Altered Mental Status Medication Review Lung Sounds MAD Device

1
Altered Mental StatusMedication ReviewLung
SoundsMAD Device

• ECRN Module I
• 2010 CE
• Condell EMS System
• Prepared by Sharon Hopkins, RN, BSN, EMT-P

2
Objectives

• Upon successful completion of this module, the
  ECRN will be able to
• Describe elements of normal mental status.
• Describe components of the neurological
  examination.
• List the three components of the Glasgow coma
  scale.
• Calculate the GCS.
• List common causes of an altered mental status.

3
Objectives contd

• Review Cincinnati Stoke Scale
• Describe the FAST concept
• Review Region X SOP Altered Mental Status
• Explain the differences between the adult and the
  pediatric airway.
• Describe the assessment of the airway and
  respiratory system.
• Describe the various lung sounds auscultated
  during assessment.

4
Objectives contd

• Discuss the methods for measuring oxygen and
  carbon dioxide in the blood in the prehospital
  setting.
• Identify pre-hospital indications,
  contraindications, dosing, side effects, and
  special considerations of Dextrose, Glucagon,
  Narcan, Albuterol, Epinephrine 11000, Benadryl,
  Lasix, and Morphine.

5
Objectives contd

• Describe the indications, contraindications,
  dosing, side effects, and special considerations
  for administering Narcan via the MAD tool.
• Describe the MAD tool and the procedure for using
  the MAD tool.
• Describe the indications, contraindications,
  complications, and the process for performing a
  cricothyrotomy in the field.

6
Normal Mental Status

• Consciousness
• Person is fully responsive to stimuli and
  demonstrates awareness of the environment
• Altered level of consciousness
• Some form of dysfunction or interruption in the
  central nervous system

7
Normal Mental Status

• Patient is awake
• Patient is alert aware of surroundings
• Patient is oriented to person, place, time
• Patient is cooperative
• Patient carries on normal conversation
• Patient able to follow/obey commands
• Gait is even and steady

8
Altered Level of Consciousness

• Hallmark sign of central nervous system injury or
  illness

9
Did You Know?

• When perfusion is declining, the first indicator
  is a changing level of consciousness
• The last indicator is a falling blood pressure

10
Assessing Mental Status - AVPU

• A awake
• V responds to verbal stimuli
• P responds to painful stimuli
• U- unresponsive

11
A Awake

• Patient is awake, alert and aware of surroundings
• OR
• Patient may be awake but confused
• Report what the patient is oriented to
• Oriented to person but not place or time
• Key is watching for a change in level of
  consciousness from the baseline taken

12
V Verbal Response

• This would need to be evaluated prior to touching
  the unconscious patient
• Problem If trauma is involved, need to manually
  control the C-spine before causing the patient
  any movement of the c-spine
• If possible, call the patients name to check for
  response to verbal stimuli prior to making
  physical contact

13
P Painful Response

• Does not necessarily mean you have to perform a
  painful task to check for response
• Start with simple tactile contact touch
• Add deeper stimulation if needed
• Sternal rub
• Pinch of thumb web space
• Trapezius muscle squeeze (near neck)
• Do not cause so much trauma as to leave
  marks/bruises
• Observe for some kind of response with muscles

14
Patient Response

• Patient response can include
• Opening of eyelids even briefly
• Fluttering of eyelids
• Wrinkling of brows
• Most important is looking for changes in the
  patients response from one evaluation/assessment
  to the next

15
U - Unresponsive

• The patient has NO response at all
• No moaning
• No muscle twitch at all
• No eyelid flutter
• No wrinkling of the eyebrow
• Muscles are flaccid with absolutely no response
  regardless of stimuli

16
Neurological Exam In the Field

• AVPU what is level of consciousness?
• Pupillary response
• Movement of distal extremities
• Wiggling fingers and toes
• Sensation of distal extremities
• Ability to feel contact with fingers and toes
• GCS
• lt10 or deteriorating mental status patient is
  considered critical and categorized as Category I
  trauma

17
Glasgow Coma Scale - GCS

• The best score possible is given
• More important is watching the trend than relying
  on any one score
• Objective tool
• All using the tool on the same patient should get
  the same score
• Evaluate
• Best eye opening
• Best verbal response
• Best motor response

18
GCS Eye Opening

• 4 Spontaneous patients eyes are open
• Does not have to be focusing
• 3 Eyes open or motion is made to verbal
• stimuli
• Start with soft voice, may have to yell at
  patient to open eyes
• 2 Eyes open with tactile or painful stimuli
• Start with gentle touch may need to add more
  intense stimuli
• 1 No eye opening no muscle motion at all

