routine Medical Care

• Provide routine medical care
• Perform initial assessment
• ABCs
• Disability (neuro evaluation)
• AVPU
• Awake, responds to verbal, responds to pain,
  unresponsive
• GCS
• Best response to eye opening, verbal response,
  and motor (scores 3-15)
• Identify a priority patient and make a transport
  decision
• Based on patient complaint and your general
  impression

7
Routine Medical Care contd

• Additional assessment
• Vital signs, pain scale (0-10)
• Determine weight
• Determine need for and method of oxygen delivery
  (ie n/c, NRB)
• Evaluate cardiac rhythm obtain 12 lead EKG if
  applicable
• Establish IV as indicated
• Determine blood glucose if indicated
• Reassess, reassess, reassess

8
Routine Medical Care contd

• Contact Medical Control
• Who do you have (ie 52 year-old male)
• What (ie with chief complaint of)
• Where (ie center of their chest radiating down
  the left arm)
• When (ie for the past 2 hours)
• Why (ie pain began while mowing the grass)
• Interventions performed and patient response
• ETA

9
Obtaining 12 Lead EKGs

• Be as accurate as possible when attaching the 6
  chest leads
• All EKGs are evaluated and compared to each
  other and measurements taken from the same
  anatomical lead placement
• Remember the limb leads really are for the limbs
• We in medicine have migrated the leads to place
  them on the torso

10
12 lead EKG Chest Leads

• Placement starts in the 4th ICS to the right of
  the sternum

11
12 Lead EKG Interpretation

• Get in the habit of reviewing the 12 lead by
  looking at contiguous leads
• Leads that face the same area of the heart
• If ST elevation is seen in one of a group,
  closely inspect the other sites of that same group

12
Groups of Anatomical Regions on EKG Contiguous
Leads

• Lateral wall I, aVL, V5, V6
• Inferior wall II, III, aVF
• Septal wall V1 and V2
• Anterior wall V3 and V4

13
ST Elevation

• Measurement
• Look 0.04 seconds after the J point
• J point is where the QRS complex and ST segment
  meet
• ST elevation significant if
• gt 1 mm (one small box) above the baseline is
  noted in 2 or more leads looking at the same
  anatomical region (contiguous leads)
• gt 1 mm in 2 or more anatomically contiguous chest
  leads (V1 through V6)

14
Where is the ST elevation?
15
ST Elevation II, III, aVF, V5, V6 (Inferiolateral
Wall)
16
Where is the ST elevation?
17
ST Elevation V2 - 5
18
Where is the ST elevation?
19
ST Elevation II, III, aVF Inf Wall
Reciprocal ST depression
20
Where is the ST elevation?
21
ST Elevation V2 3 (Septal wall)
Reciprocal ST depression
22
Routine Medical Care contd

• Transport to closest appropriate hospital
• Hospital of patients choice (when possible)
• Nearest hospital in cases of life threatening
  emergencies

23
ACS

• Determine stability of the patient
• Stable
• Alert indicating adequate perfusion
• Skin warm and dry indicating adequate perfusion
• Systolic B/P gt100 mmHg
• Unstable
• Altered level of consciousness
• Systolic B/P lt100 mmHg

24
Stable ACS

• Medication administration
• Aspirin 324 mg by mouth, chewed
• Nitroglycerin 0.4 mg sl
• May be repeated every 5 minutes
• If pain persists after 2 doses, begin Morphine
• Morphine 2 mg IVP slowly over 2 minutes
• May repeat every 2 minutes as needed to a maximum
  of 10 mg

25
Aspirin

• Used to prevent platelet aggregation in the
  setting of an acute MI
• Avoid in the patient with an allergy to aspirin
  or active GI bleed
• Dose is to chew 4 baby aspirin (total 324 mg)
• Chewing breaks down the tablet and hastens
  absorption

26
Aspirin

• What if the patient takes aspirin but cant
  remember if he took it today
• Give the dose of 4 baby aspirin
• What if the patient responds that they took their
  aspirin dose today?
• (See next slide)

27
Aspirin

• Ask what the dose was (how many tablets and what
  strength)
• If the patient is reliable, document the dose the
  patient took and inform Medical Control during
  report
• If patient is reliability is questionable, give
  full EMS dose
• Better to have the loading dose given than to not
  have any Aspirin in the system