19
GCS Verbal Response

• 5 Oriented to person, place, and time
• 4 Pleasantly confused
• 3 Inappropriate words
• You can understand the word(s) spoken but they
  are not within context
• 2 Incomprehensible words sounds
• No intelligible word understood moans and
  groans makes noises
• 1 Silent no noise is made at all

20
GCS Motor Response

• 6 Obeys commands
• 5 Localizes pain / purposeful movement
• Can push you away or grab at the noxious stimuli
  (IV, collar, bandaging, your hands)
• 4 Withdrawal
• No longer localizing, just withdraws/pulls away
  to get away from annoying/painful stimuli (IV,
  collar, bandaging, your hands)

21
Motor contd

• 3 Flexion to pain
• Arms flex/bend slowly toward center of chest when
  any stimuli applied
• 2 Extension to pain
• Arms slowly extend and curl inward and legs
  straighten when any stimuli applied
• 1 No movement at all

22
GCS Results

• Score range 3 15
• Minor head injury 13 15
• Moderate head injury 9 12
• Severe head injury (coma) - lt8
• Significant mortality risk
• Consider intubation or other means to secure the
  airway

23
GCS Practice

• Read the following case scenarios
• Determine the best eye opening, verbal response,
  motor response
• When the response is asymmetrical, award the
  highest points possible
• Dont guess or assume what you think they really
  can do
• Award points for what is performed
• Be objective
• Note Answers follow the practice slide

24
GCS Case 1

• Patient lying in the bed (no trauma), eyes are
  closed
• You need to yell the patients name and then the
  eyelids flicker
• They are mumbling
• They are grabbing at your hands and pushing you
  away. They have pulled out the IV.

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GCS Case 1 Score

• Eye opening 3
• Responded to loud voice
• Verbal response 2
• Mumbling is incomprehensible words/sounds
• Motor response 5
• Patient can recognize (localize) what feels
  obnoxious and what he wants to stop so they are
  grabbing at you and pulling at equipment
• Total GCS - 10

26
GCS Case 2

• Patient is lying in the street watching you
  approach
• They mumble as you talk to them
• They are grabbing at your hands and pushing you
  away

27
GCS Case 2 Score

• Eye opening 4
• Spontaneous doesnt necessarily indicate
  focusing
• Verbal response 2
• Mumbling, moaning, groaning
• Motor response 5
• Purposeful movement by grabbing at what the
  patient perceives as noxious stimuli
• Total GCS - 11

28
GCS Case 3

• Patient watches your approach and acknowledges
  your presence
• Patient answers most questions and thinks you are
  their relative come to visit
• Patient able to move left arm to command but not
  able to move right arm (new onset possible
  stroke)

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GCS Case 3 Score

• Eye opening 4
• Spontaneous
• Verbal response 4
• Pleasantly confused
• Motor response 6
• Highest possible score based on the arm that can
  and does move
• Total GCS - 14

30
GCS Case 4

• Childs eyelids flicker when deformed extremity
  is manipulated
• Child moans out when painful areas are
  manipulated
• Child pulls away when touched and tries to turn
  away from EMS

31
GCS Case 4 Score

• Eye opening 2
• Response to painful stimuli
• Verbal response 2
• Moans and groans are incomprehensible words /
  sounds
• Motor response 4
• Withdrawing from what is sensed as painful
  stimuli
• Flexion would be slow flexing of arms toward
  center of chest this patients response is not
  flexion
• Total GCS 8 (Protect airway consider
  intubation)

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GCS Case 5

• Patients eyes remain closed no eyelid movement
  at all
• There are no sounds heard from the patient
• The patient straightens their arms, twists their
  wrists, arches their back, and straightens their
  legs when stimulated

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GCS Case 5 Score

• Eye opening 1 (no response)
• Verbal response 1 (no response)
• Motor response 2
• Abnormal extension
• The worse level of response prior to no response
  at all
• Total GCS 4
• Patient is critical Category I
• Patient usually needs some airway intervention

34
Common Causes of Altered Mental Status

• A acidosis, alcohol
• E Epilepsy
• I Infection (brain, sepsis)
• O Overdose
• U Uremia (kidney failure)
• T Trauma, tumor, toxins
• I Insulin hypo or hyperglycemia
• P Psychosis, poison
• S Stroke, seizure

35
Initial Patient Assessment

• Airway
• Open or obstructed
• Maneuvers needed to open
• Head tilt / chin lift
• With trauma, modified jaw thrust
• Breathing
• Quality
• Quantity (eyeball assessment at this time)

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Initial Assessment contd

• Circulation
• Quality
• Quantity (dont count get estimate of range)
• Disability need to obtain baselines
• AVPU
• GCS
• Expose to examine
• Cant evaluate or fix what you cant see

37
Assessment Tools

• AVPU
• Alert (interpreted as an awake patient)
• Responds to verbal stimuli
• Responds to painful stimuli
• Unresponsive

38
Assessment Tools

• GCS
• Best eye opening response
• Best verbal response
• Best motor response
• Scores range from the lowest of 3 to highest of
  15
• Obtain and document GCS on all patient calls

39
Cincinnati Stroke Scale

• Obtain for suspicion of TIA or stroke
• Evaluate for facial droop
• Check the patients symmetry during a broad, big
  smile (teeth showing)
• Evaluate for arm drift
• Check for weakness in holding arms outstretched,
  palms up, for 10 seconds
• Evaluate for clear speech
• Have patient repeat words listening for clear
  speech patterns

40
Airway Protection and the Stroke Patient

• Crucial - high mortality rate for aspiration
• Is airway patent and can patient protect their
  own airway?
• Check if patient is able to handle swallow own
  saliva
• Detailed/involved swallow study done in-hospital
• Patient speaks in clear unobstructed voice
• Interventions to consider
• Have suction on and ready
• Ability to quickly turn patient onto their side

41
FAST - Public Educational Tool

• Tool developed by organizations for public
  recognition of stroke and to encourage FAST
  action

42
Region X SOP Altered Mental Status

• Consider etiology
• If cause of problem can be identified, then
  interventions can be focused
• Diabetes check blood sugar
• Drug overdose what are the environmental clues
• Poisoning environmental evidence around
• Alcohol related environmental evidence use
  your nose

43
SOP Altered Mental Status

• Maintain airway
• Patency extremely important
• Evaluate rate and quality
• If respirations inadequate, ventilate
• 1 breath every 5-6 seconds all patients infancy
  to elderly
• Intubate as necessary
• Use C-spine precautions as indicated
• If any doubt, err on side of extra precautions
• Provide Routine Medical Care
• IV O2 - monitor

44
SOP Altered Mental Status

• Obtain blood glucose level
• If lt60 treat
• Adult - Dextrose 50 50 ml IVP
• Child 1 15 Dextrose 25 2 ml/kg
• Infant lt1 Dextrose 12.5 4 ml/kg
• Dilute 11 ratio D 25 with normal saline
• Equal amounts of product make 11 dilution
  (Dextrose and normal saline)

45
Treating Altered Mental Status

• In absence of IV access
• Adult Glucagon 1 unit (1 ml) IM
• Pediatrics lt 15 Glucagon 0.1 mg/kg IM
• Max dose of 1 mg
• Practice math 44 pound child with no IV access
• How many kg?
• 44 ? 2.2 20 kg
• 20 kg x 0.1mg/kg 2 mg
• How much Glucagon do you give?
• Max of 1 mg (max drugs at adult dose)

46
Altered Mental Status contd

• If patient not alert, respirations decreased, or
  narcotic overdose suspected
• Narcan 2mg IN/IVP/IO
• Repeat every 5 minutes as needed until desired
  effect
• Quality of respirations have improved
• Dont need patient to be 15 on GCS
• Dont need patient awake necessarily
• Maximum total dose 10 mg
• Transport

47
Altered Mental Status contd

• Note
• Attempt to identify substances involved
• If not a safety hazard, obtain and transport
  substance container with the patient
• Consider use of restraints prior to
  administration of Narcan
• Patient may become violent when level of
  consciousness improves

48

• Adult Airway Pediatric airway
• Note funnel shaping of pediatric airway

49
Notice Difference in Tongue Size

• Adult airway

• Pediatric airway

tongue
50
Pediatric airway Differences

• Jaw smaller
• Teeth softer and more fragile
• Tongue relatively larger
• Potential to produce more obstruction
• Epilgottis floppier and rounder
• Recommend straight Miller blade over curved
  Macintosh for intubation
• Larynx more superior anterior
• Higher and more forward
• Funnel shaped due to underdeveloped cricoid
  cartilage
• Under age 10 cricoid cartilage narrowest part of
  airway
• Ribs and cartilage softer and more pliable
• Children rely on diaphragm muscle for breathing

51
Airway Assessment

• Inspection
• Begin as you are approaching the patient
• Auscultation
• Listen for audible sounds, then use stethoscope
• Palpation
• Can gather a lot of information through the art
  of touch

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Assessment of Airway

• Initial assessment
• ABCs
• Airway open?
• Fully open with adequate air exchange?
• Partially or fully obstructed with poor air
  exchange?
• Are they breathing?
• Look for chest rise and fall
• Listen for air movement
• Feel for air movement
• Do they have a pulse?