28
Nitroglycerin

• Potent vasodilator
• When administered, pools blood away from the
  heart reducing the amount of blood returning to
  the heart (preload) and therefore the workload of
  the heart is reduced
• Onset is 1-3 minutes
• After 2 doses given 5 minutes apart, if chest
  pain persists, begin Morphine
• Warn patient of common side effects after
  administration of this drug (ie headache,
  lightheadedness)

29
Nitroglycerin

• Before administering Nitroglycerin, all patients
  must be screened for a B/P gt100 systolic and use
  in the past 24-36 hours of Viagra or Viagra type
  of drugs
• Concomitant use of nitroglycerin with these drugs
  may cause an irreversible hypotension leading to
  shock and death
• Establish an IV before administering
  Nitroglycerin
• Dilation of blood vessels will make IV attempt a
  greater challenge after Nitroglycerin has been
  given
• No IV site no IV fluids infused if needed

30
Morphine Sulfate

• An opioid analgesic used for pain
• As a secondary effect, it also causes venous
  pooling and can pool blood away from the heart
  reducing preload and therefore the workload of
  the heart
• Always screen the patients B/P before and after
  administration
• B/P to remain gt100 systolic

31
Morphine Sulfate

• 2mg slow IVP (over 2 minutes)
• May repeat every 2 minutes as needed
• Maximum dose is 10mg
• Pain levels often do not decrease to 0 until an
  intervention is provided that opens up the
  blocked coronary artery

32
Unstable ACS

• Aspirin 324 mg by mouth if patient can tolerate
• Contact Medical Control
• Monitor and transport
• If the patient takes a daily aspirin, regardless
  of the dose, and are reliable, no further aspirin
  needs to be administered in the field
• Watch for hypotension especially in an inferior
  wall MI (II, III, aVF)

33
Asystole

• Total absence of ventricular electrical activity
• No pulse, no cardiac output, no blood pressure
• Occasionally may view some attempt at minimal
  atrial electrical activity
• Begin CPR and secure airway with minimal
  interruption of compressions
• Search for possible causes of the arrest

34
Possible Causes - 6 Hs

• Hypovolemia administer fluid challenges in 200
  ml increments
• First evaluate breath sounds and reevaluate
• Hypoxia connect to O2 source
• Acidosis ventilate to blow off retained CO2 (an
  acid)
• Hyper-hypokalemia be suspicious if pt on renal
  dialysis or in DKA
• Hypothermia check body temperature if cold
• Hypoglycemia obtain a blood sugar level

35
Possible Causes 5 Ts

• Toxins consider all possibilities of drug
  overdoses
• Tamponade, cardiac what is the history? JVD
  present?
• Tension pneumothorax difficulty bagging? Breath
  sounds present?
• Thrombosis coronary or pulmonary What is the
  history?
• Trauma What is the history?

36
Asystole

• Establish a drug route IV or IO
• Medications
• Epinephrine 110,000 1 mg IVP/IO every 3-5
  minutes
• Alternated with Atropine 1 mg IVP/IO every 3-5
  minutes
• Maximum total dose of 3 mg
• Remember for Atropine when theyre done (ie
  dead), give them one (ie 1 mg)

37
Epinephrine 110,000

• A vasopressor drug that mimics the sympathetic
  nervous system
• Increases heart rate, automaticity, and
  contraction strength
• At this strength and route, this drug is used on
  patients that require extensive and aggressive
  resuscitative efforts
• This drug may increase myocardial oxygen demand
  by making the heart work harder

38
Epinephrine 110,000

• Vasopressors are important medications to give at
  the onset of the arrest
• The use of vasopressors (ie Epinephrine) help to
  improve blood flow especially to the heart and
  brain
• The cardiac arrested patient does not need the
  strain on the heart that Epinephrine also causes,
  it just comes as part of the package of
  administration with this drug

39
Atropine

• Opposes the effects of the parasympathetic
  nervous system
• Increases the heart rate by increasing the rate
  of discharge at the SA node (and, in the case of
  heart block and bradycardia, decreasing the
  blockage at the AV node)
• Stimulates pupillary dilation after administration

40
PEA

• A clinical condition of the absence of breathing
  and absence of a pulse in a patient who exhibits
  organized electrical activity on the cardiac
  monitor.
• These patients need CPR and a search for the
  cause
• 6 Hs
• 5 Ts