53
Airway Assessment contd

• Inspection
• Evaluate adequacy of breathing
• Note any signs of trauma
• Assess skin color
• Paleness and diaphoresis due to sympathetic
  stimulation in early respiratory compromise
• Cyanosis if deoxygenated (LATE SIGN!!!)
• Patient positioning
• Tripod leaning forward (CHF? Asthma?)
• Orthopnea cant lay down (CHF? Asthma?)

54
Inspection contd

• Observe for dyspnea
• May cause or be caused by hypoxia
• Prolonged dyspnea can lead to anoxia (absence of
  oxygen)
• Is dyspnea a new onset or perhaps chronic in the
  patient with long standing COPD

55
Abnormal Respiratory Patterns

• Kussmauls
• Deep, slow or rapid, gasping breathing
• Commonly found in diabetic ketoacidosis in
  attempt to blow off excess CO2 (acid)
• Cheyne Stokes
• Progressively deeper, faster breathing
  alternating with gradually shallow and slower
  breathing
• Indicates brainstem injury

56
Respiratory Patterns contd

• Biots
• Irregular pattern of rate and depth with sudden,
  periodic episodes of apnea
• Indicates increased intracranial pressure
• Central neurogenic hyperventilation
• Deep, rapid respirations
• Indicates increased intracranial pressure
• Agonal
• Shallow, slow, or infrequent breathing
• Indicates brain anoxia, impending death

57
Respiratory Assessment contd

• Auscultation
• Listen 1st audibly for any abnormal sounds
• Have patient cough to clear loose secretions
• Then listen with stethoscope
• Right and left apex (under clavicles)
• Right and left bases (8th 9th intercostal
  space, midclavicular)
• Right and left lower thoracic back or right and
  left midaxillary line (lateral chest wall)

58
Auscultation contd

• Posterior aspect preferable to anterior surface
• Less tissue mass
• Lungs closer to the surface
• Less interference with heart sounds
• Anterior and lateral sections of the chest are
  more accessible especially in supine patients
• Evaluate for symmetrical equality
• Keep stethoscope in place long enough to hear end
  of exhalation
• Many abnormal sounds heard first at end of
  exhalation

59
Abnormal Lung Sounds

• Snoring
• Partial obstruction of upper airway, usually from
  tongue
• Patient needs airway repositioned
• Gurgling
• Accumulation of fluids (blood, vomitus, other
  secretions) in upper airway
• Stridor
• Harsh, high-pitched sound heard on inhalation
  usually indicates laryngeal edema or constriction

60
Lung Sounds contd

• Wheezing
• Musical, squeaking, or whistling sound heard in
  inspiration and/or exhalation
• Indicates bronchiolar constriction
• Asthma, COPD
• Quiet
• Diminished or absent breath sounds ominous
• Indicates serious problem with airway, breathing,
  or both

61
Lung Sounds contd

• Crackles (rales)
• Fine, bubbling sound heard on inspiration, sounds
  like velcro ripping
• Indicates fluid in smaller airways
• CHF
• Pneumonia
• Gas exchange may be compromised
• Rhonchi
• Course, rattling noise heard on inspiration
• Associated with inflammation, mucus, or fluid in
  bronchioles
• Gas exchange may be compromised
• Chronic bronchitis

62
Airway Assessment

• Palpation
• Often forgotten assessment tool
• Palpate chest wall for
• Tenderness
• Symmetry
• Abnormal motion
• Crepitus (bone crunching)
• Subcutaneous emphysema
• Air leakage into tissue

63
Pulse Oximetry

• Measures hemoglobin oxygen saturation in
  peripheral tissue
• Non-invasive means to measure effectiveness of
  oxygenation and ventilation
• Continually reflects changes
• May detect changes faster than assessment of
  vital signs

64
Pulse Oximetry

• Place probe over a peripheral capillary bed
• Fingertip, toe, earlobe
• 2 sensors take measurements of light reaching
  them from 2 light emitting diodes
• Oximeter calculates ratio of light received
• Influenced by amount of oxygenated versus
  deoxygenated hemoglobin
• SpO2 determined

65
Suggested SpO2 Results

• 95 99 - normal
• 91 -94 - mild hypoxia
• Perform additional evaluation
• Administer supplemental oxygen
• 86 91 - moderate hypoxia
• Perform additional evaluation
• Administer 100 supplemental oxygen
• lt85 - severe hypoxia
• Immediate intervention required

66
SpO2 Error Results

• Current equipment more accurate less error
  readings
• False readings possible
• Carbon monoxide exposure false high
• High-intensity lighting near sensors
• Hemoglobin abnormalities
• Absent peripheral pulses
• Hypovolemia severe anemia
• SpO2 may be normal but the amount of hemoglobin
  available is low
• Coordinate readings with patient assessment