41
PEA

• Begin CPR 302
• Secure airway
• Search for causes
• Establish IV/IO
• Determine if the heart rate is over or under 60
  beats per minute
• Administer medications

42
PEA Rate lt 60

• Epinephrine 110,000 1 mg IVP/IO
• Repeat every 3 5 minutes
• alternated with
• Atropine 1 mg IVP/IO
• Repeat every 3 5 minutes
• Maximum total dose is 3 mg

43
PEA Rate gt 60

• Administer Epinephrine 1 mg IVP/IO every 3 - 5
  minutes
• A time keeper needs to monitor when it is time to
  readminister successive doses of Epinephrine
• Continue to search for possible causes and treat
  the most likely (6 Hs and 5 Ts)
• Administer fluid challenge if lungs clear
• Provide supplemental O2 while ventilating
• Obtain blood glucose level

44
Bradycardia

• This rhythm is defined by a heart rate lt60
• Determine if the patient is symptomatic or not
• What is the level of consciousness?
• This is the first parameter to be affected with
  altered perfusion
• What is the quality of the peripheral pulse?
• B/P is the last parameter to be affected by a
  state of decreased perfusion

45
First Degree Heart Block

• This is a condition of a rhythm, not a true
  rhythm
• Impulses from the SA node are delayed at the AV
  node and not truly blocked
• The PR interval is greater than 0.20 seconds (5
  small boxes)
• Most patients are not symptomatic and treatment
  is not required
• Always evaluate the underlying rhythm with the
  first degree heart block

46
1st Degree Heart Block
Sinus rhythm with
47
Differentiating Heart Blocks
48
2nd Degree Type I - Wenckebach

• SA node is generating impulses in a normal
  fashion so P to P will march out (ie atrial rate
  is regular)
• Ventricular rate is irregular
• PR interval gets progressively longer until there
  is a dropped QRS
• This patient is usually asymptomatic and cardiac
  output is not affected significantly

49
Second Degree Heart block Type I - Wenckebach
P
P
P
P
P
P
P
P
P

• P to P is regular PR getting longer

50
Second Degree Heart block Type II - Classical

• The conduction delay occurs below the AV node
• Either at the bundle of His or at the bundle
  branches
• This block is more serious and can deteriorate to
  third degree
• Ventricular rhythm can be regular or irregular
• There are more P waves than QRSs

51
2nd Degree Type II - Classical
P

• P to P marches out PR interval consistent

52
Third Degree Heart Block - Complete

• Impulses generated by the SA node are blocked
  before reaching the ventricles so no P waves are
  conducted
• Atria and ventricles beat independently of each
  other
• The QRS may be wide or narrow, depending on the
  location of the escape pacemaker site

53
Complete Heart Block and Acute MI Inferior Wall

• 3rd degree with an inferior wall MI (II, III,
  aVF) is usually a result of a block above the
  bundle of His
• The escape pacemaker site is often junctional
• The QRS will be narrow
• Therefore the ventricular rate is often more than
  40

54
Complete Heart Block and Acute MI Anterior Wall

• 3rd degree with an anterior wall MI (V3 4) is
  usually from an escape pacemaker site in the
  ventricles
• This 3rd degree is often preceded by 2nd degree
  block Type II or a bundle branch block
• The ventricular rate is often lt 40
• The patient will most likely be symptomatic
  related to poor perfusion

55
3rd Degree Heart Block
P
P
P
P
P
P
P

• Remember P to P marches out in all heart blocks

56
Atropine

• Remember When theyre alive, give them 0.5
  (mg)
• Atropine is for symptomatic bradycardia (sinus
  bradycardia and second degree type I/Wenckebach)
• Type II and 3rd degree are more lethal rhythms
  and need to be aggressively cared for when
  symptomatic
• These rhythms treated with TCP

57
Electrical Therapy - Transcutaneous Pacemaker

• Apply (-) chest pad in the apical area
• Over the apex (lower portion) of the heart
• Apply () pad in mid-upper back area between the
  spine and scapula
• Set rate at 80/minute
• Sensitivity set for auto (demand)
• mA turned to lowest setting to deliver consistent
  capture
• Pacer spike followed by wide QRS

58
TCP

• For patient discomfort (and there will be some
  with electrical stimulation at a rate of
  80/minute)
• Valium 2 mg slow IVP
• Repeated every 2 minutes for chest wall
  discomfort
• Maximum of 10 mg
• You may touch the patient to provide care you
  will not feel electric shocks