67
Capnography

• Graphic recording or display of measurement of
  expired CO2 over time
• End-tidal CO2 (ETCO2) measurement of CO2
  concentration at end of expiration
• Provides information
• Systemic metabolism (production of CO2)
• Circulation
• Ventilation

68
How Does CO2 Circulate?

• CO2 is normal end product of metabolism
• Transported by venous system to right side of
  heart
• Pumped from right ventricle ? pulmonary artery ?
  lungs and pulmonary capillaries
• Diffuses into alveoli
• Removed from body via exhalation

69
Poor Perfusion States

• Shock, cardiac arrest, pulmonary embolism,
  bronchospasm, incomplete airway obstruction (ie
  mucous plugging)
• Perfusion decreased
• ETCO2 will reflect pulmonary blood flow and
  cardiac output
• Will not reflect ventilation in poor perfusion
  states

70
End Tidal CO2 Detector

• Contains pH sensitive chemically impregnated
  paper to estimate ETCO2 level
• Color change is reversible
• Will reflect changes breath to breath
• Paper will be unreliable if contaminated with
  acidic drugs or gastric contents
• Tool placed near elbow on BVM

71
Interpreting the ETCO2

• Yellow indicates measured CO2 being exhaled
• Evaluate after 6 breaths
• Tan low levels of CO2 measured
• Misplaced tube or poor carbon dioxide production
• Evaluate tube positioning
• Evaluate patient perfusion
• Blue or purple no CO2 being measured
• Suspect unsuccessful intubation

72
ETCO2

• Applications
• Verify placement of endotracheal tube
• Assess effectiveness of CPR
• CO2 levels fall abruptly at onset of cardiac
  arrest
• CO2 levels begin to rise with effective CPR

73

• Medication Review
• (Information based on Region X EMS usage)
• Indication
• Contraindication
• Dosing
• Side effects
• Special considerations

74
Dextrose

• Carbohydrate used to raise the sugar level
• No contraindication in suspected hypoglycemia
• Administered when the blood sugar level is less
  than 60
• Dose based on age
• Adult 16 and over 50 50 ml slow IVP
• 1 15 D 25 - 2 ml / kg slow IVP
• lt1 D 12.5 - 4 ml / kg slow IVP
• Mix 11 dilution with D25 and normal saline

75
Dextrose contd

• Local vein irritation may occur especially when
  small veins are used
• If glucagon was administered and then an IV site
  is secured, retest the blood sugar level
• If blood glucose remains lt60 and patient
  condition not improved, administer Dextrose

76
Glucagon

• Hormone to stimulate breakdown of glycogen
  (stored form of glucose)
• Patient may have an allergic reaction if they
  have allergies to proteins
• Adult dosing 1 mg (1 unit) IM
• Pediatric dosing up to 15 years old 0.1
  mg/kg (max dose 1 mg 1 unit)

77
Glucagon contd

• Observe for nausea and vomiting
• May take up to 20 minutes for Glucagon to be
  effective
• Will not have any effect if there are no stores
  of glycogen in the liver
• Patient requires rapid transport and continued
  efforts at IV access
• Drug must be reconstituted prior to administration

78
Albuterol

• Ventolin, Proventil
• Bronchodilator with onset 5 15 minutes after
  inhalation
• Used in asthma, to reverse bronchospasm in COPD,
  and bronchospasm laryngeal edema of an
  allergic reaction
• All patients inhale 2.5 mg via nebulizer

79
Albuterol contd

• May cause tachycardia restlessness
• Has greater influence in the lungs than on the
  heart
• Less effective if patient taking beta blockers at
  home (usually for hypertension meds end in
  alol)
• Beta blockers block bronchodilation response
• Offer aerosol mask if patient unable to keep
  mouthpiece sealed between lips

80
Albuterol Kit and Masks
Connected to O2 source
2.5 mg / 3 ml

• Watch for signs of exhaustion
• May need to be bagged

Available in adult and pediatric sizes
81
Epinephrine via Nebulizer

• In presence of croup/epiglottits
• If patient not responding to 2 doses of
  Albuterol, provide alternate treatment
• Epinephrine 11000 1 ml mixed with 2 ml
  normal saline
• Mix in nebulizer
• Connect to oxygen to create a mist
• Assist patient while inhaling the mist
• Nebulized Epinephrine for moderate to severe cases

82
Epinephrine 11000

• A drug that mimics the sympathetic nervous system
• Stimulation on the vessels trigger
  vasoconstriction
• Will raise the blood pressure
• Stimulation in the lungs triggers bronchodilation
• Will improve air exchange
• Useful in asthma, COPD, allergic reactions with
  airway involvement, and anaphylaxis