59
TCP Pad Placement
60
Ventricular Fibrillation/Pulseless Ventricular
Tachycardia

• VF is a chaotic rhythm that begins in the
  ventricles
• Absence of any organized activity
• No effective myocardial contraction and no pulse
• Wave forms over 3 mm high (3 small boxes) termed
  coarse VF
• Priorities of care are CPR and defibrillation

61
VF
62
Pulseless Ventricular Tachycardia

• When the QRS complexes of VT are of the same
  shape and amplitude, the rhythm is called
  monomorphic VT
• Complexes are such that they can be stacked upon
  each other and fit
• When the QRS complexes of VT vary in shape and
  amplitude, the rhythm is polymorphic VT (ie
  Torsades de Pointes)
• May be caused by long QT syndrome

63
Pulseless VT (Monomorphic)
64
Long QT Syndrome

• An abnormality of the electrical system
• May be acquired or inherited
• Consider long QT syndrome
• Recurrent syncope during physical exertion or
  emotional stress
• Sudden unexplained loss of consciousness during
  childhood and teenage years
• Any young person with unexplained cardiac arrest
• In the presence of family history of unexplained
  syncope and history of sudden, unexpected death

65
Torsades
66
Electrical Therapy - Defibrillation

• Safety safety safety
• Always call and look for all clear
• Older defibrillators use 360 joules to shock and
  stay at 360
• Newer biphasic units follow the specific
  manufacturers recommendations
• Usually set at lower watt settings
• Immediately after each defibrillation attempt,
  resume 2 minutes of CPR before stopping to
  evaluate the rhythm strip

67
Epinephrine

• Start with a vasopressor drug
• Supports the tone of blood vessels and tries to
  improve circulation to the heart and brain
• Administer Epinephrine 110,000 1 mg every 3
  -5 minutes
• Alternate vasopressor with antidysrhythmic
• Administer medications during 2 minute cycles of
  CPR

68
Amiodarone

• Antidysrhythmic
• Administered at 300 mg IVP/IO for 1st dose
• Alternate with vasopressor drug (Epinephrine)
• After 5 minutes may repeat Amiodarone at 150 mg
  IVP/IO
• Do not mix antidysrhythmics makes the heart
  more irritable

69
Lidocaine

• Antidysrhythmic
• First dose, if chosen, is 1.5 mg/kg
• Alternate with vasopressor drug (Epinephrine)
• After 5 minutes may repeat at 0.75 mg/kg
  IVP/IO
• Do not mix antidysrhythmics makes the heart
  more irritable

70
Antidysrhythmic Drips

• Not started until the patient is resuscitated
• If Amiodarone is given as a bolus, then the
  hospital will hang the Amiodarone drip
• If Lidocaine was used and the last dose was lt 10
  minutes ago, start Lidocaine drip at 2 mg/minute
  (30 minidrips)
• If gt10 minutes from last dose, administer
  Lidocaine 0.75 mg/kg and start drip
• If no Lidocaine was given, contact Medical
  Control for direction

71
Conscious Sedation

• What is the intent of this SOP?
• To allow the EMS provider to sedate and relax the
  patient when advanced airway maneuvers must be
  undertaken to protect the airway in a patient
  with reflexes.
• These medications are not intended to paralyze
  the patient and should not make the patient apneic

72
Conscious Sedation

• Indications
• Failure to maintain an adequate airway or
  aspiration risk
• Actual or impending respiratory failure (severe
  CHF, pulmonary edema, COPD, asthma, anaphylaxis
  with RR, 10 or gt40, shallow/labored effort, or
  SpO2 lt92)
• GCS 8 or less due to head injury
• Inability to ventilate/oxygenate adequately after
  insertion of oral/nasal airway and/or BVM
• Anticipated patient deterioration due to airway
  in imminent risk of closure

73
Conscious Sedation

• Contraindications
• Age less than 16 (15 and under)
• Systolic B/P lt100 mmHg
• Known hypersensitivity to any of the drugs

74
Lidocaine for Head Injuries

• Intent to suppress the cough reflex
• Probing into a patients mouth will stimulate
  coughing
• Coughing raises intrathoracic pressures which
  increase intracranial pressures (ICP)
• Do not want to raise ICP when the patient has a
  head injury (ie trauma, stroke)

75
Lidocaine for Head Injuries

• 1.5 mg/kg IVP/IO as one time bolus
• Effect lasts approximately 5 minutes
• No need to hang a drip
• Dont need a continuous drug level
• In the cardiac setting, avoid Lidocaine if the
  patient is in bradycardia
• In the setting of head injury, any bradycardia is
  likely a reflex reaction from the head injury -
  Lidocaine can be given

76
Versed

• Intent to relax the patient serve as an
  amnesic
• Onset of action 1 3 minutes
• Short acting
• Initial dose 5 mg IVP/IO
• If necessary, may repeat 2mg every minute until
  sedated
• After intubation, may continue 1mg every 5
  minutes for agitation
• Maximum dosage total is 15 mg

77
Morphine

• Intent to relax the patient, reduce anxiety,
  and relieve pain
• Versed does not affect pain receptors at all
• If the doses of Versed and Morphine are
  alternated, the total effect will be more
  therapeutic than giving either drug alone
• Dose 2 mg IVP/IO slow over 2 minutes
• May repeat every 3 minutes
• Max dosage of 10 mg

78
Benzocaine

• Intent to suppress the gag reflex
• If the patient is unconscious, check for a blink
  reflex to check for the presence of a gag reflex
• Stroke the eyelashes looking for movement of the
  eyelid
• If possible, ask the patient to open their mouth
  to spray Benzocaine
• If the patient cannot open their mouth, open
  their mouth and use the extender straw to spray
  the back of the throat

79
Benzocaine

• Dose
• Short 1 second spray delivered to the posterior
  aspect of the mouth
• Extended exposure to Benzocaine may produce
  methemoglobinemia
• Patient presents cyanotic and needs an antidote
  administered at the hospital
• Keep the spray to 1 second and deliver no more
  than 2 sprays, if needed

80
Region X Field Triage Criteria

• Base criteria created by IDPH and augmented by
  Region X members
• Assists in decision making regarding patient
  transport
• Give as much of a heads up as possible to allow
  the facility to prepare for the patient
• Be sure to include mechanism of injury and body
  region injured

81
Unstable Patient

• Systolic B/P lt90 on 2 readings
• OR
• For the pediatric patient, lt80 on 2 readings
• Transport to the highest Level Trauma Center
  within 25 minutes

82
Category I Trauma Patient

• Unstable vital signs
• GCS lt10 or deteriorating mental status
• Respiratory rate lt10 or gt29
• Revised trauma score lt11

83
Category I Trauma Patient

• Anatomy of injury
• Penetrating injuries to head, neck, torso, groin
• Combination trauma with burns gt20
• 2 or more proximal long bone fractures
• Unstable pelvis
• Flail chest
• Limb paralysis /or sensory deficits above the
  wrist or ankle
• Open depressed skull fracture
• Amputation proximal to wrist or ankle

84
Transport Decision Category I

• Patients with unstable vital signs and meeting
  any criteria of Category I must be transported to
  the highest level trauma center within 25 minutes
• This may mean passing up a Level II Trauma Center
  if you can get to a Level I Center within 25
  minutes
• The clock starts from time of insult

85
Category II Trauma Patient

• Mechanism of injury
• Puts patient at high risk for injury potential
  but right now the patient is stable
• Consider co-morbid factors that increase the risk
• Age lt5 without booster/car seat
• Bleeding disorders or on anticoagulants
• Pregnancy gt24 weeks

86
Category II Trauma Patient

• Mechanism of injury
• Ejection from automobile
• Death in same vehicle
• Motorcycle crash gt20mph or with separation of
  rider from bike
• Rollover unrestrained
• Falls gt20 feet or Peds falls gt3x their body
  length
• Pedestrian thrown or run over

87
Category II Trauma Patient

• Mechanism of injury continued
• Auto vs pedestrian/bicyclist with gt5mph impact
• Extrication gt 20 minutes
• High speed MVC
• Speed gt 40 mph
• Intrusion gt 12 inches
• Major deformity gt 20 inches

88
Transport Decision Category II

• Transport to the closest Trauma Center

89
Category III Trauma Patient

• All other patients receiving traumatic injuries
  and do not fit/meet criteria for a Category I
  (unstable) or Category II (stable and lucky)
  patient automatically are deemed a Category III
  trauma patient
• Transport to the closest trauma center

90
Practice Scenarios

• Review the clinical vignette
• Discuss the assessment performed
• Interpret the lead II rhythm strip or identify ST
  elevation on the 12 lead EKG
• Determine a clinical impression
• Decide on intervention(s) required

91
Scenario 1

• A 25 year-old female working in a lumberyard was
  struck in the chest with lumber begin loaded by a
  forklift.
• Upon your arrival, the scene is safe, the patient
  is unresponsive, apneic, and found to be
  pulseless. There is a large bruise on the center
  of her chest
• CPR is initiated

92
Scenario 1 Rhythm
There is no pulse

• What is this rhythm and what is the clinical
  significance for this patient?