83
Epinephrine 11000 contd

• Use with caution in the elderly and those
  with heart disease
• Can strain the heart by increasing the workload
  of the heart (rate and force of contractions)
• Adult dosing allergic reaction with airway
  involvement 0.3 mg SQ
• Adult dosing anaphylaxis 0.5 mg IM
• Faster absorption in poor perfusion

84
Epinephrine 11000 contd

• Pediatric dosing up to 15 years of age
• Allergic reaction with airway involvement
• Epi 11000 - 0.01 mg/kg SQ
• Max single dose 0.3 ml (0.3 mg)
• May repeat every 15 minutes
• Anaphylaxis
• Epi 11000 0.01 mg/kg IM
• Max single dose 0.3 ml (0.3 mg)
• IM faster absorption in poor perfusion state
• May repeat every 15 minutes

85
Epinephrine 11000 contd

• May cause
• Tachyarrhythmias
• Palpitations
• Restlessness
• Anxiety
• Headache
• May increase oxygen demand in the heart
• Use cautiously in elderly and those with heart
  disease

86
Benadryl - Diphenhydramine

• Antihistamine to block the release of histamine
  in allergic reactions
• Max effect in 1 3 hours
• Duration of effect 6 -12 hours
• Medication must be continued over several days or
  symptoms will rebound
• Useful in allergic reactions including anaphylaxis

87
Benadryl contd

• Avoid use in severe, uncontrolled asthma and COPD
• Adult dosing
• Stable allergic reaction 25 mg slow IVP or IM
• Allergic reaction with airway involvement
  anaphylaxis 50 mg slow IVP or IM
• Pediatric dosing 1 mg/kg IVP
• Stable allergic reaction max dose 25 mg
• Allergic reaction with airway involvement or
  anaphylaxis max dose 50 mg

88
Benadryl contd

• May cause drowsiness, headache, confusion,
  wheezing, palpitations, hypotension, nausea,
  vomiting, drying of secretions
• Elderly particularly sensitive to effects of
  Benadryl
• Watch for hypotension and drowsiness

89
Lasix (furosemide)

• Diuretic that stops reabsorption of sodium and
  chloride in the kidneys
• Triggers dilation of the venous system
• Could drop blood pressure
• Decreases pre-load
• Amount of blood returning to the heart
• Onset of venodilation immediate
• Onset of diuretic effect within 15 20 minutes

90
Lasix (furosemide) contd

• Useful in CHF and pulmonary edema
• Venodilation useful in hypertensive crisis
• Slight risk in persons allergic to sulfa drugs
  (typically antibiotics)
• Dosing is 40 mg IVP/IO
• If patient is on Lasix, they are sensitized to it
• Use the larger dose of 80 mg IVP/IO

91
Lasix (furosemide) contd

• May cause headache, dizziness, hypovolemia,
  nausea
• Patient may experience temporary hearing loss and
  ringing in the ears with repeated doses given
  rapid IVP/IO over a period of time

92
Morphine

• Narcotic analgesic (opioid)
• Reduces anxiety
• Creates a euphoric feeling
• Depresses the central nervous system (CNS)
• Reduces pain sensation
• Dilates venous blood vessels
• Decreases blood return to the heart (pre-load)
• Useful in ACS, pulmonary edema, pain
• Potentiates versed during conscious sedation
• Helps versed to be more effective

93
Morphine contd

• Dosing
• 2 mg given slow IVP (over 2 minutes)
• May repeat every 2-3 minutes
• Maximum total dose is 10 mg
• Side effects
• Hypotension
• Respiratory depression
• Bradycardia
• Altered level of consciousness

94
Morphine contd

• Opioids cause pupils to constrict
• Use cautiously when other depressant drugs have
  been taken
• Includes alcohol
• Reversal agent is Narcan
• Adult dosing 2 mg IVP
• May repeat every 5 minutes max total 10 mg
• Pediatric dosing lt 20kg 0.1 mg/kg IVP/IO/IM
• Max total dose is 2mg
• gt 20kg 2 mg IVP/IO/IM

95
Narcan

• Narcotic antagonist with an onset within
  2 minutes
• May cause withdrawal symptoms including seizures
• Adult dose 2 mg IN/IVP/IO
• Repeated every 5 minutes as needed up to 10 mg
• Pediatric dose up to 15 years weight based
• lt20 kg (44) 0.1 mg/kg IVP/IO/IM
• gt20 kg (44 - typically a 4-6 year old)
  2 mg IVP/IO/IM

96
Narcan contd

• Side effects are rare. Watch for hypotension,
  nausea, vomiting, blurred vision, opiate
  withdrawal (including seizures)
• Goal is to reverse severe respiratory depression
  NOT to have an awake talking patient
• Duration of Narcan may be shorter than drug it is
  trying to counteract
• Watch for return of symptoms

97
Alternate Medication Delivery - MAD

• Mucosal atomization device
• Tool to deliver medications via nasal route
• Medication atomized into tiny particles
• Nasal mucosa highly vascular
• Immediate absorption into bloodstream
• Onset of action within 3-5 minutes
• Peak onset 15-20 minutes

98
Using Nasal Route - MAD

• Unable to establish IV access
• Medication administration indicated
• Nasal mucosa intact and
  clear of blood and mucus

99
MAD

• Luer tip can be connected to variety of sizes of
  syringe
• White wedge fits firmly into nostril
• Fine mist spray covers a large surface area
• Medication adheres to nasal mucosa
  versus running down the throat
• Each nostril can tolerate up to 1 ml volume
• Narcan packaged 2mg/2ml will need to deliver 1
  ml in each nostril

100
Attaching MAD Tip to Syringe

• Nasal cavity suctioned as needed to clear blood
  or secretions
• Clear nasal passages enhance absorption of
  medication
• Medication delivered in divided doses
• Maximum of 1 ml per nares

101
Inserting MAD Nasal

• Patients head controlled with one hand
• Need to prevent movement
• MAD gently but firmly placed into one nostril
• Aimed upward and toward ear on same side
• Syringe briskly compressed to deliver the drug as
  an atomized mist into nares

102
Dispensing Mist

• Must briskly compress syringe to convert liquid
  drug to a fine atomized mist
• Mist results in broader mucosal coverage better
  chance of absorption into the blood stream than
  drops that can run straight back into the throat.

103
MAD

• Region X have implemented the MAD beginning with
  Narcan
• IN documented for route of administration
• Will have the potential in the future to add
  further medication using the MAD

104
Cricothyrotomy, QuickTrach

• Indications
• Assisted ventilations required and all other
  means have failed to secure an airway
• Contraindications
• Transected trachea
• Less invasive maneuver will be effective
• Note In ED, staff will need to assist the MD
  with this device do you know how?

105
Equipment

• BVM
• QuickTrach kit
• gt77 pounds use 4 mm kit
• 22 77 pounds use 2 mm kit
• lt 22 pounds use needle cricothyrotomy
• Skin prep material
• Where is your airway kit kept in the ED?

106
QuickTrach Kit Contents

• Needle with syringe
• Cannula with wings for strap attachment
• Extension tubing
• Velcro strap

107
QuickTrach contd

• Procedure (RN to assist MD)
• Assemble equipment
• Patient supine, neck hyperextended if no trauma
• Locate cricothyroid membrane and cleanse site
• Soft spot palpated just below Adams apple
• Or, start at notch, run fingers up toward head
• First ridge of bone palpated is cricoid cartilage
• Membrane is just above this bony cartilage

108
Procedure contd

• Anchor and stretch skin slightly
• Puncture cricothyroid membrane at 900 angle
• Aspirate syringe as needle enters trachea to
  confirm placement
• Ability to freely aspirate air
• Change angle of needle to 600 towards feet
• Advance device until stopper is flush with skin
• Remove stopper
• Stopper will be snug avoid motion of needle
• Slide plastic cannula forward until snug against
  skin as you remove needle and syringe
• Advance cannula as you remove needle like
  starting an IV

109
Procedure contd

• Hold cannula snuggly
• Patient may reflexively cough and could dislodge
  cannula
• Attach flexible connecting tube to cannula
  proximal end
• Begin to bag/ventilate the patient immediately
• Once every 6-8 seconds for all patients
• Confirm placement
• Auscultation lung sounds
• Adequate chest rise
• Finish securing cannula with neck strap

110
Case Study 1

• Your patient called 911 after dropping her tea
  cup and being unable to move her right side
• Conscious, cooperative, speech slurred
• VS 175/110 P 98 R 18 pupils cataract
• Initial care started (IV O2 monitor)
• What is your impression?
• What specific assessment should be done?

111
Case Study 1 contd

• Impression
• Acute stroke
• Additional assessment
• Cincinnati Stroke Scale
• Facial droop
• Arm drift
• Speech
• Transport decision
• Is CT scan available at receiving hospital?

112
Case Study 2

• EMS is at a local school for a patient with
  asthma
• Assessment taken walking towards child
• Sitting upright
• In obvious distress
• Use of accessory muscles neck, intercostal
• Increased respiratory rate
• Panic on their face
• Impression
• Severe acute asthma attack
• Is assessment done after vital signs?