93
Scenario 1

• With PEA, determine the underlying rate
• Rate will influence the use of Atropine or not
• As you are performing CPR, start considering the
  causes
• 6 Hs and 5 Ts
• Add treatment to the likely causes

94
Scenario 1

• What medications are indicated?
• Epinephrine as a vasopressor is always the first
  drug administered
• Atropine is indicated only if the heart rate is
  below 60
• Whoever is reading the monitor needs to convey to
  their team members what the rate is when PEA is
  discovered
• Allows the team leader and medication person to
  plan the appropriate intervention

95
Scenario 2

• You have arrived on the scene to initially find
  your 72 year-old male patient complaining of pain
  radiating to his neck for the past hour with a
  heavy weight on his chest.
• Patient is slightly short of breath, denies
  nausea or vomiting.
• Awake, skin pale and clammy
• VS B/P 102/58 P 220 RR 24
• As you connect the monitor, the patient becomes
  unresponsive

96
Scenario 2 Rhythm
The patient has lost consciousness and now has
no pulse

• What is this rhythm and what is the clinical
  significance for this patient?

97
Scenario 2 Rhythm Change

• What is this rhythm and what is the clinical
  significance for this patient?

98
Scenario 2 Rhythm Change

• Rhythm observed during a 10 second pause in CPR
  what do you do now?

99
Scenario 2 12 Lead EKG

• If you have time and opportunity, obtain a 12
  lead EKG.

100
Scenario 3

• You have a 72 year-old male who complains of
  slight chest pressure but believes it is related
  to the cold he has had for the past few days.
• Patient is awake, cooperative, dizzy.
• Lungs clear but breath sounds are decreased, skin
  pale, cool, and clammy with slight lip cyanosis.
• VS B/P 92/60 P 30 RR - 24

101
Scenario 3 Rhythm

• What is this rhythm and what is the clinical
  significance for this patient?

102
Scenario 3 Rhythm Change

• You observe 11 capture on the monitor
• Document rate (80) and what mA setting you turned
  up to
• Monitor patients tolerance and need for Valium

103
Scenario 4

• Your 72 year-old patient has been ill for the
  past 4 days with flu-like symptoms. She has mild
  shortness of breath and has nausea, vomiting, and
  diarrhea.
• Alert oriented skin pale, cool and dry with
  signs of dehydration
• VS B/P 90/60 P 56 RR 26 SpO2 93

104
Scenario 4 Rhythm

• What is this rhythm and what is the clinical
  significance for this patient?

105
Scenario 5

• Your patient is a 67 year-old female with
  complaints of confusion, nausea, abdominal
  cramps, weakness, and dizziness. They appear
  apathetic. They deny chest pain or shortness of
  breath.
• Hx MI 4 years ago, CHF, COPD, ? B/P
• VS 100/48 P 60 RR 20
• Skin pink, cool, dry. Lungs clear

106
Scenario 5 Rhythm

• What is this rhythm and what is the clinical
  significance for this patient?

107
Scenario 5

• Prepare for the TCP
• In the demand/automatic mode the TCP will
  function when the patients heart rate drops and
  will go into the standby mode when their heart
  rate picks up
• Consider Valium for the chest wall discomfort
• Obtain and transmit a 12 lead EKG
• All EKGs are to be interpreted by EMS for ST
  elevation whether they are transmitted or not

108
Bibliography

• Aehlert, B. ECGs Made Easy. 3rd Edition.
  Elsevier. 2006.
• CMC EMS System February 2009 CE. 12 Lead EKGs.
• Region X SOPs March 2007, Amended January 1,
  2008
• www.ambulancetechnicianstudy.co.uk
• www.davidge2.umaryland.edu/emig/gif/pared2.gif
• www.emedu.org/ecg/images/ami2b_ia.jpg