113
Case Study 2 contd

• Assessment performed
• Observation / visual inspection
• Initial ABCs
• To determine presence of life threats
• Breath sounds auscultated
• Bilateral wheezing heard predominately on
  exhalation
• Obtain vital signs
• 98/62 P 110 R 28 and labored SpO2 94

114
Case Study 2 contd

• Interventions required
• IV O2 monitor - medication
• Question
• Do you need an IV established prior to
  administration of medication?
• No, albuterol nebulizer should be started as soon
  as possible
• Give verbal prompts to slow breathing down, to
  take deeper breaths, and to eventually take and
  hold a deep breath

115
Case Study 3

• You are caring for a traumatically injured
  patient
• When asking them to open their eyes, you yelled
  their name and their eye opened briefly and then
  closed again
• They are using swear words during care provided
• They are pulling off equipment and grabbing at
  your hands while you provide care
• What is their GCS?

116
Case Study 3 contd

• Eye opening
• To verbal 3 points
• Verbal response
• Inappropriate words 3 points
• Motor response
• Purposeful movement 5 points
• Total GCS 11 points
• Indicates moderate head injury

117
Case Study 4

• You are caring for a patient complaining of
  dyspnea
• Your patient is 62 years-old
• They are sitting in the tripod position
• They are using accessory muscles and have an
  increased respiratory rate
• With your stethoscope, you auscultate crackling
  sounds heard in the bases during exhalation

118
Case Study 4 contd

• What are these breath sounds?
• Crackles
• What do these breath sounds indicate?
• Fluid in the smaller airways
• CHF, pulmonary edema, pneumonia
• What medications may be indicated in the field
  (per SOP) for CHF?
• Nitroglycerin venodilator
• Lasix venodilator and diuretic
• Morphine venodilator, reduce anxiety
• And of course, oxygen
• Intervention to add is CPAP

119
Case Study 5

• You received a 7 year-old patient from a local
  school with an asthma attack
• Your impression is an acute asthma attack
• You begin supplemental oxygen and begin to
  prepare to provide interventions

120
Case Study 5 contd

• If this is an asthma attack, what signs and
  symptoms do you expect?
• Sitting up leaning forward
• Dyspnea with shortness of breath
• Increased respiratory rate
• Use of accessory muscles
• Dry mucous membranes
• Possibly audible wheezing
• Bilateral wheezing heard first on exhalation
• Dry, nonproductive cough

121
Case Study 5 contd

• If you cannot hear any breath sounds, what does
  this mean?
• The airway is so constricted that no air is
  moving in or out ominous
• What does wheezing sound like?
• Whistling, musical sound that can be heard on
  inhalation and exhalation
• The louder the breath sounds the more air that is
  exchanging

122
Case Study 5 contd

• What medication is indicated?
• Albuterol 2.5 mg (in 3 ml) nebulizer
• How can you help maximize the effects of the
  treatment?
• Calmly, quietly talk the patient through
  breathing
• Get the patient to slow down the breathing
• Get the patient to take some deeper breaths
• Get the patient to inhale and hold their breath
  periodically to get the drug into the lungs

123
Case Study 6

• You have an unresponsive male in his twenties
• The patient responds to painful stimuli
• The respirations are 6 per minute and shallow
• Pupils are constricted
• What is your impression?
• What interventions were necessary in the field?

124
Case Study 6

• Impression
• Narcotic overdose
• Interventions
• Immediately support ventilations
• Bag at a rate of once every 5-6 seconds
• Protect the airway from aspiration
• Administer Narcan 2 mg (via MAD if no IV)
• Administer a maximum of 1 ml per nares if using
  MAD

125
Case Study 7

• A patient is unable to be ventilated via BVM
• What options are available?
• Reposition the airway
• Consider c-spine precautions if indicated
• Attempt intubation
• QuickTrach if unable to intubate
• Needle cricothyrotomy if unable to identify
  landmarks

126
Case Study 7

• Landmarks for Quicktrach
• Soft space just inferior/below thyroid cartilage
  (Adams apple)
• Or
• Start in notch and move finger upward
• Feel first bony prominence cricoid cartilage
• Palpate for soft space above the cricoid cartilage

127
Bibliography

• Bledsoe, B., Porter, R., Cherry, R. Paramedic
  Care Principles and Practices. Prentice Hall.
  2009.
• Campbell, J. BTLS 5th Edition. Brady. 2004.
• Region X SOP, March 2007 amended January 1,
  2008.
• videolaryngoscopy.com//AdultCobalt-Airway.jpg
• www.wolfetory.com